Nurses notes or SOAPIE, SOAP, SOAPIERS, SOI, are like integrated within a nurse’s DNA but some of student nurses are still “learning” the right way on how to make a good SOAPIE. This post will give you some tips on how to do so.

1. Assess, assess, assess.

Say that fast three times. Keep in mind that assessment is the base of a SOAPIE. To have a good assessment (and not to stick with pinkish palpebral conjunctiva and CRT ^^), be aware of the “medical diagnosis” of your patient.

For example, you have a patient who was diagnosed of congestive heart failure or heart failure. If its your first time to encounter the disease try to read before hand (that’s why you have to bring a handy-dandy handbook about diseases). Try to recall as much as possible what could be the manifestations of a patient with heart disease. Start first with the fact that it affects the heart then narrow your assessment down.

Let say you know that heart failure can be left-sided and right-sided. For right-sided HF, I know that it there is systemic edema, so I would assess for edema. I also know that there are changes in the heart’s pumping ability, thus I would assess for regularity of the pulses bilaterally. As for the left-sided HF, I know that there is pulmonary congestion thus I would assess for DOB, breath sounds (your favorite assessment), and etc.

If so you would know the signs and symptoms of a patient with CHF and thus you would assess for them (central cyanosis, jugular vein distention, edema, DOB, rhythm of pulses and etc).

Assessment is like a line from a song “it takes a lot of getting used to“. But don’t be discouraged, that’s why you are a nursing “student”, you are still in the peak of learning. Make it a habit that you do an appropriate and close to detailed assessment.

2. Know what your doing

Also make it a point that you know what to assess before your interact with your patient, instead of going back to the patient’s room q5 mins just to ask whether he voided or whether the palpebral conjunctiva is pink. Don’t be a disturbance to a patient who is recuperating.

3. NANDA out!

If its your first time to write a SOAPIE, its okay to use the NANDA, but if your a 4th year and you would be graduating in the next (let’s say) 2 weeks shame on you. (For those who doesn’t know what NANDA is, it is the best friend and most overused book by a nursing student).

So going back, if its your first semester for your hospital exposure, go ahead use your NANDA and remember the cues, the related factors, the interventions and what would you want the patient achieve.

Don’t be NANDA dependent, nandammit!

4. Stop Using Acute Pain…

Its quite a good idea that some instructors would disallow the nursing diagnosis of acute pain. “My head aches” (acute pain), “I feel like there’s an elephant in my chest” (acute pain), “my tummy feels like twisting” (acute pain) and yes there are a lot of instances where acute pain be used that is why if NANDA would write down specifically all the related factors it would be as thick as the MS book of Joyce Black.

5. …choose a better nursing diagnosis!

At the back portion of the NANDA, there’s a list of medical diagnoses and their possible nursing diagnoses and their related factors, make sure to browse that. Make sure that you have an appropriate nursing diagnosis for your patient. Here are some key points:

• Your nursing diagnosis should be “strongly supported by your assessment cues”
• It should be patient centered (as most of the time)
• and it should follow a format like the “diagnosis-related factor-cues”

Some nursing diagnoses can stand alone even without related factors like Hyperthermia. Although these type of diagnoses are limited to SOAPIEs and not on care plans.

6. Planning should be SMART and PtC

Planning is also what we know as goal setting. This is where you ask “what would I want my patient to achieve?” Goals or plans should be SMART:

• Specific and Measurable. End your planning with AEB and then cues that you would assess to confirm whether you have achieved your goal. Example: “…the patient will establish airway patency as evidenced by (AEB) effective respirations, respiratory rate within normal range and demonstration of deep breathing exercises and effective coughing exercises”.
• Attainable and Realistic. A case with severe pneumonia: “After 1 hour of NI the patient will establish normal respiration AEB…”. This is quite unattainable (go figure).
• Time Bound. Make sure that the time you’ve put in your planning is enough to achieve your desired outcomes.

Be patient centered as much as possible. The patient is at the center of planning because he/she is the chief decision maker of what treatment plans he/she would allow. You patient is not the significant other. Be cautious of also using the phrase “verbalize understanding of…” to pediatric patients. Also, don’t restrict your planning or goals on what’s written on NANDA.

7. Interventions

You can start with established rapport, then assess the general condition, monitor the vital signs and then…you can start writing the real interventions in your SOAPIE.

Make sure that all assessment-like interventions should be within the first few lines of your

Note that the assessment-like interventions are at the first few lines

interventions. Assessment-like interventions are those interventions wherein you would say that you assessed for this and that like monitored hydration status, auscultated bowel sounds, assessed neuro vital signs.

The rest of your interventions should be next. Don’t ever, ever forget to shift to past tense. Put dependent nursing interventions last like administered medications.

Also remember some “templates” for interventions like “Above IVF consumed hooked #2 D5LRS 1L…”, “hooked O2 inhalation regulated at 2-3 LPM via nasal canula” and especially “seen on rounds by Dr. Xyz with orders made and carried out:…”

And lastly, always make sure to add in your interventions the explanation of the disease of the client. A good student nurse knows the importance and impact of health education to the prognosis of the patient.

8. Horray! Evaluation.

Finally, we have arrived at the evaluation. Was your planning or goal met? partially met? or not met? How would you assess whether they were met? Simple. If you have made a good planning it should have ended with AEB and then their corresponding cues. These cues are your parameter whether you have met your goal.

As for the example above was your able to manifest effective respiration and rate within normal range? deep breathing and coughing exercises?

9. And to Top it all up…

I hope you have enjoyed and learned a lot by reading this post. If you liked this please share it on Facebook! You can click on the floating Facebook logo at the side. Also you can subscribe to our posts!

Sample SOAPIE

And lastly, here is an example SOAPIE, with all the things you have learned above can you comment what’s wrong with this SOAPIE?

• S > (none) O> Received pt sitting in bed conscious and coherent, with IVF of #7 D5W 1L infusing well on the right metacarpal vein regulated 30 gtts/min at 300 cc level, without signs of phlebitis or infiltrations. O2 inhalation therapy via NC regulated @ 2LPM pt appears fatigued and weak, pt is acyanotic, without pallor, without edema, with pink conjunctiva, moist mucous membranes, capillary refill less than 3 seconds, poor skin turgor, pt has cough with lung fields clear upon auscultation, with chest pain provoked with activity, pt’s heart rate is irregular and bradycardic, with ecchymosis on L forearm, vital signs taken as follows: BP 90/50 48 22cpm 36.7
• A > Decreased cardiac output R/T altered heart rate
• P> After 4-5 hours of NI the patient will be able to identify health interventions that will decrease cardiac workload of the heart
• I >
  • Established rapport
  • Monitored and recorded VS q1
  • Provided AM care
  • Positioned pt in fowler’s bed rest to allow easy respiratory function
  • Reinforced low sodium and low fat diet
  • Instructed pt to limit oral fluid intake
  • Arranged and straightened linens
  • Provided privacy, comfort and safety measures
  • Provided adequate rest periods
  • Assisted pt’s SO with pt’s ADLs
  • Instructed pt to avoid strenuous activities that may stimulate Valsava maneuver
  • Due available meds given as ordered
  • Seen on rounds by Dr. N with orders given and carried out as follows:
    • Atrophine sulfate ½ amp administered SIVP

E> Goal met AEB pt was able to identify health interventions that would allow decrease in cardiac work load.

The post 9 Tips on How To Make a Good SOAPIE appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Community Health Nursing & Maternal & Child Health Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance.

Situation : Nurse Macarena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.

1. Daphne, 19 years old, asks nurse Macarena how can pregnancy be prevented through tubal ligation. Which would be the best answer?

A. Prostaglandins released from the cut fallopian tubes will lead to permanent closure of the vagina.
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.

2. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:

A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for 1 year
D. A couple has wanted a child for 6 months

3. Another client named Cindy is diagnosed as having endometriosis. This condition interferes with fertility because:

A. Endometrial implants can block the fallopian tubes
B. The uterine cervix becomes inflamed and swollen
C. The endometrial lining becomes inflamed leading to narrowing of the cervix.
D. Inflammation of the endometrium causes release of substance P which kills the sperm.

4. Cindy submits herself to Fatima Medical Center and is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure?

A. Menstruation will be irregular for few months as an effect of the dye but it is just normal
B. The sonogram of the uterus will reveal any tumors present
C. The women may experience some itchiness in the vagina as an after effect.
D. Cramping may be felt when the dye is inserted

5. Cindy’s cousin on the other hand, knowing nurse Macarena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Macarena?

A. Donor sperm are introduced vaginally into the uterus or cervix
B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husband’s sperm is administered intravenously weekly

Situation . Nurse Dee-Lan was a graduate of Our Lady of Fatima University, he started working as a nurse just right after he passed and topped the board exam. She was assigned to take care of a group of patients across the lifespan.

6. Pain in geriatric clients 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 increased pain sensitivity

7. Administration of aminoglycosides 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

8. Elder clients are often at risk of having impaired skin integrity. One factor is that they often experience urinary incontinence. The elderly patient is at higher risk for urinary incontinence because of:

A. increased glomerular filtration C. decreased bladder capacity
B. decrease elasticity of blood vessels D. dilated urethra

9. Which of the following is the MOST COMMON sign of infection among the elderly?

A. decreased breath sounds with crackles C. pain
B. Increase body temperature D. Restlessness, confusion, irritability

10. Prioritization is important to test a nurse’s good judgment towards different situations. 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, circulation

11. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Achalasia?

A. Olive shaped mass on abdomen
B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. Effortless and non-projectile vomiting

12. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching?

A. Maintain bed rest with bathroom privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible when lying down.

13. Ms. Anna, a review assistant of the greatest nursing review center in the Philippines has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first?

A. Check for the presence of infection
B. Assess for Prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid

14. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to:

A. avoid covering the area of the topical medication with the diaper
B. avoid the use of clothing on top of the diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the outside of the diaper

15. Which of the following factors is most important in determining the success of relationships used in delivering nursing care?

A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants

16. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins

17. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening?

A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinutria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine.
18. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position?

A. Brow position C. Breech position
B. Right Occipito-Anterior Position D. Left Occipito-Posterior Position

Situation – With the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. The following conditions apply.

19. Which among the following is the primary focus of prevention of cancer?

A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection

20. In the prevention and control of cancer, which of the following activities is the most important function of the community health nurse?

A. Conduct community assemblies.
B. Referral to cancer specialist those clients with symptoms of cancer.
C. Use the nine warning signs of cancer as parameters in our process of detection, control and treatment
modalities.
D. Teach woman about proper/correct nutrition.

21. Who among the following are recipients of the secondary level of care for cancer cases?

A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment

22. Who among the following are recipients of the tertiary level of care for cancer cases?

A. Those under early treatment C. Those under early detection
B. Those under supportive care D. Those scheduled for surgery

23. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?

A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”

Situation : The following questions refers to common clinical encounters experienced by an entry level nurse.

24. A female client asks the nurse about the use of a cervical cap. Which statement is correct regarding the use of the cervical cap?

A. It may affect Pap smear results.
B. It does not need to be fitted by the physician.
C. It does not require the use of spermicide.
D. It must be removed within 24 hours.

25. The major components of the communication process are:

A. Verbal, written and nonverbal
B. Speaker, listener and reply
C. Facial expression, tone of voice and gestures
D. Message, sender, channel, receiver and feedback

26. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is:

A. Being raised by a parent of low intelligence quotient (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty

Situation: Mike 16 y/o has been diagnosed to have AIDS, he worked as entertainer in a cruise ship;

27. Which method of transmission is common to contract AIDS:

A. Syringe and needles A. Sexual contact
B. Body fluids B. Transfusion

28. Causative organism in AIDS is one of the following;

A. Fungus C. retrovirus
B. Bacteria D. Parasites

29. You are assigned in a private room of Mike. Which procedure should be of outmost importance;

A. Alcohol wash C. Washing Isolation
B. Universal precaution D. Gloving technique

30. What primary health teaching would you give to mike;

A. Daily exercise C. reverse isolation
B. Prevent infection D. Proper nutrition

31. Exercise precaution must be taken to protect health worker dealing with the AIDS patients . which among these must be done as priority:

A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth.

32. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to eruption behind the ears. As a nurse, your physical examination must determine complication especially:

A. Otitis media C. Inflammatory conjunctiva
B. Bronchial pneumonia D. Membranous laryngitis

33. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below?

A. Water C. Alkaline
B. Sulfur D. Salt

34. As a public health nurse, you teach mother and family members the prevention of complication of measles. Which of the following should be closely watched?

A. Temperature fails to drop C. Inflammation of the nasophraynx
B. Inflammation of the conjunctiva D. Ulcerative stomatitis

35. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is transmitted by:

A. Water supply C. Food ingestion
B. Droplet D. Sexual contact

36. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of patient includes the provision of:

A. Terminal disinfection C. Immunization
B. Injection of gamma globulin D. Comfort measures

SITUATION: Sexually Transmitted Diseases are important to identify during pregnancy because of their potential effect on the pregnancy, fetus, or newborn. The following questions pertain to STD’s.

37. Ms. Reynaldita is a promiscuous woman in Manila submits herself to the clinic for certain examinations. She is experiencing vaginal irritation, redness, and a thick cream cheese vaginal discharge. As a nurse, you will suspect that Ms. Reynaldita is having what disease?
A. Gardnerella Vaginalis
B. Candida Albicans
C. Treponema Pallidum
D. Moniliasis

38. As a knowledgeable nurse, you know that the doctor may prescribe a certain medications for Ms. Reynaldita. What is the drug of choice for Reynaldita’s infection?
A. haloperidol
B. miconazole
C. benzathine penicillin
D. metronidazole

39. Based on your learnings, you know that the causative agent of Reynaldita’s infection is:
A. Monistat Candida
B. Candida Albicans
C. Albopictus Candidiasis
D. Monakiki

40. The microorganism that causes Reynaldita’s infection is a:
A. Bacteria
B. Protozoa
C. Fungus
D. Virus

41. Another client in the Maternal Clinic was Ms. Celbong. Her doctor examined Ms. Celbong’s vaginal secretions and found out that she has a Trichomoniasis infection. Trichomoniasis is diagnosed through which of the following method?
A. Vaginal secretions are examined on a wet slide that has been treated with potassium hydroxide.
B. Vaginal speculum is used to obtain secretions from the cervix.
C. A lithmus paper is used to test if the vaginal secretions are infected with trichomoniasis.
D. Vaginal secretions are examined on a wet slide treated with zephiran solution.

