1. There are specific actions a team leader can take to make an effective team.

The following strategies promote team work EXCEPT: a. Have an outside intervention specialist to conduct team building session 2. Robin, 10 years old is scheduled for cardiac catheterization. Nurse Carmina is planning care collaboration with his parents, which of the following information should she tell the parents? d. A catheter is inserted into the femoral vein through a percutaneous procedure 4. The physician orders parenteral nutrition infused by pump. The nurse explains that the procedure: d. Allows exact amount of solution to be given for a prescribed time 5. The solution prepared for parenteral nutrition follows a standard for the hospital. Which department d. Hospital pharmacist under strict aseptic technique 6. As you assess Felix, he seems very apprehensive and tells you that if the doctor advices him to stop drinking he would probably die sooner. What would be the most therapeutic response of the nurse? b. You seem to have fears, tell me more about this 7. Felix complained of pruritus. Which of the following would you do least? b. Keep the environment warm 8. Nurse Rica noted superficial thrombophlebitis of the lower leg of Edwin. The nurse would further c. Smoking history 9. Nurse Rica would monitor for the following physical signs of Buerger s Disease EXCEPT: b. Prescence of pedal pulse 10. As a nurse, Rica knows that cessation of smoking is an important component in disease management. Which of the following measures can improve peripheral circulation? c. Keeping the affected leg warm Situation: You joined an outing with friends. Some of your friends decided to go to the garden park to see the beautiful flowers in bloom, while the rest proceeded to the beach and swim. Then all of a sudden, one of your friends shouted that she got stung by a bee. 11. What will be your initial action? d. Inspect the site and scrape stingers 12. Greatest risk for most insect stings is an allergic reaction. Which of the following is NOT an indicator of an allergic reaction? c. Excruciating pain and swelling 13. A chemotherapeutic agent known to cause alopecia is prescribed to Marian, to maintain her self esteem, what do you plan to do? a. Encourage her purchase a wig or hat or turban and wear before hair loss begins 14. After you have explained the purpose of and scheduled for chemotherapy to Olga, a 23-year-old who recently received diagnosis of acute leukemia, she asks you to repeat the information. Based on the assessment, which nursing diagnosis is most likely for Olga? a. Knowledge deficit; chemotherapy related to a lack of interest in learning about treatment Situation: When nurses encounter situation that cause conflict, ethico-moral principles should be utilized to be able to make right decisions. 15. Nita, a staff nurse, works the night shift. On 2 occasions she found the orderly asleep in the storage area. Hospital policy prohibits employees to sleep while on duty. While making her rounds at 2am, Nita found the orderly asleep again. Which of the following should Nita do? b. Wake up the orderly and tell him he is violating a hospital policy 16. The daughter of a patient complains that the nurse assigned to her has not seen her during the shift. If you were the nurse who received the complaint, which of the following will you do first? a. Go to the patient and do assessment Situation: You are working in the surgical unit

17. When caring for Marina after an abdominal surgery you will be most concerned about monitoring for wound dehiscence during what period? b. 1 week after surgery 18. Minda is obese and malnourish while she was ambulating you noticed that her dressing was saturated with drainage. What should be your FIRST action to take? d. Lift up the dressing to assess the wound 19. Which of the following is not a specific preventive measure against central line associated infections? a. Optimal catheter site selection with subclavian as preferred site. 20. Terry is receiving chemotherapy for cancer. He developed thrombocytopenia. Which nursing diagnosis should be of highest priority? b. Impaired tissue integrity 21. An immediate objective for nursing care for a client, who is over- weight mildly hypertensive ureteral colic and hematuria is to decrease: c. Pain 22. A difficult problem to deal with when care for a patient with partial thickness burns sustained 3 days ago is: c. Maintenance of sterility Situation: One of your patient, Liberty, who underwent modified radical mastectomy. Your most important responsibility to ensure her complete recovery from breast surgery. 