1. You are the nurse in an Adult Care Unit.

You over-hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say, that if she refuses to take her medications she will not be given her favorite dessert. You report your co-staffs behavior as: A. Battery B. Assault C. Negligence D. Malpractice CORRECT ANS: B RATIONALE: Involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority. Examples include making threats to retsrain the client to give him or her an injection for failure to cooperate. (Source: Psychiatric Nursing 3rd edition; Shiela Videbeck; pp. 173) OTHER OPTIONS: Battery involves harmful or unwarranted contact with a client; actual harm or injury may or may not have occurred. Examples include touching a client without consent or unnecessarily restraining the client. Negligence an unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstance. Malpractice is a type of negligence that refers specifically to professionals such as nurses & physicians. 2. Jake is in the Post Anesthesia Care Unit following a colorectal resection. He has an IV of Dextrose 5% Lactated Ringers Solution Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs, moist respiration and tachypnea. Which of the following will you do FIRST? A. Notify anaesthesiologist B. Increase 02 flow rare C. Place on Fowler's position D. Reduce IV rate CORRECT ANS: C RATIONALE: Fowlers positions improve breathing by decreasing pressure on the diaphragm as gravity pulls abdominal contents downward. These positions also facilitate visiting and divisional activities. In this position clients tend to slide toward the foot of the bed. (Source: Mosbys Nursing interventions and clinical skills 3rd edition; Elkin, Perry, Potter; pp. 116) OTHER OPTIONS: Notify Anaesthesiologist, Increase 02 Flow Rate, & Reduce IV rate Premature intervention and Needs order from Attending Physician ( Dependent Nursing Interventions) 3. As a head nurse of the unit, which of the following sources should you take into consideration when making effective assignments for the next shift? A. Seniority preferences B. Recent performance evaluation C. Personality traits D. Client classification data CORRECT ANS: D RATIONALE: Staffing levels should reflect individual and aggregate patient needs. Functions to support quality patient care should be used when determining staffing levels OPTIONS A,B and C are incorrect 4. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. As the triage nurse you would assign, the HIGHEST priority to the client with the: A. severe head injury and no blood pressure B. maxillofacial injury and gurgling respirations C. second trimester pregnancy with premature labor D. lumbar spinal cord injury and lower extremity paralysis CORRECT ANSWER: B RATIONALE: Problems in airway is always the highest priority. 5. When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible? A. Volunteer nurse, hospital and the nurse in charge B. The professional organization which the volunteer nurse represents C. Hospital D. Volunteer nurse because there is no employer employee relationship Reproduction is strictly prohibited RN International Review Center 1

CORRECT ANSWER: A RATIONALE: The nurse volunteer nurse is liable including the head nurse and the hospital based on the principle of respondeat superior. 6. Daniel with multiple myeloma complains of deep bone pain. As his nurse, which of the following will you do FIRST? A. Assess bone pain B. Administer prescribed analgesic C. Teach pain relief strategies D. Support position with pillow CORRECT ANS: D RATIONALE: Independent intervention, promotes relaxation thus reducing pain and painful stimuli. OTHER OPTIONS: A - Late intervention. Remember the patient is in pain. Assessment is of No value. B May follow after if the pain still exists. C Patient in pain may not able to learn the pain relief strategies. Should be done when pain is not present. 7. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should you expect to find? A. Increased platelet count B. Altered blood urea nitrogen (BUN) and creatinine levels C. Electrolyte imbalance D. Elevated erythrocyte sedimentation rate (ESR) CORRECT ANS: D RATIONALE: o Increased rate seen in inflammation and necrotic processes. An increase is often seen in any inflammatory connective tissue disease, often indicating increased inflammation and resulting in clustering of RBCs, which makes them heavier than normal. The higher the sedimaentation rate, the greater the inflammatory activity. o ESR is particularly useful as a guide to the management of the client with RA. (Source: Medical Surgical Nursing 7th edition; Black & Hawks) OTHER OPTIONS: A. Increased Platelet Count may indicate hemorrhage, infectious disorders, malignancies, IDA, recent surgery, recent pregnancy, recent splenoctomy, inflammatory disorders, fractures, cryoglobulinemia, asplenia, asphyxiation, rheumatoid arthritis, heart disease, cirrhosis, chronic pancreatitis, TB, recovery from bone marrow depression, multiple myeloma, primary thrombocytosis, myelofibrosis with myeloid metaplasia, polycythemia vera, or chronic myelogenous leukemia. B. BUN Measures renal function and hydration. CREATININE this blood test helps in the diagnosis of muscular diseases or trauma as well as MI. C. Electrolyte Imbalance Usually for Fluid and Electrolyte disorders. 8. Mrs. Paras is receiving total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of the following indicators will tell you that TPN was effective? A. Laboratory work up B. Adequate hydration C. Weight gain D. Diminish episode of nausea and vomiting CORRECT ANS: A RATIONALE: Laboratory work up is done to assess levels of serum albumin, total protein, transferring, prealbumin, trigycerides, glucose, and urine nitrogen balance. It is also done in the assessment phase prior to administration of TPN to provide baseline measures of nutritional status and blood glucose levels. (Source: Mosbys Nursing interventions and clinical skills 3rd edition; Elkin, Perry, Potter; pp. 904-905) OTHER OPTIONS: B, C, D inadequate indicators in measuring the effectivity of TPN. 9. While Jayvee, a burn patient is being transferred from the burn unit to the operating room, the IV bottle fell on Jayvee's head. He sustained a laceration on his forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do? A. Hold the IV bottle B. Check the IV stand C. Place the IV stand on the foot part of the stretcher D. Restrain Jayvee CORRECT ANS: B Reproduction is strictly prohibited RN International Review Center 2

RATIONALE: Negligence the commission of an act that a prudent person would not have done or the omission of the duty that a prudent person would have fulfilled, resulting in injury or harm to another person. (Source: Mosbys pocket Dictionary 4th edition; pp. 844). Appropriate and proper check up of the IV stand prior to transferring the patient would guarantee security of the IV bottle. OTHER OPTIONS: A Always support or hold the client rather than the equipment. (Source: Fundamentals of Nursing 7 th edition, Kozier et al; pp.1091) C Doesnt guarantee the security of the bottle during transfer. D Improper. Need doctors order and patients and or folks approval. 10. While Mrs. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs? A. Administer Compazine before meals B. Enrich diet with red meat C. Serve hot soup and food D. Increase the amount of spice in the diet CORRECT ANS: B RATIONALE: This is a whole-foods diet high in protein. It is designed to support the body and minimize side effects while enhancing the ability of the chemotherapeutic agents to kill the cancer. A Compazine (Prochlorperazine). This drug is indicated for control of severe Nausea and Vomiting as well as for the teatment of schizophrenia C & D may irritate the GIT linings thus increasing the risk of infection. 11. Nurses working in the 35 bed female Medical Unit were noted to implement new and innovative client care activities long before other units in the hospital. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength? A. Communication skills B. Vision and passion C. Knowledge and skills D. Interpersonal abilities CORRECT ANS: B RATIONALE: Nurse leaders have vision. They share a dream and direction that other people want to share and follow. The leadership vision goes beyond your written organizational mission statement and your vision statement. The vision of leadership permeates the workplace and is manifested in the actions, beliefs, values and goals of your organizations leaders. Leadership is passion. Without passion, a person will have very little influence as a leader. Passion provides an individual with the light of leadership and creates an undeniable drive to make a difference. 12. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. It was started at 8 am. At 10 am her relative informed you that the bottle is empty. Which of the following will you do first? A. Refer to nurse manager B. Assess Olga and check level of fluid left in the bottle C. Discontinue IV and assess Olga D. Replace the IV fluid with prescribed follow-up CORRECT ANS: B RATIONALE: Assessment process begins at the moment the nurse sees the client and continues with each encounter. It is important to have as much awareness as possible of the clients health history. Preparation of environment, equipment and client facilitates smooth assessment. Assessment provides baseline data for nurses working on clients.(Source: Mosbys Nursing Interventions and Clinical Skills 3rd Edition; Elkin, Perry, Potter; pp.298) Assessment is the first step in the nursing process. It involves getting the facts. Collect, organize, validate and recording the clients data. Before Referring to nurse manager and Replacing prescribed IV fluid, assessment should be done first. ( Kosier, B., Fundamentals of Nursing Concept, Process and Practice) OTHER OPTIONS: A Assigned nurse did nothing. Referrals should be made after an independent interventions and or when the intervention didnt work out. C Requires Physicians Order. D No assessment done. 13. A research study found out that 60% of patients complaints were due to delayed responses of nurses in the emergency department. Which of the following measurement of data was used in this study? A. Measures of variability B. Measures of central tendency C. Frequency distribution D. Inferential statistics CORRECT ANS: A Reproduction is strictly prohibited RN International Review Center 3

