NP3 Nursing Board Exam June 2008 Answer Key 'Nursing Care of Client with Physiological and Psychosocial Alteration'

100 Nursing Board Exam test questions of June 2008 Nurse Licensure Examination (NLE)
Nursing Practice III – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 2 Board Exam test questions 51 - 100

Situation – Colostomy is a surgically created anus. It can be temporary or permanent,

depending on the disease condition.\

51. Skin care around the stoma is critical. Which of the following is not indicated as a skin

care barriers?

A. Apply liberal amount of mineral oil to the area

B. Use karaya paste and rings around the stoma

C. Clean the area daily with soap and water before applying bag

D. Apply talcum powder twice a day

52. What health instruction will enhance regulation of a colostomy (defecation) of clients?

A. Irrigate after lunch everyday

B. Eat fruits and vegetables in all three meals

C. Eat balanced meals at regular intervals

D. Restrict exercise to walking only

53. After ileostomy, which of the following condition is NOT expected?

A. Increased weight

B. Irritation of skin around the stoma

C. Liquid stool

D. Establishment of regular bowel movement

54. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

A. Increase the irrigating solution flow rate when abdominal cramps is felt

B. Insert 2-4 inches of an adequately lubricated catheter to the stoma

C. Position client in semi-Fowler

D. Hang the solution 18 inches above the stoma

55. What sensation is used as a gauge so that patients with ileostomy can determine how

often their pouch should be drained?

A. Sensation of taste

B. Sensation of pressure

C. Sensation of smell

D. Urge to defecate

Situation – 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 favourite disinfectant

solution

Situation – 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.

61. 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

62. 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

63. 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

64. 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

65. 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 – Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly

66. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as follows:

A. Urethra, Kidney, Bladder

B. Urethra, Bladder wall, trigone, urethral opening

C. Bladder wall, uterine wall and urethral opening

D. Urethral opening, urethral opening bladder.

67. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy in:

A. Supine

B. Lithotomy

C. Semi-fowler

D. Trendelenburg

68. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you yell him?

A. Cystoscopy is direct visualization and examination by urologist

B. Cystoscopy is done by x-ray visualization of the urinary tact

C. Cystoscopy is done by using lasers on the urinary tract

D. Cystoscopy is an endoscopic procedure of the unrinary tract                

69. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:

A. Pink-tinged urine

B. Distended bladder

C. Signs of infection

D. Prolonged hematuria

70. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:

A. Bed rest

B. Warm moist soak

C. Early ambulation

D. Hot sitz bath

Situation – A specimen is a piece of tissue of body fluid taken from the disease body organ or tissue to aid the health care team in diagnosis and effective treatment.

71. Carmen is suspected to have a left breast CA. She is scheduled in your room on 5 for frozen section. How will you prepare the specimen for laboratoty?

A. Refrigerator and send it along with the day’s specimen

B. Send to pathology immediately without soaking solution

C. Soak it in NSS

D. Soak it in formalin

72. How will you label this specimen? What information was essential in the label?

A. Name of the client, age, sex, hospital number

B. Name of the client, age, sex

C. Name, age, site, type of specimen, hospital number, doctor

D. Name, doctor, type of specimen, hospital number

73. Foreign body extracted from the body like pins, needles, seeds or bullets are also considered as a specimen. You assisted in the multiple gunshot wound exploration. During the surgey send the specimen to:

A. The department of pathology

B. The national bureau of investigation

C. The OR head nurse

D. Client’s family

74. A post dilation and curettage (D and C) client is for discharge. Follow-up of lab result should be part of the discharge plan. You will instruct the client to follow up result at the:

A. Medical record

B. Laboratory

C. Doctor’s clinic

D. Nurse’s station

75. You are the circulating nurse in OR 2. You have 4 thyroidectomy cases for the day. How do, you prevent switching of specimens?

A. Send specimens to laboratory right away after the operation with the proper labels

B. Collect all specimens and send to laboratory at the end of the day

C. Label specimen at once

D. Prepare 4 specimen vials first thing in the morning

76. Ms. F.X. has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays would be acceptable for her?

            a. liver, fried potatoes and avocado

            b. whole milk, rice and pastry

            c. ham, mashed potatoes, cream peas

            d. skim milk, lean fish, tapioca pudding

77. Negligence in the practice of nursing can be a ground for:

            a. revocation of license by the Ombudsman

            b. revocation of license by the BON

            c. revocation of license by the DOH

            d. revocation of license by the Nursing Department

78. One way of verifying that the right message/doctor’s order was communicated effectively is by:

            a. phrasing  intelligently

            b. repeating the order message

            c. documenting

            d. speaking distinctly using enough volume

79. Maria is administering a cleansing enema to a patient with fecal impaction. Before administering the enema, she should place the patient in which of the following positions?