24. When doing climbing the wall with the finger exercise, Liberty should be taught the importance of: c. Climbing the wall higher each time with the affected arm WALL CLIMBING EXERCISES The following exercises are done while standing. 1. Stand erect, face wall and extend affected arm directly in front of your body so that fingertips touch the wall. Creep up the side of the wall with the fingertips, walk towards the wall as you reach higher and higher. Repeat with the fingertips going down the wall. 2. Repeat above, only this time do the exercise with the affected arm extended sideways. Keep the body erect and do not lean toward the wall or shrug Other exercises are usually taught, including four specific exercises: climbing the wall, arm swinging, rope pulling, and elbow spreading. They are performed as follows: Climbing the wall: The patient stands facing a wall, toes close to the wall. The elbows are bent, and the palms of the hands are placed on the wall at shoulder height. The hands are moved up the wall together until the woman feels pain or pulling on the incision, then returned to the starting position. Arm swinging: While standing, the patient bends forward from the waist, allowing both arms to relax and hang naturally. The arms are swung together from the shoulders from left to right and then in circles parallel to the floor, clockwise and counterclockwise. She straightens up slowly. Rope pulling: A rope is attached over a shower rod or a hook. Each end of the rope is grasped, and the patient alternately pulls each end, raising one arm after the other to the height at which incisional pain or pulling is felt. The rope is shortened until the affected arm is raised almost directly overhead. Elbow spreading: The hands are clasped behind the neck, and the elbows are slowly raised to chin level while the head is held erect. Gradually the elbows are spread apart to the point at which incisional pain or pulling is felt. 26. Prior to Liberty s discharge, you discuss with her ways to prevent lymph edema and infection from developing, which includes the following except: b. You can carry heavy shoulder bag and purse on your affected arm as a form of exercise 27. The ICU nurses decided to initiate quality improvement project to determine the effective interventions to prevent urinary catheter infection. Which of the following research design would be most appropriate? c. Experimental Situation: Ingrid, 94-years-old, brought to ED due to abdominal pain. She feels weak, with rapid pulse. She has type 1 DM.

28. In the ED, blood glucose was measured at 300mg/dl. Which of the following will the physician order to support his impressions of DKA? c. Urine test 29. An intravenous infusion of 1000cc normal (0.9%) saline with 20 meq potassium chloride (KCL) was started at the rate of 150ml/hr. IV regular insulin 100u/100ml 0.9 NSS to run at 5ml/hr was started also. Which of the following is the rationale behind the administration of KCL? b. Replace potassium loss Situation: Part of your independent nursing actions is doing a physical assessment of the clients. This may be done before admission or while the client is confined in the hospital. 30. Unlike the physical examination done by the doctor, the nurse s physical examination focuses on: a. Identifying client s abilities, health status appraisal 31. While taking nursing history and doing physical assessment, the client said that you are duplicating what the doctor has done. Your most appropriate response is: b. The nursing assessment allows me to plan your individualized care. 32. Glenda, a staff nurse has completed the physical assessment of her assigned clients. She is ready to cluster and document data. Which of the following should guide her in validating and interpreting assessment data? b. Classify and organize data 33. Nurse Carlota uses a card-filing system that allows guide reference to the particular need of the client. This is referred to as: c. Kardex 34. Nurse Carmen who is new to the unit is to perform a new procedure to her assigned clients. Which of the following should be the source to obtain the information? c. Procedure manual 35. Mr. Carlos Montes, 60-years-old became incontinent while confined in the hospital. He is disturbed in his sleep during the night. He reduced his fluid intake to prevent incontinence. Nurse Lea understands that this is a: a. Coping strategy 36. Mr. David Muerte is receiving intermittent tube feedings. His wife observes nurse Malou aspirate and measures the gastric contents. The wife asks the nurse what she is doing. Which of the following is the rationale behind the procedure? c. Checking for residual quantity 37. Mr. Augusto Dale who had surgery of the bowel is ordered NPO for several days. Which of the following should the nurse anticipate to be ordered by the