42. Daphne who is on her first trimester of pregnancy is also infected with trichomoniasis. You know that the drug of choice for Daphne is:
A. Flagyl
B. Clotrimazole (topical)
C. Monistat
D. Zovirax

43. Syphilis is another infection that may impose risk during pregnancy. Since we are under the practice of health science, you know that Syphilis is caused by:
A. Treponema Syphilis
B. Neisseria gonorrhoeae
C. Chlamydia Trachomatis
D. Treponema Pallidum
44. What type of microorganism is the causative agent of syphilis?
A. Spirochete
B. Fungus
C. Bacteria
D. Protozoan
45. Under the second level of prevention, you know that one of the focuses of care is the screening of diseases. What is the screening test for syphilis?
A. VDRL
B. Western blot
C. PSA
D. ELISA
46. Jarisch-Herxheimer reaction may be experienced by the client with syphilis after therapy with benzathine penicillin G. The characteristic manifestations of Jarisch-Herxheimer reaction are:
A. Rashes, itchiness, hives and pruritus
B. Confusion, drowsiness and numbness of extremities
C. sudden episode of hypotension, fever, tachycardia, and muscle aches
D. Episodes of nausea and vomiting, with bradypnea and bradycardia

47. A pregnant woman is in the clinic for consultation with regards to STD’s. She inquires about Venereal warts and asks you about its specific lesion appearance. Which of the following is your correct response to the client?
A. Why are you asking about it? You might be a prostitute woman.
B. The lesions appear as cauliflower like lesions.
C. It appears as pinpoint vesicles surrounded by erythema.
D. The lesions can possibly obstruct the birth canal.

48. Based on your past learnings in communicable diseases, you know that the causative agent of venereal warts is:
A. Chlamydia Trachomatis
B. Candida Moniliasis
C. Human Papilloma Virus
D. Staphylococcus Aureus

49. As a nurse in charge for this woman, you anticipate that the doctor will prescribe what medication for this type of infection?
A. Podophyllum (Podofin)
B. Flagyl
C. Monistat
D. Trichloroacetic acid

50. Cryocautery may also be used to remove large lesions. The healing period after cryocautery may be completed in 4-6 weeks but may cause some discomforts to the woman. What measures can alleviate these discomforts?
A. Kegel’s Exercise
B. Cool air
C. Topical steroids
D. Sitz baths and lidocaine cream

51. In order to prevent acquiring sexually transmitted diseases, what is the BEST way to consider?
A. Condom use
B. Withdrawal
C. vasectomy
D. Abstinence

SITUATION: The Gastrointestinal System is responsible for taking in and processing nutrients for all parts of the body, any problem can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development. The following questions are about gastrointestinal disorders in a child.

52. Mr. & Mrs. Alcaras brought their son in the hospital for check up. The child has failure to thrive and was diagnosed with pyloric stenosis. Which among the following statements are the characteristic manifestations of pyloric stenosis?
A. Vomiting in the early morning
B. Bile containing vomitus immediately after meal
C. sausage shaped mass in the abdomen
D. Projectile vomiting with no bile content

53. The exact cause of pyloric stenosis is unknown, but multifactorial inheritance is the likely cause. Being knowledgeable about this disease, you know that pyloric stenosis is more common in which gender?
A. Male
B. Female
C. Incidence is equal for both sexes
D. None of the above

54. To rule out pyloric stenosis, the definitive diagnosis is made by watching the infant drink. After the infant drinks, what will be the characteristic sign that will describe pyloric stenosis?
A. An olive-size lump can be palpated
B. There is gastric peristalsic waves from left to right across the abdomen
C. A hypertrophied sphincter can be seen on ultrasound.
D. A tingling sensation is felt on the lower extremities
55. Shee Jan Long a 10 months old infant was admitted to the hospital for severe abdominal pain. The doctor found out that the distal ileal segment of the child’s bowel has invaginated into the cecum. The nurse will suspect what disease condition?
A. Intussusception
B. Pyloric stenosis
C. Hirschprung’s disease
D. Vaginismus

56. In intussusceptions, children suddenly draw up their legs and cry as if they are in severe pain and possibly vomit. Another manifestation of such disease is the presence of blood in the stool. What is the characteristic stool of client with intussuscepton?
A. Coffee ground
B. Black and Tarry
C. Currant jelly stool
D. Watery stool

57. A 4-year-old child is hospitalized because of persistent vomiting. As a nurse, you must monitor the child closely for:
A. Diarrhea
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Hyperactive bowel sounds

58. A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea. The nurse prepares to take the child’s temperature and avoids which method of measurement?
A. Tympanic
B. Axillary
C. Rectal
D. Electronic

59. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions?
A. “I will use a nipple with a small hole to prevent choking.”
B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
C. “I will allow the infant time to swallow.”
D.” I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth.”

60. An infant has just returned to the nursing unit following a surgical repair of a cleft lip located at the right side of the lip. The nurse places the infant in which most appropriate position?
A. On the right side
B. On the left side
C. Prone
D. Supine

61. A clinic nurse reviews the record of an infant seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
A. Severe projectile vomiting
B. Coughing at night time
C. Choking with feedings
D. Incessant crying

SITUATION: Human development is one of the important concepts that a nurse should learn to be able to deal appropriately with their clients of different developmental stages.

62. Which statement best describes when fertilization occurs?
A. When the spermatozoon passes into the ovum and the nuclei fuse into a single cell.
B. When the ovum is discharged from the ovary near the fimbriated end of the fallopian tube.
C. When the embryo attaches to the uterine wall.
D. When the sperm and ova undergo developmental changes resulting in a reduction in the number of chromosomes.

63. A pregnant client asks you about fetal development. At approximately what gestational age does the fetus’s single chambered heart begin to pump its own blood cells through main blood vessels?
A. 10 weeks
B. 8 weeks
C. 5 weeks
D. 3 weeks

64. At 17 weeks gestation, a fetus isn’t considered to be ballotable. Ballotment means that:
A. The examiner feels rebound movement of the fetus.
B. The examiner feels fetal movement.
C. The client feels irregular, painless uterine contractions.
D. The client feels fetal movement.

65. Which hormone stimulates the development of the ovum?
A. Follicle stimulating hormone (FSH)
B. Human Chorionic Gonadotropin (HCG)
C. Luteinizing Hormone (LH)
D. Gonadotropin Releasing Hprmone (GnRH)

66. How long is the gestational period of a full term pregnancy?
A. Ranging from 245 days to 259 days
B. around 5,554 hours to 5,880 hours
C. More than 294 days
D. Averaging of 266 to 294 days

67. An 18 year old woman in her 18th week of pregnancy is being evaluated. Which positive sign of pregnancy should the nurse expect to be present?
A. Fetal heart tones detectable by Doppler stethoscope
B. Fetal movement detectable by palpation
C. Visualization of the fetus by ultrasound examination.
D. Fetal heart tones detectable by a fetoscope.

68. During her prenatal visit, a 28 year old client expresses concern about nutrition during pregnancy. She wants to know what foods she should be eating to ensure the proper growth and development of her baby. Which step should the nurse take first?
A. Give the client a sample diet plan for a 2,400 calorie diet.
B. Emphasize the importance of avoiding salty and fatty foods.
C. Instruct the client to continue to eat a normal diet.
D. Assess the client’s current nutritional status by taking a diet history.

69. A nurse is teaching a class about the reproductive system. She explains that fertilization most often takes place in the:
A. Ovary
B. Fallopian tubes
C. Uterus
D. vagina

70. A large number of neural tube defects may be prevented if a pregnant woman includes which supplement in her diet?
A. Vit. A
B. Vit. E
C. Vit. D
D. Vit. B9

71. A 22 year old client is at 20 weeks gestation. She asks the nurse about the development of her fetus at this stage. Which of the following developments occurs at 20 weeks gestation?
A. The pancreas starts producing insulin and the kidneys produce urine.
B. The fetus follows a regular schedule of turning, sleeping, sucking, and kicking.
C. Swallowing reflex has been mastered, and the fetus sucks its thumb.
D. Surfactant forms in the lungs.

SITUATION: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCI.
72. A 6 month old baby Len was brought to the health center because of fever and cough for 2 days. She weighs 5 kg. Her temperature is 38.5 taken Axillary. Further examination revealed that she has general rashes, her eyes are red and she has mouth ulcers non deep and non extensive, There was no pus draining from her eyes. Most probably Baby Len has:
a. Severe complicated measles d. Measles
b. Fever: No MALARIA e. Measles with eye or mouth complications
c. Very severe febrile disease

73. The dosage of Vit. A supplement given to Baby Len would be:
d. 100,000 IU d. 200,000 IU
e. 10,000 IU e. 20,000 IU

74. Using IMCI Chart, this child can be manage with:
f. Treat the child with paracetamol and follow up in 2 days if the fever persist
g. Give the first dose of antibiotic, give Vit. A, apply Gentian Violet for mouth ulcers and refer urgently to hospital
h. Give100, 000 international units of Vit. A
i. Give200, 000 international units of Vit. A
e. Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days
75. The following are signs of severe complicated measles:
j. Clouding of the cornea
k. Deep or extensive mouth ulcers
l. Pus draining from the eyes
m. A and b only
n. All of the above

76. If the child is having 2 ½ weeks ear discharges, how would you classify and treat the child:
1. Green 5. Dry the ear by wicking
2. Yellow 6. 5 days antibiotic
3. Pink 7. Urgent referral with first dose of antibiotic
4. Red

a. 4,7 b. 2,5,6 c. 1,5 d. 3,7 e. 2,5

77. The following are treatments for acute ear infections:
a. Dry the ear by wicking d. A and c only
b. Give antibiotics for 5 days e. All of the above
c. Follow up in 5 days

78. A child with ear problem should be assessed for the following, except:
a. Ear pain
b. If discharge is present for how long?
c. Ear discharge
d. Is there any fever?
e. None of the above

79. If the child does not have ear problem, using IMCI, what should you do as a nurse?
a. Go to the next question, check for malnutrition
b. Check for ear pain
c. Check for tender swelling behind the ear
d. Check for ear discharge

80. An ear discharge that has been present for more than 14 days can be classified as:
a. Complicated ear infection c. Chronic ear infection
b. Acute ear infection d. Mastoiditis

81. An ear discharge that has been present for less than 14 days can be classified as:
a. Complicated ear infection c. Chronic ear infection
b. Acute ear infection d. Mastoiditis

82. If the child has severe classification because of ear problem, what would be the best thing that you should do as a nurse?
a. Dry the ear by wicking
b. Give an antibiotic for 5 days
c. Refer urgently
d. Instruct mother when to return immediately

Situation: Primary Health Care (PHC) is defined by the WHO as essential health care made universally accessible to individuals, families and communities.

83. The WHO held a meeting in this place where Primary health Care was discussed. What is this place?
A. Alma Ata
B. Russia
C. Vienna
D. Geneva
Situation: The national objective for maintaining the health of all Filipinos is a primary responsibility of the DOH.

84. The following are mission of the DOH except:
a. Ensure accessibility
b.Quality of health care
c.Health for all Filipinos
d.Quality of Life of all Filipinos
e. None of the above

85. The basic principles to achieve improvement in health include all BUT:
a. Universal access to basic health services must be ensured
b. The health and nutrition of vulnerable groups must be prioritized
c. Performance of the health sector must be enhanced
d. Support the frontline workers and the local health system
e. None of the above

86. Which of the following is not a primary strategy to achieve health goals:

a. Support of local health system development
b. Development of national standards for health
c. Assurance of health care for all
d. Support the frontline workers
e. None of the above

87. According to the WHO health is:
A. state of complete physical, mental and social well being not merely the absence of disease
B. A science and art of preventing disease and prolonging life
C. A science that deals the optimum level of functioning of the Individual, family and community
D. All of the above

88. Assistance in physical therapy of a trauma patient is a:
Primary level of prevention
B. Secondary level of prevention
C. Tertiary level of prevention
D. Specialized level of prevention

89. Local health boards were established at the provincial, city and municipal levels. At the municipal level,the chairman of the board is the:

A.Rural Health physician
B.Governor
C.Mayor
D.Chairman of the Committee on Health
90. The emphasis of community health nursing is on:

A. Treatment of health problems
B. Preventing health problems and promoting optimum health
C. Identification and assessment of health problems
D. Illness end of the wellness-illness continuum.

91. In asking the mother about her child’s problem the following communication skills should be used except:
a. Use words that the mother understand
b. Give time for the mother to answer the questions
c. Listen attentively
d. Ask checking questions
e. None of the above

92. Which of the following is the principal focus of the CARI program of the Department of Health?
a. Teach other community health workers how to assess patients
b. Mortality reduction through early detection
c. Teach mothers how to detect signs and where to refer
d. Enhancement of health team capabilities

93. You were able to identify factors that lead to respiratory problems in the community where your health facility serves. Your primary role therefore in order to reduce morbidity due to pneumonia is to?
a. Seek assistance and mobilize the BHW’s to have a meeting with mothers
b. Refer cases to hospitals
c. Make home visits to sick children
d. Teach mothers how to recognize early signs and symptoms of pneumonia

94. Which of the following is the most important responsibility of a nurse in the prevention of unnecessary deaths from pneumonia and other severe disease?
a. Weighing of the child
b. Provision of careful assessment
c. Taking of the temperature of the sick child
d. Giving of antibiotics

95. A 4-month-old child was brought to your clinic because of cough and colds. Which of the following is your primary action?
a. Teach the mother how to count her child’s breathing?
b. Refer to the doctor
c. Assess the patient using the chart on management of children with cough
d. Give cotrimoxazole tablet or syrup
e. All of the above

96. In responding to the care concerns to children with severe disease, referral to the hospital is of the essence especially if the child manifests which of the following?
a. Stopped feeding well c. Wheezing
b. Fast breathing d. Difficulty to awaken

Elvira Magalpok is a 26 year old woman you admit to a birthing room. She’s been having contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to have her baby “naturally” without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Elvira doesn’t want her called. She asks if she can talk to her mother on the telephone instead. As you finish assessing contractions, she screams with pain and shouts, “Ginagawa ko na ang lahat ng makakaya ko! Kailan ba matatapos ang paghihirap kong ito?”

97. Elvira didn’t recognize for over an hour that she was in labor. A sign of true labor is:
A. Sudden increase energy from epinephrine release
B. “Nagging” but constant pain in the lower back.
C. Urinary urgency from increased bladder pressure.
D. “Show” or release of the cervical mucus plug.

98. Elvira asks you which fetal position and presentation are ideal. Your best answer would be:
A. Right occipitoanterior with full flexion.
B. Left transverse anterior in moderate flexion.
C. Right occipitoposterior with no flexion.
D. Left sacroanterior with full flexion.

