RECALLS 9 - NP3

SITUATION: Documentation is one of the topics for discussion among the nurse - orientees.

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In the hospital, narrative documentation is used. From the guidelines below the nurse orientees were made to select which are the CORRECT guidelines related to narrative documentation. Select all that apply:

1. Use blue colored ink ball pen all the time

2. Date and time all entries

3. Completely document subjective and judgmental information gathered

4. Sign and affix appropriate title

5. Avoid evaluative statement

6. Do not leave blank spaces on documentation forms

A. 3, 4, 5, and 6

B. 1, 2, 4, and 6

B. 2, 3, 4, and 6

D. 2, 4, 5, and 6

D. 2, 4, 5, and 6

SITUATION: Documentation is one of the topics for discussion among the nurse - orientees.

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Nurse Yana made an error in documenting an assessment finding on her client's chart. She must CORRECT the error by:

A. Over the wrong entry, write ERROR in red, then write the correct data

B. Draw one line over the wrong entry, write the correct data, sign and put the date

C. Erase neatly the wrong entry and write on the same place the correct data

D. Delete the wrong entry and write the correct data

B. Draw one line over the wrong entry, write the correct data, sign and put the date

SITUATION: Documentation is one of the topics for discussion among the nurse - orientees.

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Another nurse -orientee administered an inaccurate dose of Ampicillin to her client. Following the assessment, reporting to the doctor and the head nurse, she accomplishes an incident report. The orientee understand that the report:

A. Will form part of her 201 file

B. Will result to her suspension from the hospital

C. Will be reported to the Regulatory Board of Nursing

D. Is a method of promoting quality care and risk management

D. Is a method of promoting quality care and risk management

SITUATION: Documentation is one of the topics for discussion among the nurse - orientees.

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The nurse-orientee was charting while waiting for the result of the cross-matching result of her client. When the fax machine activated, the nurse saw a result of the cross- matching of her client's name but with another hospital - bed - number. The MOST appropriate action of the nurse would be to:

A. Return the result of cross - matching and send another request

B. Consider the result as that of her client

C. Refer the matter to the head nurse

D. Call the laboratory to confirm result of cross - matching

D. Call the laboratory to confirm result of cross - matching

SITUATION: Documentation is one of the topics for discussion among the nurse - orientees.

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The nurse-orientee is to present a case in the meeting with the staff nurses. She Xeroxed the chart of her client to study at home. While she was dressing up to go home, a staff nurse saw the folder of Xeroxed copies of the patient's record. The staff nurse would call the attention of the nurse-orientee that:

A. This is a violation of hospital policy

B. The owner of the record should be consulted

C. Her action is against the client's right to privacy

D. A prior permission from the Medical Record Section should be obtained

C. Her action is against the client's right to privacy

The admitting nurse understands that in pneumothorax, air accumulates abnormally in the

A. Pulmonary vascular system

B. Pleural space

C. Lung tissues

D. Thoracic cavity

B. Pleural space

The patient is diagnosed with open pneumothorax. The nurse knows that this occurs when?

A. The chest wall wound is large enough to allow air to pass freely in and out.

B. There is a buildup of positive pressure occurring with each inspiration and the air is trapped.

C. There is a rupture of air-filled bleb or blister on the surface of the lung.

D. There is a presence of bronchopleural fistula.

B. There is a buildup of positive pressure occurring with each inspiration and the air is trapped.

OPENING THROUGH THE CHEST WALL ALLOWING ENTRANCE OF POSITIVE ATMOSPHERIC AIR PRESSURE INTO PLEURAL

The chest wall wound is large enough to allow air to pass freely in, NOT OUT

C. There is a rupture of air-filled bleb or blister on the surface of the lung. = SPONTANEOUS

The nurse identifies with presence of chest tubes. Which of the following nursing interventions will be the nurse consider as APPROPRIATE?