physician? b. Administration of parenteral nutrition 38. Karla has developed upper respiratory tract infection and is afraid that her incision site from caesarean section may dehisce when she coughs. To prevent possible wound dehiscence, you will: a. Place a pillow over the incision when the client is coughing 39. The nurse avoids compromising the skin integrity of Joseph by preventing his exposure to certain body fluids. Which of the following would most likely cause skin breakdown? c. Gastric fluids 40. Application of a cold compress is most helpful for: c. Jonas who has a fractured ankle 41. Cynthia s bag of waters (BOW) has ruptured for the past 12 hours and you are assigned to plan her care. When developing a plan care for Cynthia, the nurse recognizes increased risk of: c. Chorioamnionitis 42. Cynthia goes into labor. At the peak of contraction, meconium-stained fluid gushes from the client s vagina. The nurse should immediately: b. Check the fetal heart rate

43. The nurse notes that when palpating Cynthia s abdomen during a contraction, it is not possible to indent the uterine wall. The intensity of this contraction would be termed: c. Strong (MCN, Pillitteri,page520) 44. The best approach to meet the challenges of personal and professional development in Philippine nursing, coupled with the realities of migration of nurses to countries is to: c. Put in place a Competency-Based Nursing Career Progression Program 45. Lola Basyang, 85 year old, female, went to the ER alone, because of severe headache and abdominal pain. The nurse asks Lola Basyang who her companion is. She replied I am alone. All my children are with their own family and I don t want to bother them anymore. The nurse knows that there is no Elder Abuse/Neglect Law in the Philippines, however: 1. Lola Basyang has the right to have support, family aid and protection under the family code of the Philippines 2. Lola Basyang will just have to accept that she is living alone 3. Lola Baysang may sue her children under the Penal Code for moral injuries 4. Lola Basyang s natural rights are protected by customs and common traditions in the Philippines b. 1 and 3 are correct 46. In the tertiary hospital where nurse Ana works, she is to evaluate the temperature of a mother who had just experienced seizure. The client who was still irritable at that time shouted, not now! What would be the best course of action for nurse Ana? a. Do not proceed because there is no permission from the client 47. Lola Maria, 90 years old, was brought to the ER by his 17 yr. old grandson, due to chest pain. The physician suspects CHF and plans to insert Swan Ganz catheter for hemodynamic monitoring. The physician is about to secure the client s consent. Which of the following is the nursing responsibility? d. Witness Lola Maria affix her signature 48. To ensure that the right of a client to informed consent is protected, the following responsibilities are expected of the nurse to do to her client who is to undergo an invasive procedure, EXCEPT: a. Explain the procedure to the client 49. Anthony, 42 years old, Jehovah s Witness, is for total laryngectomy. The doctor ordered to prepare 3 liters of compatible Typa A whole blood. What is the most appropriate nursing action? b. Ask the client to execute a waiver to blood transfusion if the client refuses transfusion despite explanation 50. When you ask the client, a Jehovah s Witness, to sign a waiver for blood transfusion after thorough explanation, you are practicing what universal moral principle? d. Autonomy 51. Mang Carding is a tricycle driver who was rushed to the hospital after he was side-swept by a car and sustained multiple abrasions a fractured right ankle. You and the nurse staff were very attentive to him, especially in dressing his wounds and immobilizing his right foot so that his fracture will not cause him undue pain. Your actions exemplifies: a. Beneficence 52. You are scheduled to go on leave to spend Christmas with your sister in the U.S. However the head nurse and 2 other staff went on emergency leave. You canceled your vacation and went on duty instead. You also express apology to your sister. What moral principle did you display? c. Beneficence 53. You conducted Operation Smile in Barangay Bagong Buhay. Towards noontime, you saw that there were more clients waiting for their turn but your supplies were starting to run low. You immediately informed those who just arrived that you will only do cheiloplasty until supplies last. Which moral principle are you trying to convey to the community? d. Justice Situation: The Professional Regulation Commission (PRC) regulates the practice of 43 professions in the Philippines. Nursing profession is one of them.