99. Elvira is having long and hard uterine contractions. What length of contraction would you report as abnormal?
A. Any length over 30 seconds.
B. A contraction over 70 seconds in length.
C. A contraction that peaks at 20 seconds.
D. A contraction shorter than 60 seconds.

100. You assess Elvira’s uterine contractions. In relation to the contraction, when does a late deceleration begin?
A. Forty-five seconds after the contraction is over.
B. Thirty seconds after the start of a contraction.
C. After every tenth or more contraction.
D. After a typical contraction ends.

The post Preboard Exam B — Test 2: Community, Maternal & Child Health Nursing appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Fundamentals of Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance.

SITUATION: A Nurse utilizes the nursing process in managing patient care. Knowledge of this process is essential to deliver high quality care and to focus on the client’s response to their illness.

1. During the planning phase of the nursing process, which of the following is the product developed?

A. Nursing care plan
B. Nursing diagnosis
C. Nursing history
D. Nursing notes

2. Objective data are also known as?

A. Covert data
B. Inferences
C. Overt data
D. Symptoms

3. Data or information obtained from the assessment of a patient is primarily used by nurse to:

A. Ascertain the patient’s response to health problems
B. Assist in constructing the taxonomy of nursing intervention
C. Determine the effectiveness of the doctor’s order
D. Identify the patient’s disease process

4. What is an example of a subjective data?

A. Color of wound drainage
B. Odor of breath
C. Respiration of 14 breaths/minute
D. The patient’s statement of “I feel sick to my stomach”

SITUATION : Correct application of the Nursing Process is vital in providing quality care. The nurse must use her skills and knowledge in proper assessment, planning and evaluating to meet the patient’s need and address the priority response of the client to his or her illness.

5. Which statement is a difference between comprehensive and focused assessment?

A. Comprehensive assessments can’t include any focus assessments
B. Focused assessments are more important than comprehensive assessments
C. Focused assessments are usually ongoing and concerning specific problems
D. Objective data are included only in comprehensive assessments

6. Two year old Ben’s mother states “Ben vomited 8 ounces of his formula this morning.” This statement is an example of:

A. Objective data from a primary source
B. Objective data from a secondary source
C. Subjective data from a primary source
D. Subjective data from a secondary source

7. Which expected outcome is correctly written?

A. The patient will be less edematous in 24 hours
B. The patient will drink an adequate amount of fluid daily
C. The patient will identify 5 high-salt foods from prepared list by discharge
D. The patient will soon sleep well through the night

8. An expected outcome on a patient’s care plan reads: “Patient will state seven warning signs of cancer by discharge.” When the nurse evaluates the patient progress, the patient is able to state that a change in wart or mole, a sore that doesn’t heal and a change in bowel or bladder habits are warning signals of cancer. Which of the following would be an appropriate evaluative statement for the nurse to place on the patient’s nursing care plan?

A. Patient understands the warning signals of cancer
B. Goal met; Patient cited a change in wart of mole, sore that doesn’t heal and a change in bowel or bladder habits as warning signals of cancer.
C. Goal not met
D. Goal partially met

9. A quality assurance nurse sends questionnaire to patients after discharge to determine their level of satisfaction with the nurse care they received in the facility. What type of nursing audit is this?

A. Concurrent
B. Outcome
C. Terminal
D. Retrospective

10. The nurse makes the following entry in the patient’s record: “Goal not met; patient refuses to attend smoking cessation classes.” Because this goal hasn’t been met, the nurse should:

A. Develop a completely new nursing care plan
B. Assign the patient to a more experienced nurse
C. Critique the steps involved in the development of the goal
D. Transfer the patient to another facility

SITUATION : Health care delivery system affects the health status of every filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life.

11. When should rehabilitation commence?

A. The day before discharge
B. When the patient desires
C. Upon admission
D. 24 hours after discharge

12. What exemplified the preventive and promotive programs in the hospital?

A. Hospital as a center to prevent and control infection
B. Program for smokers
C. Program for alcoholics and drug addicts
D. Hospital Wellness Center

13. Which makes nursing dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being
B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern developments that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes

14. Prevention is an important responsibility of the nurse in:

A. Hospitals
B. Community
C. Workplace
D. All of the above

15. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic payment.

A. Health Maintenance Organization
B. Medicare
C. Philippine Health Insurance Act
D. Hospital Maintenance Organization

SITUATION : Maslow’s hierarchy of needs is an integral component of prioritization. As a nurse, you must know the client’s needs that request for an immediate action.

16. The client with history of pulmonary emboli is scheduled for insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the physician has explained the procedure and obtained consent from the client. The client is lying in bed, wringing the hands, and says to the nurse, “I’m not sure about this. What if it doesn’t work, and I’m just as bad off as before?” The nurse addresses which of the following primary concerns of the client?

A. Fear related to the potential risk and outcome of surgery
B. Anxiety related to the fear of death
C. Ineffective individual coping related to the therapeutic regimen
D. Knowledge deficit related to the surgical procedure

17. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client?

A. Altered nutrition, less than body requirements
B. High risk for aspiration
C. High risk for fluid volume deficit
D. Diarrhea

18. A home care nurse finds a client in the bedroom, unconscious, with pill bottle in hand. The pill bottle contained the SSRI Sertraline (Zoloft). The nurse immediately assesses the client’s:

A. Blood pressure
B. Respirations
C. Pulse
D. Urine Output

19. A nurse is caring for a client admitted to the hospital for subclavian line placement. Which psychosocial area of assessment should the nurse address with the client?

A. Strict restrictions of neck mobility
B. Loss of ability to ambulate as tolerated
C. Possible body image disturbance
D. Continuous pain related to ongoing placement of the subclavian line

20. A hospitalized client who has a living will is being fed through a nasogastric tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?

A. Clear the client’s airway
B. Make the client comfortable
C. Start CPR
D. Stop feeding and remove the NG tube

SITUATION: Health Promotion is the priority nursing reponsibility. The nurse should be able to promote the client’s wellbeing and identify ways on improving the client’s quality of life.

21. The nurse is caring for a 16 year old female client who isn’t sexually active. The client asks if she needs a Papanicolau test. The nurse should reply:

A. Yes, she should have a Pap test after the onset of menstruation
B. No, because she isn’t sexually active
C. Yes, because she’s 16 years old
D. No, because she is not yet 21 years old

22. The nurse is assessing a client who complains of abdominal pain, nausea and diarrhea. When examining the client’s abdomen, which sequence should the nurse use?

A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, auscultation, percussion, inspection

23. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 45. Following the Philippine Cancer Society guidelines, the nurse should recommend that the women:

A. Perform breast self examination annually
B. Have a mammogram annually
C. Have a hormonal receptor assay annually
D. Have a physician conduct a clinical examination every 2 years

24. The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following instruction whould the nurse emphasize in her talk?

A. Stay out of the sun between 1 p.m and 3 p.m
B. Tanning booth are a safe alternative for those who wish to tan
C. Sun exposure is safe, provided the client wears protective clothing
D. Examine skin once per month, looking for suspicious lesions or changes in moles

25. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of prevention?

A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention

SITUATION : Basic nursing skills are essential for they are vital in many nursing procedures. Such skills are needed in order to promote health, prevent illness, cure a disease and rehabilitate infirmities.

26. A nurse has just been told by the physician that an order has been written to administer an iron injection to a client. The nurse plans to give the medication in the:

A. Gluteal muscle using Z-Track technique
B. Deltoid muscle using an air lock
C. Subcutaneous tissue of the abdomen
D. Anterolateral thigh using 5/8-inch needle

27. A client has just been told by the physician that a cerebral angiogram will be obtained. The nurse then collects data from the client about which of the following pieces of information?

A. Claustrophobia
B. Excessive weight
C. Allergy to eggs
D. Allergy to iodine or shellfish

28. A client has an order for a wound culture to be performed with the next wound irrigation and dressing change. The nurse would plan to use which of the following solutions for irrigation before this particular procedure?

A. Providone-iodine (Betadine)
B. One-half-strength hydrogen peroxide
C. Normal saline
D. Acetic acid

29. Which of the following is the best indicator in determining that the client’s airway needs suctioning?

A. Oxygen saturation measurement
B. Respiratory rate
C. Breath sounds
D. Arterial blood gas results

30. A nurse is planning to assist a diabetic client to perform self-monitoring of blood glucos levels. The nurse should incorporate which of the following strategies to best help the client obtain an adequate capillary sample?

A. Cleanse the hands beforehand using cool water
B. Let the arm hang dependently and milk the digit
C. Puncture the center of the finger pad
D. Puncture the finger as deeply as possible

SITUATION : Mastery of Intravenous therapy and all aspects that address the response of the client to complication related to it will help the new nurse in providing quality care.

31. One hour after the IV was inserted, Nurse Net found out that the 1 liter of D5NSS was empty. Patient was in severe respiratory distress with pinkish frothy sputum. The most probable complication is:

A. Speed shock
B. Renal failure
C. Congestive heart failure
D. Pulmonary edema

32. When an IV of D5W is not infusing well on patient, it is best to first:

A. Pinch the rubber part to flush out clogged blood
B. Coil tube and squeeze hard
C. Lower IV to check for return flow
D. Restart the IV

33. The doctor ordered venoclysis of dextrose 5% in water one liter KVO for 24 hours as a vehicle for IV medications. How many drops per minute should the fluid be regulated?

A. 20 drops per minute
B. 5 drops per minute
C. 10 drops per minute
D. 15 drops per minute

34. The nurse is administering I.V fluids to an infant. Infants receiving I.V Therapy are particularly vulnerable to:

A. Hypotension
B. Fluid overload
C. Cardiac arrythmias
D. Pulmonary emboli

35. A client with severe inflammatory bowel disease is receiving TPN. When administering TPN, the nusre must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

A. Hyperglycemia
B. Air embolism
C. Constipation
D. Dumping syndrome

SITUATION : Teaching and learning is a nursing responsibility. The ability of a nurse to educate and change the client’s behavior through health teaching is one important goal of nursing.

36. A client’s hypertension has been recently diagnosed. The nurse would plan to do which of the following as the first step in teaching the client about the disorder?

A. Gather all available resource material
B. Plan for the evaluation of the session
C. Assess the client’s knowledge and needs
D. Decide on the teaching approach

37. A diabetic client who is performing self-monitoring of blood glucose at home asks a clinic nurse why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate which of the following into a response?

A. This laboratory test is done yearly to predict likelihood of long term complication
B. This laboratory test gives an indication of glycemic control over the last 3 months
C. It is done as a method of verifying the accuracy of the meter used at Home
D. It is done to predict risk of hypoglycemia with the current diet and medication regimen

38. In teaching the sister of a diabetic client about the proper use of a glucometer in determining the blood sugar level of the client, The nurse is focusing in which domain of learning according to bloom?

A. Cognitive
B. Affective
C. Psychomotor
D. Affiliative

39. Which of the following is the most important condition for diabetic client to learn how to control their diet?

A. Use of pamphlets and effective teaching devices during health instruction
B. Motivation to be symptom free
C. Ability of the client to understand teaching instruction
D. Language and appropriateness of the instruction

40. When you prepare your teaching plan for a group of hypertensive clients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds to the writing of learning objectives?

A. Planning
B. Implementing
C. Evaluating
D. Assessing

SITUATION : Nursing is a science. It involves a wide spectrum of theoretical foundation applied in different health care situation. The nurse must use these theories in order to deliver the most needed quality care.

41. The theorist who believes that adaptation and manipulation of stressors are needed to foster change is:

A. Betty Neuman
B. Dorothea Orem
C. Martha Rogers
D. Sister Callista Roy

42. The theorist whose theory can be defined as the development of a science of humankind, incorporating the concepts of energy fields, openness, pattern and organization is:

A. Dorothy Johnson
B. Hildegard Peplau
C. Martha Rogers
D. Myra Levine

43. A theorist whose major theme is the idea of transcultural nursing and caring nursing is:

A. Dorothea Orem
B. Madeleine Leininger
C. Sister Callista Roy
D. Virginia Henderson

44. Florence Nightingale was born in

A. Italy, May 12, 1840
B. Italy, May 12, 1820
C. England, May 12, 1840
D. England, May 12, 1820

45. Smith conceptualizes this health model as a condition of actualization or realization of person’s potential. Avers that the highest aspiration of people is fulfillment and complete developmental actualization.

A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model

SITUATION : Oxygen is the most important physiologic requirement of the body. Absence of this vital element for over 6 minutes leads to irreversible brain damage. Measures that promotes oxygenation is integral in successfully managing client’s response to illnesses.

46. The primary effect of oxygen therapy is to:

A. Increase oxygen in the tissues and cells
B. Increase oxygen carrying capacity of the blood
C. Increase respiratory rate
D. Increase oxygen pressure in the alveolar sac

47. A nurse suctions a client who has an endotracheal tube in place. Following the procedure, which of the following would indicate to the nurse that the client is experiencing an adverse effect of this procedure?

A. Hypertension
B. Cardiac Irregularities
C. A reddish coloration in the client’s face
D. Oxygen saturation level of 95%

48. The GAUGE size in ET tubes determines:

A. The external circumference of the tube
B. The internal diameter of the tube
C. The length of the tube
D. The tube’s volumetric capacity

49. The nurse is correct in performing suctioning when she applies the suction intermittently during:

A. Insertion of the suction catheter
B. Withdrawing of the suction catheter
C. both insertion and withdrawing of the suction catheter
D. When the suction catheter tip reaches the bifurcation of the trachea

50. The purpose of the cuff in Tracheostomy tube is to:

A. Separate the upper and lower airway
B. Separate trachea from the esophagus
C. Separate the larynx from the nasopharynx
D. Secure the placement of the tube

SITUATION : To deliver a safe and quality care, Knowledge about wound care is necessary. The nurse will have to deal with different types of wound during practice. It is of outmost important to apply this knowledge to ensure optimum wound healing.

51. Based on the nurse’s knowledge of surgical wounds, simple surgical incisions heal by:

A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Quarternary intention

52. The nurse documents that the wound edges are approximated. When the edges of an incision are said to be approximated, this means edges are:

A. Brought together by sutures, tapes or staples
B. Eythematous and swollen
C. Gaping and draining
D. Necrotic and draining

53. Which vitamin is most essential for collagen synthesis?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

54. When assessing the client’s wound for sign of infection, the nurse should look for the presence of which of the following?
A. Granulation tissue
B. Pink tissue
C. Purulent drainage
D. Well approximated edges

55. The nurse is changing dressing and providing wound care. Which activity should she perform first?

A. Assess the drainage in the dressing
B. Slowly remove the soiled dressing
C. Wash hands thoroughly
D. Put on latex gloves

SITUATION : Physical examination and health assessment are important in rendering care. The nurse must use assessment knowledge in order to determine and prioritize client’s response to his or her illness.

