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
Nov. 08 NP4
Situation 1: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count.
1. Counting is performed thrice: During the preincision phase, the operative phase and closing phase. Who counts the sponges, needles and instruments?
A. The scrub nurse only
B. The circulating nurse only
C. The surgeon and the assistant surgeon
D. The scrub nurse and circulating nurse.
2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer:
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/Fat
5. Skin
A. 5,4,3,2,1
B. 5,4,2,1,3
C. 5,4,1,3,2,
D. 5,4,1,2,3
3. When is the first sponge instrument count reported?
A. Before closing the subcutaneous layer
B. Before peritoneum is closed
C. Before closing the skin
D. Before the fascia is sutured
4. Like any nursing intervention, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted?
A. Anaesthesiologist
B. Surgeon
C. OR nurse supervisor
D. Circulating nurse
5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
A. MRI and Incidence report
B. CT Scan, MRI, Incidence Report
C. X-ray, and Incidence Report
D. CT scan and Incidence Report
Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.
6. A client 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. Clamp 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 floe into a sterile container
D. Wipe the self sealing aspirations port with antiseptic solution and insert a sterile needle into the self sealing self-sealing port.
7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container
8. The best time for collecting the sputum specimen for culture:
A. Before retiring at night
B. Upon waking up in the morning
C. Anytime of the day.
D. Before meal
9. When suctioning the endotracheal tube, the nurse should:
A. Explain procedure to patient: Insert catheter gently applying suction. Withdrawn using twisting motion.
B. Insert catheter until resistance is met; then withdraw slightly, applying suction intermittently as catheter is withdrawn.
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction, catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn.
10. The purpose of NGT IMMEDIATELY after operation is:
A. For feeding or gavage
B. For gastric decompression
C. For lavage, or the cleansing of the stomach content
D. For the rapid return of peristalsis
Situation 3 – Mr. Santos, 50, is to undergo cytoscopy due to multiple problems like scantly urination, hematuria, and dysuria.
11. 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.
12. 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
13. 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
14. 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
15. 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 4 – 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.
16. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
B. Amber
C. Bright red
D. Pinkish to red
17. 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
18. 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
19. 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
20. 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 5: Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient’s needs.
21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire retardant properties. Milk and food manufacturers add melamine in order to:
A. It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods.
B. Gives a glazy and more edible look on foods
C. Make milks more tasty and creamy
D. Create an illusion of a high protein content on their products
22. Most of the milks contaminated by melamine came from which country?
A. India
B. China
C. Philippines
D. Korea
23. Which government agency is responsible for testing the melamine content of foods and food products?
A. DOH
B. MMDA
C. NBI
D. BFAD
24. Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine poisoning?
A. Irritability, Back ache, Urolithiasis
B. High blood pressure, fever
C. Anuria, Oliguria or Hematuria
D. Fever, Irritability and a large output of diluted urine
25. What kind of renal failure from melamine poisoning cause?
A. Chronic Pre-renal
B. Acute, Postrenal
C. Chronic, Intrarenal
D. Acute, Prerenal
Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15.
26. The survival rate for Acute Lymphoid Leukemia is approximately:
A. 25 %
B. 40 %
C. 75 %
D. 95 %
27. Whrereas acute nonlymphoid leukaemia has survival rate of:
A. 25 %
B. 40 %
C. 75 %
D. 95 %
28. The three main consequence of leukaemia that cause the most danger is:
A. Neutropenia causing infection, anemia causing impaired oxygenationand thrombocytopenia leading to bleeding tendencies.
B. Central nervous system infiltration, anemia causing impaired oxygenationand thrombocytopenia leading to bleeding tendencies.
C. Splenomegaly, hepatomegaly, fractures
D. Invasion by the leukemic cells to the bone causing severe bone pain
29. Gold standard in the diagnosis of leukaemia is by which of the following?
A. Blood culture and sensitivity
B. Bone marrow biopsy
C. Blood biopsy
30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the client for long term therapy. One common side effect, especially of adriamycin is alopecia. The child asks: “ Will I get my hair back once again?” The nurse respond is by saying:
A. “Don’t be silly, of course you will get your hair back.”
B. “We are not sure, let’s hope it’ll grow.”
C. “This side effect is usually permanent, but I will get the doctor to discuss it for you.”
D. “Your hair will regrow in 3 -6 months but of different color, usually darker and of different texture.”
Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in woman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer.
31. All of the following are factors that said to contribute to the development of breast cancer EXCEPT:
A. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity and children after age 30.
B. Genetics
C. Increasing age
D. Prolonged intake of Tamoxifen (Nolvadex)
32. Protective factors for the development of breast cancer includes which of the following EXCEPT:
A. Exercise
B. Prophylactic Tamoxifen
C. Breast Feeding
D. Alcohol intake
33. 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
34. Carmen, is asking the nurse the most appropriate time of the month to do her self-examination of the breast. The MOST appropriate reply by the nurse would be:
A. the 26th day of menstrual cycle
B. 7 – 8 days after conclusion of the menstrual period
C. During her menstruation
D. the same day each month
35. Carmen being treated with radiation therapy. What should 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 therapy
D. Avoid applying creams and powder to the area.
36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breast cancer that is recommended for developing countries is:
A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)
B. an annual hormone receptor assay
C. an annual mammogram
D. a physician conduct a breast clinical examination every 2 years
37. The purpose of performing the breast self examination (BSE) regularly is to discover:
A. fibrocystic masses
B. cancerous lumps
C. areas of thickness or fullness
D. changes from previous BSE
38. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:
A. on the same day of each month
B. right after the menstrual period
C. on the first day of her menstruation
D. on the last day of her menstruation
39. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:
A. thickening of the tissue
B. axillary
C. lumps in the breast tissue
D. change in size and contour
40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client’s left shoulder is to:
A. bring the breast closer to the examiner’s right hand
B. tense the pectoral muscle
C. balance the breast tissue more evenly on the chest wall
D. facilitate lateral positioning of the breast
Situation – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse
41. 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
42. 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
43. 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
44. 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
45. 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: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical.
46. A burn characterized by pale, white appearance, charred or with exposed and painlessness:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn
47. Which of the following BEST describes superficial partial thickness burn or first degrees burn?
A. Structures beneath the skin and damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged
48. A burn that is said to be “WEEPING” is classified as:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn
49. During the Acute Phase of the burn injury, which of the following is a priority?
A. Wound healing
B. Reconstructive surgery
C. Emotional support
D. Fluid resuscitation
50. While in the emergent phase, the nurse knows that the priority is to:
A. Prevent infection
B. Control pain
C. Prevent deformities and contractures
D. Return the hemodynamic stability via fluid resuscitation
CLICK HERE PART 2 (51 - 100) 'NP4 Nursing Care of Client with Physiological and Psychosocial AlterationMedical and Surgical Nursing / Psychology'
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