1. Secure a loop of the drainage tubing to the sheet or groin of the client

2. Encourage DBE and coughing as needed

3. Maintain the collection apparatus below the chest

4. When turning client, ensure chest tube and drainage tubing are not occluded under the client.

5. Clamp the chest tube to practice pleural training

A. 1, 2, 3, and 5 only

B. 3, 4 only

C. 2, 3, 4 only

D. ALL OF THE ABOVE

B. 3, 4 only

2. Encourage DBE and coughing as needed. FOR SECRETIONS, NOT PNEUMOTHORAX (AIR ACCUMULATION)

The physician ordered, "report drainage that is cloudy and in excess of 70 ml per hour. The nurse knows that a cloudy drainage would indicate:

A. Infection

B. Presence of debris

C. Impending hemorrhage

D. Occluded tubing

A. Infection

When the nurse checked the water sealed drainage, she observed that the water level does not fluctuate simultaneously with the client's breathing. The nurse interprets this observation as

A. An abnormal occurrence suggestion problem with the system's patency

B. Normal but may require water to be added to the suction control chamber

C. Emergent requiring immediate reporting to the physician

D. Expected with the client's current condition

A. An abnormal occurrence suggestion problem with the system's patency

unless the lungs have already expanded

SITUATION: A woman who underwent hysterectomy 2 days ago is under your care

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Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity?

A. Drinking coffee at least 3 to 5 cups in a day

B. Refusing to get out of bed

C. Taking soft diet only

D. Requesting for analgesics frequently

B. Refusing to get out of bed

The following are true regarding anti-emboli stockings except:

A.Too small stockings may cause skin breakdown.

B.Apply stockings in the morning.

C.The patient who has been ambulating should wait for 1 hour before applying the stockings.

D.Anti-emboli stockings can prevent edema of the legs and feet.

C.The patient who has been ambulating should wait for 1 hour before applying the stockings.

SITUATION: A woman who underwent hysterectomy 2 days ago is under your care

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The patient was prescribed to have antiembolism stockings. The nurse assess the patient knows its purpose when she states

1. It promotes venous return

2. It strengthen muscle tone

3. It prevents pooling of blood in the extremities

A. 1 & 2

B. 1 & 3

C. 2 & 3

D. 1, 2 & 3

D. 1, 2 & 3

SITUATION: A woman who underwent hysterectomy 2 days ago is under your care

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The nurse assesses the client for Homan's sign. Which of the following is the CORRECT instruction of the nurse?

A. Have the client push each foot hard against the mattress

B. Tell the client to sit on bed and point to her toes

C. Ask the client to contract her tight muscles

D. Instruct the client to extent her legs and flex each foot toward the head

D. Instruct the client to extent her legs and flex each foot toward the head

DORSIFlEXION

SITUATION: A woman who underwent hysterectomy 2 days ago is under your care

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Which client's response suggest a positive Homan's sign?

A. Inability of the client to bend her knees

B. Sudden numbness while extending the foot

C. Tingling sensation throughout the affected leg

D. Sharp, immediate calf pain in the legs

D. Sharp, immediate calf pain in the legs

SITUATION: A woman who underwent hysterectomy 2 days ago is under your care

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Based on the findings, the client has been diagnosed with thrombophlebitis. Which of the following nursing action must be AVOIDED?

A. Elevating the client's leg

B. Massaging the affected leg

C. Applying ice compress to the affected leg

D. Ambulating at least twice each shift

B. Massaging the affected leg

SITUATION: After a head injury, Mia, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus.

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The nurse in charge understands that Diabetes Insipidus (DI) is caused by an ADH deficiency resulting to which problem in metabolism?.

A. Protein

B. Water

C. Carbohydrates

D. Fat

B. Water

SITUATION: After a head injury, Mia, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus.

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The nurse caring for Mia would expect to find which characteristic assessment findings?

1. Excessive thirst

2. Polyuria

3. Hyperglycemia

4. Glycosuria

A. 1 and 3

B. 2 and 3

C. 1 and 2

D. 3 and 4

C. 1 and 2

SITUATION: After a head injury, Mia, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus.

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Which nursing action is critical in monitoring Mia's condition

A. Measuring intake and output

B. Assessing vital signs

C. Monitoring sleeping pattern

D. Analyzing blood glucose

A. Measuring intake and output

SITUATION: After a head injury, Mia, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus.

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The physician orders "weigh daily". When instructing the nursing aide to weigh the client, what essential instruction is MOST important to obtain an accurate data?

A. Weight the client on the same scale time of the day wearing the similar amount of clothing

B. Ask the client to state her weight before the disorder manifested

C. Instruct the client to weigh before breakfast daily

D. Have the client remove her footwear

A. Weight the client on the same scale time of the day wearing the similar amount of clothing

SITUATION: After a head injury, Mia, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus.

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The client was prescribed with intranasal Lypressin (Diapid) 2 spray 4x a day and as needed. Which is the CORRECT way to administer the spray?