RATIONALE: Variability refers to the "spread-out-ness" of scores in the distribution. The greater the difference between scores, the more spread out the distribution is. The more tightly the scores group together, the less variability there is in the distribution. One such measure of variability or spread is the range. OPTION B: Measures of central tendency are indexes, expressed as single number, that represent the average or typical value. OPTION C: Frequency distribution impose order on raw data, numeric values are ordered from lowest to highest, accompanied by a count of number (or percentage) of times each value was obtained. OPTION D: Inferential statistics are based on the laws of probability, provide a means for drawing conclusions about a population, given data from a sample 14. During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clear the table with: A. alcohol B. acetone C. ammonia D. bleach CORRECT ANS: D RATIONALE: Bleach such as chlorine is used in cleaning surfaces with blood spills. (Source: Fundamentals of Nursing 7th edition; Kozier et. al.: pp.647) OTHER OPTIONS: A Alcohol ( Isopropyl and Ethyl) is used on hands and vial stoppers. B Acetone is used to remove nail polish. C Ammonia is used as aromatic stimulant or a detergent or an emulsifier. 15. Nino is being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy? A. Cover the areas with thick clothing materials B. Apply 5 healing pad so the site C. Wash skin with water after the therapy. D. Avoid applying creams and powders to the area CORRECT ANS: D RATIONALE: - SKIN CARE WITHIN THE TREATMENT FIELD o Keep your skin dry o Do not wash the treatment area until you are instructed to do so. When permitted, wash the treated skin gently with mild soap, rinse well, and pat dry. Use warm or cool water, not hot water. o Do not remove the lines or ink marks placed on skin. o Avoid using powders, lotions, creams, alcohol, and deodorants on the treated skin. o Wear loose fitting clothing to avoid friction over the treatment field o Do not apply tape to the treatment site if dressings are applied. o Shave with an electric razor. Do not use pre-shave or after shave products. o Protect your skin from exposure to direct sunlight, chlorinated swimming pools, and temperature extremes. o Consult radiation therapist or nurse about specific measures for individual skin reactions. (Source: Medical Surgical Nursing 7th edition; Black & Hawks; pp. 365) 16. You are assigned to the following patients. Which of the following patient is most at risk for metabolic alkalosis? A. Grace 30 year old post surgical patient who has continuous nasogastric suction B. Rachel a 55 year old who has just experienced a stroke C. Helen 70 year old with altered level of consciousness who is unable to access water freely D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution CORRECT ANS: A RATIONALE: Loss of gastric fluid via nasogastric suction or vomiting can further contribute to metabolic alkalosis because of loss of HCl.(Source: Medical Surgical Nursing 7th edition; Black & Hawks; pp. 255) 17. Studies have shown that the highest incidence of Hodgkin's disease is common among young adults, Juana 20 years old approaches you and tells you "I am worried about the mass on my neck*. What should you do as a nurse? A. Tell her there is nothing to worry if it does not bother her B. Palpate Juana's neck and explain the possible cause C. Tell her Hodgkin's disease is common among young adults like her D. Tell her to see a doctor CORRECT ANS: D RATIONALE: Proper referral. Remember that the patient is worried. So as not to worry, consult a doctor.

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18. As a nurse, you accidentally administer 40 mg of Propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, you should: A. complete an incident report B. call the hospital attorney C. inform the client's family D. do nothing because the client's condition is stable CORRECT ANS: A RATIONALE: An incident report (also called unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contribute to statistical data about accidents or incidents, and to help personnel prevent future incidents or accidents. All accidents are usually reported on incident forms. The nurse includes the following in an incident report: Identify the client by name, initials, and hospital or identification number. Give the date, time and place of the incident. Describe the facts of the incident. Avoid any conclusions or blame. Describe the incident as you saw it even if your impressions differ from those of the others. Incorporate the clients account of the incident. State the clients comments by using direct quotes. Identify witnesses to the incident. Identify any equipment by number and any medication by name and dosage. The person who identifies that the incident occurred should complete the incident report. This may not be the same person actually involved with the incident. When an accident occurs, the nurse should first assess the client and intervene to prevent injury. If a client is injured, nurses must take steps to protect the client, themselves, and their employer. (Source: Fundamentals of Nursing 7th edition, Kozier et al; pp.61-62) OTHER OPTIONS: B & C Premature actions. D Guilty of Negligence. 19. You are the nurse manager of the Medical Unit. Which of the following is a priority for you to consider when planning for the care of a group of clients utilizing evidence-based practice? A. Client's care is planned based on the nurse's clinical expertise and latest research findings B. Standardized care plans are used on all of the nurse's clients. C. Standards of care are developed by this hospital nursing service and should be followed D. Clients' needs are assessed and individualized care plan are developed for each client CORRECT ANS: D RATIONALE: Standardized care plans were developed to save documentation time. These plans may be based on an institutions standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans must be individualized by the nurse in order to adequately address individual client needs. (Source: Fundamentals of Nursing 7th edition; Kozier et al; pp339) 20. Because of increase incidents of medication error due to wrong transcription of physician medication orders by nurses, a tertiary hospital utilized a computerized medication order system. Which of the following procedures may be done through the said system? A. Correct errors in the physician medication order B. Eliminate drug interaction C. Provide a list of drugs with their generic name D. Document drug administration

CORRECT ANS: C RATIONALE: Because it is impossible to commit to memory all pertinent information about a very large number of drugs, nurses must have a reliable reference readily available to avoid committing errors. 21. A client presents to the emergency department with a spinal cord injury at the C-3 level. Which of the following represents the priority at this time? A. Neurological status B. Sensation C. Paralysis D. Respiratory status CORRECT ANSWER : D RATIONALE: Respiratory paralysis is common with injury to the C-1 to C-4 level. Clients who survive these injuries require mechanical ventilator assistance to breathe. Injuries below the C-4 may increase the risk of respiratory failure if edema ascends the cord. After stabilizing the respiratory function, neurological function should be assessed.

