Nursing Practice IV – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology
PART 1 Board Exam test questions 1 - 50
Situation – Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.
1. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
A. empty the drainage system at the end of the shift
B. clamp the chest tube when suctioning
C. palpate the surrounding areas for crepitus
D. change the dressing daily using aseptic techniques
2. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be:
A. a tender, painful area on the leg
B. a pitting edema of the ankle
C. a reddened area at the ankle
D. pruritus on the calf and ankle
3. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
A. seek early treatment for respiratory infections
B. take showers instead of tub bath
C. continue to take the same restrictions on fluid intake
D. avoid situations that involve physical activity
4. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first?
A. Recognize that prompt closure of the tracheal opening may occur
B. Keep calm because there is no immediate emergency
C. Reinsert another tubing immediately
D. Notify the physician at once
5. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:
A. supplementary oxygen
B. ventilation exchange
C. chest tube drainage
D. blood replacement
Situation – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented.
6. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what will be your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway
7. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?
A. Tell her family that probably she can’t hear them
B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently
8. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke?
A. Place June on an upright lateral position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for support
9. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic environment by doing which of the following?
A. honoring her request for a television
B. placing her bed near the window
C. dimming the light in her room
D. allowing the family unrestricted visiting privileges
10. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he:
A. probably has meningitis
B. is going to be blind because of trauma
C. is permanently paralyzed
D. has received a significant brain injury
Situation – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older patients.
11. During a meal a client with hepatitis B dislodge her IV 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 clean the table with:
12. Nino is being treated with radiation therapy. What would 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 a heating pad to the site
C. Wash skin with water after the therapy
D. Avoid applying creams and powders to the area
13. You are assigned to the following patients. Which of the following patients is most at risk for metabolic alkalosis?
A. Grace, 30 years old post surgical patient who has continuous nasogastric suction
B. Rachel, 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
14. 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
15. As a nurse, you accidentally administer 40mg of Propanolol (Inderal) to a client instead of 10mg 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
Situation – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse
16. 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. Reassures him that these feelings are normal
D. Help him plan his activities
17. Immediately following the radiation teletherapy, Albert is:
A. Considered radioactive fro 24hours
B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from Radiation
18. 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
19. What nursing diagnosis should be the highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal
20. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C
Situation - You are assigned to take care of four patients with different conditions.
21. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine and prednisone? You recognized that KJ understood the teaching when he states, “I must take these medications:
A. until the anastomosis heals
B. during the preoperative period
C. until the supply is over
D. for the rest of my life
22. After the kidney transplant, you must observe KJ for signs of rejection which includes:
A. fever and weight gain
B. hematuria and seizure
C. polyuria and jaundice
D. moon face and muscle atrophy
23. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB tells you “I want to go off dialysis, I’d rather not live than to be in this treatment the rest of my life”. How would you respond to him?
A. leave the room and allow him to collect his thoughts
B. tell FB that “ We all have days when we don’t feel like going on”
C. tell FB that “ Treatments are only three times a week, you can live with that”
D. take a sit next to him and sit quietly
24. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which statement by DS indicates the need for further teaching before true informed consent can be obtained?
A. “a wire from the generator will be attached to my heart”
B. “the physician will make a small incision in my chest wall and place the generator there”
C. “I wonder if there is another way to protect these bad rhythms”
D. “this implanted defibrillator will protect me from those bad rhythms my heart goes into”
25. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates a lack of understanding about his rights as a research study participant?
A. “My confidentiality will not be compromised in this study”
B. “ I understand the risk associated in this study”
C. “I can withdraw from the study anytime”
D. “ I’ll have to find a new physician if I don’t complete this study”
Situation - Foot care among patients with peripheral vascular problems is very important.
26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions:
A. avoid wearing canvas shoes
B. avoid using a nail clipper to cut toe nails
C. avoid use of cornstarch on the foot
D. avoid wearing cotton socks
27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the appropriate management, you should:
A. shave the affected leg in anticipation of surgery
B. place a healing pad around the calf
C. keep the affected leg level or slightly dependent
D. elevate the affected calf as high as possible
28. Peripheral neuropathies primarily affect:
A. sensory functions
B. vascular functions
C. optic functions
D. motor functions
29. Peripheral neuropathy can BEST be controlled by:
A. good glucose control
B. steroid therapy
C. vitamin supplement
D. nothing, there is no slowing the process
30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with:
C. liver disease
D. diabetes insipidus
Situation - The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.
31. 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
B. 1 hour
C. 4 hours
D. 2 hours
32. 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
33. 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
34. WQ is undergoing blood transfusions 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
35. 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 - 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.
36. 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
37. 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
38. 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:
39. 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
B. restrict your salt intake
C. monitor your fruit intake and eat plenty of bananas
D. be sure to eat meat every meal
40. 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 – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and
issues relevant to the older patients.
41. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
42. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
43. Merle, age 86, is complaining of dizziness when she stands up. This may
B. a visual problem
C. functional decline
D. drug toxicity
44. Cardiac ischemia in an older patient usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion
45. The most dependable sign of infection in the older patient is:
A. change in mental status
D. decreased breath sounds with crackles
Situation – A “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody’s business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency
phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.
46. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.”?
47. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention
48. During the disaster you see a victim with a green tag, you know that the person:
A. has injuries that are significant and require medical care but can wait hours with
threat to life or limb
B. has injuries that are life threatening but survival is good with minimal
C. indicates injuries that are extensive and chances of survival are unlikely even
with definitive care
D. has injuries that are minor and treatment can be delayed from hours to
49. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment:
50. Which of the following terms refer to a process by which the individual receives education about recognition of stress reaction and management strategies for handling stress which may be instituted after a disaster?
A. Clinical incident stress management
Situation – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.
51. While eating his meal, Matthew accidentally dislodges his IV lines and bleeds. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with:
52. You are a member of the infection control team of the hospital. Based on a feedback during the meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority activity?
A. Establish policies for surveillance and monitoring
B. Do data gathering about the possible sources of infection (observation,
chart review, interview).
C. Assign point persons who can implement policies.
D. Meet with the nursing group working in the burn unit and discuss problem with
53. Part of your responsibility as a member of the diabetes core group is to getreferrals from the various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4 patients are referred to you. How would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start your session taking into consideration
their distance from your office
B. Contact the nurse in-charge and find out from her the reason for the referral
C. Determine their learning needs then prioritize
D. Involve the whole family in the teaching class
54. You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity?
A. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task force before contacting the
C. Determine the VIPs and Celebrities who will be invited
D. Find out how many support groups there are in the hospital and get the contact
number of their president
55. You are invited to participate in the medical mission activity of your alumni association. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. You thought it is also your chance to share what you can do for others. What will be your most important role where you can demonstrate the impact of nursing in health?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator
Situation – One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.
56. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma’s family could be helpful if they knew what Irma has told to you. What should you do first?
A. Tell the physician who in turn could tell the family
B. Obtain Irma’s permission to share the information in the family
C. Tell Irma that she has to tell her family what she told you
D. Make an appointment to discuss the situation with the family
57. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by:
A. Coming back periodically and indicating your availability if she
would like you to sit with her
B. Insisting that Ruby should talk with you because it is not good to keep
C. Leaving her alone because she is uncooperative and unpleasant to be
D. Encouraging her to be physically active as possible
58. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves, is depressed. Which of the following would best help him during his depression?
A. Arrange for visitors who might cheer him
B. Sit down and talk with him for a while
C. Encourage him to look at the brighter side of things
D. Sit silently with him
59. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending death?
A. “I’m ready to go.”
B. “I have resigned myself to dying.”
C. “What’s the use?”
D. “I’m giving up”
60. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and emotionally. This is recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued life
D. Awareness that death will soon occur
Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.
61. As Andrea’s nurse, what will be your priority interventions?
A. Insert and intravenous catheter
B. Insert an oral or nasopharyngeal airway
C. Obtain arterial blood gases
D. Give 100% oxygen
62. Andrea’s arterial blood gases respiratory acidosis. This most likely related to:
A. Partially obstructed airway
B. Ineffective breathing pattern
C. Head injury
63. Andrea loses consciousness. You should prepare for which of the following FIRST?
A. Placement of nasogastric tube
B. Placement of a second IV line
C. Endotracheal intubation or surgical airway placement
D. CT scan of head
64. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. 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
65. 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 ahead of bed 30-35 degrees elevated
C. Maintain Andrea’s head in straight alignment and prevent hip flexion
D. Prevent constipation and increases in intra-abdominal pressure
66. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:
C. Cheyne Stokes
67. What do you call the triad of sign and symptoms seen in a client with increasing ICP?
A. Virchow’s Triad
B. The Chinese triad
C. Cusching’s Triad
D. Charcot’s Triad
68. Which of the following is true with the Cushing’s Triad seen in head injuries?
A. Narrowing of Pulse Pressure, Cheyne strokes respiration, Tachycardia
B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmaul’s respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia
69. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?