A. Siting in an upright position, insert the spray into the nostril then inhale while compressing the container

B. Shaking the spray vigorously before inhaling in both nostrils

C. Tilting the head to the side, and inhale the spray 2 times

D. Inhaling with each spray 2 times

A. Siting in an upright position, insert the spray into the nostril then inhale while compressing the container

SITUATION: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client.

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While nurse Michelle was making her rounds before endorsement to the next shift, her client asks her which would be a comfortable position to assume. The nurse would recommend the following positions EXCEPT

A. Flexing the left leg

B. Leaning forward

C. Lying in supine position

D. Sitting up

C. Lying in supine position

fetal position = best

SITUATION: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client.

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There has been an increasing rate of acute pancreatitis in the Philippines. She is aware that the most common cause of acute pancreatitis is?

A. Alcohol Use

B. Trauma

C. Infections

D. Gallstones

D. Gallstones

SITUATION: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client.

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Nurse Michelle is aware that the treatment of acute pancreatitis consist of pain relief and "putting the pancreas to rest". This is BEST accomplished by which of the following?

A. Serving clear liquid diet

B. Following a frequent but small feeding

C. Feeding by nasogastric tube

D. Parenteral nutrition administration as prescribed

D. Parenteral nutrition administration as prescribed

SITUATION: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client.

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The client has a standing order of Meperidine HCL (Demerol) 100mg intramuscularly (IM) every 4 hours. At 8am, nurse Michelle administered Demerol as prescribed. At 10am, the client asked for the next dose. The nurse verified the intensity of pain and the client said, it is not so painful. I just don't want to feel any sort of pain". What would be the MOST appropriate action of the nurse

A. Apply warm compress over the painful area

B. Inject the prescribed dose and the other half at 12 noon

C. Change patient's position and implement diversional activity

D. Administer the full dose of Demerol now.

C. Change patient's position and implement diversional activity

SITUATION: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client.

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When the client said, "it is not so painful". What is the client trying to describe?

A. Unrelieved pain

B. Location of pain

C. Pain tolerance

D. Quality of pain

C. Pain tolerance

SITUATION: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery.

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Nurse Michelle was waiting for her turn to use the Comfort room (CR) of the Nurses Station, when a nursing attendant Lili came out drying her face with sterile gauze dressing. Nurse Michelle immediately called her attention to:

A. Bring their own personal toiletries

B. Use hospital supplies like dressings, judiciously

C. Conserve water as there is not enough for everyone

D. Limit the use of the nurse's station comfort room for the staff on duty

B. Use hospital supplies like dressings, judiciously

SITUATION: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery.

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A nurse is preparing to start an intravenous infusion of D5% Lactated Ringer's solution with 40 mEq Kcl on a postoperative client with an infusion pump. When she attempted to plug the pump cord into the wall socket, the pump did not seem to work. Which of the following is MOST appropriate nursing action?

A. Initiate the intravenous line without using the pump

B. Use an extension cord from the corridor to plug the pump

C. Contact the electrical maintenance for assistance

D. Plug the pump cord in the available plug above the room sink

C. Contact the electrical maintenance for assistance

SITUATION: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery.

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A nurse is going to change the soiled beddings of the client with ulcerative colitis. When personal protective equipment (PPE) should be worn by the nurse?

A. Gown and gloves

B. Gloves

C. Goggles and gloves

D. Gloves and mask

A. Gown and gloves

SITUATION: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery.

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Nurse Michelle has four clients. After the endorsement rounds, she plans to do assessment of her four clients. Which client would she attend FIRST?

A. Client on oxygen inhalation who had difficulty of breathing last night

B. Client for chest x-ray

C. A preoperative client for cardio pulmonary clearance

D. The post vagotomy client who is for discharged

A. Client on oxygen inhalation who bad difficulty of breathing last night

SITUATION: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery.

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Nurse Michelle observed that during meal hours, there are no orderlies present in the unit. Which nursing management strategy must be done?

A. Plan a schedule of meal so that every staff will have a fix time to take lunch for 30 minutes.

B. Any orderly who leaves the unit should ask permission from the head nurse

C. When the orderly leaves for lunch, she/he should log in and out

D. Allow a mid A.M. break of 15 minutes

A. Plan a schedule of meal so that every staff will have a fix time to take lunch for 30 minutes.

SITUATION: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS).

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As you reviewed the client's chart, you found out that the reason for the emergency CS is "fetal distress". Which of the following assessment findings would confirm the indication of emergency CS?