54. What is the basic requirement for a nurse to practice her profession? a. A nursing license 55. The Code of Good Governance E.O. 220, for the professions in the Philippines shall be adapted by all: a. Registered professionals (E.O. 220, Section 1, June 23, 2003) 56. RA 9173 stipulates that any failed examinee can take the Nurse s Licensure Examination: d. Anytime the examinee wants to take the examination again Situation: Client s evaluation shows that quality and effective clinical practice is the clamor of each client from the healthcare workers. 57. You are on PM shift. How can you best show your clients that your nursing rounds are with intent or purpose? c. Introduce yourself and offer to help client 58. Safe and quality drug administration dictates that drugs and dosages should be spelled out. However, you observed that doctors still abbreviate drugs in their orders. The doctor s order reads: MgSO, 6mg, IM . You will administer: c. Magnesium sulfate 59. Intravenous fluids (IV) are ordered and administered at different flow rates depending on the client s need. The MD ordered IV KVO . You will administer the IV solution to: a. Run at 7-10 drops per hour ---- 10 drops per minute, or 1 drop every 6 seconds b. Finish in 12 hours c. Consume 60. You are to administer an antibiotic via heparin lock. The BEST procedure of administration is to inject: a. Heparin, saline, antibiotic, saline c. Saline, antibiotic, saline, heparin 61. You are now to administer medication to your clients what is the correct way of identifying each client before you administer their medications? d. Check the wristband first and ask him his name 62. A student nurse assigned to a child in pain asks Nurse Glenda how to apply the Wong Baker method of assessing pain among children. Nurse Glenda would describe method as: = visual-analog scale 63. Nurse Myrna should call the attention of the intern who was scrubbing to assist in the case because the: a. Intern s hands and elbows were held close to the body 64. Once Myrna has donned the sterile gown and gloves, she is considered sterile. Describe the extent of what is sterile: b. Infront from the shoulder to the waist line and sleeves to the gloved hands 65. The members of the surgical team are expected to demonstrate the surgical conscience at all times. Which action of the circulating nurse demonstrates this: c. Using mask at all times while inside the OR suite (Surgical conscience is the professional behavior that demonstrates understanding and application of principles of surgical technology and legal, ethical, and moral responsibilities to patients and team members for which each practitioner is accountable. Source: AORN Standards and Recommended Practices for Perioperative Nursing. Denver, CO, Association of Operating Room Nurses, 1988.) 66. The surgeon asked Myrna for a knife to make an incision for the T-tube. Which knife the scrub nurse hand the surgeon? a. Second knife 67. Efren was referred to the Health Center for possible assistance and management through the Department of Health (DOH) TB-program Directly Observed Treatments Short Course (DOTS) Program. The elements of DOTS that need to be fulfilled include the following EXCEPT: d. Regular chest x-ray diagnosis

68. Efren was put on triple anti-TB drug regimen. The success of this regimen is highly dependent on which factor? d. Strict adherence to prescription 69. TB, like other infectious diseases, carries a social stigma that may lead to the problem of denial, the MOST effective way to overcome this problem is: a. Strong family or group support 70. A client is scheduled for transurethral resection of the prostate and asked where the incision would be. Your appropriate response would be: b. There will be no incision 71. Gerard turns to his room after TURP, with continuous bladder irrigation (CBI). Which of the following statements best explains the rationale of the procedure? d. Remove blood clots from the bladder 72. Post TURP, Gerard complained of pain and bladder spasm. Which is the MOST appropriate nursing intervention? d. Administer ordered narcotics plus anticholinergic drugs 73. As you prepare Gerard for discharge, you would emphasize which of the following instructions to prevent bleeding? a. Avoid constipation or straining when defecating 74. If the aim of the research is to determine the competency of the nursing graduate, the researcher is reflecting which of the following characteristics of a good research problem? c. Clearly defined research purpose 75. As a nurse-researcher, you should be able to determine if the theory is able to deal satisfactory with your perspective of nursing competency. Which of the following characteristics of theoretical framework is reflected? c. Significance 76. Research findings are NOT implemented as desired because of the failure to: b. Communicate 