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22. When implementing a teaching plan for a client with spinal cord injury, the nurse teaches the client that which of the following is the general cause of autonomic dysreflexia? A. Warm soaks B. Bright colored walls C. Full bladder D. Quiet environment CORRECT ANSWER: C RATIONALE: Autonomic dysreflexia is an exaggerated sympathetic response that occurs in clients with spinal cord injuries at or above the T-6 level. As stimuli are unable to ascend the cord, stimulation of the sympathetic nerves occurs, triggering massive vasoconstriction. The vagus nerve responds and caused bradycardia and vasodilation above the level of the injury. Autonomic dysreflexia is triggered by stimuli that would normally cause abdominal discomfort, and a full bladder is the most common cause. SITUATIONAL Situation 1 A client 35 years old went to the clinic with suspected hyperthyroidism. 23. When assessing a client, the nurse should expect the client to exhibit: A. Increased appetite, slow pulse, dry skin B. Loss of weight, constipation, listlessness C. Nervousness, weight loss, increased appetite D. Protruding eyeballs, slow pulse, sluggishness CORRECT ANSWER: C RATIONALE: Excessive thyroid hormones increase the metabolic rate, causing nervousness, weight loss, increased appetite, heat intolerance, and tachycardia. OPTION A- Although the appetite is increased, a slow pulse rate and dry skin accompany hypothyroidism because of a decreased metabolic rate. OPTION B - Although loss of weight is associated with hyperthyroidism, constipation and listlessness occur with hypothyroidism because of a decreased metabolic rate. OPTION D - Exophthalmos is common in hyperthyroidism; however, the pulse rate is rapid, not slow, and the client is nervous and hyperactive, not sluggish. 24. A client is to receive Lugol's iodine solution before a subtotal thyroidectomy is performed. This medication is given to: A. Decrease the total basal metabolic rate B. Maintain the function of the parathyroid glands C. Block the formation of thyroxine by the thyroid gland D. Decrease the size and vascularity of the thyroid gland CORRECT ANSWER: D RATIONALE: Lugol's solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed. OPTION A - Thyroid hormone substitutes regulate the body's metabolism. OPTION B - Calcium is needed to maintain parathyroid function. OPTION C - Antithyroid drugs, not iodine, prevent the formation of thyroxine. 25. A client is returning from a subtotal thyroidectomy for the treatment of hyperthyroidism. The immediate priority in assessing this client would include which of the following? A. Assess for respiratory distress B. Assess fluid volume status C. Assess neurological status D. Assess for pain CORRECT ANSWER: A RATIONALE: Though fluid volume status, neurological status, and pain are all important assessments, the immediate priority for postoperative thyroidectomy is airway management. Respiratory distress may result from hemorrhage, edema, laryngeal damage, or tetany. Assessment of respiratory status should include rate, depth, rhythm, and effort. Situation 2 - To be able to help our clients with their psychological concerns we have to explore how they view themselves and their body image 26. When assessing patient's body intake, which of the following would be most important to ask? A. What are your hobbies? B. What kind of work did you do prior to this illness? C. Are your living accommodation all on one level? D. What kind of food do you like? CORRECT ANS: D Reproduction is strictly prohibited RN International Review Center 6

RATIONALE: Assessment phase of the nursing process. On the components of a Nursing Health History under Lifestyle part, Diet category, Subjective data, describes/description of the typical diet on a normal day. 27. The most appropriate nursing intervention to facilitate client's acceptance of a change in body image would be to: A. encourage dependence B. establish a therapeutic relationship C. joke with the client D. establish a social relationship CORRECT ANS: B RATIONALE: Nurse-client relationships are referred to by some as interpersonal relationships, by the others as therapeutic relationships, and by still others as helping relationships. It strives to achieve two basic goals (Egan, 1998): Helps clients manage their problems in living more effectively and develop unused or underused opportunities more fully. Helps clients become better at helping themselves in their everyday lives. (Source: Fundamentals of Nursing 7th edition; Kozier et.al; pp. 429) 28. Which of the following responses would indicate that the client is beginning to accept change in his/her body image? A. Feeling of the dressing over the incisional site B. Stating he/she is too tired to have visitors C. Discussing his/her stamp collection with the nurse D. Showing no interest in the dressing change CORRECT ANS: D RATIONALE: Resistive behaviours are those that inhibit involvement, cooperation, or change. Showing no interest is a sign of resistive behaviour which means that the client has the difficulty in acknowledging the need for help and thus a dependent role, fear of exposing and facing feelings, anxiety about the discomfort involved in changing problem-causing behaviour patterns, and fear or anxiety in response to the nurses approach, which may, in clients opinion, be inappropriate.(Source: Fundamentals of Nursing 7th edition; Kozier et. al. Pp. 433) 29. It is important for you to remember, that a sudden change in body image would occur from: A. weight gain B. side effects of medication on skin C. radiation treatment of the breast D. surgical removal of an eyeball CORRECT ANS: A RATIONALE: Body weight is a sensitive indicator of body image perception. Thus, Weight gain is the direct, objective and or subjective indicator of change in body image. 30. Before you can help Lorna accept a change in body image you must FIRST: A. be in agreement with the philosophy of therapy for the client B. become aware of her own attitude toward mutilation and disfigurement C. be aware of the attitudes and feelings of the client and her family D. accept the fact that a person can live with a body part missing CORRECT ANS: B RATIONALE: Self Awareness refers to the relationship between ones perception of himself/herself and others perceptions of him or her. One important component of the process is introspection, which involves the client considering his or her own beliefs, attitudes, motivations, strengths, and limitations. (Eckroth-Butcher, 2001). (Source: Fundamentals of Nursing 7th edition; Kozier et.al: pp. 957) Situation 3 - Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse. 31. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert? A. Tell him that sometimes these feelings can be psychogenic B. Refer him to the physician C. Reassure him that these feelings are normal D. Help him plan his activities and rest period CORRECT ANS: D RATIONALE: Fatigue and malaise are common side effects of radiation therapy. However, related fatigue is often not recognized, and its effect not appreciated, by health professionals. Anemia, Dehydration & electrolyte imbalances, lack of rest and sleep are other side effects of radiation therapy which could directly worsen fatigue. (Source: Fundamentals of Nursing 7th edition; Kozier et.al: pp. 370) Reproduction is strictly prohibited RN International Review Center 7

32. Immediately following the radiation teletherapy, Albert is A. considered radioactive for 24 hours B. given a complete bath C. placed on isolation for 6 hours D. free from radiation CORRECT ANS: D RATIONALE: External beam radiation therapy is radiation delivered from a distant source, from outside the body and directed at the patient's cancer site. External beam therapy is painless. Most patients do not need to stay in the hospital while they are having external beam therapy. Patients do not see or feel the actual treatment. Many patients can go home following each treatment, and most patients can even continue with their normal daily activities. http://training.seer.cancer.gov/module_cancer_treatment/unit2_radiation3_types.html 33. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms: A. Petechiae, ecchymosis. epistaxis B. Weakness, easy fatigability, pallor C. Headache. dizziness, blurred vision D. Severe-sore throat, bacteremia, hepatomegaly CORRECT ANSWER: A Thrombocytopenia is an abnormally low level of platelets in the blood. Platelets are made by the bone marrow, and they help your blood to clot. People with thrombocytopenia can have excessive bleeding. Signs and symptoms of a low blood platelet count may include: Easy or excessive bruising (ecchymosis) Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs Prolonged bleeding from cuts Spontaneous bleeding from your gums or nose (epistaxis) Blood in urine or stools Unusually heavy menstrual flows Profuse bleeding during surgery http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/23812.html 34. What nursing diagnosis should be of highest priority in patient with thrombocytopenia ? A. Knowledge deficit regarding thrombocytopenia precautions B. Activity intolerance C. Impaired tissue integrity D. Ineffective tissue perfusion; peripheral, cerebral, cardiovascular, gastrointestinal, renal CORRECT ANSWER: D RATIONALE: refer to the stem of the question. Thrombocytopenia bleeding hypovolemic shock making OPTION D the priority. 35. What intervention should you include in your care plan of patient with thrombocytopenia? A. Inspect his skin for petechiae, bruising, Gl bleeding regularly B. Place Albert on strict isolation precaution C. Provide rest in between activities D. Administer antipyretics if his temperature exceeds 38C CORRECT ANSWER: A RATIONALE: People with thrombocytopenia can have excessive bleeding. OPTION B is obviously incorrect OPTION C for fatigue OPTION D for fever Situation 4 -Andrea is admitted to the ER following an assault where she was hit in the face and head. She was brought to the ER by 2 police woman. Emergency measures were started. 36. As Andrea's nurse, what will be your priority interventions? A. Insert an intravenous catheter B. Insert an oral or nasopharyngeal airway C. Obtain arterial blood gases D. Give oxygen 2 liters per minute CORRECT ANSWER: D RATIONALE: The priority of the nurse is to establish airway. 37. Andrea's arterial blood gases reflect respiratory acidosis. This is most likely related to : Reproduction is strictly prohibited RN International Review Center 8

