RECALLS: NP4

Situation

Ms. Hange is the charge

nurse of a medical unit. She is responsible for the management and supervision

of the unit.

1. Ms. Hange observes that one of the female staff nurses is not performing her duties very well. Which of the following strategies will she implement to assist the staff nurse?

*

1 point

A. Discuss with the staff nurse her performance and ways she can improve.

B. Allow the staff nurse to select own assignment.

C. Assign the staff nurse several clients with various illnesses.

D. Ask the staff nurse to work as an assistant charge nurse.

A. Discuss with the staff nurse her performance and ways she can improve.

2. Ms. Hange notes one of the male staff nurse is frequently absent and his absence has adversely affected the quality of care given to the clients unit. Which of the following would be the BEST approach?

*

1 point

A. Talk with the staff nurse regarding the concern and remind him of the standards of the agency.

B. Write the staff nurse a memorandum regarding his absence.

C. Inform the staff nurse that his absence will be a ground for termination.

D. Record the absence of the staff nurse in a log book.

A. Talk with the staff nurse regarding the concern and remind him of the standards of the agency.

3. Ms. Hange assigns a new staff nurse to administer the medications of a client. Which detail of the client's drug therapy is the staff nurse legally responsible to document? The ________.

A. Peak concentration time of the drug.

B. Safe ranges of the drug.

C. Client's socio-economic status.

D. Client's reaction to the drug.

D. Client's reaction to the drug.

4. Ms. Hange decides what is best for a recovering client and acts on the decision without consulting the client. Ms. Hange is applying a moral principle which is ______________.

A. Paternalism

B. Beneficence

C. Fidelity

D. Autonomy

A. Paternalism

Situation

The nurse cares for a female client who is

terminally ill and is experiencing pain.

5. The nurse prepares a care plan for the client. The overall goal for the client is ________.

The client will:

A. Achieve control of pain and discomfort.

B. Receive adequate cerebral oxygenation and perfusion.

C. Be free from infection.

D. Receive life sustaining food and liquids.

A. Achieve control of pain and discomfort.

6. The nurse is aware of the document that expresses a client's wish for life sustaining treatment in the event of terminal illness or permanent unconsciousness. This document is the ______;

A. No-code order

B. Durable power of attorney

C. Living will

D. Last will and testament

C. Living will

7. The client nears death and requests that no medication be given that would cause a loss of consciousness, including pain medication. The nurse would promote the best end-of-life care for the client by which of the following?

*

1 point

A. Discuss the request of the dying client with family members and respect their wishes.

B. Comfort is the highest priority in this situation so give medications as ordered.

C. Respect the client's wishes and withhold pain medications and other medications ordered.

D. Be compassionate and give half of dose of the medication ordered.

C. Respect the client's wishes and withhold pain medications and other medications ordered.

8. Which of the following statement is TRUE about terminally ill clients?

A. Terminally ill clients require minimum physical care.

B. Health care personnel do not understand their own feelings about death and dying therefore they avoid caring for terminally clients.

C. Terminally ill clients have the right to die with dignity.

D. Terminally ill client's experiences pain most of the time.

C. Terminally ill clients have the right to die with dignity.

9. The dying client wishes to donate her eyes after she dies. Which of the following statements is NOT TRUE about organ donation?

*

1 point

A. Any individual, at least 15 years old of age and of a sound mind may donate a part of his body to take the effect after transplantation needed by the recipient.

B. Sharing of human organs or tissues shall be made only through exchange programs duly approved by the Department of Health.

C. The choice to donate an organ must be a written document.

D. Laws do not require the consent of a family members to retrieve organs if the donor has expressed his last wish to donate.

A. Any individual, at least 15 years old of age and of a sound mind may donate a part of his body to take the effect after transplantation needed by the recipient.

SITUATION

You are a nurse tasked to

care for patients with different pituitary disorders. You are to take care of

Karoo and Koza, both diagnosed with SIADH, and Paula, who is diagnosed with

diabetes insipidus. You utilize your knowledge on this concept to help care for

your patients safely.

10. One of the clients in your unit, Karoo, is diagnosed to have a pituitary tumor. Karoo developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which of the following interventions should you implement as Karoo's primary nurse?

*

1 point

A. Assess for dehydration and monitor blood glucose levels.

B. Assess for nausea and vomiting and weigh daily.

C. Monitor potassium levels and encourage fluid intake.

D. Administer vasopressin IV and conduct a fluid deprivation test

B. Assess for nausea and vomiting and weigh daily.

11. You are reviewing the chart of Karoo who has SIADH. Which of the following clinical manifestations you noted in Karoo's chart should be reported to his primary care physician?

A. Serum sodium of 112 mEq/L and a headache.

B. Serum potassium of 5.0 mEq/L and a heightened awareness.

C. Serum calcium of 10 mg/dL and tented tissue turgor.

D. Serum magnesium of 1.2 mg/dL and large urinary output.

A. Serum sodium of 112 mEq/L and a headache.

12. Another patient in your unit, Koza, was diagnosed with SIADH secondary to cancer of the lung. He tells you that he wants to discontinue his fluid restriction and that he does not care if he dies. Which of the following actions by the nurse is an example of the ethical principle of autonomy?