77. Over dosage of medication of anesthetic can happen even with the use of infusion pumps, and similar devices/machines. As a staff, what is theprimary consideration of using infusion pumps? a. Check the functionality of the pump before use 78. Universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following EXCEPT: a. Take a video of the entire intra-operative procedure 79. You identified a potential risk to client safety. To reduce the risk of client harm from fall preoperatively, you may implement the following EXCEPT: Allow client to walk with relative to the OR 80. As a nurse, you can improve on accuracy of patient s identification by 2 patient identifiers EXCEPT c. Call the client by his/her case and bed number Situation: You are relieving a senior training office for 1 month and you are assigned to provide instruction to active retired women with diabetes. 81. In case of hypoglycemia, you ask the participants to tell you the best food to take. Which of the following is the CORRECT response? d. Orange juice 82. Which of the following statements of the participants regarding medication, exercise and diet need reinstruction? a. If I exercise regularly and eat the prescribed diet my medication maybe discontinued

83. Nurse Rica noted superficial thrombophlebitis of the lower leg, the nurse would further assess the client for: c. Smoking history 84. Nurse Rica would monitor for the following physical signs of the Buerger s disease EXCEPT: b. Presence of pedal pulse 85. As a nurse, Rica knows that cessation of smoking is an important component of Buerger s disease management. Which of the following measures can improve peripheral blood flow? c. Keeping the affected leg warm 86. Edwin was prescribed Isoptin. Rica explains that this drug would: a. Cause vasodilatation 87. You prepared a discharge plan for Edwin. Aside from cessation of smoking, what would be your priority instruction? c. Regular leg exercise 88. In a pre-hospital setting, after ensuring that a patent airway has been maintained on a victim of heat stroke, which of the following is NOT recommended as a first aid measure? c. Immerse victim in cold water 89. A researcher studied sequelae of near fatal classic heat stroke in 58 clients and admitted in the intensive care unit. 100% of the clients developed multi-organ dysfunction; one half had renal insufficiency, and 10% experienced respiratory distress. Mortality rate was 21%. The findings of this research would be MOST useful for which of the following skills of the Emergency Department (ED) nurse? b. Multitasking 90. You are on duty in the surgical ward. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound. He is being guarded by a police from the local police unit. During your rounds you heard a commotion. You saw a policeman trying to hit Martin. You asked why he was trying to hurt Martin. He denied the matter. Which among the following activities will you do FIRST? a. Write an incident report 91. Due to lack of evidences of its effectiveness, which of the following is not an acceptable first aid intervention for snake bite? d. Excising the bite and sucking the venom 92. Review of researches showed that as compared to activated charcoal, gastric lavage has little or no effect in reducing absorption of toxic substances especially when done 1 hour after ingestion of poison among children. Which of the following statements is an appropriate application of this research study? a. Administration of activated charcoal should not be delayed by use of gastric lavage 93. Luisito eats poorly because of joint pain and fatigue. Which of the following advices would be MOST helpful for the mother to ensure that nutrition is adequately provided? Serve: d. Meals when pain is at its lowest level 94. The BEST nursing recommendation to promote ROM exercises to a client with joint pain and fatigue is: a. Bicycle riding 95. It be MOST important for you to check pulse oximetry for which of these patients? a. Troy who has just received morphine sulfate for postoperative pain 96. While assessing Jason, with chronic lung disease, you note a sudden onset of agitation and confusion. Which action should you take FIRST? b. Place the bed to lowest position 97. Ariel , a 22-year-old factory worker is in respiratory distress. Which of the following assessment findings of the nurse will indicate that Ariel is in acute respiratory failure? c. Partial pressure of arterial oxygen (PaO2) of 45 mm Hg

