NURSING PRACTICE 3

GENERAL INSTRUCTIONS:1. This test booklet contains 100 test questions.2. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.3. Write the subject title “NURSING PRACTICE III” on the box provided.4. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is SET B.5. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.6. AVOID ERASURES.

Situation  – Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.

1. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:A. empty the drainage system at the end of the shiftB. clamp the chest tube when suctioningC. palpate the surrounding areas for crepitusD. change the dressing daily using aseptic techniques

2. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be:A. a tender, painful area on the legB. a pitting edema of the ankleC. a reddened area at the ankleD. pruritus on the calf and ankle

3. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:A. seek early treatment for respiratory infectionsB. take showers instead of tub bathC. continue to take the same restrictions on fluid intakeD. avoid situations that involve physical activity

4. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first?A. Recognize that prompt closure of the tracheal opening may occurB. Keep calm because there is no immediate emergencyC. Reinsert another tubing immediatelyD. Notify the physician at once

5. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:A. supplementary oxygenB. ventilation exchangeC. chest tube drainageD. blood replacement

Situation  – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented.

6. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what will be your priority goal?A. Prevent skin breakdownB. Preserve muscle functionC. Promote urinary eliminationD. Maintain a patent airway

7. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?A. Tell her family that probably she can’t hear themB. Talk loudly so that Wendy can hear youC. Tell her family who are in the room not to talk

D. Speak softly then hold her hands gently

8. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke?A. Place June on an upright lateral positionB. Perform range of motion exercisesC. Apply antiembolic stockingsD. Use hand rolls or pillows for support

9. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic environment by doing which of the following?A. honoring her request for a televisionB. placing her bed near the windowC. dimming the light in her roomD. allowing the family unrestricted visiting privileges

10. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he:A. probably has meningitisB. is going to be blind because of traumaC. is permanently paralyzedD. has received a significant brain injury

Situation – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older patients.

11. During a meal a client with hepatitis B dislodge her IV line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:A. AlcoholB. AcetoneC. AmmoniaD. Bleach

12. Nino is being treated with radiation therapy. What would be included in the plan of care to minimize skin damage from the radiation therapy?A. Cover the areas with thick clothing materialsB. Apply a heating pad to the siteC. Wash skin with water after the therapyD. Avoid applying creams and powders to the area

13. You are assigned to the following patients. Which of the following patients is most at risk for metabolic alkalosis?A. Grace, 30 years old post surgical patient who has continuous nasogastric suctionB. Rachel, 55 year old who has just experienced a strokeC. Helen, 70 year old with altered level of consciousness who is unable to access water freely.D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution

14. Studies have shown that the highest incidence of Hodgkin’s disease is common among young adults. Juana, 20 years old approaches you and tells you “I am worried about the mass on my neck. What should you do as a nurse?A. Tell her there is nothing to worry if it does not bother herB. Palpate Juana’s neck and explain the possible causeC. Tell her Hodgkin’s disease is common among young adults like herD. Tell her to see a doctor

15. As a nurse, you accidentally administer 40mg of Propanolol (Inderal) to a client instead of 10mg although the client exhibits no adverse reactions to the larger dose, you should:A. Complete an incident reportB. Call the hospital attorneyC. Inform the client’s familyD. Do nothing because the client’s condition is stable

Situation – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse

16. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert?A. Tell him that sometimes these feelings can be psychogenicB. Refer him to the physicianC. Reassures him that these feelings are normalD. Help him plan his activities

17. Immediately following the radiation teletherapy, Albert is:A. Considered radioactive for 24hoursB. Given a complete bathC. Placed on isolation for 6 hoursD. Free from Radiation

18. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms:A. Petechiae, ecchymosis, epistaxisB. Weakness, easy fatigability, pallorC. Headache, dizziness, blurred visionD. Severe sore throat, bacteremia, hepatomegaly

19. What nursing diagnosis should be the highest priority?A. Knowledge deficit regarding thrombocytopenia precautionsB. Activity intoleranceC. Impaired tissue integrityD. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

20. What intervention should you include in your care plan?A. Inspect his skin for petechiae, bruising, GI bleeding regularlyB. Place Albert on strict isolation precautionC. Provide rest in between activitiesD. Administer antipyretics if his temperature exceeds 38 C

Situation - You are assigned to take care of four patients with different conditions.

21. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine and prednisone? You recognized that KJ understood the teaching when he states, “I must take these medications: A. until the anastomosis heals                                        B. during the preoperative periodC. until the supply is overD. for the rest of my life

22. After the kidney transplant, you must observe KJ for signs of rejection which includes:A. fever and weight gain                                             B. hematuria and seizure                                   C. polyuria and jaundiceD. moon face and muscle atrophy

23. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB tells you “I want to go off dialysis, I’d rather not live than to be in this treatment the rest of my life”. How would you respond to him?            A. leave the room and allow him to collect his thoughts            B. tell FB that “ We all have days when we don’t feel like going on”            C. tell FB that “ Treatments are only three times a week, you can live with that”            D. take a sit next to him and sit quietly

24. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which statement by DS indicates the need for further teaching before true informed consent can be obtained?            A. “a wire from the generator will be attached to my heart”            B. “the physician will make a small incision in my chest wall and place the generator there”            C. “I wonder if there is another way to protect these bad rhythms”

            D. “this implanted defibrillator will protect me from those bad rhythms my heart goes into”

25. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates a lack of understanding about his rights as a research study participant? A. “My confidentiality will not be compromised in this study” B. “ I understand the risk associated in this study” C. “I can withdraw from the study anytime” D. “ I’ll have to find a new physician if I don’t complete this study”

Situation - Foot care among patients with peripheral vascular problems is very important.

26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions:A. avoid wearing canvas shoes                                   B. avoid using a nail clipper to cut toe nails          C. avoid use of cornstarch on the foot     D. avoid wearing cotton socks

27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the appropriate management, you should:A. shave the affected leg in anticipation of surgery                       B. place a healing pad around the calfC. keep the affected leg level or slightly dependentD. elevate the affected calf as high as possible

28. Peripheral neuropathies primarily affect:A. sensory functions                                                  B. vascular functions     C. optic functionsD. motor functions

29. Peripheral neuropathy can BEST be controlled by:A. good glucose control                                             B. steroid therapy                     C. vitamin supplement               D. nothing, there is no slowing the process

30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with:A. hypertension                                                 B. hyperthyroidism                                C. liver disease           D. diabetes insipidus

Situation - The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.

31. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?A. 6 hours                                                    B. 1 hour                                                     C. 4 hoursD. 2 hours

32. What should you do FIRST before you administer blood transfusion?A. verify client identity and blood product, serial number, blood type, cross matching results, expiration dateB. verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse           C. check IV site and use appropriate BT set and needle  D. verify physician’s order

33. As WQ’s nurse, what will you do AFTER the transfusion has started?                 A. add the total amount of blood to be transfused to the intake and output                 B. discontinue the primary IV of  Dextrose 5% Water

                 C. check the vital signs every 15 minutes                 D. stay with WQ for 15 minutes to note for any possible BT reactions

34. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:                 A. oliguria and jaundice                                                              B. urticaria and wheezing                  C. hypertension and flushing  D. headache, chills, fever

35. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?                 A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician                 B. stop the blood transfusion and monitor the patient closely                 C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank                 D. immediately stop the BT, notify the blood bank and administer antihistamines

Situation - The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the kidney’s functions can cause disease. As a nurse it is important that you understand the rationale behind the treatment regimen used.

36. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase?                 A. urine output directly related to the amount of IV fluid infused                 B. urine output is less than 400 ml/24 hours                 C. urine output of 30-60 ml/hour                 D. no urine output, kidneys in a state of suspension

37. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?                 A. increased urine output, increased absorption of sodium and water                 B. decreased urine output, decreased absorption of sodium and water                  C. increased urine output, decreased absorption of sodium and water                  D. decreased urine output, increased absorption of sodium and water 

38. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:A. hyperkalemia                                                     B. hypercalcemia      C. hypokalemia                                D. hypernatremia

39. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge?A. drink plenty of water                                                         B. restrict your salt intake C. monitor your fruit intake and eat plenty of bananasD. be sure to eat meat every meal     

40. BN, is also advised not to use salt substitute in the diet because:                 A. salt substitute contain potassium which must be limited to prevent arrhythmias                 B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood                 C. fluid retention is enhanced when salt substitutes are included in the diet                 D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane

Situation  – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations andissues relevant to the older patients.

