Nursing Practice IV – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology
PART 2 Board Exam test questions 51 - 100
Situation 11: Because of the serious effects of severe burns, management requires a multidisciplinary approach. You have important responsibilities as a nurse.
51. When caring for DS, who sustained 40% severe flame burn yesterday, which among these interventions should be your PRIORITY?
A. provide a calm, efficient and safe environment
B. keep the body parts in good alignment to prevent contractures
C. assess for airway, breathing and circulation problems
D. assess the injury for signs of sepsis
52. Your primary therapeutic goal for DS during the ACUTE PHASE is:
a. wound healing c. emotional support
b. reconstructive surgery d. fluid resuscitation
53. CV who sustained upper torso and neck burns. Which action is MOST likely to cause a functional contracture?
a. hourly hyperextension neck exercises
b. helping the patient to a position of comfort
c. encouraging self-care
d. discouraging pillows behind the head
54. AW, 3 year old boy just sustained full thickness burns of the face, chest and neck. What will be your PRIORITY nursing action?
a. Risk for infection related to epidermal disruption
b. Impaired urinary elimination related to fluid loss
c. Ineffective airway clearance related to edema
d. Impaired body image related to physical appearance
55. FG, with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascular checks to detect:
a. hypothermia c. arteriosclerotic changes
b. ischemia d. adequate wound healing
Situation 12: Infection can cause debilitating consequences when host’s resistance is compromised and environmental factors are favorable. As a nurse you have important roles and responsibilities in infection control.
56. EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. To assess her risk factors, what question should you ask?
a. “Have you taken any analgesic recently?”
b. “Do you have pain at your back?”
c. “Do you hold your urine for a long time before voiding?”
d. “Have you had any sore throat lately?”
57. While caring for a patient with an infected surgical incision, you observe for signs of systemic response. These include all of the following EXCEPT:
a. a febrile state due to release of pyrogens
b. anorexia, malaise, and weakness
c. loss of appetite and pain
d. leukopenia due to increased WBC production
58. One of the MOST effective nursing procedures for reducing nosocomial infection is:
a. proper handwashing technique
b. aseptic wound care
c. control of upper respiratory tract infection
d. administration of prophylactic antibiotic
59. A wound that has hemorrhaged has increased risk for infection because:
a. dead space and dead cells provide a culture medium
b. retrograde bacterial contamination may occur
c. the tissue becomes less resilient
d. of reduced amounts of oxygen and nutrients are available
60. You are instructing EP regarding skin tests for hypersensitivity reactions. You should teach her to:
a. stay out of the sun until the skin tests are read
b. come back on the specified date to have the skin tests read
c. wash skin test areas with soap and water daily
d. keep skin test areas moist with mild lotion.
Situation 13: TR attends a Health Education Class on colostomy care. The following are taken up: types of ostomies, indications and care.
61. A colostomy can BEST be defined as:
a. cutting the colon and bringing the proximal end through the abdominal wall
b. creating a stomal orifice from the ileum
c. excising a section of the colon and doing an end-to-end anastomosis
d. removing the rectum and suturing the colon to the anus.
62. When an abdominoperineal resection is done, the patient should be informed he/she will have a;
a. temporary colostomy c. transverse loop colostomy
b. permanent colostomy d. double-barreled
63. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT:
a. corn and peanuts c. mangoes and pineapples
b. cabbage and asparagus d. chewing gum and carbonated beverages
64. During the first post operative week, the nurse can BEST help the patient with a colostomy to accept the change in body image by:
a. changing the dressing just prior to meals
b. encouraging the patient to observe the stoma and its care
c. deodorizing the room periodically with a spray can
d. applying a large bulky dressing over the stoma to decrease odors
Situation 14: These are gastrointestinal disease that can compromise life and that would necessitate extensive surgical management. You are assigned to take care of a patient with such a condition.
66. BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery, a low residue diet is ordered. You explain to BC that this is necessary to:
a. prevent irritation of the intestinal mucosa
b. reduce the amount of stool in the large bowel
c. limit production of flatus in the intestines
d. lower the bacterial count in the GI tract
67. Several days prior to bowel surgery, the patient may be given sulfasuxidine and neomycin, primarily to:
a. soften the stool by retaining water in the colon
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. promote rest of the bowel by minimizing peristalsis
68. To promote perineal wound healing after an abdominoperineal resection, you should encourage BC to assume:
a. dorsal recumbent position
b. left or right Sim’s position
c. left or right side lying position
d. knee-chest position
69. BC returns from surgery with a permanent colostomy. During the 24 hours, the colostomy does not drain. You, as the nurse should realize that this is a result of:
a. the absence of intestinal motility
b. a presurgical decrease in fluid intake
c. proper functioning of the nasogastric tube
d. intestinal edema following surgery
70. On the second day following abdominoperineal resection, you anticipate that the colostomy stoma will appear:
a. moist, pink, with flushed skin and painful when touched
b. moist, red and raised above the skin surface
c. dry, pale pink and with flushed skin
d. dry, purple and depressed below the skin surface
Situation 15: Specific surgical interventions may be done when lung cancer is detected early. You have important peri-operative responsibilities in caring for patients with lung cancer.
71. GM is scheduled to have lobectomy. The purpose of closed chest drainage following a lobectomy is:
a. expansion of the remaining lung
b. facilitation of coughing
c. prevention of mediastinal shift
d. promotion of wound healing
72. Following thoracic surgery, you can BEST help GM to reduce pian during the deep breathing and coughing exercises by:
a. splinting the patient’s chest with both hands during the exercises
b. administering the prescribed analgesic immediately prior to exercises
c. providing rest for 6 hours before exercises
d. placing the patient on his/her operative side during exercises
73. During the immediate post operative period following a pneumonectomy, deep tracheal suction should be done with extreme caution because:
a. the remaining normal lung needs minimal stimulation
b. the patient will not be able to tolerate coughing
c. the tracheobronchial tree are dry
d. the bronchial suture line maybe traumatized
74. What should you do as a nurse when the chest tubing is accidentally disconnected?
a. reconnect the tube c. notify the physician
b. change the tubing d. clamp the tubing
75. Which of the following observations indicates that the closed chest drainage system is functioning properly?
a. less than 25 ml drainage in the drainage bottle
b. absence of bubbling in the suction-control bottle
c. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
d. intermittent bubbling through the long tube of the suction control bottle.
Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. As a nurse of BL which of the following nursing diagnosis will be your PRIORITY?
76. BL was brought to the Emergency Room for severe left flunk pain, nausea and vomiting. The physician gave a tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your PRIORITY?
a. imbalance nutrition: less than body requirements
b. impaired urinary elimination
c. acute pain
d. risk for infection
77. Which of the following is the appropriate intervention for BL who has ureterolithiasis?
a. inserting an indwelling urinary catheter
b. administering opioid analgesics preferably intravenously
c. administering intravenous solution at a keep vein open rate
d. inserting a nasogastric tube (low suction)
78. You are caring for YA, 30 year old business woman, with renal stones. Her skin and mucous membranes are dry and her 24 hour intake and output record reveal an oral intake of 900 ml and a urinary output of 700 ml. Her urine is dark amber. Based on the above data, your nursing diagnosis is:
a. imbalance nutrition, less than body requirements
b. fluid volume deficit
c. impaired urinary elimination
d. knowledge deficit regarding health
79. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity?
a. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine
b. drain urine from the drainage bag into the sterile container
c. disconnect the tubing from the urinary catheter and let urine flow into a sterile container
d. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle
80. You are caring for WE, a 56 year old man who is dehydrated and with urinary incontinent. Upon physical examination, you noted perineal excoriation. What will be your PRIORITY intervention?
a. orient him to time, person and place
b. offer the bed pan every 4 hours
c. encourage oral fluid intake
d. keep the perineal area clean, and dry
Situation 17: You are caring for several patients with various disease problems.