A. B. C. D.

partially obstructed airway ineffective breathing pattern head injury pain

CORRECT ANSWER: C RATIONALE: in head injury there is an increased ICP brainstem herniation decreased RR (respiratory depression) decreased carbon dioxide elimination respiratory acidosis 38. Andrea loses consciousness. You should prepare for which of the following FIRST? A. Placement of a nasogastric tube B. Placement of a second IV line C. Endotracheal intubation or surgical airway placement D. CT scan of the head. CORRECT ANSWER: C RATIONALE: Established airway OPTION A is contraindicated OPTION B and D are least priority 39. Andrea's physician gives an order of Mannitol 0.25g/kg IV bolus for increased ICR. This is given to: A. promote cerebral-tissue fluid movement B. promote renal perfusion C. correct acid-base imbalances D. enhance renal excretion of drugs CORRECT ANSWER: A RATIONALE: Mannitol is used as an osmotic diuretic agent and a weak renal vasodilator. Mannitol is used clinically to reduce acutely raised intracranial pressure, until more definitive treatment can be given. It is administered intravenously, and is filtered by the glomerulus of the kidney, but is incapable of being resorbed from the renal tubule, resulting in decreased water and Na+ reabsorption via its osmotic effect. Consequently, mannitol increases water and Na+ excretion, thereby decreasing extracellular fluid volume. http://en.wikipedia.org/wiki/Mannitol 40. As Andrea's nurse your goal is to prevent increased intracranial pressure (ICP). Which of the following independent nursing interventions is NOT suited for her? A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration B. Keep head of bed 30-45 degrees elevated C. Maintain Andrea's head in straight alignment and prevent hip flexion D. Prevent constipation and increases in intra abdominal pressure CORRECT ANSWER: B RATIONALE: Elevation of the head could further increase intracranial pressure. Other option are maintained to prevent increased ICP. Situation 5 Specific surgical interventions may be done when lung cancer is detected early. You have important pertoperative responsibilities in caring for patients with lung cancer. 41. Horace underwent lobectomy. Which of the following is the purpose of Horace's closed chest drainage post lobectomy? A. Facilitation of coughing B. Promotion of wound healing C. Expansion of the remaining lung D. Prevention of mediastinal shift CORRECT ANSWER: C RATIONALE: Closed chest drainage help re expand the remaining lung tissue by re-establishing normal negative pressure in the pleural space. OPTION D follows after establishing re expansion of the lungs OPTIONS A and B are incorrect Black and Hawks. Medical Surgical Nursing.Vol. 2.7th Edition.pp. 1857 42. Which of the following observations indicates that the closed chest drainage system is functioning property? A. Absence of bubbling in the suction control bottle B. The fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration C. Intermittent bubbling through the long tube of the suction control bottle D. less than 25 ml. drainage in the drainage bottle CORRECT ANSWER: B Reproduction is strictly prohibited RN International Review Center 9

RATIONALE: Normal finding, fluctuation of fluid occurs during respiration; this fluctuation is called tidaling or oscillation OPTION A: Bubbling in the water seal compartment should be present. It is caused by air passing out of the pleural space into the fluid in the chamber. OPTION C: Intermittent bubbling should be found in the water-seal compartment. OPTION D: The drainage is too small. You should check for any kinking or obstruction. Black and Hawks. Medical Surgical Nursing.Vol. 2.7th Edition.pp. 1863 43. Following lobectomy, you can best help Horace to reduce pain during deep breathing and coughing exercises by: A. placing him on his operative side during exercises B. splinting his chest with both hands during the exercises C. administering the prescribed analgesic immediately prior to exercises D. providing rest for six hours before exercises CORRECT ANSWER: B RATIONALE: Splinting techniques are used to promote effective coughing and deep breathing. Apply firm, even pressure after the client has taken a deep breath and during forced expiratory cough. Black and Hawks. Medical Surgical Nursing.Vol. 2.7th Edition.pp.1857 44. Peter underwent pneumonectomy. During the immediate postoperative period, deep tracheal suction should be done with extreme caution because: A. Peter will not be able to tolerate coughing B. the tracheobronchial trees are dry C. the remaining normal lung needs minimal stimulation D. the bronchial suture line may be traumatized CORRECT ANSWER: D RATIONALE: Deep tracheal suctioning can traumatize the suture line. 45. On which of the following positions should you place Peter who just underwent pneumonectomy? A. Prone position B. On the side opposite the surgery C. On the side of surgery D. Any position is acceptable CORRECT ANSWER: C RATIONALE: The patient should be placed on the side of the surgery to allow the remaining lung to reexpand. Situation 6 - As a nurse you should be able to address problems and discomforts experienced by the acutely ill older persons. 46. Pain in the older persons require careful assessment because they: A. are expected to experience chronic pain B. experienced reduce sensory perception C. have increased sensory perception D. have a decreased pain threshold CORRECT ANS: B RATIONALE: Elderly decreased sensation or perception of pain (Fundamentals of Nursing 7th edition; Kozier 1139) Pain is usually initiated by sensory stimuli, the individualized by a persons memory, expectations, emotions and behaviour. The individuals perception of and psychological response to pain is complex. The widespread belief that aging brings decreased pain sensitivity or increased pain tolerance lacks scientific support, yet older people have been known to present painless myocardial infarctions and intraabdominal catastrophes. Its unclear whether these clinical observations result from deficient pain reporting or age related changes in pain receptors, nerve transmission, or central nervous system (CNS) processing. (Source: Better Elder Care, A Nurses Guide to Caring for Older Adults; Springhouse; pp. 445) 47. Administration of analgesics to the older persons requires careful patient assessment because older people: A. have decreased hepatic, renal, and gastrointestinal function B. mobilize drug more rapidly C. have increased sensory perception D. are more sensitive to drugs CORRECT ANSWER: A RATIONALE: The absorption of drugs (which affects the duration and intensity of the drug effect) does not appear to be significantly impaired by aging. However, aging may affect how the drug is distributed throughout the body. (IOM 1997) Changes in the way drugs are delivered to the heart, brain, liver, and other body organs do not necessarily result in higher drug concentrations, but the accompanying decreases in lean body mass and total body water may heighten the effects of certain medications. Aging research is more definitive on the way an older Reproduction is strictly prohibited RN International Review Center 10