98. Gary, in acute respiratory failure, as a complication of COPD, has a PaCO2 of 65 mmHg, rhonchi audible in the right lung, and marked fatigue with a weak cough. Which of the following is your priority plan? a. Allow Gary to rest to help conserve energy (rationale: rest promotes oxygen conservation. It s best to place client in prone position to improve oxygenation by altering distribution of perfusion. MV with PEEP to increase residual capacity. Nitric oxide may be inhaled to prevent calcium influx into cell and causes vasodilation.) 99. The physician orders transfusion with packed RBCs for Genoveva who is hospitalized with severe anemia. To prevent transfusion reaction when administering the blood, as ___ nurse, your MOST important action is: = follow a standard blood transfusion policy 100. After being bitten by an unknown insect, Dona, who is allergic to wasp stings, is brought to a clinic by a co-worker. Upon her arrival she was anxious and was having difficulty breathing. The FIRST action that you should do as a nurse is to: a. Remove the stinger from the site 101. For people who are known to be allergic to bee or wasp stings, the following are ways to avoid stings, EXCEPT: a. Wear brightly colored clothing, and strong frangrances or perfumes 102. Norma who went swimming complained of a sudden severe pain and burning sensation at her back. They were informed that there were several jellyfishes that were seen in the area. Which of the following actions BEST deactivate nematocytes of the jellyfishes? c. Soak wound with 5% acetic acid for 15-30 minutes 103. Harriet, a 56 year old housewife with Type 2 diabetes, had vomiting and diarrhea for the past 3 days and is admitted to the hospital with a blood glucose of 748mg/dL and a urinary output of 120 ml in the first hour. The vital signs are: blood pressure (BP) 72/62; pulse 128, irregular and thready, respiration 38, and temperature 36.1C. harriet is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. As her nurse, you recognize that Harriet is experiencing the: b. Progressive stage of hypovolemic shock 104. A client is admitted and diagnosed with acute respiratory failure. You use the findings revealed by which of the following? d. Arterial blood gas (ABG) analysis 105. Sandra who underwent bowel surgery 2 days ago, has been receiving normal saline intravenously at 100ml/hr. has a gastric tube to low, intermittent suction, and is on NPO. Which of the following assessment findings would indicate that you need to contact Sandra s physician immediately? d. Gradually decreasing level of consciousness (LOC) 106. Bernie who has been on NPO with gastric suction and IV fluid replacement for 2 days following gastric resection, develops nausea and vomiting, weakness and confusion has a serum level of 125 mEq/L (125 mmol/L). As his nurse, which of the following physician s postoperative orders should you seek immediate clarification for? b. IV morphine sulfate 4 mg every 4 hours pm 107. Immediate post-operative following bowel surgery, the physician ordered gastric tube on low, intermittent suction. Which would be MOST important for you to report about the gastric drainage? a. No drainage 108. Conrad, a postoperative patient with nasogastric tube connected low, intermittent suction is complaining of anxiety and severe incisional pain. He has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mmHg. PaCO2 30 mmHg, and HCO2 23 mm Hg. Which intervention is MOST appropriate for you to implement? a. Teach Conrad about the importance of taking slow deep breaths 109. Trinidad, who is receiving iso-osmolar continuous tube feedings, develops restlessness, agitation and weakness. As his nurse, the laboratory data that will be of PRIORITY concern to you is: a. Na+ 154 mEq/L (154 mmol/L)

110. The physician ordered abdominal paracentesis STAT. which of the following is the primary purpose of this procedure? d. Decrease portal hypertension 111. The nurse is expected to include in her intervention which of the following measures intended to prevent possible puncturing of the abdominal organs during paracentesis? c. Position patient seated on a chair with feet supported 112. The nurse monitors client s neurologic functioning such as asterexis. To elicit this, which of the following is the correct technique used during physical assessment? d. Have patient extend arm, dorsiflex wrist and extend the fingers 113. Which of the following should be your FIRST action to take when admitting a client with compromised systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? c. Place Joy in a private room 114. David, with metastatic cancer of the colon, experiences severe vomiting following administration of chemotherapy. An important nursing intervention that you will implement is to: b. Administer prescribed antimetics 1 hour before the treatment 115. When you are administering a vesicant chemotherapeutic agent intravenously, an important consideration for you to observe is to: a. Stop the infusion if swelling is observed at the site Situation: Sergio, a 40 year old barangay tanod, was brought to the Emergency Room (ER) for ingesting muriatic acid. Based on the initial assessment of the physician, Sergio has altered level of consciousness, moaning and keeps on spitting blood tinged sputum. His co-workers informed you that they had a drinking session last night but Sergio decided to sleep at the barangay hall after. In the morning, when they were near the barangay hall, they heard somebody moaning and saw the muriatic (hydrochloric) acid bottle beside Sergio. Initial poisoning management was started. 