RECALLS 3 NP3

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

 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

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

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

B. 3, 4 only

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

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

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

D. 1, 2 & 3

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

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 musclesma

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

B. Massaging the affected leg

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

C. 1 and 2

The nurse caring for Samantha 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

D. Gallstones

There has been an increasing rate of 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. Parenteral nutrition administration as prescribed

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

C. Pain tolerance

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

B. Use hospital supplies like dressings, judiciously

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

A. Gown and gloves

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. Supine with wedge support under the right hip

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

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

D. Suction the mouth and nose of the newborn

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

C. “What brought you to the hospital?”

Mrs. Richards told the nurse that she was concerned about her husband. Which of the following responses of the nurse would encourage Mrs. Richards 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?”

D. Uninterested to hear what the client has to say

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

C. Avoiding a painful subject

Mrs. Richards, 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. Richards?

A. Need of support system

B. Changing life roles

C. Avoiding a painful subject

D. Resolved grief

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.

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

v

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. FOBT

D. EGD - esophagogastroduodenoscopy

C. Potential for alteration in gastric emptying

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.

D. She maintains modifications in her lifestyle

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

A. 74ml/hr

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. 74ml/hr

B. 62-63ml/hr 

C. 147ml/hr

D. 125ml/hr

D. client with aplastic anemia which developed pancytopenia.

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.

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

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

B. Toys with small and loose part

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. Magic slate

 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 slate

B. Call bell

C. Pen and paper

D. Picture board

A. Private room with strict isolation

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

c. 1, 2 and 3

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

A. Tachycardia

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 - middle stage

C. High temperature - Late

D. Muscle rigidity - late

C. 600 ml

 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

B. Hypervolemia

James 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. Priapism does not cause pain.

James 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 James?

A. Some men may develop hypogonadism.

B. Priapism does not cause pain.

C. Low testosterone level can occur.

D. All of the above

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

As Patient James 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.

d. all of these

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

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

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

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

Michelle, 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

Like any client on Coumadin, Michelle 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

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

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

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

A. Elevated 

B. Flattened

C. Normal

D. Depressed

The client was put on nitrates and the nurse Michelle 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 sites

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

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

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

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

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.

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

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