56. The component that should receive the highest priority before physical examination is the:

A. Psychological preparation of the client
B. Physical Preparation of the client
C. Preparation of the Environment
D. Preparation of the Equipments

57. When inspecting a client’s skin, the nurse finds a vesicle on the client’s arm. Which description applies to a vesicle?

A. A flat, nonpalpable, and colored
B. Solid, elevated, and circumscribed
C. Circumscribed, elevated, and filled with serous fluid
D. Elevated, pus-filled, and circumscribed

58. When assessing a client with abdominal pain, the nurse should assess:

A. Any quadrant first
B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The sympomatic quadrant either second or third

59. To assess the client’s dorsalis pedis pulse, the nurse should palpate the:

A. Medial surface of the ankle
B. Lateral surface of the ankle
C. Ventral aspect of the top of the foot
D. Medial aspect of the dorsum of the foot

60. Which of the following assessment would be a priority for a 2 year old after bronchoscopy?

A. Cardiac rate
B. Respiratory quality
C. Sputum color
D. Pulse pressure changes

61. The nurse checks the client’s gag reflex. The recommended technique for testing the gag reflex is to:

A. touch the back of the client’s throat with a tongue depressor
B. observe the client for evidence of spontaneous swallowing when the neck is stroked
C. place a few milliliters of water on the client’s tongue and note whether or not he swallows
D. observe the client’s response to the introduction of a catheter for endotracheal suctioning

62. The nurse is evaluating a client’s lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields?

A. Vesicular
B. Bronchial
C. Bronchovesicular
D. Adventitious

63. The night nurse informs the primary nurse that a client receiving intermittent gavage feedings is not tolerating them. The primary nurse should first:

A. Change the feeding schedule to omit nights
B. Request that the type of solution be changed
C. Observe the night nurse administering a feeding
D. Suggest that the prescribed antiemetic be given first

64. A client has a chest tubes attached to a pleural drainage system. When caring for this client, the nurse should:

A. Palpate the surrounding are for crepitus
B. Clamp the chest tubes when suctioning the client
C. Change the dressing daily using aseptic technique
D. Empty drainage chamber at the end of the shift

65. The nurse, aware of a client’s 25 year history of excessive alcohol use, would expect the physical assessment to reveal a:

A. Liver infection
B. Low blood ammonia
C. Small liver with a rough surface
D. High fever with a generalizedrash

SITUATION : Nursing is a profession. Miss Linda is a newly appointed nurse in a hospital in Manila. Born May 1985, Her knowledge of nursing’s professional development is required in order to project the profession in a way that it lifts the standards of nursing.

66. Mrs. Linda defined nursing as one of the following except:

A. Assisting individual, family and community in attaining health
B. Assisting basic health needs
C. Establishing nursing diagnosis and implementing nursing care
D. Diagnosing, treating, prescribing medication and doing minor surgery

67. PNA was established in:

1. 1922
2. 1926
3. With Mrs. Rosario Delgado as first president
4. With Mrs. Anastacia Tupas as first president

A. 1,3
B. 1,4
C. 2,3
D. 2,4

68. As a national nurses association, it is characterized as follows except:

A. Both a professional body and a labor union
B. Affiliated with the International Council Of Nurses
C. Advocating for improved work and life condition of Nurses
D. Accrediting body for continuing education program

69. CPE Units per year is needed for license renewal. The number of CPE units per year should be:

A. 20 units
B. 30 units
C. 60 units
D. 100 units

70. As a nurse, R.A 1080 Exempts her from:

A. Paying her professional tax
B. Examination for civil service eligibility
C. Qualifying for the CGFNS
D. Paying business permit

71. In resigning for her job as a staff nurse, she must give advance notice of:

A. 15 days
B. 30 days
C. 45 days
D. 60 days

72. Why is there an ethical dilemma?

A. Because the law do not clearly state what is right from what is wrong
B. Because morality is subjective and it differs from each individual
C. Because the patient’s right coincide with the nurse’s responsibility
D. Because the nurse lacks ethical knowledge to determine what action is correct and what action is unethical

73. Who among the following can work as a practicing nurse in the Philippines without taking the Licensure examination?

A. Internationally well known experts which services are for a fee
B. Those that are hired by local hospitals in the country
C. Expert nurse clinicians hired by prestigious hospitals
D. Those involved in medical mission who’s services are for free

74. The nurse is correct in determining that a License is:

A. A personal property
B. Can be revoked by the Board of Nursing
C. A Right
D. Can be revoked by the PNA

75. A License is renewed every:

A. 1 year
B. 2 years
C. 3 years
D. 4 years

76. Which of the following persons cannot have free access to a patient’s record?

A. The patient
B. The physical therapist
C. The pharmacist
D. The lawyer

77. Ms. Linda’s license will expire in 2007, She must renew her license when?

A. January 2007
B. December 2007
C. May 2007
D. May 2008

78. The practice of Nursing in the Philippines is regulated by:

A. RA 9163
B. RA 9173
C. RA 7164
D. RA 7146

79. This quality is being demonstrated by a Nurse who raise the side rails of a confuse and disoriented patient?

A. Autonomy
B. Responsibility
C. Prudence
D. Resourcefulness

80. Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the student. The case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of crimes. They are correct in identifying which of the following Circumstances that will be best applied in this case?

A. Justifying
B. Aggravating
C. Mitigating
D. Exempting

SITUATION : This is the first day of Mark, R.N. to report as a staff nurse in a tertiary hospital. As a morning duty nurse, she is about to chart her nursing care.

81. Which of the following is not an accepted medical abbreviation?

A. NPO
B. PRN
C. OD
D. NON

82. Communication is best undertaken if barriers are first removed. Considering this statement, which of the following is considered as deterrent factor in communication?

A. Not universally accepted abbreviation
B. Wrong Grammar
C. Poor Penmanship
D. Old age of the client

83. Which of the following chart entries are not acceptable?

A. Patient complained of chest pain
B. Patient ambulated to B/R
C. Vital signs 130/70; 84; 20
D. Pain relieved by Nitrogylcerine gr 1/150 sublingually

84. Which of the following indicates narrative charting?

A. Written descriptive nurse’s notes
B. Date recorded on nurse activity sheet
C. Use of checklist
D. Use of flowsheet

85. Being a new staff nurse, Mark remembers that information needed for daily nursing care of clients are readily available in which of the following?

A. Kardex
B. Order sheet
C. Admission notes
D. Nurses notes

SITUATION : Mr. Orlando is assigned to Mang Carlos, A 60 years old, newly diagnosed diabetes patient. He is beginning to write objectives for his teaching plan.

86. Which of the following is written in behavioral term?

A. Mang Carlos will know about diabetes related foot care and the techniques and equipment necessary to carry it out
B. Mang Carlos sister will be able to determine his insulin requirement based on blood glucose levels obtained from glucometer in two days
C. Mang Carlos daugter should learn about diabetes milletus within the week
D. Mang Carlos wife needs to understand the side effects of insulin

87. Which of the following is the best rationale for written objectives?

A. Document the quality of care
B. Facilitate evaluation of the performance of the nurse
C. Ensure learning on the part of the nurse
D. Ensure communication among staff members

88. Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is no longer capable to do so. As a Nurse, You know that this is called:

A. Last will and testament
B. DNR
C. Living will
D. Durable Power of Attorney

89. Which of the following behavior of Mang Carlos least indicates readiness to learn?

A. Talking with the nurse in charge and doctor
B. Reading brochures and pamphlets about diabetes
C. Inquiring about date of discharge
D. Asking question about diabetes milletus

90. Which of the following behaviors best contribute to the learning of Mang Carlos regarding his disease condition?

A. Drawing him into discussion about diabetes
B. Frequent use of technical terms
C. Loosely structured teaching session
D. Detailed lengthy explanation

SITUATION : Mrs. Purificacion is now the Chief nurse of a hospital in Manila. She is carefully reviewing different management styles and theories that will best help her in running the nursing services in the hospital.

91. Which leadership style best empower the staff towards excellence?

A. Autocratic
B. Situational
C. Democratic
D. Laissez Faire

92. As a Nurse Manager, DSJ enjoys his staff of talented and self motivated individuals. He knew that the leadership style to suit the needs of this kind of people is called:

A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire

93. A fire has broken in the unit of DSJ R.N. The best leadership style suited in cases of emergencies like this is:

A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire

94. Mrs. Purificacion is thinking of introducing the Primary Nursing Model Approach. You understand that this nursing model is:

A. The nurse manager assigns tasks to the staff members
B. Critical paths are used in providng nursing care
C. A single registered nurse is responsible for planning and providing individualized nursing care
D. Nursing staff are led by an RN leader in providing care to a group of clients

95. Structure, Process and Outcome are components of which step of the management process?

A. Planning
B. Organizing
C. Directing
D. Controlling

SITUATION : Nursing research is the term used to describe the evidence used to support nursing practice. Nursing, as an evidence based area of practice, has been developing since the time of Florence Nightingale to the present day, where many nurses now work as researchers based in universities as well as in the health care setting.

96. Mr. DSJ Plans to undertake a research of Community 1 and 2 on how they manage their health using Primary health care after an organization and training seminars. This type of research is:

A. Experimental
B. Historical
C. Descriptive
D. Basic

97. The independent variable is:

A. Primary Health Care
B. Community 1 and 2
C. Organization and training seminars
D. Management of their health

98. In this design, the variable that is being manipulated is

1. Independent
2. Organization and training seminars
3. Dependent
4. Management of Primary Health Care

A. 1,2
B. 1,4
C. 2,3
D. 3,4

99. In general, the research process follows the ff. ordered sequence:

1. Determination of design
2. Statement of the problem
3. Definition of variables
4. Collection and analysis of data
5. Review of related literature

A. 2,5,3,1,4
B. 3,5,4,1,2
C. 2,5,3,4,1
D. 2,5,1,3,4

100. Studies done in natural setting such as this one, posses difficulty of controlling which variable?
A. Independent
B. Dependent
C. Extraneous
D. Organismic

The post Preboard Exam B — Test 1: Fundamentals of Nursing appeared first on Nurseslabs.

Sample questions for Leadership & Management in Nursing, Research & Bioethics, and Nursing Jurisprudence. Questions in this Nursing Leadership & Management Exam 1 (40 Items) can be used for your NCLEX review or Nurse Licensure Examination (NLE)/Board Examination.

1. Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take?

A. Identify the source of the conflict and understand the points of friction
B. Disregard what she feels and continue to work independently
C. Seek help from the Director of Nursing
D. Quit her job and look for another employment.

2. As a young manager, she knows that conflict occurs in any organization. Which of the following statements regarding conflict is NOT true?

A. Can be destructive if the level is too high
B. Is not beneficial; hence it should be prevented at all times
C. May result in poor performance
D. May create leaders

3. Katherine tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

A. Smoothing
B. Compromise
C. Avoidance
D. Restriction

4. Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do?

A. Advise her staff to go on vacation.
B. Ignore her observations; it will be resolved even without intervention
C. Remind her to show loyalty to the institution.
D. Let the staff ventilate her feelings and ask how she can be of help.

5. She knows that performance appraisal consists of all the following activities EXCEPT:

A. Setting specific standards and activities for individual performance.
B. Using agency standards as a guide.
C. Determine areas of strength and weaknesses
D. Focusing activity on the correction of identified behavior.

6. Which of the following statements is NOT true about performance appraisal?

A. Informing the staff about the specific impressions of their work help improve their performance.
B. A verbal appraisal is an acceptable substitute for a written report
C. Patients are the best source of information regarding personnel appraisal.
D. The outcome of performance appraisal rests primarily with the staff.

7. There are times when Katherine evaluates her staff as she makes her daily rounds. Which of the following is NOT a benefit of conducting an informal appraisal?

A. The staff member is observed in natural setting.
B. Incidental confrontation and collaboration is allowed.
C. The evaluation is focused on objective data systematically.
D. The evaluation may provide valid information for compilation of a formal report.

8. She conducts a 6-month performance review session with a staff member. Which of the following actions is appropriate?

A. She asks another nurse to attest the session as a witness.
B. She informs the staff that she may ask another nurse to read the appraisal before the session is over.
C. She tells the staff that the session is manager-centered.
D. The session is private between the two members.

9. Alexandra is tasked to organize the new wing of the hospital. She was given the authority to do as she deems fit. She is aware that the director of nursing has substantial trust and confidence in her capabilities, communicates through downward and upward channels and usually uses the ideas and opinions of her staff. Which of the following is her style of management?

A. Benevolent –authoritative
B. Consultative
C. Exploitive-authoritative
D. Participative

10. She decides to illustrate the organizational structure. Which of the following elements is NOT included?

A. Level of authority
B. Lines of communication
C. Span of control
D. Unity of direction

11. She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

A. Staffing
B. Scheduling
C. Recruitment
D. Induction

12. She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary?

A. Certificate of previous employment
B. Record of related learning experience (RLE)
C. Membership to accredited professional organization
D. Professional identification card

13. Which phase of the employment process includes getting on the payroll and completing documentary requirements?

A. Orientation
B. Induction
C. Selection
D. Recruitment

14. She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

A. Centralized
B. Decentralized
C. Matrix
D. Informal

15. In a horizontal chart, the lowest level worker is located at the

A. Left most box
B. Middle
C. Right most box
D. Bottom

16. She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing?

A. greater control of activities
B. Conserves time
C. Compatible with computerization
D. Promotes better interpersonal relationship

17. Aubrey thinks about primary nursing as a system to deliver care. Which of the following activities is NOT done by a primary nurse?

A. Collaborates with the physician
B. Provides care to a group of patients together with a group of nurses
C. Provides care for 5-6 patients during their hospital stay.
D. Performs comprehensive initial assessment

18. Which pattern of nursing care involves the care given by a group of paraprofessional workers led by a professional nurse who take care of patients with the same disease conditions and are located geographically near each other?

A. Case method
B. Modular nursing
C. Nursing case management
D. Team nursing

19. St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?

A. Make an interpretation about strengths and weaknesses
B. Identify the values of the department
C. Identify structure, process, outcome standards & criteria
D. Measure actual performances

20. Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?