*

1 point

A. Discuss the information the client told the nurse with the health-care provider and significant other.

B. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions.

C. Notify the health-care provider of the client's wishes and give the client fluids as desired.

D. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.

C. Notify the health-care provider of the client's wishes and give the client fluids as desired.

13. Paula, another patient assigned to you in the unit, is recently diagnosed with diabetes insipidus. Which of the following interventions should you implement as Paula's primary nurse?

A. Administer sliding-scale insulin as ordered.

B. Restrict caffeinated beverages.

C. Check urine ketones if blood glucose is >250.

D. Assess tissue turgor every four (4) hours

D. Assess tissue turgor every four (4) hours

14. Following Paula's diagnosis of diabetes insipidus, she stayed in the hospital for a few days. She is now about to be discharged and you are conducting your health teaching regarding her condition. Which of the following statements made by Paula warrants further intervention?

*

1 point

A. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet."

B. "I should take my medication in the morning and leave it refrigerated at home."

C. "I should weigh myself every morning and record any weight gain."

D. "If I develop a tightness in my chest, I will call my health-care provider."

B. "I should take my medication in the morning and leave it refrigerated at home."

SITUATION

You are a new nurse

assigned to take care of patients with various eye disorders. You use your

knowledge to help these patients with their condition.

15. One of the patients in your unit, Pagaya, is diagnosed with glaucoma. Which of the following symptoms should you expect the client to report during your initial assessment with him?

A. Loss of peripheral vision.

B. Floating spots in the vision.

C. A yellow haze around everything.

D. A curtain coming across vision.

A. Loss of peripheral vision.

16. Pagaya has now been prescribed a miotic cholinergic medication for his glaucoma. Which of the following data indicates that the medication has been effective on Pagaya?

*

1 point

A. No redness or irritation of the eyes

B. A decrease in intraocular pressure

C. The pupil reacts briskly to light

D. The client denies any type of floaters

B. A decrease in intraocular pressure

17. You are caring for Gan Fall, a postoperative patient, after his retinal detachment surgery. Gas tamponade was used to flatten the patient's retina during the procedure. Which of the following interventions should you implement first?

*

1 point

A. Teach the signs of increased intraocular pressure.

B. Position the client as prescribed by the surgeon.

C. Assess the eye for signs/symptoms of complications.

D. Explain the importance of follow-up visits.

C. Assess the eye for signs/symptoms of complications.

18. You are caring for Conis, a patient with severe myopia. She is scheduled for a laser assisted in situ keratomileusis (LASIK) surgery. Which of the following instructions should you discuss with Conis prior to her discharge from the surgery?

*

1 point

A. Wear bilateral eye patches for three (3) days.

B. Wear corrective lenses until the follow-up visit.

C. Do not read any material for at least one (1) week.

D. Teach the client how to instill corticosteroid ophthalmic drops.

D. Teach the client how to instill corticosteroid ophthalmic drops.

19. Eneru, a 65 year old male client is complaining of blurred vision, but denies having any type of pain. He reports to you, "I feel like I need to clean my glasses all the time". Which of the following eye disorders should you suspect that Eneru has?

*

1 point

A. Corneal dystrophy

B. Conjunctivitis

C. Diabetic retinopathy

D. Cataracts

D. Cataracts

SITUATION

You are a nurse caring for

patients with inflammatory bowel disease.

20. Pierre is a patient admitted to the hospital with a diagnosis of ulcerative colitis. You are currently reviewing his history and physical assessment chart. Based on Pierre's diagnosis, which of the following information should you expect to see in Pierre's medical records?

*

1 point

A. Abdominal pain and bloody diarrhea

B. Weight gain and elevated blood glucose

C. Abdominal distension and hypoactive bowel sounds

D. Heartburn and regurgitation

A. Abdominal pain and bloody diarrhea

21. Pierre had a recent exacerbation of ulcerative colitis. He is put on mesalamine (Asacol), which is to be administered rectally via an enema. Pierre finds this procedure distasteful and he asks you, "Why can't the medication just be given orally?". You answer Pierre correctly by saying which of the following?

*

1 point

A. "It can be given orally; I'll contact the doctor and see if the change can be made."

B. "Rectal administration delivers the medication directly to the affected area."

C. "Oral administration will not be as effective for the disease condition."

D. "It can be given orally, I'll make the change and we'll tell the doctor in the morning."

B. "Rectal administration delivers the medication directly to the affected area."

22. You overhear a licensed practical nurse (LPN) talking to one of your patients, Mousse, who is being prepared for a total colectomy with creation of an ileoanal reservoir for her ulcerative colitis. To decrease Mousse's anxiety, you should intervene to clarify the information given by the LPN when you hear the LPN saying:

*

1 point

A. "This surgery will prevent you from developing colon cancer."

B. "After this surgery you will no longer have ulcerative colitis."

C. "When you return from surgery you will not be able to eat solid food for several days."

D. "You will have an ileostomy when you return from this surgery."

D. "You will have an ileostomy when you return from this surgery."

23. Wyper, a 20 year old male client, is admitted to your unit because of the exacerbation of their ulcerative colitis. You go into Wyper's room to complete an initial assessment, and he yells, "Get outta here! I am tired of you nurses and doctors looking at my body all the time!" Which of the following is your best action?