body eliminates drugs through the liver or kidney. Liver mass clearly decreases with age, and renal function also declines. As the elimination process slows, a drug can more readily accumulate in the body, and side effects and toxicity are more likely. The main message from studies on the effects of aging on drug therapies is that the issue is complex and yet unresolved. (IOM 1997, Solomon 1997) http://aspe.hhs.gov/health/reports/Drug-papers/Stuart-Final.htm 48. The older person is at higher risk for incontinence because of A. increased glomerular filtration B. decreased bladder capacity C. diuretic use D. dilated urethra CORRECT ANS: B RATIONALE: After age 40, a persons renal function may diminish; if he/she lives to age 90, it may have decreased for as much as 50%. This changed is reflected by a decline in the glomerular filtration rate caused by age-related changes in renal vasculature that disturb glomerular hemodynamics. Renal blood flow decreases by 53% from reduced cardiac output and age related atherosclerotic changes. As a person ages, his bladder muscles weakens, which may result in incomplete bladder emptying and chronic urine retention predisposing the bladder to infection. (Source: Better Elder Care, A Nurses Guide to Caring for Older Adults; Springhouse; pp. 12) 49. The most dependable effect of infection in the older person is A. change in mental status B. increase in temperature C. decreased breath sounds with crackles D. pain CORRECT ANSWER: C RATIONALE: this may indicate presence of a pulmonary infection. 50. Your priorities when caring for the older person who sustained traumatic injuries include: A. circulation, airway, breathing B. airway, breathing. disability (neurologic) C. airways, breathing, circulation, diability (neurologic) D. disability (neurologic), airway, breathing CORRECT ANSWER: C RATIONALE: The order of assessment in triage is the assessment of (1) airway, (2) breathing, (3) circulation, and (4) neurologic condition. Situation 7 - Mang Felix, a 79 year-old man is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling urinary catheter for continuous last drip bladder irrigation which is connected to a straight drainage. 51. Immediately after surgery, what would you expect his urine to be? A. Light yellow B. Amber C. Bright red D. Pinkish CORRECT ANSWER: C RATIONALE: Some hematuria is usual for several days after surgery. It is bright red in color due to numerous clots. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1024 52. The purpose of the continuous bladder irrigation is to: A. allow continuous monitoring of the fluid output status B. provide continuous flushing of clots and debris from the bladder C. allow for proper exchange of electrolytes and fluid D. ensure accurate monitoring of intake and output CORRECT ANSWER: B RATIONALE: The purpose of the continuous bladder irrigation is to prevent urinary infection by flushing out small blood clots that form after prostate and bladder surgery. 53. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action? A. Remove his catheter then allow him to void on his own B. Irrigate the catheter C. Tell him to "Go ahead and void." "You have a catheter." Reproduction is strictly prohibited RN International Review Center 11

D. Assess color and rate of outflow; if there is a change refer to urologist for possible irrigation CORRECT ANSWER: D RATIONALE: Assessment is done first before any interventions. Bleeding is common following TURP and monitoring for hemorrhage is an important nursing intervention. SOURCE: Saunders, Comprehensive Review for NCLEX-RN Examination, 3rd ed, p 595 54. You decided to check on Mang Felix's IV fluid infusion. You noted a change in flow rate, pallor and coldness around the insertion site. What is your assessment finding? A. Phlebitis B. Infiltration to subcutaneous tissue C. Pyrogenic reaction D. Air embolism CORRECT ANSWER: B RATIONALE: Infiltration is caused by the dislodgement of the needle. Fluid leak to the subcutaneous tissues causing edema, pain and is cool to touch. OPTION A- Phlebitis is the inflammation of a vein. There is redness, heat, swelling and pain OPTION C- Produces fever. There is sudden increase in the temperature. OPTION D- Air enters into the central veins 55. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during the first post operative day, which of the following is the LEAST relevant to document in the case of Mang Felix? A. Chest pain and vital signs B. Intravenous infusion rate C. Amount, color, and consistency of bladder irrigation drainage D. Activities of dairy living started CORRECT ANSWER: D RATIONALE: Vital signs are important to document post-op because any unwanted reactions can be obtained thru vital signs. Activities of daily living can not b started immediately post-op. Clients are taught to avoid heavy lifting, stressful exercise, driving, Valsalvas maneuver and sexual intercourse for 2-6 weeks to prevent strain. SOURCE: Saunders, Comprehensive Review for NCLEX-RN Examination, 3rd ed, p 597 Situation 8 - Many hospitals form bioethical review committees to ensure better quality of life of patients. You are invited by the nursing service department to participate in their bioethical review committee. You are expected to know the purpose and apply bioethical principles. 56. Which of the following is the purpose of the ethical review committee? A. Promote implementation of general standards B. Enhance health care provider's liability C. Increase individuals responsibility for decision making D. Decrease public scrutiny of health care provider's action CORRECT ANSWER: C RATIONALE: Ethical review committee is composed of philosophers, doctors, nurses, lawyers, clergy and social workers. They discuss sensitive issues such as the right to die, informal consent, right to choose or refuse treatment, right to know who is treating the patient. SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed, p 104 57. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20,000/dL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulin has not been successful. Her physician recommended splenectomy. Daria states "I don't need surgery. This will go away on to own.' in considering your response to Daria you must depend on the ethical principle of: A. Beneficence B. Justice C. Autonomy D. Advocacy CORRECT ANSWER: C RATIONALE: It involves self-determination and freedom to choose and implement ones decision, free from deceit, threat, constraint and coercion OPTION A- It promotes doing acts of kindness and mercy that directly benefit the patient. OPTION B- Right to demand to be treated justly, fairly and equally. OPTION D- Helping others to grow, and fulfill their potential SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed, pp 99,101, 103

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58. Zorayda is terminally ill and is experiencing severe pain. She has bone and liver metastasis. She has been on morphine for several months now. Zorayda is aware that they are having financial problems. She decides to sign a DNR form. What ethical principle did Zorayda and her family utilize as basis for their decision to sign a DNR? A. Justice B. Autonomy C. Beneficence D. Advocacy CORRECT ANSWER: B RATIONALE: It involves self-determination and freedom to choose and implement ones decision, free from deceit, threat, constraint and coercion OPTION A- Right to demand to be treated justly, fairly and equally. OPTION C- It promotes doing acts of kindness and mercy that directly benefit the patient. OPTION D- Helping others to grow, and fulfill their potential SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed, pp 99, 101, 103 59. Tricia, a staff nurse working in a cancer unit, is considered a role model not only by her colleagues, but also by her patients. She goes out of her way to help other. She is very active in their professional organization and she practices what she teaches. What ethical principles is she practicing? A. Beneficence B. Autonomy C. Advocacy D. Justice CORRECT ANSWER: C RATIONALE: Helping others to grow and fulfill their potential. Being a good example to other people OPTION A- It promotes doing acts of kindness and mercy that directly benefit the patient OPTION B-It involves self-determination and freedom to choose and implement ones decision, free from deceit, threat, constraint and coercion OPTION D- Right to demand to be treated justly, fairly and equally SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed, pp 99, 101, 103 60. You ore commuting to work riding the LRT. An older person collapsed and nobody seems to notice her. The security guard tried to make her sit down but she remained unconscious. You saw what happened and you decided to help. With help, you brought the patient to the nearest hospital. You learned later that woman was diabetic. She was on her way to the diabetes clinic to have her fasting blood sugar tested. She developed hypoglycemia. You were able to save a life. You felt good. What principle was applied? A. Advocacy B. Beneficence C. Justice D. Autonomy CORRECT ANSWER: B RATIONALE: - It promotes doing acts of kindness and mercy that directly benefit the patient OPTION A- Helping others to grow and fulfill their potential. Being a good example to other people OPTION C- Right to demand to be treated justly, fairly and equally OPTION D- It involves self-determination and freedom to choose and implement ones decision, free from deceit, threat, constraint and coercion SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed, pp 99, 101, 103 Situation 9 - Ensuring safety before, during arid after a diagnostic procedure is an important responsibility of the nurse. 61. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure. A. clenching his fist every 2 minutes B. breathing in and out through the nose with his mouth open C. tensing the shoulder muscles while lying on his back D. holding his breath periodically for 30 seconds CORRECT ANSWER: D RATIONALE: Making him hold his breath periodically for 30 seconds will help him have an increase tolerance to no breathing for a period of time because when the tube passes through your vocal cords, you may feel like you cannot catch your breath. The feeling is not unusual and is temporary. Your physician will stop to let you catch your breath before continuing the examination. 62. Following a bronchoscopy, which of the following complains of Fernan should be noted as a possible complication? A. nausea and vomiting B. shortness of breath and laryngeal stridor C. blood tinged sputum and coughing Reproduction is strictly prohibited RN International Review Center 13