A. The patients verbalized satisfaction of the nursing care received
B. Rotation of duty will be done every four weeks for all patient care personnel.
C. All patients shall have their weights taken recorded
D. Patients shall answer the evaluation form before discharge

21. When she presents the nursing procedures to be followed, she refers to what type of standards?

A. Process
B. Outcome
C. Structure
D. Criteria

22. The following are basic steps in the controlling process of the department. Which of the following is NOT included?

A. Measure actual performance
B. Set nursing standards and criteria
C. Compare results of performance to standards and objectives
D. Identify possible courses of action

23. Which of the following statements refers to criteria?

A. Agreed on level of nursing care
B. Characteristics used to measure the level of nursing care
C. Step-by-step guidelines
D. Statement which guide the group in decision making and problem solving

24. She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?

A. Instructing the members of the standards committee to prepare policies
B. Reviewing the existing policies of the hospital
C. Evaluating the credentials of all nursing staff
D. Checking if activities conform to schedule

25. Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?

A. Initial assessment shall be done to all patients within twenty four hours upon admission.
B. Informed consent shall be secured prior to any invasive procedure
C. Patients’ reports 95% satisfaction rate prior to discharge from the hospital.
D. Patient education about their illness and treatment shall be provided for all patients and their families.

26. Which of the following is evidence that the controlling process is effective?

A. The things that were planned are done
B. Physicians do not complain.
C. Employees are contended
D. There is an increase in customer satisfaction rate.

27. Ms. Valencia is responsible to the number of personnel reporting to her. This principle refers to:

A. Span of control
B. Unity of command
C. Carrot and stick principle
D. Esprit d’ corps

28. She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority?

A. Evaluate the overall result of the unrest
B. Initiate a group interaction
C. Develop a plan and implement it
D. Identify external and internal forces.

29. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study?

A. Date of admission
B. Length of stay
C. Age of patients
D. Absence of complications

30. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation?

A. Martha Rogers
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson

31. He opts to use a self-report method. Which of the following is NOT TRUE about this method?

A. Most direct means of gathering information
B. Versatile in terms of content coverage
C. Most accurate and valid method of data gathering
D. Yields information that would be difficult to gather by another method

32. Which of the following articles would Kevin least consider for his review of literature?

A. “Story-Telling and Anxiety Reduction Among Pediatric Patients”
B. “Turnaround Time in Emergency Rooms”
C. “Outcome Standards in Tertiary Health Care Institutions”
D. “Environmental Manipulation and Client Outcomes”

33. Which of the following variables will he likely EXCLUDE in his study?

A. Competence of nurses
B. Caring attitude of nurses
C. Salary of nurses
D. Responsiveness of staff

34. He plans to use a Likert Scale to determine

A. degree of agreement and disagreement
B. compliance to expected standards
C. level of satisfaction
D. degree of acceptance

35. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration?

A. Validity
B. Reliability
C. Sensitivity
D. Objectivity

36. Which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied?

A. Sensitivity
B. Reliability
C. Validity
D. Objectivity

37. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure?

A. Validity
B. Reliability
C. Meaningfulness
D. Sensitivity

38. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked?

A. Random
B. Accidental
C. Quota
D. Judgment

39. Raphael is interested to learn more about transcultural nursing because he is assigned at the family suites where most patients come from different cultures and countries. Which of the following designs is appropriate for this study?

A. Grounded theory
B. Ethnography
C. Case study
D. Phenomenology

40. The nursing theorist who developed transcultural nursing theory is

A. Dorothea Orem
B. Madeleine Leininger
C. Betty Newman
D. Sr. Callista Roy

The post Nursing Leadership & Management Exam 2 (40 Items) appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Medical-Surgical Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Note: In the actual board exams, this test is entitled as Care of Clients with Physiologic and Psychosocial Alterations Nursing. 

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?

a. Sudden weight loss
b. Polyuria
c. Hypertension
d. Shock

2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:

a. Pain
b. Weight
c. Hematuria
d. Hypertension

3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:

a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid glands.
c. Block the formation of thyroxine by the thyroid gland.
d. Decrease the size and vascularity of the thyroid gland.

4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:

a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism

5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:

a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia

6. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.

7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:

a. Lie on my left side while instilling the irrigating solution.”
b. Keep the irrigating container less than 18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.”
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.”

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.

9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min

10.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

a. Face and neck
b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk

11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature

12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports

13.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.

14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:

a. Reduce incisional pain.
b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space.
d. Increase venous return

15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be:

a. Food and fluids will be withheld for at least 2 hours.
b. Warm saline gargles will be done q 2h.
c. Coughing and deep-breathing exercises will be done q2h.
d. Only ice chips and cold liquids will be allowed initially.

16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.

17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
d. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

18.Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?

a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.

19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:

a. Increased pH with decreased hydrogen ions.
b. Increased serum levels of potassium, magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?

a. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
d. Alteration in the size, shape, and organization of differentiated cells.

21. During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

a. Squamous cell carcinoma
b. Multiple myeloma
c. Leukemia
d. Kaposi’s sarcoma

22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?

a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias

23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

a. Auscultate bowel sounds.
b. Palpate the abdomen.
c. Change the client’s position.
d. Insert a rectal tube.

24.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?

a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor

25.A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?

a. Blood supply to the stoma has been interrupted.
b. This is a normal finding 1 day after surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.

26.Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?

a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client’s palms
d. Performing shoulder range-of-motion exercises

27.Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
b. Urine output of 20 ml/hour.
c. White pulmonary secretions.
d. Rectal temperature of 100.6° F (38° C).

28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

a. Turn him frequently.
b. Perform passive range-of-motion (ROM) exercises.
c. Reduce the client’s fluid intake.
d. Encourage the client to use a footboard.

29.Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

a. With a circular motion, to enhance absorption.
b. With an upward motion, to increase blood supply to the affected area
c. In long, even, outward, and downward strokes in the direction of hair growth
d. In long, even, outward, and upward strokes in the direction opposite hair growth

30.Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and
sympathetic nerve stimulation is:

a. Beta -adrenergic blockers
b. Calcium channel blocker
c. Narcotics
d. Nitrates

31.A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?

a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position

32.The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?

a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents

33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?

a. Fiber intake of 25 to 30 g daily
b. Less than 30% of calories form fat
c. Cholesterol intake of less than 300 mg daily
d. Less than 10% of calories from saturated fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?

a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
b. The CCU nurse notifies the on-call physician about a change in the client’s condition
c. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
d. At the client’s request, the CCU nurse updates the client’s wife on his condition

35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?

a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
b. Check endotracheal tube placement.
c. Obtain an arterial blood gas (ABG) sample.
d. Administer atropine, 1 mg L.V.

36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?

a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?

a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.
d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel

38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?

a. Pancytopenia
b. Idiopathic thrombocytopemic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?

a. Acetylsalicylic acid (ASA)
b. Corticosteroids
c. Methotrezate
d. Vitamin K

40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?

a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic

41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?

a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa

42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?

a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
d. Von Willebrand’s disease

43. The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin’s disease?

a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia

44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?

a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability

46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?

a. Less than 5 years
b. 5 to 7 years
c. 10 years
d. More than 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?

a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?

a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?

a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive

Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.

50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?

a. “I should contact the physician if Stacy has difficulty in sleeping”.
b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
c. “My physician should be called if Stacy is irritable and unhappy”.
d. “Should Stacy have continued hair loss, I need to call the doctor”.

51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

a. “Stacy looks very nice wearing a hat”.
b. “You should not worry about her hair, just be glad that she is alive”.
c. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.

52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:

a. Provide frequent mouthwash with normal saline.
b. Apply viscous Lidocaine to oral ulcers as needed.
c. Use lemon glycerine swabs every 2 hours.
d. Rinse mouth with Hydrogen Peroxide.

53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:

a. Notify the physician
b. Flush the IV line with saline solution
c. Immediately discontinue the infusion
d. Apply an ice pack to the site, followed by warm compress.

54. The term “blue bloater” refers to a male client which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

55. The term “pink puffer” refers to the female client with which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

56. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?

a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg

57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respirator y alkalosis

58. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?

a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis

Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:

59. Which laboratory test indicates liver cirrhosis?

a. Decreased red blood cell count
b. Decreased serum acid phosphate level
c. Elevated white blood cell count
d. Elevated serum aminotransferase

60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

a. Impaired clotting mechanism
b. Varix formation
c. Inadequate nutrition
d. Trauma of invasive procedure

61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

a. Increased urine output
b. Altered level of consciousness
c. Decreased tendon reflex
d. Hypotension

62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:

a. “I’ll see if your physician is in the hospital”.
b. “Maybe your reacting to the drug; I will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
d. “Frequently, bowel movements are needed to reduce sodium level”.

63. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?

a. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
c. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
d. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

a. Call for help.
b. Obtain vital signs
c. Ask the client to “lift up”
d. Apply gloves and assess the groin site

65. Which of the following treatment is a suitable surgical intervention for a client with unstable angina?

a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary angioplasty (PTCA)

66. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:

a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)

67. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?

a. Kidneys’ excretion to sodium only.
b. Kidneys’ retention of sodium and water
c. Kidneys’ excretion of sodium and water
d. Kidneys’ retention of sodium and excretion of water

68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

a. It dilates peripheral blood vessels.
b. It decreases sympathetic cardioacceleration.
c. It inhibits the angiotensin-coverting enzymes
d. It inhibits reabsorption of sodium and water in the loop of Henle.

69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

a. Elavated serum complement level
b. Thrombocytosis, elevated sedimentation rate
c. Pancytopenia, elevated antinuclear antibody (ANA) titer
d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels

70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?

a. “Your son had a mild concussion, acetaminophen is strong enough.”
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
c. “Narcotics are avoided after a head injury because they may hide a worsening condition.”
d. Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”

71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?

a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
b. Emergent; the client is poorly oxygenated
c. Normal
d. Significant; the client has alveolar hypoventilation

72. When prioritizing care, which of the following clients should the nurse Olivia assess first?

a. A 17-year-old clients 24-hours postappendectomy
b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days postmyocardial infarction
d. A 50-year-old client with diverticulitis

73. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization

74. Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?

a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form of arthritis
d. Osteoarthritis afflicts people over 60

75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications?

a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema

76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

a. Pitting edema of the legs
b. An irregular apical pulse
c. Dry mucous membranes
d. Frequent urination

77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

a. Above-normal urine and serum osmolality levels
b. Below-normal urine and serum osmolality levels
c. Above-normal urine osmolality level, below-normal serum osmolality level
d. Below-normal urine osmolality level, above-normal serum osmolality level

78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

a. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
b. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
c. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
d. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

79. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?

a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism

80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

a. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
b. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
c. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
d. “I’ll take the entire dose at bedtime.”

81. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

a. High corticotropin and low cortisol levels
b. Low corticotropin and high cortisol levels
c. High corticotropin and high cortisol levels
d. Low corticotropin and low cortisol levels

82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?

a. Testing for ketones in the urine
b. Testing urine specific gravity
c. Checking temperature every 4 hours
d. Performing capillary glucose testing every 4 hours

83. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:

a. onset to be at 2 p.m. and its peak to be at 3 p.m.
b. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
c. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
d. onset to be at 4 p.m. and its peak to be at 6 p.m.

84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
b. A decreased TSH level
c. An increase in the TSH level after 30 minutes during the TSH stimulation test
d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

a. “Inject insulin into healthy tissue with large blood vessels and nerves.”
b. “Rotate injection sites within the same anatomic region, not among different regions.”
c. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
d. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

86. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

a. Elevated serum acetone level
b. Serum ketone bodies
c. Serum alkalosis
d. Below-normal serum potassium level

87. For a client with Graves’ disease, which nursing intervention promotes comfort?

a. Restricting intake of oral fluids
b. Placing extra blankets on the client’s bed
c. Limiting intake of high-carbohydrate foods
d. Maintaining room temperature in the low-normal range

88. Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?

a. Fracture of the distal radius
b. Fracture of the olecranon
c. Fracture of the humerus
d. Fracture of the carpal scaphoid

89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium

90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Atelectasis
c. Bronchitis
d. Pneumonia

91. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?

a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism

92. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax

93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?

a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)

94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and consolidates the region
d. The tissue from the other lung grows over to the other side

95. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?

a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in the occluded area
c. Loss of lung parenchyma
d. Loss of lung tissue

96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?

a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube

98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?

a. 18
b. 21
c. 35
d. 40

99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml

100. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?

a. “I will wear the stockings until the physician tells me to remove them.”
b. “I should wear the stockings even when I am sleep.”
c. “Every four hours I should remove the stockings for a half hour.”
d. “I should put on the stockings before getting out of bed in the morning.”

The post Preboard Exam C — Test 4: Medical-Surgical Nursing appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Fundamentals of Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:

a. The physician’s orders.
b. The action of a clinical nurse specialist who is recognized expert in the field.
c. The statement in the drug literature about administration of terbutaline.
d. The actions of a reasonably prudent nurse with similar education and experience.

2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C

3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record?

a. “Digoxin .1250 mg P.O. once daily”
b. “Digoxin 0.1250 mg P.O. once daily”
c. “Digoxin 0.125 mg P.O. once daily”
d. “Digoxin .125 mg P.O. once daily”

4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?

a. Ineffective peripheral tissue perfusion related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.

5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:

a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”

10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

12. Nurse Amy is aware that the following is true about functional nursing

a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

13.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?”

a. Single order
b. Standard written order
c. Standing order
d. Stat order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation?

a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client’s ear by:

a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:

a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.

17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

a. Encourage the client to void following preoperative medication.
b. Explore the client’s fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.

18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis?

a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.

19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?

a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.

20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?

a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.

21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?

a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.

22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?

a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.

23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?

a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge

24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?

a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.

25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is:

a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational

26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?

a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc

27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:

a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour

28.The nurse is aware that the most important nursing action when a client returns from surgery is:

a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.

29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?

a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular
d. BP – 180/100, Pulse – 90 irregular

30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?

a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
b. Measure the client’s arm, if you are not sure of the size of cuff to use.
c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
d. Document the measurement, which extremity was used, and the position that the client was in during the measurement.

31.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?

a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals

32.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?

a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination

33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:

a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow

34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

35.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed

a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing

36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:

a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia

37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the
client receive?

a. 0.75
b. 0.6
c. 0.5
d. 0.25

38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?

a. It’s a common measurement in the metric system.
b. It’s the basis for solids in the avoirdupois system.
c. It’s the smallest measurement in the apothecary system.
d. It’s a measure of effect, not a standard measure of weight or quantity.

39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?

a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C

40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical
signs of aging is:

a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.

41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:

a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.

42.Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to:

a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and wait a client to repeat it.
d. Check the room number and the client’s name on the bed.

43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:

a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute

44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately?

a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.

45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order:

a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.

46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the:

a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand

47. Which type of evaluation occurs continuously throughout the teaching and learning process?

a. Summative
b. Informative
c. Formative
d. Retrospective

48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have
mammogram how often?

a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline

49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?

a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal illness.
c. To ensure that the client gets counseling regarding health care costs.
d. To teach the client and family about cancer and its treatment.