*

1 point

A. Leave the room and ask a male colleague to complete the assessment.

B. Verbally acknowledge the client's frustration and anger.

C. Call the health-care practitioner and ask for a sedative order.

D. Tell the client that gathering data about his current condition will promote effective timely treatment of his health concerns.

B. Verbally acknowledge the client's frustration and anger.

24. You are caring for Conis, a patient admitted in your unit who is diagnosed with Crohn's disease. She has undergone a barium enema that demonstrated the presence of strictures in her ileum. Based on this finding, you should monitor the client closely for signs of:

*

1 point

A. peritonitis.

B. obstruction.

C. malabsorption.

D. fluid imbalance.

B. obstruction.

SITUATION

You are a nurse studying

the different types of shock and its appropriate nursing interventions. You

come across the following patients in your unit. You applied the concepts

you've learned to your nursing practice.

25. Foxy is a client admitted to the emergency department. Assessment findings include diaphoresis, pale clammy skin, and a blood pressure reading of 90/70. Which of the following interventions should you implement first?

*

1 point

A. Start an IV with an 18-gauge catheter.

B. Administer dopamine intravenous infusion.

C. Obtain arterial blood gases (ABGs).

D. Insert an indwelling urinary catheter.

A. Start an IV with an 18-gauge catheter.

26. Porche is a patient diagnosed with neurogenic shock. As a knowledgeable nurse, you expect to note which of the following signs and symptoms in this client?

A. Cool, moist skin.

B. Bradycardia.

C. Wheezing.

D. Decreased bowel sounds

B. Bradycardia.

27. One of the patients in your unit, Hamburg, was diagnosed with septicemia. The following are the orders given by Hamburg's primary physician. Which of these orders will have the highest priority?

*

1 point

A. Provide a clear liquid diet.

B. Initiate IV antibiotic therapy.

C. Obtain a STAT chest x-ray.

D. Perform hourly glucometer checks.

B. Initiate IV antibiotic therapy.

28. You wrote the nursing diagnosis of "alteration in comfort related to chills in fever" in one of your patients who has sepsis. Which of the following interventions would you include in this patient's plan of care?

*

1 point

A. Ambulate the client in the hallway every shift.

B. Monitor urinalysis, creatinine level, and BUN level.

C. Apply sequential compression devices to the lower extremities.

D. Administer an antipyretic medication every four (4) hours PRN.

D. Administer an antipyretic medication every four (4) hours PRN.

29. A patient named Chiqicheetah presents themselves in the emergency department complaining of abdominal pain, is pale and clammy, and has a pulse of 110 and a blood pressure reading of 92/60. Chiqicheetah has vertebral fractures, and she reported she has been self-medicating with Ibuprofen, a type of nonsteroidal anti-inflammatory drug (NSAID). Which of the following type of shocks should you expect in patient Chiqicheetah?

*

1 point

A. Cardiogenic shock.

B. Hypovolemic shock.

C. Neurogenic shock.

D. Septic shock.

B. Hypovolemic shock.

SITUATION

You are caring for patients

in your unit with alterations in their fluid and electrolytes. As a

knowledgeable nurse, you apply the concepts of fluid and electrolytes in your

nursing practice.

30. As an experienced nurse, you know that client incidence of hypermagnesemia is rare in comparison with hypomagnesemia. A student nurse approached you and asked how hypermagnesemia develops. You answer her correctly by saying that hypermagnesemia generally occurs secondary to:

*

1 point

A. Cardiac contractility.

B. Hypokalemia.

C. Liver failure.

D. Renal insufficiency.

D. Renal insufficiency.

31. You are assigned to care for Ace, a patient diagnosed to have hypokalemia. As a knowledgeable nurse, you know that the electrolyte that must be corrected in this scenario is:

*

1 point

A. Calcium.

B. Magnesium.

C. Manganese.

D. Zinc.

B. Magnesium.

32. You are caring for a group of patients in the ward. While reviewing each of the patient's charts, you determine which of the following patients is most likely at risk for fluid volume deficit?

*

1 point

A. A client with an ileostomy

B. A client with heart failure

C. A client on long-term corticosteroid therapy

D. A client receiving frequent wound irrigations

A. A client with an ileostomy

33. You are refreshing your knowledge on sodium imbalances. As a knowledgeable nurse, you know that which of the following patients in the ward is most likely to develop a sodium level at 130 mEq/L (130 mmol/L)?

*

1 point

A. The client who is taking diuretics

B. The client with hyperaldosteronism

C. The client with Cushing's syndrome

D. The client who is taking corticosteroids

A. The client who is taking diuretics

34. You are reviewing one of your patient's progress notes. You read that the physician has documented "insensible fluid loss of approximately 800mL daily". As a knowledgeable nurse, you make a notation that insensible fluid loss occurs through which of the following types of excretion?

*

1 point

A. Urinary output

B. Wound drainage

C. Integumentary output

D. The gastrointestinal tract

C. Integumentary output

SITUATION

You are a nurse assigned to

care for and educate patients in the cancer unit of the hospital you are

working on. You apply the concepts you've learned regarding cancer to ensure a

safe nursing practice.