D. sore throat and hoarseness CORRECT ANSWER: B RATIONALE: He is suffering already from respiratory distress. Signs of respiratory distress includes: dyspnea, changes in respiratory rate, use of accessory muscles and changes in or absent lung sounds SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1769 63. Immediately after bronchoscopy, you instructed Fernan to: A. exercise the neck muscles B. avoid eating or drinking until gag reflex returns C. refrain from coughing and talking D. clear his throat CORRECT ANSWER: B RATIONALE: Nothing is given by mouth until the cough and swallowing reflexes have returned, usually 1-2 hours, because your throat muscles will still be numb. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1768 64. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: A. keep the sterile equipment from contamination B. assist the physician C. open and close the three-way stopcock D. observe the patient's vital signs CORRECT ANSWER: D RATIONALE: During the procedure, assist the physician by monitoring vital signs of the patient, observing for dyspnea, difficulty in breathing, nausea and pain, for these are signs of possible complications. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1772 65. Right after thoracentesis, which of the following is most appropriate intervention? A. instruct the patient not to cough or deep breathe for two hours B. observe for symptoms of tightness of chest for bleeding C. place an ice pack to the puncture site D. remove the dressing to check for bleeding CORRECT ANSWER: A RATIONALE: Patient is encouraged to avoid coughing because it can traumatize the visceral pleura and lung, and even avoid respiratory distress. SOURCE: Brunner, Medical Surgical Nursing, 10th ed, p488 Situation 10 - As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients. 66. Getty is receiving chemotherapy for cancer. You review Gettys laboratory report and note that he has anemia, To which nursing diagnosis should you give the highest priority? A. Activity intolerance B. Impaired oral mucous membrane C. impaired tissue perfusion, cerebral, cardiovascular, gastrointestinal D. Impaired tissue integrity CORRECT ANSWER: A RATIONALE: Destruction of red blood cells by chemotherapy can lead to anemia. This can cause excessive tiredness, pale skin color, shortness of breath, irritability, decreased attention span, headaches and dizziness. These symptoms are primarily due to the decrease in oxygen going to the brain and other body tissues. SOURCE: curesearch.org 67. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease: A. hypertension B. pain C. hematuria D. weight CORRECT ANSWER: B RATIONALE: ureteral colic causes severe pain 68. A difficult problem to deal with when caring for a patient with partial-thickness bums sustained 3 days ago is: A. alteration in body image B. maintenance of sterility C. frequent dressing change Reproduction is strictly prohibited RN International Review Center 14

D.

severe pain

CORRECT ANSWER: A RATIONALE: During the acute burn phase, the client recognizes extent of injury and realizes that his/her body is changed forever. Depression, guilt, fear and anxiety confront the client. The client should be expected to experience emotional lability in progress through recovery. Staff members should provide an accepting atmosphere for the client. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 1459 69. Which outcome criterion would be most appropriate for a client with a nursing diagnosis of ineffective airway clearance? A. Continued use of oxygen when necessary B. Breath sounds clear on auscultation C. Respiratory rate of 24bpm D. Presence of congestion CORRECT ANSWER: B RATIONALE: When breath sounds are already clear upon auscultation, it signifies that there is no congestion anymore and that airway is already cleared from any obstruction. 70. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related to purulent wound drainage? A. Heart rate of 88 beats/min B. Dry and intact wound dressing C. Oral temperature of 38.8 deg C D. Wound healing by first intention CORRECT ANSWER: C RATIONALE: Purulent drainage from a wound may be indicative of infection, and if there is infection, body temperature rises.

Situation 11 - Nurses have important responsibilities when caring for hospitalised acutely ill patients. 71. Domingo, 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. His physician was considering dementia. Side rails were placed to ensure that he will not fall from bed. At 2:00 am, the call light at his room was on. You came in and saw Domingo slumped on the floor moaning. His daughter told you that he got out of bed to go to the toilet. He climbed over the side rail but his foot got caught in the beddings. He has an open wound on his forehead. Which among the following wilt you do FIRST? A. Transfer him to bed B. Apply restraints C. Ensure airway, breathing, circulation D. Call his physician CORRECT ANSWER: C RATIONALE: In emergency cases, never touch the patient first to transfer him/her immediately without assessing the patient, because maybe he/she is suffering from any injury secondary to fall. The first thing to do is assessment. Assess patients airway, breathing and circulation. After that, if there are no other injuries, you can now transfer the patient to a stretcher or bed and then call the physician. 72. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Based on the ECG obtained on admission at the ER and clinical findings, the physician gave a diagnosis of myocardial infarction (Ml) and prescribed IV morphine to relieve continuing pain. A primary goal of nursing care for Aimee is to recognize lifethreatening complications of Ml. As Aimee's nurse, you have to anticipate occurrence of complications. Take note that the major cause of death after an Ml is: A. Cardiac arrhythmias B. Heart failure C. Cardiogenic shock D. Pulmonary embolism CORRECT ANSWER: A RATIONALE: Cardiac arrhythmia is the cause of 40-50 % of deaths after MI. Ectopic rhythms arise in or near the border of intensely ischemic damaged myocardial tissue. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 1716 73. The cardiac monitor indicates that Cedrics heart rate has increased to 150 beats per minute. Shortly after this increase, you notice Cedric is in ventricular tachycardia. After reporting this to the physician, you anticipate that the physician will order: A. intracardiac epinephrine Reproduction is strictly prohibited RN International Review Center 15

