NP3 Nursing Board Exam June 2007 Answer Key 'Nursing Care of Client with Physiological and Psychosocial Alteration'

100 Nursing Board Exam test questions of June 2007 Nurse Licensure Examination (NLE)
Nursing Practice III – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology


PART 1 Board Exam test questions 51 - 100
 

Situation 11 – After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count.

51. When is the first sponge/instrument count reported?

A. Before closing the subcutaneous layer

B. Before peritoneum is closed

C. Before closing the skin

D. Before the fascia is sutured

52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture?

A. Fascia

B. Muscle

C. Peritoneum

D. Skin

53. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a patient who is prone to keloid formation and has low threshold of pain, what needle would you prepare?

A. Round needle

B. Atraumatic needle

C. Reverse cutting needle

D. Tapered needle

54. Another alternative “suture” for skin closure is the use of ____________

A. Staple

B. Therapeutic glue

C. Absorbent dressing

D. Invisible suture

55. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted?

A. Anesthesiologist

B. Surgeon

C. OR nurse supervisor

D. Circulating nurse

Situation 12 – As a nurse, you should be aware and prepared of the different roles you play.

56. What role do you play when you hold all client’s information entrusted to you in the strictest confidence?

A. Patient’s advocate

B. Educator

C. Patient’s Liaison

D. Patient’s arbiter

57. As a nurse, you can help improve the effectiveness of communication among healthcare givers by:

A. Use of reminders of ‘what to do’

B. Using standardized list of abbreviations, acronyms, and symbols

C. One-on-one oral endorsement

D. Text messaging and e-mail

58. As a nurse, your primary focus in the workplace is the client’s safety. However, personal safety is also a concern. You can communicate hazards to your co-workers through the use of the following EXCEPT:

A. Formal training

B. Posters

C. Posting IR in the bulletin board

D. Use of labels and signs

59. As a nurse, what is one of the best way to reconcile medications across the continuum

of care?

A. Endorse on a case-to-case basis

B. Communicate a complete list of the patient’s medication to the next provider of service

C. Endorse in writing

D. Endorse the routine and ‘stat’ medications every shift

60. As a nurse, you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT:

A. Provide information to clients about a variety of services that can help alleviate the client’s pain and other conditions

B. Advising the client, by virtue of your expertise, that which can contribute to the client’s well-being

C. Health education among clients and significant others regarding the use of chemical disinfectant

D. Endorsement thru trimedia to advertise your favorite disinfectant solution

Situation 13 – You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know, is very subjective.

61. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment revelas bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take

A. Medicate client as prescribed

B. Encourage client to do imagery

C. Encourage deep breathing and turning

D. Call surgeon stat

62. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will be your priority nursing action?

A. Check abdominal dressing for possible swelling

B. Explain the proper use of PCA to alleviate anxiety

C. Avoid overdosing to prevent dependence/tolerance

D. Monitor VS, more importantly RR

63. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is:

A. Instruct client to go to sleep and relax

B. Advice the client to close the lips and avoid deep breathing and talking

C. Offer hot and clear soup

D. Turn to sides frequently and avoid too much talking

64. Surgical pain might be minimized by which nursing action in the O.R.

A. Skill of surgical team and lesser manipulation

B. Appropriate preparation for the scheduled procedure

C. Use of modern technology in closing the wound

D. Proper positioning and draping of clients

65. One very common cause of postoperative pain is:

A. Forceful traction during surgery

B. Prolonged surgery

C. Break in aseptic technique

D. Inadequate anesthetic

Situation 14 – You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor’s diagnosis was hypothyroidism.

66. Your independent nursing care for hypothyroidism includes:

A. administer sedative round the clock

B. administer thyroid hormone replacement

C. providing a cool, quiet, and comfortable environment

D. encourage to drink 6-8 glasses of water

67. As the nurse, you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism?

A. Levothyroxine

B. Lidocaine

C. Lipitor

D. Levophed

68. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following?

A. Activity intolerance related to tiredness associated with disorder

B. Risk to injury related to incomplete eyelid closure

C. Imbalance nutrition to hypermetabolism

D. Deficient fluid volume related to diarrhea

69. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics.

A. Hyperglycemia

B. Hypothermia

C. Hyperthermia

D. Hypoglycemia

70. As a nurse, you know that the most common type of goiter is related to a deficiency of:

A. thyroxine

B. thyrotropin

C. iron

D. iodine

Situation 15 – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”

71. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis?

A. Support and reassure client during the procedure

B. Ensure that informed consent has been signed

C. Determine if client has allergic reaction to local anesthesia

D. Ascertain if chest x-rays and other tests have been prescribed and

completed

72. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions?

A. Trendelenburg position

B. Supine position

C. Dorsal Recumbent position

D. Orthopneic position

73. During thoracentesis, which of the following nursing intervention will be most crucial?

A. Place patient in a quiet and cool room

B. Maintain strict aseptic technique

C. Advice patient to sit perfectly still during needle insertion until it has

been withdrawn from the chest

D. Apply pressure over the puncture site as soon as the needle is withdrawn

74. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?

A. Place flat in bed

B. Turn on the unaffected side

C. Turn on the affected side

D. On bed rest

75. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

A. to rule out pneumothorax

B. to rule out any possible perforation

C. to decongest

D. to rule out any foreign body

Situation 16 – In the hospital, you are aware that we are helped by the use of a variety of equipment / devices to enhance quality patient care delivery.