A. Fetal heart rate of 180 beats per minute

B. Multiple pregnancy

C. Non-progressing labor

D. A 6 to 6.7 lbs baby

A. Fetal heart rate of 180 beats per minute

SIGN OF FETAL DISTRESS

NORMAL FHR: 120-160 BPM

SITUATION: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS).

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The circulation nurse prepares the client to which of the following positions?

A. Supine with wedge support under the right hip

B. Supine with pillows for head support

C. Lithotomy with padded stirrups

D. Semi -Fowler's position with one pillow under the knees

A. Supine with wedge support under the right hip

SITUATION: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS).

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As soon as the baby is out, the scrub nurse must focus FIRST on which of the following nursing action?

A. Slap the newborn to induce crying

B. Wipe the mouth, nose and eyes with a sterile operating sponge (OS)

C. Attach the name tag

D. Suction the mouth and nose of the newborn

D. Suction the mouth and nose of the newborn

FETAL DISTRESS PRIORITY: AIRWAY

SITUATION: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS).

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Prior to the closure of the endometrium, the scrub and circulating nurses should perform which of the MOST critical nursing intervention?

A. Change drapes

B. Have a large basin to contain the placenta

C. Report sponge count status to the surgeon

D. Prepare chronic cut gut suture for the endometrium

C. Report sponge count status to the surgeon

SITUATION: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS).

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One week after surgery, the mother developed high fever and was found out that the cause of infection was a sponge left inside her body. The health care professional most liable for this case is:

A. Anesthesiologist

B. Surgeon

C. Scrub Nurse

D. Circulating Nurse

B. Surgeon

SITUATION: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure.

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Mrs. Ricos told the nurse that she was concerned about her husband. Which of the following responses of the nurse would encourage Mrs. Ricos to open the discussion

A. "Would you like to talk about the reason for your visit?"

B. "Would it help to discuss your feelings?

C. "What brought you to the hospital?"

D. "Does it concern you on what happen to your husband?"

C. "What brought you to the hospital?"

DO NOT ANSWER CLOSE-ENDED QUESTIONS

SITUATION: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure.

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While Listening to your patient about his near death experience during his last surgery, you crossed your arms on your chest. What message is the nurse conveying to the client?

A. Trying to end the conversation with your client

B. Conveying that you have ample time to listen to the client

C. Pretending to listen to what the client is narrating

D. Uninterested to hear what the client has to say

D. Uninterested to hear what the client has to say

SITUATION: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure.

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Another client told you that he was not looking forward to having this hemorrhoids removed. Which statement of the nurse would MOST likely stir up an expression of fear to the client?

A. "Are you implying that surgery is frightening?"

B. "Why don't you just look forward to your surgery to relieve you of the present discomfort?"

C. "Don't you think your surgeon is competent enough?"

D. "Have you ever bad surgery before?"

A. "Are you implying that surgery is frightening?"

SITUATION: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure.

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You are assessing a 60 year old client who lives alone by herself and with permanent colostomy. Which of the following statements of the client indicate that she has fully accepted her-present condition?

A. "My children no longer visit me. I'm just waiting for my Creator to take me"

B. "My life is slowly deteriorating each day"

C. "I was a good O.R. nurse when I was younger. Now I'm just client"

D. "I had a good life and I intend to enjoy it"

D. "I had a good life and I intend to enjoy it"

SITUATION: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure.

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Mrs. Ricos, a post hysterectomy client with 7 children, made no comment about the recent death of her 13 year old daughter in a tragic car accident. She shifted topics quickly when asked about how her other children were adjusting to the loss of their sister. Which of the following interpretation of her actuation should receive your PRIORITY nursing intervention for Mrs. Ricos?

A. Need of support system

B. Changing life roles

C. Avoiding a painful subject

D. Resolved grief

C. Avoiding a painful subject

SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD.

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Kiara presents to the hospital stating she his having gastric ulcer. Which of the following assessment data supports the diagnosis?

A. The client is experiencing blood in his stool for the past month

B. After eating a heavy fatty meal, the patient experiences upper abdominal pain.

C. The patient reports wave-like burning sensation

D. After ingesting food, the patient complains epigastric pain 30 to 60 minutes.

D. After ingesting food, the patient complains epigastric pain 30 to 60 minutes.

SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD.

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The nurses performs physical examination to the client. The nurse is knowledgeable when she implements which among the following first?

A. Examine the abdominal area for tenderness using fingertips

B. Listening to each of the quadrants using a stethoscope

C. Use plexor and pleximeter in assessing the abdominal borders to identify organs

D. Assess the tender area from progressing to nontender

B. Listening to each of the quadrants using a stethoscope

SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD.