B. insertion of a pacemaker C. bolus of Lidocaine D. manual cardiopulmonary resuscitation (CPR) CORRECT ANSWER: C RATIONALE: Physician will order IV antidysrhythmic agent, usually Lidocaine. When the client is unconscious and in ventricular tachycardia, it is not time for meds but time to defibrillate. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1685 74. Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. You should recognize this as signs and symptoms of: A. cardiogenic shock B. right-sided heart failure C. acute pulmonary edema D. pneumonia CORRECT ANSWER: C RATIONALE: In clients with severe cardiac decompensation, the capillary pressure with in the lungs becomes so elevated that fluid is pushed from the circulating blood into the interstitium and then into the alveoli, bronchioles and bronchi, which in turn causes severe dyspnea, pallor, tachycardia, expectoration of large amounts of frothy, blood-tinged sputum. SOURCE: Black, medical-Surgical Nursing, 7th ed, p1655 75. You are caring for Lulu who has acute pulmonary edema. To immediately promote oxygenation and relief of dyspnea, you should first: A. perform chest physiotherapy B. have her take deep breaths and cough C. place Lulu on high fowler's position D. administer oxygen CORRECT ANSWER: C RATIONALE: To reduce preload and relieve dyspnea, the client is placed in an upright position or high-fowlers position. They are not made to lie down because of orthopnea and feeling of choking when supine. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1879 Situation 12 - Acute respiratory distress is life threatening. Your presence and critical decision making as a nurse are important. 76. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. When assessing Frank you would expect to find: A. an altered mental status B. hypertension C. labored breathing D. tenacious secretion CORRECT ANSWER: C RATIONALE: Earliest manifestation of ARDS is usually an increase respiratory rate and profound dyspnea, 12-24 hours after initial injury. Breathing becomes increasingly labored: the client may exhibit air hunger and retractions SOURCE: Black, Medical-Surgical Nursing, 7th ed, pp 1895-1896 77. Frank's respiratory status necessitates endotracheal intubation and positive pressure ventilation. Your most immediate nursing intervention for Frank at this time would be to: A. facilitate Frank's verbal communication B. maintain sterility of the ventilation system C. assess his response to the equipment D. prepare him for emergency intubation CORRECT ANSWER: D RATIONALE: As his condition implies, the patient needs to be intubated, so the immediate action is to prepare the client for emergency intubation. Let the patient lie flat on bed with neck hyperextended in order to open the airway, and then prepare intubation set at bedside. The next step is to maintain the sterility of the ventilation system and then assess his/her response to the equipment. 78. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, you should: A. apply Suction while inserting the catheter B. use short and jabbing movements of the catheter to loosen secretions C. hyperoxygenate with 100% oxygen before and after suctioning D. suction two to three times in quick succession to remove all secretions Reproduction is strictly prohibited RN International Review Center 16

CORRECT ANSWER: C RATIONALE: Because the client loses the ability to cough while on mechanical ventilation and secretions tend to pool and obstruct the airways, suctioning is often required. Priority when suctioning a client is to hyperoxygenate before and after suctioning to prevent hypoxemia. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 1888 79. As a nurse you should observe Bernard, who has a restrictive airway disease, for early indications of respiratory acidosis, which include: A. light-headedness B. bradypnea C. bradycardia D. restlessness CORRECT ANSWER: D RATIONALE: In an attempt to compensate for the obstructed airway, the respiratory rate and depth increases, rapid, irregular pulse, there is a feeling of fullness in the head and restlessness. SOURCE: Saunders, Comprehensive review for the NCLEX-RN Examination, 3rd ed, pp 104-105 80. The physician orders low concentration oxygen to be given continuously for Kenneth who has a chronic obstructive pulmonary disease to prevent: A. an excessive drying of the respirator/ mucosa B. depression of the respiratory center C. rupture of emphysematous bullae D. a decrease in red blood cell formation CORRECT ANSWER: B RATIONALE: Oxygen is used when the client has severe exertion or resting hypoxemia. Oxygen, 1-3 L, by nasal cannula may be required to raise the PaO2 to no less than 60 mmHg. Oxygen is used cautiously in clients with emphysema, however. Because of long-standing hypercapnia, the respiratory drive is triggered by low oxygen levels rather than high carbon dioxide levels. If high levels of oxygen are administered, the respiratory drive can be destroyed and carbon dioxide retention can occur leading to respiratory center depression. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p1822 Situation 13 - As a nurse you have to be prepared to care for patients receiving blood transfusion. The physician has ordered 3 units of whole blood to be transfused to Diego following a repair of a dissecting aneurysm of the aorta. 81. You are preparing a unit of whole blood for transfusion. From the time you obtain it from the blood bank how long should you infuse it? A. 4 hours B. 1 hour C. 2 hours D. 6 hours CORRECT ANSWER: A RATIONALE: Blood should be transfused for 4 hours to avoid septicemia and crystallization of blood. Also, blood life is good for 4 hours only. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2284 82. What should you do FIRST before you administer blood transfusion? A. Check IV site and use appropriate BT set and needle B. Verify physician's order C. Verify client identity and blood product blood product, serial number, blood type, cross matching results, expiration date with another nurse D. Verify client identity and blood product, serial number, blood type, cross matching results, expiration date CORRECT ANSWER: C RATIONALE: The most crucial phase of transfusion is confirming product compatibility and verifying the clients identity. An estimated of 80% of transfusion reactions are due to labelling errors. Before going to the clients bedside, verify ABO and Rh compatibility, usually by comparing the bag label with the medical record and forms issued from the blood bank. Also check the bag label to ensure that the correct component has been issued, and check for the expiration date. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2283 83. As Diego's nurse what will you do after the transfusion has been started? A. Discontinue the primary IV of Dextrose 5% water B. Stay with Diego for 15 minutes to note for any possible BT reaction C. Check his vital signs every 15 minutes D. Add the total amount of the blood to be transfused to the intake and output CORRECT ANSWER: B Reproduction is strictly prohibited RN International Review Center 17

RATIONALE: The first10-15 minutes of any transfusion are the most critical. If a major ABO incompatibility exists or a severe allergic reaction such as anaphylaxis occurs, it is usually evident within the first 50 ml of the transfusion. Therefore it is recommended that the transfusion begin slowly and that the client must be monitored closely. Stay with the patient for 15 minutes. If no evidence of a reaction is noted within the first 15 minutes, flow rate can be increased to the prescribed rate and vital signs be obtained. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2284 84. Diego is undergoing blood transfusion of the first unit, The earliest signs of transfusion reactions are: A. oliguria and jaundice B. urticaria and wheezing C. hypertension and flushing D. headache, chills, fever CORRECT ANSWER: D RATIONALE: Symptoms comes first than signs. Febrile reactions are the earliest signs of transfusion reactions. It is caused by sensitization to donor white blood cells, platelets, plasma and proteins. It is characterized by fever, sudden chills, headache, flushing, anxiety and muscle pain. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2281 85. In case Diego will experience an acute hemolytic reaction, what will be your priority intervention? A. Immediately stop the blood transfusion, infuse Dextrose 5% in water and call the physician B. Slow the blood transfusion and monitor the patient closely C. Immediately stop the blood transfusion, notify the blood bank and administer antihistamines D. Immediately stop the blood transfusion, infuse normal saline solution, call the physician, notify the blood bank CORRECT ANSWER: D RATIONALE: In all cases, stop the transfusion, and keep the IV line open with normal saline. Contact the clients physician and the blood bank. In accordance with institutional policy, obtain appropriate laboratory samples. Samples are used to evaluate a reaction include blood and urine. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2284 Situation 14 - Based on studies of nurses working in special units like the intensive care unit and coronary care unit, it is important for nurses to gather as much information to be able to address their needs for nursing care. 86. Critically ill patients frequently complain about which of the following when hospitalized? A. Hospital food B. Lack of blankets C. Lack of privacy D. Inadequate nursing staff CORRECT ANSWER: A RATIONALE: Food in the hospital actually varies according to the condition of the patient. It is low in sodium which in turn has a bland taste, which most people dont like due to it being tasteless. Its tastiness is poor. 87. Who of the following is at greatest risk of developing sensory problem? A. Female patient B. Adolescent patient C. Transplant patient D. Unresponsive patient CORRECT ANSWER: D RATIONALE: Unresponsive patients or comatose patients, as the term suggest, they do not respond anymore to any stimuli. Their sensory system is already impaired. The only sense that remains and is the last one to fade is their sense of hearing. 88. Which of the following factors may inhibit learning in critically ill patients? A. Gender B. Medication C. Educational level D. Previous knowledge of illness CORRECT ANSWER: C RATIONALE: Your understanding or comprehension is basically dependent on your educational attainment. You perceive and/or comprehend things and learnings according to your level of thinking which is affected by your level of educational attainment. In addition, critically ill patients have poor judgment and concentration already brought about by their own condition. 89. Which of the following statements does not apply to critically ill patients? A. Majority need extensive rehabilitation B. All have been hospitalized previously Reproduction is strictly prohibited RN International Review Center 18

