Nursing Practice III – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology
PART 1 Board Exam test questions 1 - 50
June 2008
NURSING PRACTICE III SET B
SITUATIONAL
Situation - One learns by doing especially when you practice the best methods.
1. Which action by a new nurse signifies a need for further teaching in infection control?
A. The nurse places the side rails the time to an unconscious patient.
B. The nurse elevates the head of the bed to check the BP
C. The nurse uses her bare hands to change the dressing
D. The Nurse applies oxygen catheter to the mouth.
2. You are a PM shift and about 5 patients are discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue?
A.Call the attention of the orderly in private.
B. Ignore the situation because you are busy.
C. Report this behavior to the nurse in charge.
D. Monitor the situation and note whether any other items are reported missing.
3. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient?
A. Try to explore the interaction with the nursing attendant concerned.
B. Change the attendant’s assignment.
C. Initiate a group discussion with all other nursing attendants.
D. Discuss the matter with the patient’s family.
4. Disposal of Medical Records in the Government hospital needs collaboration with which of the following department:
A. DOH
B. MMDA
C. DILG
D. RMAO
5. You saw one colleague charting medication administration that she has not yet administered. After talking to her, you also report the incident to the charge nurse. The charge nurse should:
A. Required the staff to submit an incident report.
B. Terminate the nurse
C. Charge the erring nurse with dishonesty.
D. Report to the Board of Nursing.
Situation - You are assigned at the PACU
6. Which nursing diagnosis has priority among the client in the PACU?
A. Acute Pain related to discomfort of wound and immobility
B. Body image disturbance of wound dressing and drains.
C. Ineffective airway clearance related to anesthesia.
D. Knowledge deficit related to lack of information because patients are all sedated.
7. Which of the following clients at the PACU will demonstrate the effectiveness of the nurse teaching?
A. The client demonstrates deep breathing, coughing, splintering and leg exercises.
B. The client manifests normal temperature.
C. The client sleeps well
D. The client has good balance I and O.
8. Which of the following remark indicates that the client’s relative understood the discharged instructions for would care?
A. “If the wound is painful, I will say it is normal.”
B. “It is alright to use adhesive tape over the wound to keep it intact.”
C. “It is ok for his pet to remain at his bedside to keep him company.”
D. It will report any redness or swelling of the wound.”
9. You must transfer out a post-op client to her room. What would your instructions to the family include to prevent accidents?
A. Report when the IV infusion is almost finished.
B. Test the call system if functioning.
C. Keep the room lights on for 24hrs.
D. Make sure the side rails are up.
10.One of your post-op patients has a temperature of 27.9 C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9 C. The nursing student asked you to explain the absence of shivering even if the temperature was higher.
A. The patient is no longer febrile thus he is no longer chilling.
B. Shivering normally disappears as temperature becomes higher.
C. The body has reached its new set point thus the absence of shivering.
D. The patient is feeling better.
Situation - Patients with chest tubes can be very challenging to new nurses.
11. The chest drainage of Tirso has continuous bubbling in the water seal drainage. After an hour you noticed that the bubbling stops. Which of the following condition is the possible cause of the malfunctioning sealed drainage?
A. A suction being to high
B. An air leak
C. A tube being too small
D. A tension pneumothorax
12. While you were making your endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action?
A. Assist the client back to his bed and place him on the affected side.
B. Cover the end of the chest tube with sterilize gauze
C. Reconnect the tube to the chest tube system
D. Put the end of the chest tube into a cup of sterile normal saline
13. Dr. Reyes asked you top assist him with the removal of Tirso’s chest tube. You would instruct the client to:
A. Continuously breathe normally during the chest tube
B. Take a deep breath, exhale, and bear down
C. exhale upon actual removal of the tube
D. Hold breath until the chesty tube is pulled out
14. Chest tube diameter is measured or expressed in:
A. French
B. Gauge
C. Millimeters
D. Inches
15. When transporting clients with a chest tube, the system should be:
A. Disconnected
B. Closed
C. Placed lower than the patient’s chest
D. Placed between the legs of the client to prevent breakage
Situation – The preoperative nurse collaborates with the client significant others, and healthcare providers.
16. To control environment hazards in the OR, the nurse collaborates with the following departments EXCEPT:
A. Biomedical division
B. DOH
C. Infection control committee
D. DILG
17. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated limbs) disposal should be coordinated with the following agencies EXCEPT:
A. Crematorium
B. DOH
C. MMDA
D. DILG
18. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 8 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with:
A. Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty
19. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do?
A. Double check the doctor’s order and call the attending MD
B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated
D. Incorporate insulin as ordered
20. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatment
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.
Situation – Technology and patients education has dramatically improved the management of the diabetic client.
21. The current insulin pumps available in the market have the following capability, EXCEPT:
A. Prevent unexpected saving in blood glucose measurement
B. Detect signs and symptoms of hypoglycemia and hypercalcemia
C. Deliver a pre-meal bolus dose of insulin before each meal
D. Deliver a continuous basal rate of insulin at 5.0 units to 2.0 units per hour
22. Discharge plan of diabetic clients include injection-site-rotation. You should emphasize that the space between sites should be:
A. 6 cm
B. 5 cm
C. 2.5 cm
D. 4 cm
23. It is critical also that a diabetic client should be educated in the possible sites if regular insulin injection. The fastest absorption rate happens at the tissue areas of:
A. Gluteal area
B. Deltoid area
C. Anterior area
D. Abdominal area
24. Self-monitoring of blood glucose (SMBG) is recommended for patients use. You will recommend this technology in the following diabetic patients EXCEPT:
A. Client with proliferative retinopathy
B. Unstable diabetes
C. Hypoglycemia without warning
D. Abdominal renal glucose threshold
25. It is necessary for a diabetic client to exercise regularly. What is the effect of regular exercise to a diabetic client?