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Kiara was referred to a gastrointestinal doctor and was informed that she should undergo diagnostic test. What tests confirms the diagnosis?

A. MRI

B. CTSCAN

C. FOB

D. EGD

D. EGD

SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD.

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Which physiological complications is expected for the nurse to consider in creating plan of care for patient diagnosed with PUD

A. Knowledge deficit in the causes of ulcers

B. Inability to cope in bowel elimination

C. Potential for alteration in gastric emptying

D. Alteration in bowel elimination patterns.

C. Potential for alteration in gastric emptying

SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD.

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Kiara was discharged and was given home instructions. Which among the following statements means that Kiara learned the expected outcome?

A. She should not present any signs and symptoms of hemoptysis

B. She should take antacids with each meal to prevent excessive gastric acid.

C. She controls her pain by taking NSAIDs

D. She maintains modifications in her lifestyle

D. She maintains modifications in her lifestyle

SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it.

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The nurse is admitting Roy, a 26-year-old male. In gathering his past medical history, he stated that he undergone a gastric bypass surgery for his obesity 3 years ago. The following assessment findings includes height 5'7'', weight 81kg, P112, R26, BP110/70, pale mucous membranes and dyspnea on exertion. Upon assessment, the nurse suspects that the client is having what type of anemia.

A. Folic Acid Deficiency

B. Vitamin B12 Deficiency

C. Sickle cell anemia

D. Iron deficiency Anemia

B. Vitamin B12 Deficiency

SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it.

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The client with a diagnosis of IDA is prescribe FeSO4 orally. The patient should be educated about:

A. Taking laxative for diarrhea

B. Exercise being limited until tolerance to the supplement is achieved

C. Red meats and organ meats are the only foods that should be consumed to increase the level of iron in the body

D. The stools may appear dark green-black which may mask blood

D. The stools may appear dark green-black which may mask blood

SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it.

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The anemia of the patient diagnosed with CHF became so severe that requires the HCP to order two units of PRBCs to transfuse. The unit has 250 mL of RBC plus 45mL of additive. The nurse set the IV pump at what rate to infuse each unit of PRBC?

A. 74 ml/hr

B. 62-63 ml/hr

C. 147 ml/hr

D. 125 ml/hr

A. 74 ml/hr

SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it.

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You are the charge nurse assigned in the ward. Patients with different types of anemia was admitted. As a charge nurse, you assigned which among the patient to the most experienced nurse?

A. Client with IDA taking supplements

B. Client with Vitamin B12 deficiency requiring intramuscular administration

C. Client with Renal problem with deficiency of erythropoietin

D. Client with aplastic anemia which developed pancytopenia.

D. Client with aplastic anemia which developed pancytopenia.

SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it.

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The client diagnosed with anemia was discharged. Which among the health education given by the nurse is correct?

A. Take the prescribed iron until it is consumed

B. Checking the vital signs specially pulse and BP at botika weekly

C. Performing exercises at least three times a week

D. Have a regular blood workup for CBC at HCP's office.

D. Have a regular blood workup for CBC at HCP's office.

SITUATION:

Many times clients would ask to be admitted to their room of choice. The hospital is not always ready to give client their preferred room but consider other parameters that would nonetheless enhance safe environment while confined in the hospital.

The nursing aide is asked to prepare a room for a child with post-operative fever. The room should be equipped with the following EXCEPT:

A.Game board

B.Bedside rails

C.Air conditioning unit

D.Call system

A.Game board

A client with active tuberculosis is admitted to the medical ward. When planning a bed assignment, the nurse in-charge should do which of the following proper acid-fast bacteria precaution?

A.Place the client in a private, well-ventilated room

B.Assign the client to a double room and hang a sign "strict hand washing"

C.Allocate the client to a double room to have company

D.Transfer the client to the intensive care unit for close monitoring

A.Place the client in a private, well-ventilated room

A 3 year old boy, febrile, is admitted for observation to one of the private rooms in your unit. You instructed the nursing aid to ensure safety in the room. The aid asks which poses greatest hazard inside the room? Your reply would be which of the following items?

A.Hot water heater

B.Toys with small and loose part

C.Video games

D.Plastic toy guns

A.Hot water heater

The nurse is about to leave the room of a post laryngectomy client. Which of the following would you furnish the client to communicate readily?

A.Magic state

B.Call bell

C.Pen and paper

D.Picture board

?