81. You are obtaining a history of MR. who is admitted with acute chest pain. Which question will be MOST HELPFUL for you to ask?
a. Why do you think you had a heart attack?
b. Do you need anything now?
c. What seem you doing when the pain started?
d. Has anyone in your family been sick lately?
82. BO who received general anesthesia returns from surgery. Post-operatively, which nursing diagnosis takes HIGHEST PRIORITY for BO?
A. impaired physical mobility related to surgery
B. decrease fluid volume related to blood and fluid loss from surgery
C. risk for infection related to anesthesia
D. acute pain related to surgery
83. WW is blind. She is admitted for treatment of gastroenteritis. Which nursing diagnosis takes HIGHEST PRIORITY for WW?
A. anxiety C. activity intolerance
B. risk for injury D. impaired physical mobility
84. You are documenting your care for CC who has iron deficiency anemia. Which nursing diagnosis is MOST appropriate?
A. ineffective breathing pattern C. deficient fluid volume
B. impaired gas exchange D. ineffective airway clearance
85. RR, age 89, has terminal cancer, he demonstrates signs of dementia. You should give HIGHEST PRIORITY to which nursing diagnosis:
A. risk for injury C. ineffective cerebral tissue perfusion
B. bathing or hygiene self care deficit D. dysfunctional grieving
Situation 18: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.
86. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?
A. 6 hours C. 4 hours
B. 1 hour D. 2 hours
87. What should you do FIRST before you administer blood transfusion?
A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date
B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with
another nurse
C. check IV site and use appropriate BT set and needle
D. verify physician’s order
88. As WQ’s nurse, what will you do AFTER the transfusion has started?
A. add the total amount of blood to be transfused to the intake and output
B. discontinue the primary IV of Dextrose 5% Water
C. check the vital signs every 15 minutes
D. stay with WQ for 15 minutes to note for any possible BT reactions
89. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:
A. oliguria and jaundice C. hypertension and flushing
B. urticaria and wheezing D. headache, chills, fever
90. In case WQ 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. stop the blood transfusion and monitor the patient closely
C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank
D. immediately stop the BT, notify the blood bank and administer antihistamines
Situation 19. The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the kidney’s functions can cause disease. As a nurse it is important that you understand the rationale behind the treatment regimen used.
91. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase?
A. urine output directly related to the amount of IV fluid infused
B. urine output is less than 400 ml/24 hours
C. urine output of 30-60 ml/hour
D. no urine output, kidneys in a state of suspension
92. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?
A. increased urine output, increased absorption of sodium and water
B. decreased urine output, decreased absorption of sodium and water
C. increased urine output, decreased absorption of sodium and water
D. decreased urine output, increased absorption of sodium and water
93. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:
A. hyperkalemia C. hypokalemia
B. hypercalcemia D. hypernatremia
94. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge?
A. drink plenty of water C. monitor your fruit intake and eat plenty of bananas
B. restrict your salt intake D. be sure to eat meat every meal
95. BN, is also advised not to use salt substitute in the diet because:
A. salt substitute contain potassium which must be limited to prevent arrhythmias
B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood
C. fluid retention is enhanced when salt substitutes are included in the diet
D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane
Situation 20. You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are common concerns experienced by them. You should be able to address the concerns in a holistic manner.
96. Pain in the elder persons require careful assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold
97. Administration of analgesics to the older persons requires careful patient assessment because older people:
A. are more sensitive to drugs
B. have increased hepatic, renal and gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
98. The elderly patient is at higher risk for urinary incontinence because of:
A. increased glomerular filtration C. decreased bladder capacity
B. diuretic use D. dilated urethra
99. Which of the following is the MOST COMMON sign of infection among the elderly?
A. decreased breath sounds with crackles C. pain
B. fever D. change in mental status
100. Priorities when caring for the elderly trauma patient:
A. circulation, airway, breathing C. airway, breathing, disability (neurologic)
B. disability (neurologic), airway, breathing D. airway, breathing, circulationCLICK HERE PART 1 (1 - 50) 'NP4 Nursing Board Exam December 2006 Answer Key 'Nursing Care of Client with Physiological and Psychosocial Alteration'
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