35. You are reviewing your notes on cancer. After much reading, you know that cancer prevalence is defined as?

*

1 point

A. The likelihood cancer will occur in a lifetime.

B. The number of persons with cancer at a given point in time.

C. The number of new cancers in a year.

D. All cancer cases more than 5 years old.

B. The number of persons with cancer at a given point in time.

36. Gol is your patient diagnosed to have testicular cancer. He expressed his concerns regarding fertility since him and his partner desires to eventually have a family. As Gol's primary nurse, you discuss the option of sperm banking. You inform Gol and his partner that sperm banking needs to be performed when?

*

1 point

A. Before treatment is started.

B. Once the client is tolerating the treatment.

C. Upon completion of treatment.

D. When tumor markers drop to normal levels.

A. Before treatment is started.

37. You are working with Bellamy, a client with known risks for lung cancer. He asks you why he is scheduled for a computed tomography (CT) scan as part of his initial workup. You answer Bellamy correctly when you respond by saying:

*

1 point

A. "CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis."

B. "CT is noninvasive and readily available."

C. "CT is useful for distinguishing small differences in tissue density and detecting nodal involvement."

D. "CT can distinguish malignant adenopathy from nonmalignant adenopathy."

C. "CT is useful for distinguishing small differences in tissue density and detecting nodal involvement."

38. You are caring for Cricket, a patient with pain related to bone cancer. You conducted an assessment on Cricket in relation to this. You know that which of the following is the most important component of a thorough pain assessment specific for patient Cricket?

*

1 point

A. Intensity.

B. Cause.

C. Aggravating factors.

D. Location.

A. Intensity.

39. Noland is a cancer patient you are tasked to care for. He is receiving the medication vincristine (Oncovin). You plan your health teaching for Noland regarding this medication. Which of the following should you include in your instructions to Nolan?

*

1 point

A. Use of loperamide (Imodium).

B. Fluid restriction.

C. Low fiber, bland diet.

D. Bowel regimen.

D. Bowel regimen.

40. Sarquiss is a 57 year old client receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms would you note in Sarquiss that could indicate a toxic response to the chemotherapy?

*

1 point

A. Decrease in appetite.

B. Drowsiness.

C. Spasms of the diaphragm.

D. Cough and shortness of breath.

D. Cough and shortness of breath.

41. Hina is one of the patients you are tasked to care for her in the unit. She is beginning external beam radiation therapy to the right axilla after her lumpectomy for breast cancer. You plan to conduct a health teaching. Which of the following would you include in your education to Hina?

*

1 point

A. Use a heating pad under the right arm.

B. Immobilize the right arm.

C. Place ice on the area after each treatment.

D. Apply deodorant only under the left arm.

D. Apply deodorant only under the left arm.

42.Tony Tony is a patient receiving radiation therapy for lung cancer. He complains that he is having difficulty sleeping. After hearing this statement from your patient, you should:

*

1 point

A. Suggest the client stop watching television before bed.

B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.

C. Tell the client sleeplessness is expected with radiation therapy.

D. Suggest that the client stop drinking coffee until the therapy is completed.

B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.

43. You are caring for Nico, a patient with cancer who requires a bolus tube feeding. You prepare to administer the bolus tube feeding and as a skilled nurse, which of the following nursing interventions is most appropriate to decrease the risk of aspiration in this patient?

*

1 point

A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.

B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.

C. Assist the client out of bed to sit upright in a chair for 1 hour.

D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.

C. Assist the client out of bed to sit upright in a chair for 1 hour.

44. Portgas is a cancer patient receiving chemotherapy. He is experiencing a flare up of pruritus. You are planning to develop a care plan for Portgas. In order to develop the nursing care plan, you should ask him if he has been:

*

1 point

A.Wearing clothes made from 100% cotton.

B. Sleeping in a cool, humidified room.

C. Increasing fluid intake to at least 3,000 mL/ day.

D. Taking daily baths with a deodorant soap.

D. Taking daily baths with a deodorant soap.

SITUATION

You are a nurse caring for

patients with cardiac complications. You use your knowledge on cardiovascular

concepts to help these patients.

45. You are working on the unit with patient Brogy. At 7:30 AM, you received a verbal order from his primary HCP for a cardiac catheterization to be completed on him by 2:00 PM. Which of the following actions should you initiate first in Brogy?

*

1 point

A. Initiate NPO (nothing per mouth) status for the client.

B. Teach the client about the procedure.

C. Start an intravenous (IV) infusion of 0.9% NaCl.

D. Ask the client to sign a consent form.

A. Initiate NPO (nothing per mouth) status for the client.

46. You are working with Dorry, a male patient who experienced a myocardial infarction a few days ago. You noted that patient Dorry seems unusually fatigued. Upon your assessment, you find that patient Dorry is dyspneic with activity, has a heart rate of 110 bpm, and has generalized edema. Which of the following actions would be most appropriate for this patient?