41. Hypoxia may occur in the older patients because of which of the followingphysiologic changes associated with aging.A. Ineffective airway clearanceB. Decreased alveolar surfaced areaC. Decreased anterior-posterior chest diameterD. Hyperventilation

42. The older patient is at higher risk for incontinence because of:

A. dilated urethraB. increased glomerular filtration rateC. diuretic useD. decreased bladder capacity

43. Merle, age 86, is complaining of dizziness when she stands up. This mayindicate:A. dementiaB. a visual problemC. functional declineD. drug toxicity

44. Cardiac ischemia in an older patient usually produces:A. ST-T wave changesB. Very high creatinine kinase levelC. Chest pain radiating to the left armD. Acute confusion

45. The most dependable sign of infection in the older patient is:A. change in mental statusB. feverC. painD. decreased breath sounds with crackles

Situation  – A “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody’s business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergencyphases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.

46. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.”?A. RecoveryB. MitigationC. ResponseD. Preparedness

47. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included:A. Tertiary preventionB. Primary preventionC. Aggregate care preventionD. Secondary prevention

48. During the disaster you see a victim with a green tag, you know that the person:A. has injuries that are significant and require medical care but can wait hours withthreat to life or limbB. has injuries that are life threatening but survival is good with minimalinterventionC. indicates injuries that are extensive and chances of survival are unlikely evenwith definitive careD. has injuries that are minor and treatment can be delayed from hours toDays

49. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment:A. ImmediateB. EmergentC. Non-acuteD. Urgent

50. Which of the following terms refer to a process by which the individual receives education about recognition of stress reaction and management strategies for handling stress which may be instituted after a disaster?A. Clinical incident stress managementB. Follow-upC. DebfriefingD. Defusion

Situation  – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.

51. While eating his meal, Matthew accidentally dislodges his IV lines and bleeds. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with:A. AcetoneB. AlcoholC. AmmoniaD. Bleach

52. You are a member of the infection control team of the hospital. Based on a feedback during the meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority activity?A. Establish policies for surveillance and monitoringB. Do data gathering about the possible sources of infection (observation,chart review, interview).C. Assign point persons who can implement policies.D. Meet with the nursing group working in the burn unit and discuss problem withthem.

53. Part of your responsibility as a member of the diabetes core group is to getreferrals from the various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4 patients are referred to you. How would you start prioritizing your activities?A. Bring your diabetes teaching kit and start your session taking into considerationtheir distance from your officeB. Contact the nurse in-charge and find out from her the reason for the referralC. Determine their learning needs then prioritizeD. Involve the whole family in the teaching class

54. You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity?A. Find out if there is a budget for this activityB. Clarify objectives of the activity with the task force before contacting thesupport groupsC. Determine the VIPs and Celebrities who will be invitedD. Find out how many support groups there are in the hospital and get the contactnumber of their president

55. You are invited to participate in the medical mission activity of your alumni association. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. You thought it is also your chance to share what you can do for others. What will be your most important role where you can demonstrate the impact of nursing in health?A. Conduct health education on healthy life styleB. Be a triage nurseC. Take the initial history and document findingsD. Act as a coordinator

Situation  – One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.

56. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma’s family could be helpful if they knew what Irma has told to you. What should you do first?A. Tell the physician who in turn could tell the familyB. Obtain Irma’s permission to share the information in the familyC. Tell Irma that she has to tell her family what she told youD. Make an appointment to discuss the situation with the family

57. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by:A. Coming back periodically and indicating your availability if shewould like you to sit with herB. Insisting that Ruby should talk with you because it is not good to keepeverything insideC. Leaving her alone because she is uncooperative and unpleasant to bewithD. Encouraging her to be physically active as possible

58. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves, is depressed. Which of the following would best help him during his depression?A. Arrange for visitors who might cheer himB. Sit down and talk with him for a whileC. Encourage him to look at the brighter side of thingsD. Sit silently with him

59. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending death?A. “I’m ready to go.”B. “I have resigned myself to dying.”C. “What’s the use?”D. “I’m giving up”

60. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and emotionally. This is recognized as:A. Acceptance that death is inevitableB. Avoidance of the true situationC. Denial with planning for continued lifeD. Awareness that death will soon occur