51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute
independently?

a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per day.

52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should apply the bandage beginning at the client’s:

a. Knee
b. Ankle
c. Lower thigh
d. Foot

53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?

a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia

54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience:

a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take which action first?

a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the client’s level of consciousness

56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting the client is to stand:

a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.

57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse determines that the standard of care had been maintained if which of the following data is observed?

a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg

58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen?

a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.

59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to:

a. Immediately walk out of the client’s room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.

60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen?

a. Ask the client to expectorate a small amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
d. Provide tissues for expectoration and obtaining the specimen.

61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client:

a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor.

62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error?

a. Erases the error and writes in the correct information.
b. Uses correction fluid to cover up the incorrect information and writes in the correct information.
c. Draws one line to cross out the incorrect information and then initials the change.
d. Covers up the incorrect information completely using a black pen and writes in the correct information

63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should:

a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.

64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath?

a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles

65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating?

a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker

66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure?

a. Prone with head turned toward the side supported by a pillow.
b. Sims’ position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated 45 degrees.
d. Left side-lying with the head of the bed elevated 45 degrees.

67.Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration?

a. Validity
b. Specificity
c. Sensitivity
d. Reliability

68.Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity?

a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study

69.Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. What type of research is appropriate for this study?

a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical

70.Nurse Ronald is aware that the best tool for data gathering is?

a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation

71.Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this?

a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design

72.Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this?

a. Footnote
b. Bibliography
c. Primary source
d. Endnotes

73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle:

a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity

74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of:

a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine

75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is:

a. The Board can issue rules and regulations that will govern the practice of nursing
b. The Board can investigate violations of the nursing law and code of ethics
c. The Board can visit a school applying for a permit in collaboration with CHED
d. The Board prepares the board examinations

76. When the license of nurse Krina is revoked, it means that she:

a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing

77.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process?

a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework

78. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred to as :

a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect

79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?

a. Plans to include whoever is there during his study.
b. Determines the different nationality of patients frequently admitted and decides to get representations samples from each.
c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.
d. Decides to get 20 samples from the admitted patients

80. The nursing theorist who developed transcultural nursing theory is:

a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy

81.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is:

a. Random
b. Accidental
c. Quota
d. Judgment

82.John plans to use a Likert Scale to his study to determine the:

a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance

83.Which of the following theory addresses the four modes of adaptation?

a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson

84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:

a. Span of control
b. Unity of command
c. Downward communication
d. Leader

85.Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of:

a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence

86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction?

a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.

87.A client is admitted with multiple pressure ulcers. When developing the client’s diet plan, the nurse should include:

a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties

88.The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure?

a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral

89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first?

a. Arrange for typing and cross matching of the client’s blood.
b. Compare the client’s identification wristband with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the client’s vital signs.

90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required?

a. Independent
b. Dependent
c. Interdependent
d. Intradependent

91.A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client’s leg is pain-free, without redness or edema. The nurse’s actions reflect which step of the nursing process?

a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

92.Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention?

a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.

93.Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion?

a. Instructing the client to report any itching, swelling, or dyspnea.
b. Informing the client that the transfusion usually take 1 ½ to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the client’s vital signs when the transfusion ends.

94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler’s position while feeding.
d. Change the feeding container every 12 hours.

95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should:

a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when administering oxygen by face mask to a female client?

a. Secure the elastic band tightly around the client’s head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client’s chin up over the nose.
d. Loosen the connectors between the oxygen equipment and humidifier.

97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

98.Nurse Monique is monitoring the effectiveness of a client’s drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level?

a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.

99.Nurse May is aware that the main advantage of using a floor stock system is:

a. The nurse can implement medication orders quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.

100. Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse report as abnormal?

a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries.

The post Preboard Exam C — Test 1: Fundamentals of Nursing appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Fundamentals of Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today.

1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and population. This is the most accepted definition of nursing as defined by the:
A. PNA
B. ANA
C. Nightingale
D. Henderson

2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT expanded career role for nurse?
A. Nurse practitioner
B. Clinical Nurse Specialist
C. Nurse Researcher
D. Nurse anaesthesiologist

3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following EXCEPT:
A. Issue, suspend revoke certificates of registration
B. Issue subpoena duces tecum, ad testificandum
C. Open and close colleges of nursing
D. Supervise and regulate the practice

4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make judgments about them is in what stage of Nursing Expertise?
A. Novice
B. Newbie
C. Advanced Beginner
D. Competent

5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:
A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations

Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer this.

6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is to be administered to the client. Which of the following site will you choose?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

8. In order to decrease discomfort in Z track administration, which of the
A. Pierce the skin quickly and smoothly at 90 degree angle
B. Inject the medication at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle

9. After injection using the Z track technique, the nurse should know that she needs to wait for few second before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle?
A. 2 second
B. 5 seconds
C. 10 seconds
D. 15 seconds

10. The rationale in using the Z track technique in an intramuscular injection is:
A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissue.
B. It will allow a faster absorption of the medication
C. The Z track technique prevent irritation of the muscle
D. It is much more convenient for the nurse

Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment:

11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff sound
C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control

12. You attached a pulse oximeter to the client. You know that the purpose id to:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertension medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be

14. Through the client’s health history, you gather that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes

15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximiter is. Your action will be to:
A. Set and turn on the alarm of the oximeter
B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours

16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of:
A. 15 seconds
B. 1 to 2 minutes
C. 30 minutes
D. 15 minutes

17. If the arm is said to be elevated when taking the blood pressure. It will create a:
A. False high reading
B. False low reading
C. True False reading
D. Indeterminate

18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 15 minutes
19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down to 80 mmHg and then silence. What is the client’s pressure?
A. 130/80
B. 150/100
C. 100/80
D. 150/100

20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading?
A. 10 – 20 seconds
B. 30 – 45 seconds
C. 1 – 1.5 minutes
D. 3 – 3.5 minutes

Situation 4 – Oral care is an important part of hygienic practices and promoting client
comfort.

21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
B. hydrogen peroxide
C. Mineral oil
D. Normal saline solution

22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal
mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food

24. A possible problem while providing oral care to unconscious clients is the risk of fluid
aspiration to lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid
rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity

25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:
A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment

Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.

26. 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

27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication:
A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness

28. Immediately after bronchoscopy, you instructed Fernan to:
A. Exercise the neck muscles
B. Breathe deeply
C. Refrain from coughing and talking
D. Clear his throat

29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the 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

30. 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 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions.

31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the involvement at which type of acid base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimen are drawn?
A. Guthing test
B. Allen’s test
C. Romberg’s test
D. Weber’s test

34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

35. Allen’s test checks the patency of the:
A. Ulnar artery
B. Radial artery
C. Carotid artery
D. Brachial artery

37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.

38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’s buttocks
D. to the patient lower abdomen

39. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda

40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area

Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary.

41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland:
A. Hypothalamus
B. Anterior pituitary gland
C. Posterior pituitary gland
D. Thyroid gland

42. All of the following are secreted by the anterior pituitary gland except:
A. Somatotropin/Growth hormone
B. Follicle stimulating hormone
C. Thyroid stimulating hormone
D. Gonadotropin hormone releasing hormone

43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:
A. Vasopressin
B. Oxytocin
C. Anti-diuretic hormone
D. Growth hormone

44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the:
A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

Situation 8 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.

46. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention

47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated

48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life

49. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike

50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education

Situation 9: As a nurse, you are aware that proper documentation in the patient chart is your responsibility.

51. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting?
A. Bill of rights as provided in the Philippine Constitution
B. Scope of nursing practice as defined in R.A. 9173
C. Board of Nursing resolution adopting the Code of Ethics
D. Patient’s Bill of Rights

52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication?
A. Incident Report
B. Oral report
C. Nursing kardex
D. Complain report

53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges?
A. Fraud
B. Assault and Battery
C. Harassment
D. Breach of confidentiality

54. Which of the following is the essence of informed consent?
A. It should have a durable power of attorney
B. It should have coverage from an insurance company
C. It should respect the client’s freedom from coercion
D. It should discloses previous diagnosis, prognosis and alternative treatments available for the client.

55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation?
A. The RN must supervise all delegated tasks
B. After a task has been delegated. It is no longer a responsibility of the RN.
C. The RN is responsible and accountable for the delegated task in a adjunct with the delegate.
D. Follow up with a delegated task necessary only if the assistive personnel is not trustworthy.

Situation 10 – When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke.

56. The most important risk factor is:
A. Cigarette smoking
B. Hypertension
C. binge drinking
D. heredity

57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT:
A. Embolic stroke
B. Hemorrhagic stroke
C. diabetic stroke
D. thrombotic stroke

58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT:
A. phlebitis
B. trauma
C. damage to blood vessel
D. aneurysm

59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this?
A. Amphetamines
B. Cocaine
C. shabu
D. Demerol

60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:
A. “More red blood cells thicken blood and make clots more possible.”
B. “Increased RBC count is linked to high cholesterol.”
C. “More red blood cell increases hemoglobin content.”
D. “High RBC count increases blood pressure.”

Situation 11: Recognition of normal values is vital in assessment of clients with various disorders.

61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following?
A. 60%
B. 47%
C. 45%
D. 32%

62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?
A. ST depression
B. Inverted t wave
C. Prominent U wave
D. Tall peaked T waves

63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?
A. U waves
B. Absent P waves
C. Elevated T waves
D. Elevated ST segment

64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding?
A. Neutrophils 60%
B. White blood cells (WBC) 9000/mm
C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr
D. Iron 75 mg/100 ml

65. Which of the following laboratory test result indicate presence of an infectious process?
A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18,000/mm3
C. Iron 90 g/100ml
D. Neutrophils 67%

Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Question to 66 to 70 refer to this?

66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion?
A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachypnea and shortness of breath.
B. Hypoxemia
C. Noisy respiration, crackles, stridor and wheezing
D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds

67. Thoracentesis is performed to the client with effusion. The nurse knows that he removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause:
A. Pneumothorax
B. Pleurisy or Pleuritis
C. Cardiovascular collapse
D. Hypertension

68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that the pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to:
A. Restore positive intrathoracic pressure
B. Restore negative intrathoracic pressure
C. To visualize the intrathoracic content
D. As a method of air administration

69. The chest tube is functioning properly if:
A. There is an oscillation
B. There is no bubbling in the drainage bottle
C. There is a continuous bubbling in the water seal.
D. The suction control bottle has a continuous bubbling

70. In a client with pleural effusion, the nurse is instructing a appropriate breathing technique. Which of the following is included in the teaching?
A. Breath normally
B. Hold the breath after each inspiration for 1 full minute
C. Practice abdominal breathing
D. Inhale slowly and hold the breath for 3-5 seconds after each inhalation.

Situation 13: Health care delivery system affects the health status of every Filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life.

71. When should rehabilitation commence?
A. The day before discharge
B. When the patient desires
C. Upon admission
D. 24hours after discharge

72. What exemplified the preventive and promotive programs in the hospital?
A. Hospitals as a center to prevent and control infection
B. Program for smokers
C. Program for alcoholics and drug addicts
D. Wellness Center

73. Which makes nursing dynamic?
A. Every patient is a unique physical, emotional, social and spiritual being
B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern development that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes.

74. Prevention is an important responsibility of the nurse in:
A. Hospitals
B. Community
C. Workplace
D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a periodic payment.
A. Health Maintenance Organization
B. Medicare
C. Philippine Health Insurance Act
D. Hospital Maintenance Organization

91. Health care reports have different purposes. The availability of patients record to all health ream members demonstrates which of the following purposes:
A. Legal documentation
B. Education
C. Research
D. Vehicle for communication

92. When a nurse commits medication error she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes:
A. Research
B. Nursing Audit
C. Legal documentation
D. Vehicle for communication

93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should include:
A. Prescription of the doctor to the patient’s illness
B. Plan of care for patient
C. Patient’s perception of one’s illness
D. Nursing Problem and Nursing Diagnosis

94. The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording?
A. POMR
B. SOAPIE
C. Modified POMR
D. SOMR

95. Which of the following is the advantage of SOMR or Traditional Recording?
A. Increase efficiency of Data gathering
B. Reinforces the use of the nursing process
C. The caregiver can easily locate proper section for making charting entries
D. Enhances effective communication among health care team members

Situation 17: June is 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest X-ray revealed pleural effusion. The physician will perform thoracentesis

96. Thoracentesis is useful in treating which of the following pulmonary disorders except:
A. Hemothorax
B. Tuberculosis
C. Hydrothorax
D. Empyema

97. Which of the following psychological preparation is not relevant for him?
A. Telling him that the gauge of the needle and anesthesia to be used
B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place.
C. Allow June to express his feeling and concerns
D. Physician’s explanation on the purpose of the procedure and how it will be done.

98. Before thoracentesis, the legal consideration you must check is:
A. Consent is signed by the client
B. Medicine preparation is correct
C. Position of the client is correct
D. Consent is signed by relative and physician

99. As a nurse, you know that the position for June before thoracentesis is:
A. Orthopneic
B. Knee-chest
C. Low fowlers
D. Sidelying position on the affected side

100. Which of the following anesthetic drug is used for thoracentecis?
A. Procaine 2 %
B. Valium 250 mg
C. Demerol 75 mg
D. Phenobarbital

The post Preboard Exam D — Test 1: Fundamentals of Nursing appeared first on Nurseslabs.

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Medical-Surgical Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

Situation 1: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort.

1. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken?
A. Fecal oral
B. Droplet
C. Airborne
D. Sexual contact

2. Which of the following is concurrent disinfection in the case of Leo?
A. In
B. Sanitary disposal of feces, urine and blood
C. Quarantine of the sick individual
D.

3. Which of the following must be emphasized during mother’s class to Leo’s mother?
A. Administration of immunoglobulin to families
B. Thorough hand washing before and after eating and toileting
C. Use of attenuated vaccines
D. Boiling of food especially meat

4. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority?
A. Eliminate fecal contamination from foods
B. Mass vaccination of uninfected individuals
C. Health promotion and education to families and communities about the disease it’s cause and transmission.
D. Mass administration of immunoglobulin

5. What is the average incubation period of Hepatitis A?
A. 30 days
B. 60 days
C. 50 days
D. 14 days

Situation 2: As a nurse researcher you must have a very good understanding of the common terms of concept used in research.

