NP4 Nursing Board Exam November Answer Key 'Nursing Care of Client with Physiological and Psychosocial Alteration'

100 Nursing Board Exam test questions of November 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

51. The MOST effective method of delivering pain medication during the emergent phase is:

A. intramuscularly

B. subcutaneously

C. orally

D. intravenously

52. When a client accidentally splashes chemicals to his eyes. The initial priority care of the following the chemical burns 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

53. Which of the following can be fatal complication of upper airway burns?

A. stress ulcers

B. hemorrhage

C. shock

D. laryngeal spasm and swelling

54. When a client will rush towards you and he has burning clothes on, it is your priority to do which of the following first?

A. log roll on the grass/ground

B. slap the flames with his hands

C. Try to remove the burning clothes

D. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most important:

A. cover client with warm blanket

B. Give him sips of water

C. Calculate the extent of this burns

D. Assess the Sergio’s breathing

56. During the first 24 hours after thermal injury, you should assess Sergio for:

A. hypokalemia and hypernatremia

B. hypokalemia and hyponatremia

C. hyperkalemia and hyponatremia

D. hyperkalemia and hypernatremia

57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness . You recognize that this most likely indicates that the client is developing:

A. Cerebral hypoxia

B. Hypervolemia

C. Metabolic acidosis

D. Renal failure

58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right and left arm, and at the anterior chest sparing the abdominal area. He also has superficial partial thickness burn at the posterior trunk and at the half upper portion of the left leg. He the emergent phase of burns using the parkland’s formula, you know that during the first 8 hours of burn the amount of fluid will be given is:

A. 5, 400ml

B. 10,500 ml

C. 9,450 ml

D. 6,750 ml

59. The doctor incorporated insulin on the client’s fluid during the emergent phase. The nurse knows that insulin is given because:

A. Clients with burn also develops Metabolic Acidosis

B. Clients with burn also develops hyperglycemia

C. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound healing, regain of consciousness and rapid return of hemodynamic stability.

D. For hyperkalemia

60. The IV fluid of choice for burn as well as dehydration is:

A. 0.45% NaCl

B. NSS

C. Sterile water

D. D5LR

Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.

61. You plan to teach Fermin how to irrigate the colostomy when:

A. The perineal wound heals And Fermin can sit comfortably on the commode

B. Fermin can lie on the side comfortably, about the 3rd postoperative day

C. The abdominal incision is closed and contamination is no longer a danger

D. The stools starts to become formed, around the 7th postoperative day

62. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:

A. When Fermin would have normal bowel movement

B. At least 2 hours before visiting hours

C. Prior to breakfast and morning care

D. After Fermin accepts alteration in body image

63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin:

A. Lubricates the tip of the catheter prior to inserting into the stoma

B. Hangs the irrigating bag on the bathroom door cloth hook during fluid

insertion

C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

D. Clamps of the flow of fluid when felling uncomfortable

64. You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report:

A. If I have any difficulty inserting the irrigating tub into the stoma.”

B. If I noticed a loss of sensation to touch in the stoma tissue.”

C. The expulsion of flatus while the irrigating fluid is running out.”

D. When mucus is passed from the stoma between the irrigations.”

65. You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is important that I eat:

A. Soft food that are easily digested and absorbed by my large intestines.”

B. Bland food so that my intestines do not become irritated.”

C. Food low in fiber so that there is less stool.”

D. Everything that I ate before the operation, while avoiding foods that

cause gas.”

Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit it is important for nurses to gather as much information to be able to address their needs for nursing care.

66. Critically ill patient frequently complain about which of the following when hospitalized?

A. Hospital report

B. Lack of blankets

C. Lack of privacy

D. Inadequate nursing staff

67. Who of the following is at greatest risk of developing sensory problem?

A. Female patient

B. Adolescent

C. Transplant patient

D. Unresponsive patient

68. Which of the following factors may inhibit learning in critically ill patients?

A. Gender

B. Medication

C. Educational level

D. Previous knowledge of illness

69. Which of the following statements does not apply to critically ill patients?

A. Majority need extensive rehabilitation

B. All have been hospitalized previously

C. Are physically unstable

D. Most have chronic illness.

70. Families of critically ill patients desire which of the following needs to be met first by the nurse?

A. Provision of comfortable space

B. Emotional support

C. Updated information on the client’s status

D. Spiritual counselling

Situatuon: Johnny, sought consultation to the  hospital before

71. His diagnosis was hyperthyroidism, the following are expected symptoms except:

A. Anorexia

B. Palpitation

C. Fine tremors of the hand

D. Hyper alertness

72. He has to take drugs to treat hyperthyroidism, which of the following will you not expect that the doctor will prescribe?

A. Colace (Docusate)

B. Cytomel (Llothyronine)

C. Tapazole (

D. (Levothyroxine)

73. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding of the medication?

A. Death

B. Sore throat

C. Hyperthermia

D. Thrombocytosis

74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the evidence of:

A. Thyroid storm

B. Mediastinal shift

C. Damage to the laryngeal nerve

D. Hypocalcemia tetany

75. Should you check for haemorrhage, you will:

A. Slip your hand under the nape of her neck

B. Check for hypotension

C. Apply neck collar to prevent haemorrhage

D. Observe the dressing if is soaked with blood

76. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the standard procedure, you need to tell Johnny that:

A. Obstructing his vision

B. Restraining his upper and lower extremities

C. Obstructing his hearing

D. Obstructing his nostril with a clamp

77. The BMR is based on the measurement that:

A. Rate of respiration under different condition of activities and rest

B. Amount of oxygen consumption under resting condition over a measured period of time

C. Amount of oxygen consumption under stressed condition over a measured period of time

D. Ratio of respiration to pulse rate over a measured period of time

78. Her physician ordered lugol’s solution in order to:

A. Decrease the vascularity and size of the thyroid gland

B. Decrease the size of the thyroid gland only

C. Increase the vascularity and size of the thyroid gland

D. Increase the size of the thyroid gland only

79. Which of the following is a side effect of lugol’s solution?

A. Hypokalemia

B. Nystagmus

C. Enlargement of the Thyroid gland

D. Excessive salivation

80. In administering Lugol’s solution, the precautionary measure should include:

A. Administer with glass only

B. Dilute with juice and administer with a straw

C. Administer it with milk and drink it

D. Follow it with milk of magnesia

Situation: Pharmacological treatment was not effective for Johnny’s hyperthyroidism and now he is  scheduled for Thyroidectomy.

81. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON CRITICAL. If the instrument are introduced directly into the blood stream or into any normally sterile cavity or area of the body it is classified as:

A. Critical

B. Semi critical

C. Non critical

D. Ultra critical

82. Instruments that do not touch the patient or have contact only to the intact skin is classified as:

A. Critical

B. Semi critical

C. Non critical

D. Ultra critical

83. If an instrument is classified as Semi Critical an acceptable method of making the instrument ready for surgery is through:

A. Sterilization

B. Decontamination

C. Disinfection

D. Cleaning

84. While critical items and should be:

A. Clean

B. Decontaminated

C. Sterilized

D. Disinfected

85. As a nurse, you know that intact skin as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin or mucous membranes should be:

A. Disinfected

B. Sterile

C. Clean

D. Alcoholized

86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Johnny to:

A. Perform range and motion exercise on the head or neck

B. Apply gentle pressure against the incision when swallowing

C. Cough and deep breathe every hours

D. Support head with the hands when changing position

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.

96. 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

97. 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

98. 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

99. 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

100. 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

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