B.Call bell

You are assigning bed to a newly admitted teenager with right iliac pain. Upon assessment you noted rashes in the trunk and extremities. During interview, you learned that the client was exposed to varicella. Which bed assignment is MOST appropriate for the client?

A.Private room with strict isolation

B.Room nearest the nurses station

C.Dark private room

D.Any available bed

A.Private room with strict isolation

SITUATION:

Sunshine, 49 year old mother of a healthy children is to undergo dilation and curettage (D and C) under General Anesthesia for vaginal bleeding. She is heavily sedated when she was wheeled to the operating room. The following situations are relevant.

Perioperative nurses are aware that effects of general anesthesia include which of the following:

1.Amnesia

2.Analgesic

3.Muscle relaxation

4.Drying of oral and respiratory secretion

A.1 and 2

B.3 and 4

C.1, 2 and 3

D.2 and 3

C.1, 2 and 3

In the Philippine health care setting, only the _________ is allowed to administer anesthetic agents:

A.Perioperative nurses

B.Nurse anesthetist

C.Circulating nurse

D.Anesthesiologist

D.Anesthesiologist

The circulating nurse assists Sunshine to lithotomy position by placing the client on her back with:

A.Head elevated with pillows

B.Head lowered so the plane of the body meets the horizontal on an angle

C.Legs and thighs positioned on a stirrup

D.Arms comfortably positioned on her sides

C.Legs and thighs positioned on a stirrup

Clients undergoing general anesthesia stand the risk of malignant hyperthermia. The circulating nurse should monitor along with the anesthesiologist which EARLY sign of malignant hyperthermia?

A.Tachycardia

B.Hypertension

C.High temperature

D.Muscle rigidit

A.Tachycardia

After the surgery, the circulating nurse must send which specimen to the Department of Pathology?

A.Blood sample

B.Endometrial scrapings

C.Vaginal smear

D.Placenta tissues

B.Endometrial scrapings

SITUATION:

John, a 25-year-old patient, is admitted due to fever, abdominal pain, and painful swelling of hands, feet, and joints. He has a diagnosis of sickle cell anemia.

Based on the signs and symptoms, which type of sickle cell crisis is John experiencing?

A.Vaso-occlusive crisis

B.Splenic sequestration

C.Hyperhemolytic crisis

D.Aplastic crisis

A.Vaso-occlusive crisis

The nurse hooks a 1500 ml IV solution of D5W as ordered by the physician at 11 AM to infuse 150 ml/hr via a macro drop infusion set (20gtts = 1 ml). On the assessment of the infusion, what would be the level of the remaining amount in the IV bag at 5 PM?

A.450 ml

B.500 ml

C.600 ml

D.700 ml

C.600 ml

John mentions the precipitating factors related to sickle cell crisis. He is correct if he does not include which of the following?

A.Stress

B.Hypervolemia

C.Illness

D.Trauma

B.Hypervolemia

John wants to confirm to the nurse the possibilities of having reproductive problems as he lives with sickle cell disease. Which of the following is a wrong statement made by John?

A.Some men may develop hypogonadism.

B.Priapism does not cause pain.

C.Low testosterone level can occur.

D.All of the above

B.Priapism does not cause pain.

As Patient John is prescribed to take Hydroxyurea for his sickle cell anemia, what should the nurse include in their health teaching?

A.You should always monitor your blood pressure.

B.You should wash your hands often and do not go near people who are sick.

C.You should avoid getting cuts or wound because you can bleed heavily.

D.You should have your liver function monitored regularly.

B.You should wash your hands often and do not go near people who are sick.

SITUATION:

Nurse Maya is assigned to take care of Sam, 39 years old with ecchymosis, oligomenorrhea and weakness. The physician's admitting impression is Cushing's syndrome. The following questions apply.

While nurse Sam assessed the client, she had in mind that the major Cushing's syndrome that represents an exaggeration of the action of cortisol on the metabolism which includes any of the following?

1.Fat

2.Protein

3.Glucose

4.Carbohydrates

A.1, 2, and 3

B.1 and 2 only

C.2, 3 and 4

D.all of these

D.all of these

Fat: Cortisol promotes fat breakdown and storage, often leading to central obesity (fat accumulation around the abdomen) in Cushing's syndrome patients.

Cortisol plasma determination was ordered. The nurse would anticipate that 3 blood samples would be drawn in what time schedules?