6. The information that an investigator collects from the subjects or participants in a research study is usually called:
A. Hypothesis
B. Data
C. Variable
D. Concept

7. Which of the following usually refers to the independent variables in doing research?
A. Result
B. Cause
C. Output
D. Effect

8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called;
A. Setting
B. Subjects
C. Treatment
D. Sample

9. The device or techniques an investigator employs to collect data is called?
A. Sample
B. Instrument
C. Hypothesis
D. Concept

10. The use of another persons ideas or wordings giving appropriate credit results from inaccurate attribution of materials to its sources. Which of the following is referred to when another persons idea is inappropriate credited as one’s own?
A. Plagiarism
B. Quotation
C. Assumption
D. Paraphrase

Situation 3: Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”

11. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis?
A. Support and reassure client during the procedure
B. Ensure that informed consent has been signed
C. Determine if client has allergic reaction to local anesthesia
D. Ascertain if chest x-rays and other tests have been prescribed and completed

12. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions?
A. Trendelenburg position
B. Supine position
C. Dorsal Recumbent position
D. Orthopneic position

13. During thoracentesis, which of the following nursing intervention will be most crucial?
A. Place patient in a quiet and cool room
B. Maintain strict aseptic technique
C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
D. Apply pressure over the puncture site as soon as the needle is withdrawn

14. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
A. Place flat in bed
B. Turn on the unaffected side
C. Turn on the affected side
D. On bed rest

15. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:
A. to rule out pneumothorax
B. to rule out any possible perforation
C. to decongest
D. to rule out any foreign body

Situation 4: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.

16.Just as nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
A. Ease the patient to the floor
B. Lift the patient and put him on the bed
C. Insert a padded tongue depressor between his jaws
D. Restrain patient’s body movement

17. Mr. Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
A. Shampoo hair thoroughly to remove oil and dirt
B. No special preparation is needed. Instruct the patient to keep his head still and stead.
C. Give a cleansing enema and give until 8 AM
D. Shave scalp and securely attach electrodes to it

18. Mr. Santos is placed on seizure precaution. Which of the following would be contraindicated?
A. Obtain his oral temperature
B. Encourage to perform his own personal hygiene
C. Allow him to wear his own clothing
D. Encourage him to be out of bed.

19. Usually, how does the patient behave after his seizure has subsided?
A. Most comfortable walking and moving about.
B. Becomes restless and agitated.
C. Sleeps for a period of time
D. Say he is thirsty and hungry.

20. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
A. Low fowler’s
B. Modified trendelenburg
C. Side Lying
D. Supine

Situation 5: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site.

21. Choledocholithotomy is:
A. The removal of the gallbladder
B. The removal of the stones in the gallbladder
C. The removal of the stones in the common bile duct
D. The removal of the stones in the kidney

22. The simplest pain relieving technique is:
A. Distraction
B. Taking aspirin
C. Deep breathing exercise
D. Positioning

23. Which of the following statement on pain is true?
A. Culture and pain are not associated
B. Pain accomplished acute illness
C. Patient’s reaction to pain varies
D. Pain produces the same reaction such as groaning and moaning

24. In a pain assessment, which of the following condition is a more reliable indicator?
A. Pain rating scale of 1 – 10
B. Facial expression and gestures
C. Physiological responses
D. Patients description of the pain sensation

25. When a client complains of pain, your initial response is:
A. Record the description of pain
B. Verbally acknowledge the pain
C. Refer the complaint to the doctor
D. Change to a more comfortable position

Situation 6: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective.

26. A one-day post operative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in 1 – 10 pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take?
A. Medicate client as prescribed
B. Encourage client to do-imagery
C. Encourage deep breathing exercise
D. Call surgeon stat

27. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain, which will be your priority nursing action?
A. Check abdominal dressing for possible swelling
B. Explain the proper use of PCA to alleviate anxiety
C. Avoid overdosing to prevent dependence/tolerance
D. Monitor VS, more importantly RR

28. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is:
A. Instruct client to go to sleep and relax
B. Advice the client to close the lips and avoid deep breathing and talking
C. Offer hot and clear soup
D. Turn to sides frequently and avoid too much talking

29. Surgical pain might be minimized b which nursing action in the O.R.
A. Skill of surgical team and lesser manipulation
B. Appropriate preparation for the scheduled procedure
C. Use of modern technology in closing the wound
D. Proper positioning and draping of client.

30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post-op patients. If general anesthesia is desired, it will involve loss of consciousness. Which of the following are the 2 general types of GA?
A. Epidural and Spinal
B. Subarachnoid block and intravenous
C. Inhalation and Regional
D. Intravenous and inhalation

Situation 7: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain.

31. Nurses should be aware of that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following beliefs EXCEPT:
A. Older patients seldom tend to report pain than the younger ones
B. Pain is a sign of weakness
C. Older patients do not believe in analgesics, they are tolerant.
D. Complaining of pain will lead to being labelled a bad patient

32. Nurses should understand that when a client responds favourably to a placebo, it is known as the placebo effect. Placebos do not indicate whether or not a client has:
A. Conscience
B. Real pain
C. Disease
D. Drug tolerance

33. You are the nurse in the pain clinic where you have client who has difficulty specify the location of pain. How can you assist such client?
A. The pain is vague
B. By charting-it hurts all over
C. Identifying the absence and presence of pain
D. Ask the client to point to the painful are by just one finger.

34. What symptom more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain?
A. Forgetfulness
B. Constipation
C. Drowsiness
D. Allergic reactions like pruritus

35. Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice?
A. Start another drug and slowly lessen the opioid dosage
B. Indulge in recreational outdoor activities
C. Isolate opioid dependent to a restful resort
D. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms.

Situation 8: The nurse is performing health education activities for Janevi Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus.

36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she:
A. Draw insulin from the vial of clear insulin first
B. Draw insulin from the vial of the intermediate acting insulin first
C. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously
D. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first.

37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry first?
A. Withhold the client’s next insulin injection
B. Test the client’s blood glucose level
C. Administer Tylenol as ordered
D. Offer fruit juice, gelatine and chicken bouillon

38. Janevi administered regular insulin at 7 A.M. and the nurse should instruct Jane to avoid exercising at around:
A. 9 to 11 A.M.
B. After 8 hours
C. Between 8 A.M. to 9 A.M.
D. In the afternoon, after taking lunch.

39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient?
A. Glycosylated Hemoglobin
B. Fasting blood glucose
C. Ketone levels
D. Uirne glucose level

40. Upon the assessment of HbA1C of Mrs. Segovia. The nurse has been informed of a 9 % HbA1C result. In this case, she will teach the patient to:
A. Avoid infection
B. Take adequate food and nutrition
C. Prevent and recognize hypoglycaemia
D. Prevent and recognize hypoglycaemia

41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan?
A. Soak feet in hot water
B. Avoid using mild soap on the feet
C. Apply a moisturizing lotion to dry feet but not between the toes
D. Always have a podiatrist to cut your toe nails; never cut them yourself

42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately prepare to initiate which of the following anticipated physician’s order?
A. Endotracheal intubation
B. 100 units of insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate

43. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis?
A. Comatose state
B. Decreased urine output
C. Increased respiration and increase in pH
D. Elevated blood glucose level and plasma bicarbonate level

44. The nurse teaches Jane to know the difference between hypoglycaemia and ketoacidosis. Jane demonstrates understanding of the teaching by stating that glucose will be taken of which of the following symptoms develops?
A.
B. Shakiness
C. Blurred vision
D. Foul breath odor

45. Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane to eat or drink after midnight. Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said yes. Which of the following is the best nursing action?
A. Administer syrup of ipecac to remove the distilled water from the stomach.
B. Suction the stomach content using NGT prior to specimen collection
C. Advice to physician to reschedule to diagnostic examination next day
D. Continue as usual and have the FBS analysis performed and specimen be taken.

Situation 9: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population.

46. 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
D. Hyperventilation

47. 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

48. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity

49. 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

50. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles

Situation 10 – In the OR, there are safety protocols that should be followed. The OR nurseshould be well versed with all these to safeguard the safety and quality of patient delivery outcome.

51. Which of the following should be given highest priority when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
D. Check for jewelry, gown, manicure, and dentures

52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference

53. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure…
A. the surgeon greets his client before induction of anesthesia
B. the surgeon and anesthesiologist are in tandem
C. strap made of strong non-abrasive materials are fastened securely
around the joints of the knees and ankles and around the 2 hands around
an arm board.
D. Client is monitored throughout the surgery by the assistant anaesthesiologist

54. Another nursing check that should not be missed before the induction of general
anesthesia is:
A. check for presence underwear
B. check for presence dentures
C. check patient’s ID
D. check baseline vital signs

55. Some lifetime habits and hobbies affect postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk
for:
A. perioperative anxiety and stress
B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory function

Situation 11: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility.

56. There are 3 general types of sterilization use in the hospital which one is not included?
A. Steam sterilization
B. Chemical sterilization
C.
D. Sterilization by boiling

57. Autoclave or steam steam under pressure is the most common method of sterilization in the hospital. The nurse knows that the temperature and time is set to the optimum level to destroy not only the microorganism, but also the spores. Which of the following is the ideal setting of the autoclave machine?
A. 10,000 degree Celsius for 1 hour
B. 5,000 degree Celsius for 30 minutes
C. 37 degree Celsius for 15 minutes
D. 121 degree Celsius for 15 minutes

58. It is important that before a nurse prepares the material to be sterilized, A chemical indicator strip should be placed above the package, preferably, Muslin sheet. What is the color of the striped produced after autoclaving?
A. Black
B. Blue
C. Gray
D. Purple

59. Chemical indicators communicate that:
A. The items are sterile
B. That the items had undergone sterilization process but not necessarily sterile
C. The items are disinfected
D. That the items had undergone disinfection process but not necessarily disinfected

60. If a nurse will sterilize a heat and moisture labile instruments, it is according to AORN recommendation to use which of the following method of sterilization?
A. Ethylene oxide gas
B. Autoclaving
C. Flash sterilizer
D. Alcohol immersion

Situation 12 – Nurses hold a variety of roles when providing care to a perioperative patient.
61. Which of the following role would be the responsibility of the scrub nurse?
A. Assess the readiness of the client prior to surgery
B. Ensure that the airway is adequate
C. Account for the number of sponges, needles, supplies, used during the surgical procedure.
D. Evaluate the type of anesthesia appropriate for the surgical client

62. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic?
A. Put side rails up and ask the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form

63. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing\ surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?
A. Draped
B. Pulled
C. Clipped
D. Shampooed

64. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection?
A. Localized heat and redness
B. Serosanguinous exudates and skin blanching
C. Separation of the incision
D. Blood clots and scar tissue are visible

65. Which of the following nursing interventions is done when examining the incision wound and changing the dressing?
A. Observe the dressing and type and odor of drainage if any
B. Get patient’s consent
C. Wash hands
D. Request the client to expose the incision wound

Situation 13: The preoperative nurse collaborates with the client significant others, and healthcare providers.

66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:
A. Biomedical division
B. Chaplancy services
C. Infection control committee
D. Pathology department

67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last patients will need surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the nurse expect?
A. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures
B. Forwarding the trauma client to the nearest hospital that has available sterile equipment is appropriate
C. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes.
D. In such cases, flash sterilizer will be use at 132 degree Celsius in 3 minutes.

68. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 8 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with:
A. Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty

69. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do?
A. Double check the doctor’s order and call the attending MD
B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated
D. Incorporate insulin as ordered

70. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatment
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.

Situation 14 – Team efforts is best demonstrated in the OR.

71. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
A. Who is your internist
B. Who is your assistant and anesthesiologist, and what is your preferred
time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant
D. Who is your anesthesiologist

72. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses

73. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?
A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

74. Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating room?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist

75. The breakdown in teamwork is often times a failure in:
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication

Situation 15: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes.

76. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure?
A. 0.45 % sodium chloride
B. Normal saline solution
C. o.33% sodium chloride
D. Lactated ringer’s solution

77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe?
A. 5 % dextrose in water
B. 10 % dextrose in water
C. 0.45 % sodium chloride
D. 0.5 % dextrose in 0.9% sodium chloride

78. The nurse is making initial rounds on the nursing unit to assess the condition or assigned clients. The nurse notes that the client’s IV site is cool, pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombophlebitis

79. A nurse reviews the client’s electrolytes laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the lectrocardiogram as a result of the laboratory value?
A. U waves
B.
C. Elevated T waves
D. Elevated ST segment

80. One patient has a runaway IV of 50 % dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order?
A. Any IV solution available to KVO
B. Isotonic solution
C. Hypertonic solution
D. Hypotonic solution

81. An informed consent is required for:
A. Closed reduction of a fracture
B. Insertion of intravenous catheter
C. Irrigation of the external ear canal
D. Urethral catheterization

82. Which of the following is not true with regards to the informed consent?
A. It should describe different treatment alternatives
B. It should contain a thorough and detailed explanation of the procedure to be done
C. It should describe the client’s diagnosis
D. It should given an explanation of the client’s prognosis

83. You know that the hallmark of nursing accountability is the:
A. Accurate documentation and reporting
B. Admitting your mistakes
C. Filing an incidence report
D. Reporting a medication error

84. A nurse is assigned to care for a group of clients. On review of the client’s medical records the nurse determines that which client is at risk for excess fluid volume?
A. The client taking diuretics
B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning

85. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for deficient fluid volume?
A. A client with colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigation

Situation 16: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.

86. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?
A. Material compatibility and efficiency
B. Odor and availability/
C. Cost and duration of disinfection process
D. Duration of disinfection and efficiency

87. Before you used disinfected instrument it is essential that you:
A. Rinse with tap water followed by alcohol
B. Wipe the instrument with sterile water
C. Dry the instrument thoroughly
D. Rinse with sterile water

88. You have a critical heat labile instrument to sterilize and are considering to use high level of disinfectant. What should you do?
A. Cover the soaking vessel to contain the vapour
B. Double the amount of high level of disinfectant
C. Test the potency of the high level of disinfectant
D. Prolong the exposure time according to manufacturer’s direction

89. To achieve sterilization using disinfectants, which of the following is used?
A. Low level disinfectants immersion in 24 hours
B. Intermediate level disinfectants immersion in 12 hours
C. High level disinfectants immersion in 1 hour
D. High level disinfectants immersion in 10 hours

90. Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the following?
A. Autoclaving at 121 degree Celsius in 15 minutes
B. Flash sterilizer at 132 degree Celsius in 3 minutes
C. Ethylene Oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 10 hours

Situation 17: The OR is divided in three zones to control traffic flow and contamination.

