NP4 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 IV – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 2 Board Exam test questions 51 - 100

 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:

A. Acetone

B. Alcohol

C. Ammonia

D. Bleach

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

them.

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

support groups

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

everything inside

C. Leaving her alone because she is uncooperative and unpleasant to be

with

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

D. Pain

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:

A. Biot’s

B. Kussmaul’s

C. Cheyne Stokes

D. Eupnca

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

B. Amber

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?

A. Phlebitis

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”.

A. Beneficence

B. Justice

C. Autonomy

D. Advocacy

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.

A. Justice

B. Autonomy

C. Advocacy

D. Beneficence

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?

A. Beneficence

B. Justice

C. Autonomy

D. Advocacy

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?

A. Advocacy

B. Beneficence

C. Justice

D. Autonomy

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:

A. Hypertension

B. Pain

C. Hematuria

D. Weight

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

CLICK HERE PART 1 (1 - 50) 'NP4 Nursing Care of Client with Physiological and Psychosocial AlterationMedical and Surgical Nursing / Psychology'