*

1 point

A. Administer high-flow oxygen

B. Encourage the client to rest more

C. Continue to monitor the client's heart rhythm

D. Compare the client's admission weight with the client's current weight

D. Compare the client's admission weight with the client's current weight

47. You are caring for patient Whitebeard immediately following an insertion of a permanent pacemaker via his right subclavian vein. As a skilled nurse, you know that the action that can best prevent pacemaker lead dislodgement is:

*

1 point

A. inspecting the incision site dressing for bleeding and the incision for approximation

B. limiting the client's right arm activity and preventing the client reaching above shoulder level

C. assisting the client with getting out of bed and ambulating with a walker

D. ordering a stat chest x-ray following return from the implant procedure

B. limiting the client's right arm activity and preventing the client reaching above shoulder level

48. You are increasing activity for patient Bon with an admitting diagnosis of acute coronary syndrome. Which of the following symptoms experienced by patient Bon best supports the nursing diagnosis of activity intolerance?

*

1 point

A. Pulse rate increased by 15 beats per minute during activity

B. Blood pressure (BP) 130/86 mm Hg before activity; BP 108/66 mm Hg during activity

C. Increased dyspnea and diaphoresis relieved when sitting in a chair

D. A mean arterial pressure (MAP) of 80 following activity

B. Blood pressure (BP) 130/86 mm Hg before activity; BP 108/66 mm Hg during activity

49. Cobra is a patient who suffered an inferior septal wall myocardial infarction. Which of the following complications would you suspect in Cobra when you note on your assessment a jugular venous distention and ascites?

*

1 point

A. Left-sided heart failure

B. Pulmonic valve malfunction

C. Right-sided heart failure

D. Ruptured septum

C. Right-sided heart failure

SITUATION

You are an emergency nurse

tasked to work with patients with medical emergencies. You utilize your

knowledge to help these patients.

50. A patient's wife is allowed to be present during resuscitation efforts for a patient in the ICU. Which of the following statements made by you would be the most correct and appropriate?

*

1 point

A. "You can hold your loved one's hand; sometimes a recovering person remembers that touch."

B. "Another staff member will be with you; I will show you where you can stand near your husband."

C. "Because the resuscitation team needs to work quickly, you need to stay out of their way and not \ interfere."

D. "If the resuscitation efforts fail, the health-care provider will ask you if you want to terminate resuscitation efforts."

B. "Another staff member will be with you; I will show you where you can stand near your husband."

51. An apartment fire broke out near the hospital. The injured victims are sent to the emergency department of the hospital. Five families of the injured patients arrived in the ED subsequently to inquire about the health status of their family members. Which of the following is your best action?

*

1 point

A. Take the families to the triage area so they can be with their loved ones

B. Ask the families to wait in the waiting area until information is available

C. Ensure that there is a designated area for family staffed by available social workers or clergy

D. Direct families to a lounge where a receptionist will be keeping families informed

C. Ensure that there is a designated area for family staffed by available social workers or clergy

52. Patient Aokiji is a male client that presented themself in the emergency department after vomiting a "large" amount of bright red blood. Which of the following actions should you implement first?

*

1 point

A. Start an intravenous line with an 18-gauge needle.

B. Have the UAP take the client's vital signs.

C. Ask the client to provide a stool specimen for blood.

D. Send the client to radiology for an abdominal CT scan.

A. Start an intravenous line with an 18-gauge needle.

53. You are working as a triage nurse in a large trauma center. The center has been notified of an explosion in a nearby major chemical manufacturing plant. Which of the following actions should you implement first when the injured patients arrive at the emergency department?

*

1 point

A. Triage the clients and send them to the appropriate areas.

B. Thoroughly wash the clients with soap and water and then rinse.

C. Remove the clients' clothing and have them shower.

D. Assume the clients have been decontaminated at the plant.

C. Remove the clients' clothing and have them shower.

54. You are attending a seminar on codes. After the session, you recall that which of the following interventions is the most important for you to implement when participating in a code?

*

1 point

A. Elevate the arm after administering medication.

B. Maintain sterile technique throughout the code.

C. Treat the client's signs/symptoms; do not treat the monitor.

D. Provide accurate documentation of what happened during the code.

C. Treat the client's signs/symptoms; do not treat the monitor.

Situation

The nurse in the

emergency department admits a 45 year old female for vomiting blood. According

to a family member who accompanied the client, the client had a gastric ulcer

for several years. The nurse assesses that the client is in shock.

55. Which of the following assessment findings indicate hypovolemic shock?

*

1 point

A. Systolic blood pressure is less than 90 mmHg.

B. Pupils are unequally dilated. - may indicate brain stem damage

C. Respiratory rate is more than 30 breaths per minute.

D. Pulse is less than 60 beats per minute

C. Respiratory rate is more than 30 breaths per minute.

56. In the early stages of shock, the nurse expects the result of arterial blood gas (ABG) analysis to indicate which of the following conditions ____________:

*

1 point

A. Respiratory alkalosis

B. Respiratory acidosis

C. Metabolic alkalosis

D. Metabolic acidosis

A. Respiratory alkalosis

57. The physician orders intravenous infusion of packed red blood cells and normal saline solutions. The nurse assesses the client for which of the following _____________:

*

1 point

A. Hypovolemia

B. Anaphylactic reaction

C. Altered level of consciousness

D. Pain

B. Anaphylactic reaction

58. The nurse understands that the best indication that fluid replacement for the client in hypovolemic shock is adequate is when the ___________:

*

1 point

A. Systolic blood pressure is above 110 mmHg.

B. Diastolic blood pressure is above 90 mmHg.

C. Urine output of 20- 30 mL/Hour.

D. Urine output is greater than 30 mL/Hour.

D. Urine output is greater than 30 mL/Hour.

59. The physician schedules the client for surgery within six hours. The nurse minimize anxiety of the client by answering the client's questions regarding the surgery in calm manner, keeps the client warm, advise the client to be on bed rest and dims the lights in the room. The reason for these interventions is to ________:

*

1 point

A. Increase comfort of the client and her family.

B. Minimize oxygen consumption.

C. Prevent infection.

D. Stabilize fluid and electrolyte balance.

A. Increase comfort of the client and her family.

Situation

A 60 year old male is

admitted to the oncology unit. According to the client, he felt a growth during

a routine digital prostate examination. He complains of pain on urination and

frequent urination.

60. The nurse understands that the function of the prostate gland is primarily to ______;

*

1 point

A. Regulate the acidity and alkalinity environment for proper sperm development.

B. Produce a secretion that aids the nourishment and passage of sperm.

C. Secrete a hormone that stimulates the production and maturation of sperm.

D. Store undeveloped sperm before ejaculation.

B. Produce a secretion that aids the nourishment and passage of sperm.

61. The nurse analyzes the laboratory values and notes that the serum phosphate level is elevated. This finding indicates which of the following:

*

1 point

A. It confirms the diagnosis of prostate cancer.

B. The progression or regression of prostate cancer.

C. The likelihood of metastasis to the bones.

D. There are complications associated with cancer.

C. The likelihood of metastasis to the bones.

62. The nurse knows that hormone therapy is the mode of treatment for a client with prostate cancer. The goal of this form of treatment is to ______:

*

1 point

A. Limit the amount of circulating androgens.

B. Increase prostaglandin level.

C. Increase the amount of circulating androgens.

D. Increase testosterone level.

A. Limit the amount of circulating androgens.

63. The nurse writes a nursing diagnosis of Fear and Anxiety secondary to the diagnosis of prostate cancer. Which of the following interventions would be BEST for the nurse?

*

1 point

A. Encourage the client to keep his feelings to himself so his family will not be affected.

B. Establish a nurse patient therapeutic relationship.

C. Advise the client to have a positive outlook relationship.

D. Provide spiritual support to the client.

D. Provide spiritual support to the client.

Situation

Nurse Petra works in the

oncology unit. She takes care of cancer patients in pain. She is aware that

cancer pain management is one of her responsibilities.

64. Nurse Petra plans care for a cancer client experiencing pain. She is aware that an important principle of using medication to manage pain is to:

*

1 point

A. Individualize the medication therapy to the client.

B. Provide the medication as soon as the client requests for it.

C. Discontinue the medications periodically to discourage the development of drug tolerance.

D. Avoid giving client addictive medications.

B. Provide the medication as soon as the client requests for it.

65. Nurse Petra collaborates with the physician in the development of a drug regimen for the clients. Which of the following medications should be avoided in the treatment of cancer pain?

*

1 point

A. Morphine

B. Acetaminophen (Tylenol)

C. Meperidine (Demerol)

D. Hydrocodone

B. Acetaminophen (Tylenol)

66. When titrating a drug for the client in pain, which of the following actions is MOST appropriate?

*

1 point

A. Ask the physician to include a medication order for breakthrough pain.

B. Follow the physician's order for the first 24 hours.

C. Reassess the client every 8 hours for drug effectiveness.

D. Seek a new order after 2 doses that do not achieve a tolerable level of pain relief.

D. Seek a new order after 2 doses that do not achieve a tolerable level of pain relief.

67. One of the clients experiences severe, intractable pain and complains that the pain medication is not working for him. Which of the following actions is MOST appropriate for Nurse Petra?

*

1 point

A. Suggest to the client to try deep breathing to cope with the pain.

B. Explore the nature of the pain and encourage the client to perceive it in a different way.

C. Support the client emotionally and tell him he will receive the next dose of medication as soon as possible.

D. Refer the client to the attending physician immediately and report that the pain medication is not providing adequate pain relief.

D. Refer the client to the attending physician immediately and report that the pain medication is not providing adequate pain relief.

68. Nurse Petra assesses a client complaining of acute pain. The MOST appropriate nursing assessment would include which of the following?

*

1 point

A. The nurses' impression of clients' pain.

B. The clients' pain rating.

C. Nonverbal cues from the client.

D. Pain relief after appropriate nursing interventions.

B. The clients' pain rating.

Situation

Ms. Helen is a nurse

supervisor of three departments in hospital X. She attends an orientation

seminar on hospital records management.

69. Ms. Helen understands that good client care relies on good record keeping. Which of the following is NOT a purpose of hospital record keeping?