1.One in the morning

2.One at midday

3.After a PM snack

4.Early evening

5.The following morning after a midnight dose of dexamethasone

A.1, 2 and3

B.1, 4 and 5

C.2, 3 and 5

D.1, 2 and 4

B.1, 4 and 5

The health team taking care of Maya is keenly observing the standard precaution because the client is vulnerable to:

A.Hypertension

B.Gastrointestinal bleeding

C.Hyperglycemia

D.Infection

D.Infection

The physician ordered "accurately measure intake and output and weight patient daily before breakfast. Nurse Sam is fully aware that one liter fluid retention corresponds to gain:

A.2 lbs. body weight

B.1 lb. body weight

C.3 lbs. body weight

D.0.5 body weight

A.2 lbs. body weight

Treatment of choice was adrenalectomy. Prior to surgery, the surgeon requested for dietary consultation that is necessary for tissue repair and wound healing. The nurse would expect a diet prescription high in

A.Carbohydrate high protein

B.Vitamins and proteins

C.Protein high fat

D.fiber high calorie

A.Carbohydrate high protein

SITUATION:

The pyramid of success in cardiovascular disorder therapy points to client education is very essential

Mabel, a 65 year old retired teacher, post MI, lives alone and is in anti - coagulant therapy with warfarin sodium (Coumadin). The nurse would include in her instruction that warfarin sodium is usually given for 2 to 6 months after MI to:

A.Enhancement cardiac muscle recovery

B.Increase over-all percentage of recovery

C.Facilitate oxygenation of myocardial tissue

D.Decrease incidence of deep vein thrombosis and thromboembolism

D.Decrease incidence of deep vein thrombosis and thromboembolism

Like any client on Coumadin, Mabel should be advised to be monitored on prothrombin time and international normalized ratio (INR). If the INR is 1.5, Coumadin is:

A.Maintained

B.Increased

C.Decreased

D.Discontinued

B.Increased

Target INR for post-MI patients: Typically falls between 2.0-3.0.

INR of 1.5: Below the recommended target range, indicating increased clotting risk.

Coumadin dose adjustment: In this case, the Coumadin dose would likely need to be increased to bring the INR closer to the target range.

The client should also be instructed regarding measures to prevent which of the following?

A.Infection

B.Excitement

C.Bleeding

D.Exposure to extreme temperature

C.Bleeding

The nurse would include in her dietary instruction to avoid which of the following?

A.Yellow fruits and vegetables

B.Nuts and seeds

C.Green leafy vegetables

D.Fish and poultry

C.Green leafy vegetables

will affect blood thinners

Mica wants to be secured at home while on Coumadin. Which drug must be kept ready in the event of Coumadin overdose?

A.Aqua mephyton

B.Vitamin K

C.Protamine sulfate

D.Aqua gel

B.Vitamin K

SITUATION:

Mary, a new hired nurse was assigned by the charge nurse to admit a 61 year old housewife with chief complaint of substernal chest discomfort that occurs with moderate to prolonged household chores. The admitting impression is angina pectoris.

Which of the following statements below would BEST describe Angina Pectoris

A.A permanent condition of imbalance between the supply and demand of oxygen of the cardiac muscle

B.The constriction of the coronary arteries resulting to insufficient blood supply to the myocardium

C.The temporary condition of imbalance between the supply and demand of blood and oxygen existing in the cardiac system

D.A temporary imbalance between the myocardial blood supply and demand resulting from reduced coronary blood flow

D.A temporary imbalance between the myocardial blood supply and demand resulting from reduced coronary blood flow

Characteristically, the pain in angina usually lasts for 15 minutes and it is relieved by:

A.Rest

B.Nitroglycerin

C.Intake of cold water

D.Chest massage

A.Rest

ECG was taken during the angina episode. The nurse would expect to see _______ ST segments:

A.Elevated

B.Flattened

C.Normal

D.Depressed

D.Depressed

Elevated ST segments typically indicate a more serious event like a heart attack (myocardial infarction) where there's permanent damage to the heart muscle.

The client was put on nitrates and the nurse Mary was concerned about the client developing tolerance to the drug. The charge nurse explained that tolerance can be prevented by

A.Alternating the use of sublingual nitroglycerin and ointment

B.Wearing gloves when applying nitroglycerin ointment

C.Removing the residual transdermal patch or ointment at bedtime

D.Rotating ointment or transdermal patch site

C.Removing the residual transdermal patch or ointment at bedtime

The attending physician prescribed that nitroglycerin patch be applied. The nurse understands that the purpose of the application is to promote:

A.Therapeutic

B.Prophylactic

C.Short-Term

D.Sustained

D.Sustained

SITUATION:

You are a staff nurse in the Medical Ward of the hospital. You are taking care of the patients with liver cirrhosis.