A. Ineffective airway clearance
B. Ineffective breathing pattern
C. Impaired gas exchange
D. Activity Intolerance
70. You know the apnea is seen in client’s with cheyne stoke respiration, APNEA is defined as:
A. Inability to breath in a supine position so the patient sits up in bed to breathe.
B. The patient is dead, the breathing stops
C. There is an absence of breathing for a period of time usually 15 seconds or more
D. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of normal respiratory functioning
Situation - 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. Horace underwent lobectomy. Which of following is the purpose of Horace’s closed chest drainage post lobectomy:
a. expansion of the remaining lung
b. facilitation of coughing
c. prevention of mediastinal shift
d. promotion of wound healing
72. Which of the following observations indicates that the closed chest drainage system is functioning properly?
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
73. Following lobectomy, you can BEST help Horace to reduce pain during the deep breathing and coughing exercises by:
A. placing the patient on his/her operative side during exercises
B. splinting the patient’s chest with both hands during the exercises
C. administering the prescribed analgesic immediately prior to exercises
D. providing rest for 6 hours before exercises
74. Peter underwent pneumonectomy. During the immediate post operative 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 maybe traumatized
75. On which of the following positions should you place Peter who just underwent pneumonectomy?
A. Prone position
B. On his abdomen or on the side opposite the surgery
C. On his back or on the side of surgery
D. Any position is acceptable
Situation – Mang Felix, a 79 year old man who 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 catheter for continuous fast dip bladder irrigation which is connected to a straight drainage.
76. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
C. Bright red
D. Pinkish to red
77. The purpose of the continuous bladders 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
D. Ensure accurate monitoring of intake and output
78. 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 his own
B. Irrigate his catheter
C. Tell him “Go ahead and void. You have an indwelling catheter”
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation
79. You decided to check on Mang Felix’s IV fluid infusion. You noted in flow rate, pallor and coldness around the insertion site. What is your assessment finding?
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism
80. Knowing that proper documentation of assessment findings and interventions share important responsibilities of the nurse during first post operative days, 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 daily living started
Situation – Many hospitals from bioethical review committees to ensure quality of life of patients. You are invited by the nursing service departments to participate in their bioethical review committee. You are expected to know the purpose and apply bioethical principles.
81. Which of the following is the purpose of the ethical review committee?
A. Promote implementation of general standards
B. Enhance health care providers liability
C. Increase individuals responsibility
D. Decrease Public security of health care provider’s action
82. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20,000/ml develops epistaxis and melena. Treatment with corticosteroid and immunoglobulin has not been successful. Her physician recommend splenectomy. Daria states “I don’t need surgery. This will go away on its own”.
83. Zorayda is terminally ill and is experiencing sever 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 DNR form,. What ethical principle did Zorayda and her family utilize as basis for their decision to sign a DNR.
84. 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 he practices what she teaches. What ethical principles is she practicing?
85. You are commuting to work riding the LRT. An older person collapsed and nobody seems to notice her. The security guard tried to make ker 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 fasting blood sugar tested. She developed hypoglycemia. You were able to save a life. You felt good. What principle was applied?
Situation – Ensuring safety before, during, and after a diagnostic procedure is an important responsibility of the nurse
86. 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
87. Following bronchoscopy, which of the following complains to Fernan should be noted as possible complication:
A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness
88. Immediately after bronchoscopy, you instructed Fernan to:
A. Exercise the neck muscles
B. Breathe deeply
C. Retrain from coughing and talking
D. Clear his throat
89. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during 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
90. 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 or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding
Situation – Brain tumor, whether malignant or benign, has serious
management implications. As a nurse, you should be able to understand the consequences of the disease and the treatment.
91. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?
A. Administer bowel softener
B. Position Conrad with his head turned toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep breathing
92. Keeping Conrad’s head and neck alignment results in:
A. increased inthrathoracic pressure
B. increased venous outflow
C. decreased venous outflow
D. increased intrabdominal pressure
93. Which of the following activities may increase intracranial pressure (ICP)?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalva’s maneuver
94. After you asses Conrad, you suspected increased ICP. Your most appropriate respiratory goal is to:
A. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg
B. lower arterial pH
C. prevent respiratory alkalosis
D. promote CO2 elimination
95. Conrad underwent craniotomy. As his nurse, you know that drainage on a craniotomy dressing must be measured and marked. Which findings should you report immediately to the surgeon?
A. Foul-smelling drainage
B. Yellowish drainage
C. Greenish drainage
D. Bloody drainage
Situation – As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients.
96. Getty is receiving chemotherapy for cancer. You review Getty’s 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
97. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease:
98. A difficult problem to deal with when caring for a patient with a partial thickness burns sustained 3 days ago is:
A. Alteration in body image
B. Maintenance of sterility
C. Frequent dressing change
D. Severe pain
99. Which outcome criterion would be appropriate for a client with a nursing diagnosis of effective airway clearance?
A. Continued use of oxygen when necessary
B. Breath sound clear on auscultation
C. Respiratory rate of 24/min
D. Presence of congestion
100. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related to purulent drainage?
A. Heart rate of 88 beats/min
B. Dry and intact wound dressing
C. Oral temperature
D. Wound healing by first intention