*

1 point

A. Records provide evidence of a hospital's accountability.

B. Records are a key source of data for medical research or statistical reports.

C. Records provide data on health information system.

D. Records provide personal information on the physicians and nurses caring for the clients.

D. Records provide personal information on the physicians and nurses caring for the clients.

70. Ms. Helen is aware that when a client is readmitted to a hospital, the client's file is retrieved from the _______________.

*

1 point

A. physician's file

B. civil service file

C. master patient index file

D. hospital library record file

C. master patient index file

71. Ms. Helen is aware that when a client is readmitted to a hospital, the client's file is retrieved from the__________.

*

1 point

A. Physician's file

B. Civil service file

C. Master patient index file

D. Hospital library record file

C. Master patient index file

72. Ms. Helen is aware that when a client is discharged or dies, the following details should be entered in the client's record which is the_______________.

A. Final diagnosis

B. Outcomes classification

C. Educational attainment

D. Religion

A. Final diagnosis

73. The following statements are true about patients and hospital records EXCEPT:

*

1 point

A. Confidential records must be protected against loss, damage , unauthorized access, modification and disclosure

B. Patients have the right to confidential treatment of information they provide to health professional

C. Health records are the property of community where the patient is treated

D. Hospital records maybe released without the patient's consent when required in investigation for serious criminal offenses

C. Health records are the property of community where the patient is treated

Section

Ms. Mika is a director

of the critical care unit of hospital x. She utilizes the nursing process to

communicate care to the client.

74. She is called to the bedside of a client who is scheduled to have laparoscopic cholecystectomy. The client's pulse is slightly irregular. Ms. Mika confers with the primary nurse regarding the client's condition, which step of the nursing process is Ms. Mika applying?

*

1 point

A. Implementation

B. Evaluation

C. Planning

D. Assessment

C. Planning

75. Ms. Mika calls for a conference with the staff members who are attending to the client. They decide to obtain a 12-lead ECG for a more definitive picture. They conclude that the client has no serious cardiac or pulmonary problems. Which step of the nursing process is in effect in this situation?

*

1 point

A. nursing diagnosis

B. assessment

C. evaluation

D. planning

B. assessment

76. Ms. Mika consults with the attending physician and the anesthesiologist. She advises the primary nurse to proceed with the preparations and to remain alert for any adverse symptoms. Which step of the nursing process is this?

*

1 point

A. Assessment

B. nursing diagnosis

C. planning

D. evaluation

C. planning

77. Ms. Mika confers with the client's primary nurse the following morning. Together they determine that the client is ready for surgery. This step of the nursing process is:

*

1 point

A. evaluation

B. planning

C. nursing diagnosis

D. assessment

A. evaluation

78. Ms. Mika applies the human relations approach in this situation. She is aware that the key to productivity is _________________.

*

1 point

A. the degree of independence allowed

B. meeting the objectives of the critical care unit

C. Firm control of the situation

D. the behavior of people under direction

A. the degree of independence allowed

Situation

A mother with the

diagnosis of AIDS states that she has been caring for her baby even though she

has not been feeling well.

79. What important information should the nurse determine?

A. is she has kissed the baby

B. if the baby is breastfeeding

C. when the baby last received antibiotics

D. how long she has been caring for the baby

B. if the baby is breastfeeding

80. The nurse is planning to provide discharge teaching to the family of a client with AIDS. Which statement should the nurse include in the teaching plan?

A. "Wash the dishes in hot soap as you usually do."

B. "Let the dishes soak in hot water overnight before washing."

C. "You should boil the client's dishes for 30 minutes after use."

D. "have the client eat from paper plates so they can be discharged."

A. "Wash the dishes in hot soap as you usually do."

81. During an AIDS education class a client states, "Vaseline works great when I use condoms." Which conclusions about the client's knowledge of condom use can the nurse draw this statement?

*

1/1

A. an understanding of safer sex

B. an ability to assume self-responsibility

C. ignorance concerning correct condom use

D. ignorance concerning the transmission of HIV

D. ignorance concerning the transmission of HIV

82. The client with AIDS is experiencing nausea and vomiting. The Nurse would make which of the following dietary alterations for this client to enhance nutritional intake?

*

1 point

A. Avoid dairy products and red meat

B. Plan large nutritious meals

C. Add spices to food to enhance flavour

D. Serve foods while they are warm

A. Avoid dairy products and red meat

83. The Physician orders a Paracentesis. How should the nurse instruct the client to prepare for the radiograph?

*

1 point

A. void before the procedure

B. a laxative the evening before the procedure

C. nothing by mouth for 8 hours before the procedure

D. a low soapsuds enema the morning of the procedure

A. void before the procedure

Situation

In a Medical ward there

are clients with potential or actual disorders of fluids and electrolytes

disturbance and homeostatic mechanisms.

84. The nurse is caring for a client with chronic kidney failure. The nurse understands that ammonia is normally exerted by the kidney to help maintain:

A. osmotic pressure of the blood

B. acid-base balance of the body

C. low bacterial level in the urine

D. normal red blood cell production

B. acid-base balance of the body

85. Which finding best suggests that nursing interventions for a client with an excess fluid volume have been effective?

*

1 point

A. clear breath sounds

B. positive pedal pulses

C. normal potassium level

D. increased urine specific gravity

A. clear breath sounds

86. The nurse understands that a client with albuminuria has edema because of:

*

1 point

A. fall in tissue hydrostatic pressure

B. rise in plasma hydrostatic pressure

C. rise in tissue colloid osmotic pressure

D. fall in plasma colloid oncotic pressure

D. fall in plasma colloid oncotic pressure

87. When the nurse uses the clamp on the administration set to manually adjust the flow of IV fluid into a client by gravity, what change in energy takes place?