            a. on the right side of the body with the head of the bed elevated 45 degrees

            b. left Sim’s position

            c. on the left side of the body with the head of the bed elevated 45 degree

            d. right Sim’s position

80. The functionality and integrity of instruments and medical devices used in surgical procedure, is the responsibility of the:

            a. surgeon                                                                    

b. bio-med technician

c. OR nurse                                                     

d. scrub nurse

81. Maria will be preparing a patient for thoracentesis. She should assist the patient to which of the following positions for the procedure?

            a. prone with the head turned to the side and supported by a pillow

            b. lying in bed on the affected side with the head of the bed elevated  45 degrees

            c. Sim’s position with the head of the bed flat

            d. Lying in bed on the unaffected side with the head of the bed elevated  45 degrees

82. When a patient comes to the clinic for an eye examination, the ophthalmologists administers phenylephrine 2.5% drops to:

            a. dilate  retinal blood vessels

            b. anesthetize the cornea

            c. dilate the pupil

            d. removed any obstruction on the cornea

83. Which of the following statements by Ms. S.O. a chemotherapy  patient with a low WBC count, a low platelet count and a hemoglobin measurement of 5.6 g would indicate the need for further teaching?

            a. “My lips are dry an d cracking. I need some lubricant”

            b. “My husband and I have been using vaginal lubrication before my intercourse”

            c. “I check my mouth and teeth after each meal”

            d. “I’ve been very constipated and need an enema”

84. Patients undergoing surgery display different levels of anxiety. This is researchable. At present, it has been found out that music can decreases anxiety. What other factors can reduce anxiety that is currently done among postoperative cases?

            a. pre-anesthetic drugs                                    

            b. pre-operative visit              

c. shower prior to surgery  

d. presence of any members of the family

85. A heavily researched topic in infection control is about the single most important procedure for preventing hospital-acquired infections. What is this procedure called?

            a. handwashing                                            

            b. use of scrub suite

c. use of facemask                                           

d. brain washing

86. A most critical strategy in nursing communication is:

            a. non-verbal communication

            b. giving stereotyped comments

            c. verbal communication

            d. active listening

87. Mr. T.O. has undergone surgery for lyses of adhesions. He is transferred from Post Anesthesia Care Unit (PACU) to the Surgical floor, the nurse should obtain blood pressure, pulse and respiration every:

            a. 3 minutes                                         

            b. 30 minutes                            

c. 15 minutes 

d. 20 minutes

88. Mr. K, age 13, is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breath. An abnormal condition in which there is discomfort in breathing in any bed or sitting position is:

            a. Cheyne-stokes                                  

            b. orthopnea                          

c. eupnea         

d. dyspnea

89. The nurse recognizes that the MOST common causative organism in pyelonephritis is:

            a. E.Coli                                               

            b. Klebsiella                  

c. Candida Albicans                    

d. Pseudomonas

90. Mr. WT is cleaning the garage and splashes a chemical to his eyes. The initial priority care following the chemical burn is to:

            a. irrigate with normal saline for 1 to 15 minutes

            b. transport to a physician immediately

            c. irrigate with water for 15 minutes or longer

            d. cover the eyes with a sterile gauze

91. Licensed nurses from foreign countries can practice nursing in the Philippines in the following condition:

            a. employed in state colleges and universities

            b. special projects with hospitals with a fixed fee

            c. employees by private hospitals

            d. medical mission whose services are free

92. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patients that the lumpectomy with radiation.

A. Reduces the fear and anxiety that accompany the diagnosis and treatment of cancer

B. Has about the same 10 years survival rate as the modified radical mastectomy

C. Provides shorter treatment period with a fewer long term complications

D. Preserves the normal appearance and sensitivity of the breast

93. The patient has a right to information regarding the operation or other invasive procedure and potential effects. This right is achieved through:

            a. informed consent                                     

            b. preoperative visit                                         

c. charting        

d. doctor’s rounds

94. Which statement about a person’s character is evident in the OR team?

            a. it assists in the control of feelings, thoughts and emotions in the face of difficulty

   b. it reflects the moral values and beliefs that are used as guides to personal behavior and actions

            c. it encourages the constructive use of the pleasure of the senses

            d. it refers to the quality of being righteous, correct, fair and impartial

95. Mrs. XP underwent D and C for dysfunctional bleeding. What is inserted vaginally to prevent postoperative bleeding?

            a. perineal pad                                                  

            b. vaginal packing                               

            c. vaginal suppository      

           d. gelfoam

Situation – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for

thoracentesis this pm to remove excess air from the pleural cavity.”

96. 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

97. 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

98. 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

99. 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

100. 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

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