76. You are to initiate an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare?

A. Blood transfusion set

B. Macroset

C. Volumetric chamber

D. Microset

77. Kyle is diagnosed to have measles. What will your protective personal attire include?

A. Gown

B. Eyewear

C. Face mask

D. Gloves

78. What will you do to ensure that Kyle, who is febrile, will have a liberal oral fluid intake?

A. Provide a glass of fruit juice every meal

B. Regulate his IV to 30 drops per minute

C. Provide a calibrated pitcher of drinking water and juice at the bedside and monitor intake and output

D. Provide a writing pad to record his intake

79. Before bedtime, you went to ensure Kyle’s safety in bed. You will do which of the following:

A. Put the lights on

B. Put the side rails up

C. Test the call system

D. Lock the doors

80. Kyle’s room is fully mechanized. What do you teach the watcher and Kyle to alert the nurses for help?

A. How to lock side rails

B. Number of the telephone operator

C. Call system

D. Remote control

Situation 17 – Tony, 11 years old, has ‘kissing tonsils’ and is scheduled for tonsillectomy and adenoidectomy or T and A.

81. You are the nurse of Tony who will undergo T and A in the morning. His mother asked you if Tony will be put to sleep. Your teaching will focus on:

A. spinal anesthesia

B. anesthesiologist’s preference

C. local anesthesia

D. general anesthesia

82. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask what food to prepare and give their children after surgery. You as the nurse will say:

A. balanced diet when fully awake

B. hot soup when awake

C. ice cream when fully awake

D. soft diet when fully awake

83. The RR nurse should monitor for the most common postoperative complication of:

A. hemorrhage

B. endotracheal tube perforation

C. osopharyngeal edema

D. epiglottis

84. The PACU nurse will maintain postoperative T and A client in what position?

A. Supine with neck hyperextended and supported with pillow

B. Prone with the head on pillow and turned to the side

C. Semi-fowler’s with neck flexed

D. Reverse trendelenburg with extended neck

85. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You as the RN will make sure that the family knows to:

A. offer osterized feeding

B. offer soft foods for a week to minimize discomfort while swallowing

C. supplement his diet with Vitamin C rich juices to enhance healing

D. offer clear liquid for 3 days to prevent irritation

Situation 18 – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so that an A-V shunt was surgically created.

86. Which of the following action would be of highest priority with regards to the external

shunt?

A. Avoid taking BP or blood sample from the arm with the shunt

B. Instruct the client not to exercise the arm with the shunt

C. Heparinize the shunt daily

D. Change dressing of the shunt daily

87. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:

A. Recommend protein of high biologic value like eggs, poultry and lean

meats

B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes

C. Allowing the client cheese, canned foods and other processed food

D. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet

88. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. He asked you how this can be prevented. Your response is:

A. maintain a conducive comfortable and cool environment

B. maintain fluid and electrolyte balance

C. initial hemodialysis shall be done 30 minutes only so as not to rapidly

remove the waste from the blood than from the brain

D. maintain aseptic technique throughout the hemodialysis

89. You are assisted by a nursing aide with the care of the client with renal failure. Which delegated function to the aide would you particularly check?

A. Monitoring and recording I and O

B. Checking bowel movement

C. Obtaining vital signs

D. Monitoring diet

90. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect…

A. 48 hour urine specimen

B. first morning urine

C. 24 hour urine specimen

D. random urine specimen

Situation 19 – Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician.

91. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health instruction will include:

A. assure the client that the pain is associated with the warm sensation

during the administration of the Hypaque by IV

B. assure the client that the procedure painless

C. assure the client that contrast medium will be given orally

D. assure the client that x-ray procedure like IVP is only done by experts

92. What will the nurse monitor and instruct the client and significant others post IVP?

A. Report signs and symptoms for delayed allergic reaction

B. Observe NPO for 6 hours

C. Increased fluid intake

D. Monitor intake and output

93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include more vegetables in the diet and:

A. increase fluid intake

B. barium enema

C. cleansing enema

D. gastric lavage

94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you instructed her to force fluids and do which of the following?

A. Balanced diet

B. Ambulate more

C. Strain all urine

D. Bed rest

95. The presence of calculi in the urinary tract is called

A. Colelithiasis

B. Nephrolithiasis

C. Ureterolithiasis

D. Urolithiasis

Situation 20 – At the medical-surgical ward, the nurse must also be concerned about drug interactions.

96. You have a client with TPN. You know that in TPN like blood transfusion, these should be no drug incorporation. However the MD’s order read; incorporate insulin to present TPN. Will you follow the order?

A. No, because insulin will induce hyperglycemia in patients with TPN

B. Yes, because insulin is chemically stable with TPN and can enhance

blood glucose level

C. No, because insulin is not compatible with TPN

D. Yes, because it was ordered by the MD

97. The RN should also know that some drugs have increased adsorption when infused in the PVC container. How will you administer drugs such as insulin, nitroglycerine hydralazine to promote better therapeutic drug effects?

A. Administer by fast drip

B. Inject the drugs as close to the IV injection site

C. Incorporate to the IV solutions

D. Use volumetric chamber

98. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order?

A. Any IV solution available to KVO

B. Isotonic solution

C. Hypertonic solution

D. Hypotonic solution

99. How can nurses prevent drug interaction including adsorption?

A. Always flush with NSS after IV administration

B. Administering drugs with more diluents

C. Improving on preparation techniques

D. Referring to manufacturer’s guidelines

100. In insulin administration, it should be understood that our body normally releases insulin according to our blood glucose level. When is insulin and glucose level highest?

A. After excitement

B. After a good night’s rest

C. After an exercise

D. After ingestion of food

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