*

1 point

A. potential energy is converted to kinetic energy

B. kinetic energy is converted to potential energy

C. chemical energy is converted to kinetic energy

D. potential energy is converted to chemical energy

A. potential energy is converted to kinetic energy

88. The client with which condition has an increased risk for developing Hyperkalemia?

A. Crohn's disease

B. Cushing's syndrome

C. Chronic heart failure

D. End-stage renal disease

D. End-stage renal disease

Situation

The

nurse assists in the care of a 15 year old female experiencing anaphylaxis due

to insect bite by honeybees.

89. Upon assessment, the nurse observes the client reacting to the insect bites. The following are common reactions to an insect sting EXCEPT:

*

1 point

A. Swelling

B. Redness

C. Appearance of lesions

D. Pain

C. Appearance of lesions

Situation

Nurse

Gab is a staff nurse in the oncology unit of a tertiary hospital. An activity

in the unit for continuing professional development is to disseminate

information among the personnel and staff in the unit regarding trends and

treatment for cancer. Nurse Gab read an article entitled "Understanding

Colorectal Cancer" which was recently published in a national newspaper.

90. According to the Philippine Cancer Facts and Estimates for 2010, one of the most common cancer among men is colorectal cancer. It ranks ______ among all the diseases:

*

1 point

A. First

B. Fourth

C. Second

D. Third

D. Third

91. The nurse assigned to his care anticipates that the client would be particularly susceptible to which of the following fluid and electrolyte imbalances during the emergent phase of burn case.

*

1 point

A. Metabolic acidosis

B. Hypernatremia

C. Hypokalemia

D. Metabolic alkalosis

A. Metabolic acidosis

92. The nurse assesses the client for fluid shifting. During the emergent phase of a burn injury, shifts occur due to fluid moving from the_______________.

*

1 point

A. Extracellular to intracellular space.

B. Intracellular to extracellular space.

C. Vascular to interstitial space.

D. Interstitial to vascular space

C. Vascular to interstitial space.

93. The nurse understands that the fluid shift results from an increase in the_____________.:

*

1 point

A. Total volume of intravascular plasma

B. Total volume of circulating whole blood

C. Permeability of capillary walls

D. Permeability of the kidney tubules

C. Permeability of capillary walls

94. The client receives fluid resuscitation therapy. The nurse adjusts the infusion rate by evaluating the client's __________:

*

1 point

A. Hourly urine output

B. Daily body weight

C. Hourly urine specific gravity

D. Hourly body temperature

A. Hourly urine output

95. The client receives total parenteral nutrition (TPN). The nurse understands this therapy will help the client__________.

*

1 point

A. Provide adequate nutrition

B. Ensure adequate caloric and protein intake

C. Correct water and electrolyte imbalances

D. Allow the gastrointestinal tract to rest

B. Ensure adequate caloric and protein intake

SITUATION

You are caring for patient

Igaram, a patient with Addison's disease. You utilize your knowledge on this

concept to help care for the patient.

96. Igaram was just recently diagnosed with Addison's disease. He still lacks knowledge about his disease so he decided to ask you some questions. Igaram asked you, "How does the disease happen?" You answer him correctly by stating that this disease results from:

*

1 point

A. Insufficient secretion of growth hormone (GH).

B. Dysfunction of the hypothalamic pituitary.

C. Idiopathic atrophy of the adrenal gland.

D. Oversecretion of the adrenal medulla.

C. Idiopathic atrophy of the adrenal gland.

97. Igaram is admitted to your unit. After your assessment on him, you formulated the nursing diagnosis Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As Igaram's oral intake increases, which of the following fluids would be the most appropriate for him?

*

1 point

A. Milk and diet soda.

B. Water and eggnog.

C. Bouillon and juice.

D. Coffee and milkshakes.

C. Bouillon and juice.

98. You are instructing Igaram how to adjust the dose of the glucocorticoids he is taking. As his nurse, you should explain to him that he may need an increased dosage of glucocorticoids in which of the following scenarios?

*

1 point

A. Completing the spring semester of school.

B. Gaining 4 pounds.

C. Becoming engaged.

D. Undergoing a root canal.

D. Undergoing a root canal.

99. Igaram is diagnosed with Addison's disease. As a knowledgeable nurse, you know that this condition may lead to Addisonian crisis if not adequately managed. Which of the following manifestations would be expected in Igaram if he develops this condition?

*

1 point

A. Fluid retention.

B. Pain.

C. Peripheral edema.

D. Hunger.

B. Pain.

100. If Igaram develops Addisonian crisis, which of the following would be your priority as Igaram's primary nurse?

*

1 point

A. Controlling hypertension.

B. Preventing irreversible shock.

C. Preventing infection.

D. Relieving anxiety.

B. Preventing irreversible shock.