A. It burns excess glucose
B. It improves insulin utilization
C. It lowers glucose, improves insulin utilization, and decreases total triglyceride levels.
D. It will make you fit and energized.
26. Following a fracture of the forearm or tibia, complaints of sharp, deep, unrelenting pain in the hand or foot unrelieved by analgesics or elevation of the extremity indicate which complication?
a. cast syndrome
b. compartment syndrome
c. gangrene
d. fat embolism
27. Another worthy study is the compliance to the principles of aseptic technique among the sterile OR team. Who does NOT belong to the sterile OR team?
a. scrub nurse
b. assistant surgeon
c. x-ray technician
d. surgeon
28. Circulation must be restored within 4 minutes of cardiopulmonary arrest because:
a. the lungs fill with fluid
b. the blood begins to coagulate
c. brain cells begin to die
d. irreversible kidney failure develops
29. Benny elaborated on the concept of informed consent. He determines that the nurses need more explanation if their response is one of the following:
a. the consent should provide a description of alternative treatments or procedures
b. the consent should offer a thorough explanation of the procedures to be done and the consequences of it.
c. the consent should include the medical diagnosis and explanation of the patient’s condition
d. the consent should describe the prognosis if the recommended care is refused.
30. Which of the assessment findings would indicate a need for possible glaucoma testing?
a. intermittent loss of vision
b. presence of floaters
c. halos around lights
d. pruritus and erythema of the conjunctiva
31. The diabetic patient asks for a snack and something to drink. The MOST appropriate choice for this client to meet nutritional needs would be which of the following:
a. crackers with cheese and tea
b. toast with peanut butter and cocoa
c. vanilla wafers and coffee with cream
d. graham crackers and warm milk
32. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks about:
a. Who will be with me in the OR?
b. How is the post operative pain over the site like?
c. Will I be naked during the operation?
d. Is it cold inside the
33. In teaching the mother the proper administration of tetracycline eye ointment, which of the following is MOST crucial?
a. squirt a small amount on the inside of the infected eye’s lower lid
b. use clean, wet cloth to gently wipe away the pus
c. wash hands before medication administration
d. do not use other eye ointments or drops or put anything else in eyes.
34. The primary goal of nursing interventions after a craniotomy is:
a. avoiding need for secondary surgery
b. ensuring patient comfort
c. preventing increased intracranial pressure
d. prevention of infection
35. Mr. Salvo, a 35 year old male, has been admitted with the diagnosis of peptic ulcers. The nurse recognizes which drugs as those MOST commonly used in these patients to decrease acid secretions?
a. erythromycin and flagyl
b. Tagamet and zantac
c. Maalox and kayexalate
d. Dyazide and carafate
36. When reading the urinalysis report, the nurse recognizes this result as abnormal:
a. red blood cells 15-20
b. turbid
c. glucose negative
d. ph 6.0
37. Mr. Hizon has had cataract surgery. Discharge teaching would include:
a. wearing eye patches for the first 72 hours
b. bending at the waist acceptable if done slowly
c. bending at the knees and keeping the head straight
d. lifting light objects is acceptable
38. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. What department should the nurse collaborate which is unusual in conventional surgery?
a. engineering department
b. x-ray department
c. blood bank services
d. linen section
39. When the client is discharged from the hospital and is not capable of doing the needed care services, the following can assume the role, EXCEPT:
a. family members
b. chaplain
c. significant others
d. responsible caregiver
40. R.N. denotes that a nurse:
A. Has satisfactory completed with the requirements to practice nursing as set by the state.
B. Has a baccalaureate degree in nursing
C. Is professionally ready to practice nursing
D. Just a title
Situation – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient
safety goals and requirements include the care and efficient use of technology in the OR and
elsewhere in the healthcare facility.
41. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm
systems?
A. Limit suppliers to a few so that quality is maintained
B. Implement a regular inventory of supplies and equipment
C. Adherence to manufacturer’s recommendation
D. Implement a regular maintenance and testing of alarm systems
42. Overdosage of medication or anesthetic can happen even with the aid of technology like
infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
A. Check the functionality of the pump before use
B. Select your brand of infusion pump like you do with your cellphone
C. Allow the technician to set the infusion pump before use
D. Verify the flow rate against your computation
43. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site,
wrong person, and wrong procedure/surgery includes the following, EXCEPT:
A. Mark the operative site if possible
B. Conduct pre-procedure verification process
C. Take a video of the entire intra-operative procedure
D. Conduct ‘time out’ immediately before starting the procedure
44. You identified a potential risk of pre-and postoperative clients. To reduce the risk of
patient harm resulting from fall, you can implement the following, EXCEPT:
A. Assess potential risk of fall associated with the patient’s medication regimen
B. Take action to address any identified risks through Incident Report (IR)
C. Allow client to walk with relative to the OR
D. Assess and periodically reassess individual client’s risk for falling
45. As a nurse, you know you can improve on accuracy of patient’s identification by 2
patient identifiers, EXCEPT:
A. identify the client by his/her wrist tag and verify with family members
B. identify client by his/her wrist tag and call his/her by name
C. call the client by his/her case and bed number
D. call the patient by his/her name and bed number
Situation – Team efforts is best demonstrated in the OR.
46. If you are the nurse in charge for scheduling surgical cases, what important information
do you need to ask the surgeon?
A. Who is your internist
B. Who is your assistant and anesthesiologist, and what is your preferred
time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant
D. Who is your anesthesiologist
47. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses
48. While team effort is needed in the OR for efficient and quality patient care delivery, we
should limit the number of people in the room for infection control. Who comprise this
team?
A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
49. When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
50. The breakdown in teamwork is often times a failure in:
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
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