116. Which among the following will be your priority activity as an ER nurse? b. Ensure patency of airway, breathing and circulation 117. The following factors should be considered in establishing the degree of damage ingested acids, EXCEPT: b. Age and gender of the person 118. Which of the following is a PRIORITY guideline in the management of caustic or acid ingestion? d. Do not induce vomiting 119. General poisoning management measures were started. These include intravenous solution of D5 0.9 NaCl 1 Liter to run for 8 hours which was started right away. This fluid is an example of ____ solution? b. Hypertonic 120. To facilitate the excretion of muriatic acid, 20% Mannitol 200mg/kg IV was given within 10 minutes. Part of your collaborative responsibility as a nurse is to: a. Insert urinary catheter and monitor adequacy of urine output 121. In a pre-hospital setting, after ensuring that a patent airway has been maintained on a victim of heat stroke, which of the following is NOT recommended as a first aid measure? c. Immerse victim in cold water 122. A researcher studied sequelae of near fatal classic heat stroke in 58 clients admitted in the ICU. 100% of the clients developed multi organ dysfunction, one half had renal insufficiency, and 10% experienced respiratory distress. Mortality rate was 21%. The findings of this research would be MOST useful for which of the following skills of the ED nurse? b. Multitasking 123. Which OUTCOME CRITERION would be most appropriate for Fanoy, 40 year old teacher, with a nursing diagnosis of Ineffective Airway clearance? a. Breath sounds clear on auscultation 124. Which assessment would be MOST SUPPORTIVE of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?

c. Oral temperature of 38.8 degrees Celsius 125. Julio asks you where the donor kidney will be placed. Which of the following will be your CORRECT response? c. Either the right or left lumbar region slightly below either the right or left kidney. 126. Immunosuppressive therapy was started prior to renal transplant. Which of the following is a PRIORITY nursing intervention to be included in the nursing care plan? Monitor for signs and symptoms of: a. Infections 127. When a physician visited two of his patients, the nurse observed that the physician did not wash his hands but just wore a pair of gloves between patient contacts. Which of the following is the most appropriate action of the nurse to ensure that the infection control measures in the ICU are improved? d. Inform the physician of the standard hand washing measures 128. To prevent aspiration as a possible cause of ventilator-associated pneumonia, which of the following preventive measures is MOST appropriate? a. Elevation of head of the bed and positioning 129. While being prepared for a biopsy of a lump in the right breast, Jane asks you what the difference is between a benign tumor and a malignant tumor. You explain that a benign tumor differs from a malignant tumor in that benign tumors: c. Do not spread to other tissues and organs 130. Roy who smokes tells you, I want to have a yearly chest x-ray so that if I get cancer, it will be detected early. Which will be your MOST appropriate response? a. Chest x-rays do not detect cancer until tumors are already at least a half-inch in size. 131. Irma is terminally ill. She speaks to you in confidence. You now feel that Irma s family could be helpful if they knew what Irma has told you. What should you do FIRST? d. Tell Irma that she has to tell her family. (family solidarity is enhanced when the patient and the family are informed of the true sickness of the patient. the oncology nurse has the duty to keep in confidence all the diagnoses and treatments of the patients that she cares for. In other words, he/she should never discuss these matters with other people even if they are close to the patient. Option D, provides the nurse an assessment of client s readiness to share information with her family. It is best to promote client s openness with the family by initiating the discussion rather than the nurse doing it in the client s behalf. Though option A is primary to observe autonomy, however, in general, it is the duty of the physician to disclose the information to the patient and her family.) (Reference: Abaquin, Carmencita & Kuan, Letty. N262 Oncology Nursing, c2002. pp425-430) 132. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can BEST help her by: d. Making yourself available for her.