91. What OR attires are worn in the restricted area?
A. Scrub suit, OR shoes, head cap
B. Head cap scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, Mask, gloves, shoes

92. Nursing intervention for a patient on low dose IV insulin therapy includes the following EXCEPT:
A. Elevation of serum ketones to monitor ketosis
B. Vital signs including BP
C. Estimate serum potassium
D. Elevation of blood glucose levels

93. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going IV. The strength is 500/ml. How much should you incorporate into the IV solution?
A. 10 ml
B. 2 ml
C. 0.5 ml
D. 5 ml

94. Multiple vial-dose-insulin when in use should be:
A. Kept at room temperature
B. Kept in the refrigerator
C. Kept in narcotic cabinet
D. Store in the freezer

95. Insulin using insulin syringe are given using how many degrees of needle insertion?
A. 45
B. 180
C. 90
D. 15

Situation 18: Maintenance of sterility is an important function a nurse should perform in any OR setting.

96. Which of the following is true with regards to sterility?
A. Sterility is time related items are not considered sterile after a period of 30 days of being not in use.
B. for 9 months sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers.
C. Sterility is event related, not time related.
D. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization process

97. 2 organizations endorsed that sterility are affected by factors other that the time itself, these are:
A. The PNA and the PRC
B. AORN and JCAHO
C. ORNAP and MCNAP
D. MMDA and DILG

98. All of these factors affect the sterility of the OR equipments, these are the following except:
A. The material used for packaging
B. The handling of the materials as well as its transport
C. Storage
D. The chemical or process used in sterilizing the material

99. When you say sterile, it means:
A. The material is clean.
B. The material as well as the equipments are sterilized and had undergone a rigorous sterilization process
C. There is a black stripe on the paper indicator
D. The material has no microorganism nor spores present that might cause an infection

100. In using liquid sterilizer versus autoclave machine, which of the following is true?
A. Autoclave is better in sterilizing OR supplies verus liquid sterilizer
B. They are both capable of sterilizing the equipments, however, it is necessary to soak supplies in the liquid sterilizer for a longer period of time.
C. Sharps are sterilized using autoclave and not cidex.
D. If liquid sterilizer sterilization process is used, rinsing it before using is not necessary.

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Communication is one of the means in establishing rapport and a helping-healing relationship to our clients. It is an essential element in nursing and this post will help you understand the concept of communication. This is also a primer teaching you documentation and reporting in nursing.

Definition

Communication is the process of exchanging information or feelings between two or more people. It is a basic component of human relationship, including nursing.

Communication

Is the means to establish a helping-healing relationship. All behavior communication influences behavior. Communication is essential to the nurse-patient relationship for the following reasons:

• Is the vehicle for establishing a therapeutic relationship.
• It the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.

Basic Elements of the Communication Process

1. Sender – is the person who encodes and delivers the message
2. Messages – is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
3. Receiver – is the person who receives the decodes the message.
4. Feedback – is the message returned by the receiver. It indicates whether the meaning of the sender’s message was understood.

Modes of Communication

Verbal Communication

Verbal Communication – use of spoken or written words.

1. Pace and Intonation

• The manner of speech, as in the pace or rhythm and intonation, will modify the feeling and impact of the message. For example, speaking slowly and softly to an excited client may help calm the client.

2. Simplicity

• Includes the use of commonly understood words, brevity, and completeness.
• Nurses need to learn to select appropriate, understandable terms based on the age, knowledge, culture and education of the client. For example, instead of saying to a client, “the nurses will be catheterizing you tomorrow for a urinalysis”, I would be more appropriate to say, “Tomorrow we need to get a sample of your urine, so we will collect it by putting a small tube into your bladder”.

3. Clarity and Brevity

• A message that is direct and simple will be more effective. Clarity is saying precisely what is meant, and brevity is using the fewest words necessary.
• The goal is to communicate clearly so that all aspects of a situation or circumstances are understood. To ensure clarity in communication, nurses also need to speak slowly and enunciate carefully.

4. Timing and Relevance

• No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure that words are heard.
• This involves sensitivity to the client’s needs and concerns. E.g., a client who is enmeshed in fear of cancer may not hear the nurse’s explanations about the expected procedures before and after gallbladder surgery.

5. Adaptability

• What the nurse says and how it is said must be individualized and carefully considered. E.g., a nurse who usually smiles, appears cheerful, and greets his clients with an enthusiastic “Hi, Mrs. Jones!” notices that the client is not smiling and appears distressed. It is important for the nurse to then modify his tone of speech and express concern in his facial expression while moving toward the client.

6. Credibility

• Means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility by being consistent, dependable, and honest.
• Nurses should convey confidence and certainly in what they are saying, while being to acknowledge their limitations (e.g., “I don’t know the answer to that, but I will find someone who does”.

7. Humor

• The use of humor can be a positive and powerful tool in nurse- client relationship, but it must be used with care. When using humor, it is important to consider the client’s perception of what is considered humorous.

Nonverbal Communication

Nonverbal Communication – use of gestures, facial expressions, posture/gait, body movements, physical appearance and body language

1. Personal Appearance

• When the symbolic meaning of an object is unfamiliar the nurse can inquire about its significance, which may foster rapport with the client.
• How a person dresses is often an indicator of how person feels. E.g. For acutely ill clients n hospital or home care settings, a change in grooming habits may signal that the client is feeling better. A man may request a shave, or a woman may request a shampoo and some makeup.

2. Posture and Gait

• The ways people walk and carry themselves are often reliable indicators of self-concept, current mood, and health. Erect posture and an active, purposeful stride suggest a feeling of well being. Slouched posture and slow, shuffling gait suggest depression or physical discomfort.
• The nurse clarifies the meaning of the observed behavior, e.g. “You look like it really hurts you to move. I’m wondering how your pain is and if you might need something to make you more comfortable?”

3. Facial Expression

• No part of the body is as expressive as the face
• Although he face may express the person’s genuine emotions, it is also possible to control these muscles so the emotion expresses does not reflect what the person is feeling. When the message is not clear, it is important to get feedback to be sure of the intent of expression.
• Nurses need to be aware of their own expressions and what they are communicating to others. It is impossible to control all facial expression, but the nurse must learn to control expressions of feelings such as fear or disgust in some circumstances.
• Eye contact is another essential element of facial communication

4. Gesture

• Hand and body gestures may emphasize and clarify the spoken word, or they may occur without words to indicate a particular feeling or give a sign

Electronic Communication

Electronic Communication- many health care agencies are moving toward electronic medical records where nurses document their assessments and nursing care.

E-mail

• Most common form of electronic communication.
• Advantage: It is fast, efficient way to communicate and it is legible. It provides a record of the date and time of the message that was sent or received.
• Disadvantage: risk of confidentiality
• When Not to Use Email:

• Agencies usually develop standards and guidelines in use of e-mail

Characteristics of Good Communication 

1. Simplicity – includes uses of commonly understood, brevity, and completeness.
2. Clarity – involves saying what is meant. The nurse should also need to speak slowly and enunciate words well.
3. Timing and Relevance – requires choice of appropriate time and consideration of the client’s interest and concerns. Ask one question at a time and wait for an answer before making another comment.
4. Adaptability – Involves adjustments on what the nurse says and how it is said depending on the moods and behavior of the client.
5. Credibility – Means worthiness of belief. To become credible, the nurse requires adequate knowledge about the topic being discussed. The nurse should be able to provide accurate information, to convey confidence and certainly in what she says.

Factors Influencing the Communication Process

1. Development

• Language, psychosocial, and intellectual development move through stages across the lifespan.

2. Gender

• Girls tend to use language to seek confirmation, minimize differences, and establish intimacy. Boys use language to establish independence and negotiate status within a group.

3. Values and Perception

• Values are the standards that influence behavior, and perceptions are the personal view of event.

4. Personal Space

• Personal space is the distance people prefer in interactions with others.
• Proxemics is the study of distance between people in their interactions
• Communication 4 distances:

a. Intimate: Touching to 1 ½
b. Personal: 1 ½ to 4 feet
c. Social: 4 to 12 feet
d. Public: 12 to 15 feet

5. Territoriality

• Is a concept of the space and things that an individual considers as belonging to the self

6. Roles and Relationships

• Choice of words, sentence structure, and tone of voice vary considerably from role to role. (E.g. nursing student to instructor, client and primary care provider, or parent and child).

7. Environment

• People usually communicate most effectively in a comfortable environment.

8. Congruence

• The verbal and nonverbal aspects of message match. E.g., when teaching a client how to care for a colostomy, the nurse might say, “You won’t have any problem with this.” However, if the nurse looks worried or disgusted while saying this, the client is less likely to trust the nurse’s words.

9. Interpersonal Attitudes

• Attitudes convey beliefs, thoughts, and feelings about people and events.
• Caring and warmth convey a feeling of emotional closeness
• Respect is an attitude that emphasizes the other person’s worth and individuality. A nurse coveys respect by listening open mindedly even if the nurse disagrees.Acceptance emphasizes neither approval nor disapproval .The nurse willingly receives the client’s honest feelings.

Communicating With Clients Who Have Special Needs

Clients who cannot speak clearly (aphasia, dysarthria, muteness)

• Listen attentively, be patient, and do not interrupt.
• Ask simple question that require “yes” and “no” answers.
• Allow time for understanding and response.
• Use visual cues (e.g., words, pictures, and objects)
• Allow only one person to speak at a time.
• Do not shout or speak too loudly.
• Use communication aides: Pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm.

Clients who are cognitively impaired

• Reduce environmental distractions while conversing.
• Get client’s attention prior to speaking
• Use simple sentences and avoid long explanation.
• Ask one question at a time
• Allow time for client to respond
• Be an attentive listener
• Include family and friends in conversations, especially in subjects known to client.

Clients who are unresponsive

• Call client by name during interactions
• Communicate both verbally and by touch
• Speak to client as though he or she could hear
• Explain all procedures and sensations
• Provide orientation to person, place, and time
• Avoid talking about client to others in his or her presence
• Avoid saying things client should not hear

Communicating with hearing impaired client

• Establish a method of communication (pen/pencil and paper, sign-language)
• Pay attention to client’s non-verbal cues
• Decrease background noise such as television
• Always face the client when speaking
• It is also important to check the family as to how to communicate with the client
• It may be necessary to contact the appropriate department resource person for this type of disability

Client who do not speak English

• Speak to client in normal tone of voice (shouting may be interpreted as anger)
• Establish method for client o signal desire to communicate (call light or bell)
• Provide an interpreter (translator) as needed
• Avoid using family members, especially children, as interpreters.
• Develop communication board, pictures or cards.
• Have dictionary (English/Spanish) available if client can read.

Reports

• Are oral, written, or audiotape exchanges of information between caregivers.

Common reports

1. Change-in-shift report
2. Telephone report
3. Telephone or verbal orders – only RN’s are allowed to accept telephone orders.
4. Transfer report
5. Incident report

Documentation

1. Is anything written or printed that is relied on as record or proof for authorized person.
2. Nursing documentation must be:
   • accurate
   • comprehensive
   • flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflects current standards of nursing practice
3. Effective documentation ensures continuity of care saves time and minimizes the risk of error.
4. As members of the health care team, nurses need to communicate information about clients accurately and in timely manner
5. If the care plan is not communicated to all members of the health care team, care can become fragmented, repetition of tasks occurs, and therapies may be delayed or omitted.
6. Data recorded, reported, or communicated to other healthcare professionals are CONFIDENTIAL and must be protected.

Confidentiality

1. Nurses are legally and ethically obligated to keep information about clients confidential.
2. Nurses may not discuss a client’s examination, observation, conversation, or treatment with other clients or staff not involved in the client’s care.
3. Only staff directly involved in a specific client’s care has legitimate access to the record.
4. Clients frequently request copies of their medical record, and they have the right to read those records.
5. Nurses are responsible for protecting records from all unauthorized readers.
6. When nurses and other healthcare professionals have a legitimate reason to use records for data gathering, research, or continuing education, appropriate authorization must be obtained according to agency policy.
7. Maintaining confidentiality is an important aspect of professional behavior.
8. It is essential that the nurse safeguard the client’ right to privacy by carefully protecting information of a sensitive, private nature.
9. Sharing personal information or gossiping about others violates nursing ethical codes and practice standards.
10. It sends the message that the nurse cannot be trusted and damages the interpersonal relationships.

Guidelines of Quality Documentation and Reporting

1. Factual 

• A record must contain descriptive, objective information about what a nurse sees, hears, feels, and smells.
• The use of vague terms, such as appears, seems, and apparently, is not acceptable because these words suggest that the nurse is stating an opinion.

Example:
“The client seems restless” (the phrase seems restless is a conclusion without supported facts.)

2. Accurate 

• The use of exact measurements establishes accuracy. (example: “Intake of 350 ml of water” is more accurate than “ the client drank an adequate amount of fluid”
• Documentation of concise data is clear and easy to understand.
• It is essential to avoid the use of unnecessary words and irrelevant details

3. Complete 

• The information within a recorded entry or a report needs to be complete, containing appropriate and essential information.

Example: 

The client verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 15 minutes ago after twisting his foot on the stair. Client rates pain as 8 on a scale of 0-10. 

4. Current 

• Timely entries are essential in the client’s ongoing care. To increase accuracy and decrease unnecessary duplication, many health care agencies use records kept near the client’s bedside, which facilitate immediate documentation of information as it is collected from a client

5. Organized 

• The nurse communicates information in a logical order.

Example:
An organized note describes the client’s pain, nurse’s assessment, nurse’s interventions, and the client’s response 

Legal Guidelines for Recording

1. Draw single line through error, write word error above it and sign your name or initials. Then record note correctly.
2. Do not write retaliatory or critical comments about the client or care by other healthcare professionals.
   • Enter only objective descriptions of client’s behavior; client’s comments should be quoted.
3. Correct all errors promptly
   • Errors in recording can lead to errors in treatment
   • Avoid rushing to complete charting, be sure information is accurate.
4. Do not leave blank spaces in nurse’s notes.
   • Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.
5. Record all entries legibly and in blank ink
   • Never use pencil, felt pen.
   • Blank ink is more legible when records are photocopied or transferred to microfilm.
   • Legal Guidelines for Recording
6. If order is questioned, record that clarification was sought.
   • If you perform orders known to be incorrect, you are just as liable for prosecution as the physician is.
7. Chart only for yourself
   • Never chart for someone else.
   • You are accountable for information you enter into chart.
8. Avoid using generalized, empty phrases such as “status unchanged” or “had good day”.
   • Begin each entry with time, and end with your signature and title.
   • Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure to sign each entry.
9. For computer documentation keep your password to yourself.
   • Maintain security and confidentiality.
   • Once logged into the computer do not leave the computer screen unattended.

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