C. Are physically unstable D. Most have chronic illness CORRECT ANSWER: C RATIONALE: Not all critically ill patients are physically unstable. Some are only emotionally or psychologically unstable. 90. Families of critically ill patients desire which of the following needs to be met first by the nurse? A. Provision of comfortable space B. Emotional support C. Updated information on client's status D. Spiritual counseling CORRECT ANSWER: B RATIONALE: Families and significant others of the critically ill client also experiences stress. The impact of critical illness is great. As the demand of the family is increased, adaptation and coping mechanisms are depleted, anxiety levels are heightened and maladaptation may occur. Family members must have their physical and emotional needs met. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 160, 162 Situation 15 - Pain is one of the most common reasons why people consult their physicians. It is now regarded as the 5th Vital Sign. This strategy is used to give emphasis on how pain should be managed. You have collaborative as well as independent nursing interventions for pain. 91. The WHO Analgesic ladder provides the health professional with: A. pharmacologic and nonpharmacologic pain management choices B. general pain management choices based on level of pain C. nonpharmacologic interventions based on level of pain D. specific pain management choices based on severity of pain CORRECT ANSWER: A RATIONALE: Various factors are considered in selecting the most effective analgesic for a specific client. The WHO has suggested that decisions regarding pain medications may be aided by use of a pain ladder. It describes the steps in treating cancer pain and pain management strategies. It depicts strategies from least invasive to most invasive. It uses both pharmacological and nonpharmacological pain management. SOURCE: Black, Medical-Surgical Nursing, 7th ed, pp 461-462 92. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT: A. A physical dependence B. Pruritus C. Respiratory depression D. Constipation CORRECT ANSWER: A RATIONALE: Practically all drugs have side effects: that is, they cause effects other than those that are desired. As is the case with opioids, they are often related to drug dosage. They include constipation, nausea and vomiting, respiratory depression, urinary retention, pruritus SOURCE: Black, Medical-Surgical nursing, 7th ed, p491 93. Which of the following statements about cancer pain is NOT TRUE? A. Undertreatment of pain is often due to a clinician's failure to evaluate the severity of the client's problem B. Adjuvant medications such as steroids, anticonvulsants, nonsteroidal anti inflammatory drugs enhance pain perception C. Opioids are drugs of choice for severe pain D. Pain associated with cancer and the terminal phase of the disease occurs in majority of patients CORRECT ANSWER: B RATIONALE: A clients reaction to pain is intensely personal and accounts for the great variability in pain experiences from person to person. Cancer pain is managed according to strategies specific to it. A diagnosis of cancer adds an additional psychological component associated with potential physical deformity and the potential for impending death, preceded by agonizing suffering. The mental anguish may intensify the perception of pain. SOURCE: Black, Medical-Surgical Nursing, 7th ed, pp 447, 451 94. Jack has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that Jack is: A. becoming psychologically dependent B. needing to have the morphine discontinued C. developing tolerance to the morphine Reproduction is strictly prohibited RN International Review Center 19

D. exaggerating his level of pain CORRECT ANSWER: C RATIONALE: Tolerance to a certain drug develops when the liver becomes efficient at metabolizing the medications and higher doses are required to achieve the same level of pain control or comfort. The tolerance to certain medications does not mean that the client is addicted or psychologically dependent upon them. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 444 95. The guidelines for choosing nonpharmacologic interventions for pain include all of the following, EXCEPT? A. pain problem identification B. type of opioid being used C. skill of the health professional D. effectiveness for patient CORRECT ANSWER: B RATIONALE: Opioid provides a pharmacologic means of relieving pain. Situation 16- The nurses' accurate assess merit is very crucial in preventing complication during severe post burn period. 96. Dino sustained circumferential thermal burns of the left upper extremity and chest. You noted that pulse could not be appreciated in his injured extremity. Which of the following will you do FIRST? A. Elevate the injured extremity to increase blood flow to the heart B. Remove the dead tissues which impede circulation C. Try to take the pulse in the uninjured extremity D. Notify the physician immediately as this requires emergency intervention

CORRECT ANSWER: C RATIONALE: Since only the left side is injured and the right extremity is not, verify on the left side if pulse is present. If it is not also appreciated, then thats the time for you to contact the physician for emergency intervention, as it may suggest nerve ending damage and vein collapse already. 97. While unloading containers with chemicals from a truck, Mark accidentally spilled the whole ran of corrosive chemicals all over his body. Which of the following would you consider as the priority intervention in the emergency management of Mark? A. Maintain a patent airway B. Wash the chemical off with cool water C. Assess for associated injuries D. Remove all clothing containing the chemical CORRECT ANSWER: A RATIONALE: The adequacy of the airway and breathing should take prime importance during the emergent phase of burn injury. Asses oropharynx for evidence of blisters, erythema or ulcerations. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 1445 98. You are assigned in the Bum Unit and you are going to evaluate the status of Raymond who sustained a burn injury 12 hours ago and has a urinary output of 200 ml since the injury. Which of the following will you do FIRST? A. Increase the rate of the IV fluid B. Administer the prescribed Furosemide (Lasix) C. Check catheter for kinks D. Increase the oral intake to 30 ml/hr CORRECT ANSWER: C RATIONALE: Before implementing anything, assessment should be done first. Options A and D is already implementation and that Option A requires doctors order. Option D is only 30 ml/hr which is too little. 99. Kathy, who has partial-thickness bums on the face, inquires about skin care after discharge. Which of the following should you include in your discharge teaching? A. Continue to eat high caloric high food for the next month B. Wear a pressure garment daily for one year C. Avoid sunlight for the next three months D. Avoid facial makeup for at least a year CORRECT ANSWER: D RATIONALE: Facial make-up, fabric softeners are avoided because they are considered chemical irritants and they may irritate the patients skin. It takes 18 months to 2 years for the burn scar tissue to mature. SOURCE: Saunders, Comprehensive Review for the NCLEX-RN Exam, 3rd ed, p 550 Reproduction is strictly prohibited RN International Review Center 20

100. You are caring for Lenard who sustained severe burn injury and he is in the emergent phase of burn injury. As his nurse, you gathered the following: Hemoglobin 13.5 g/100 ml, hematocrit 50%, serum Na 130 mEq/L. How will you explain the laboratory results? A. These are due to hemodilution from rapid IV fluid replacement B. All the laboratory tests are within normal range C. They are slightly abnormal but will normalize once IV fluids have been started D. These are due to a loss of serum and interstitial fluid through the burn wound CORRECT ANSWER: D RATIONALE: The patient is having a hypovolemic shock. It occurs most often in people who sustained severe burn injury. It is caused primarily by a shift of plasma from the vascular space into the interstitial space. SOURCE: Black, Medical-Surgical Nursing, 7th ed, p 2444

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