You are aware that the possible causes of liver cirrhosis are:

I. Hepatitis B

II. Being alcoholic

III. Hyperlipidemia

IV. Autoimmune

A.All of the above

B.I, II, III

C.I, II

D.II, III

A.All of the above

What finding will you anticipate from Patient Leah who is in the early stage of liver cirrhosis?

A.Anorexia

B.Icterus

C.Peripheral edema

D.Ascites

A.Anorexia

While anorexia can occur throughout the course of cirrhosis, it's more likely to be present in the early stages as the body struggles to process nutrients effectively due to impaired liver function.

B. Icterus (yellowing of the skin and eyes): This is a more advanced symptom that typically develops as liver damage progresses.

C. Peripheral edema (swelling in the extremities): Similar to jaundice, this symptom is more common in later stages when fluid retention becomes more significant.

D. Ascites (accumulation of fluid in the abdomen): Ascites is another later-stage symptom that develops due to increased pressure in the portal vein system and decreased albumin production by the damaged liver.

Another patient with liver cirrhosis is experiencing severe pruritus. You are aware that all of the following will relieve his pruritus except:

I.Change linens and gowns as needed.

II.Change position at regular intervals.

III.Maintain a warm environment.

IV.Apply Mupirocin ointment.

A.I, II

B.I, III

C.II, III

D.III, IV

D.III, IV

III.Maintain a warm environment: Warm environments can worsen itching for people with liver cirrhosis. A cool and loose environment is preferred.

IV. Apply Mupirocin ointment: Mupirocin ointment is an antibiotic used for bacterial skin infections. It won't relieve itching caused by liver cirrhosis.

Medications like cholestyramine or bile acid sequestrants are typically used for pruritus in cirrhosis.

Patient Daisy's chart indicated presence of asterixis. As a nurse, how will you assess its presence?

A.Instruct the patient to extend all four extremities.

B.Dorsiflex the client's foot.

C.Ask the patient to flex the arms.

D.Ask the patient to extend the arms.

D.Ask the patient to extend the arms.

A liver cirrhosis patient's wife asked you what fetor hepaticus is. What is the most appropriate answer that you can give?

A.t happens when the liver undergoes shape transformation that makes it resemble a fetus in shape.

B.It is the sweet but malodorous breath odor that may indicate severe chronic liver disease.

C.It is the secretion of sulfur by the liver.

D.It is the elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver.

B.It is the sweet but malodorous breath odor that may indicate severe chronic liver disease.

SITUATION:

A nurse admitted a 6 year old boy who is dyspneic, tachypneic with respiratory rate of 40 breaths/minute, afebrile, and with paroxysmal, irritative non - productive cough. Physician's diagnosis is asthma

Which of the following correctly describes asthma?

A.Often irreversible

B.Inflammatory disorder of the airways

C.Characterized by hypoventilation

D.Dyspnea with respiratory rate of 40/minute

B.Inflammatory disorder of the airways

When the nurse examines the patient's chest on auscultation, which of the following assessment findings would indicated that the obstruction progresses?

A.Productive cough

B.Audible wheeze

C.Silent chest

D.Prominent sweating

C.Silent chest

The nurse administered aminophylline as ordered. Which of the following assessment indicates effectiveness of the drug?

A.Thinning of the tenacious purulent sputum

B.Normal breath sounds

C.Normal body temperature

D.Decreasing bronchial secretions

B.Normal breath sounds

The client was prescribed with a short term corticosteroid therapy, The nurse knows that the preferred route of administration is through metered-dose inhalation because it:

A.Is well tolerated

B.Minimizes mucous secretions

C.Reduces cushingoid effects

D.Enhances absorption of drug

C.Reduces cushingoid effectss absorption of drug

Cushingoid effects are a range of side effects associated with long-term use of systemic corticosteroids (like oral steroids).

These effects can include weight gain, moon face, high blood pressure, and mood swings.

By delivering the medication directly to the lungs, MDIs reduce the amount of medication that enters the bloodstream, thereby minimizing the risk of developing these cushingoid effects.

Throat irritation is associated with nebulizer use. What nursing intervention is BEST to decrease irritation

A.Taking lozenges

B.Drinking ice cold fruit juices

C.Sipping or gargling water

D.Chewing gum

C.Sipping or gargling water