RECALLS 8 - NP3

SITUATION: Nurse Ryuu is a newly registered nurse from the Philippines. He is assigned to the Medicine Ward of hospital X. The following questions apply.

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Nurse Ryuu is tasked to administer a continuous IV fluid replacement to a patient in the ward with a diagnosis of dehydration. Which among the following is the MOST important for nurse Ryuu to assess prior to initiation of IV fluid?

A. Intake and Output

B. Ability to Ambulate

C. Body weight

D. Usual Sleep patterns

C. Body weight

SITUATION: Nurse Ryuu is a newly registered nurse from the Philippines. He is assigned to the Medicine Ward of hospital X. The following questions apply.

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Jessica, a patient confined in the medicine ward, is for an CT scan using a contrast dye. As a competent nurse, Nurse Ryuu will assess which is the most essential of the following?

A. Intake and Output

B. Vital Signs

C. Height and Weight

D. Allergy to Shellfish or Iodine

D. Allergy to Shellfish or Iodine

SITUATION: Nurse Ryuu is a newly registered nurse from the Philippines. He is assigned to the Medicine Ward of hospital X. The following questions apply.

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Nurse Ryuu is performing a Cardiovascular assessment to a patient diagnosed with right-sided heart failure. Among the choices, which would indicate the confirmation of the diagnosis of patient Joseph?

A. Status of breath sounds

B. Rate of respiration

C. Syncope

D. Presence of peripheral edema

D. Presence of peripheral edema

SITUATION: Nurse Ryuu is a newly registered nurse from the Philippines. He is assigned to the Medicine Ward of hospital X. The following questions apply.

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A patient in the medicine ward was admitted because of peptic ulcer disease. She has been taking huge amounts of oral antacids to manage her peptic ulcer disease.knowing the effects of oral antacids, nurse Ryuu interprets that the client is at MOST at risk for which acid-base balance?

A. Metabolic acidosis

B. Respiratory alkalosis

C. Metabolic alkalosis

D. Respiratory acidosis

C. Metabolic alkalosis

SITUATION: Nurse Ryuu is a newly registered nurse from the Philippines. He is assigned to the Medicine Ward of hospital X. The following questions apply.

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Referring to the acid-base imbalance from the previous question, which among the following most likely indicates a metabolic alkalosis?

A. pH: 7.44; CO2: 19mmHg; HCO3: 12mEq/L

B. pH: 7.54; CO2: 53mmHg; HCO3: 44mEq/L

C. pH: 7.32; CO2: 24mmHg; HCO3: 12mEq/L

D. pH: 7.32; CO2: 48mmHg; HCO3: 27mEq/L

B. pH: 7.54; CO2: 53mmHg; HCO3: 44mEq/L

SITUATION: Buknoy, a 22 year old patient, is admitted to the hospital because of severe flank pain, hematuria, and fever and chills for the past 3 days. Nurse Aly is the nurse assigned to him. The following questions apply.

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Upon admission to the hospital, which among the following should nurse Aly do first?

A. Use a safety gait belt when walking the patient

B. Increase the client's oral fluid intake

C. Monitor the client's urine output

D. Assess the client's pain and rule out complications

D. Assess the client's pain and rule out complications

SITUATION: Buknoy, a 22 year old patient, is admitted to the hospital because of severe flank pain, hematuria, and fever and chills for the past 3 days. Nurse Aly is the nurse assigned to him. The following questions apply.

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Buknoy is scheduled for a renal ultrasound to determine the size of the renal stone. After explaining the procedure to the patient, which statement made by Buknoy needs additional teaching?

A. "I shall not drink nor eat for eight (8) hours before the procedure to achieve the most accurate result."

B. "The procedure is quick and painless."

C. "I do not need to sign an informed consent because ultrasound is not a scary procedure."

D. "My allergies in seafood and other shellfish will not affect the outcome of the procedure."

A. "I shall not drink nor eat for eight (8) hours before the procedure to achieve the most accurate result."

full bladder = bladder dx

SITUATION: Buknoy, a 22 year old patient, is admitted to the hospital because of severe flank pain, hematuria, and fever and chills for the past 3 days. Nurse Aly is the nurse assigned to him. The following questions apply.

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Upon examination of Buknoy's renal stone, it revealed that it is a uric acid stone in composition. Which food should the client eliminate from his diet to help prevent recurrence?

A. Asparagus and cabbage

B. Beer and colas

C. Cheese and eggs

D. Chicken liver and sardines

D. Chicken liver and sardines

SITUATION: Buknoy, a 22 year old patient, is admitted to the hospital because of severe flank pain, hematuria, and fever and chills for the past 3 days. Nurse Aly is the nurse assigned to him. The following questions apply.

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Buknoy is scheduled for a 24-hour urine specimen collection. Which among the interventions should the nurse implement? Select all that apply.

I. Check for the ordered diet and medication modifications

II. Instruct the client to urinate, then discard this when starting collection

III. Insert a foley catheter in the client after having the client empty his bladder.

IV. Collect all urine during the 24 hours and place in appropriate specimen collection

V. Post notice on the client's chart to save all urine collection

A. I, II, IV

B. I, II, III

C. II, IV, V

D. II, III, V

A. I, II, IV

I. Check for the ordered diet and medication modifications

II. Instruct the client to urinate, then discard this when starting collection

IV. Collect all urine during the 24 hours and place in appropriate specimen collection

put notice in pt's door not in chart

SITUATION: Buknoy, a 22 year old patient, is admitted to the hospital because of severe flank pain, hematuria, and fever and chills for the past 3 days. Nurse Aly is the nurse assigned to him. The following questions apply.

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Percutaneous nephrolithotomy is done to Buknoy. Which among the laboratory values would warrant an IMMEDIATE intervention by the nurse?

A. Urinalysis that shows microscopic hematuria

B. A WBC count of 15,000mm/dL

C. A creatinine level of 1.2

D. Serum potassium level of 4.8mEq/L

B. A WBC count of 15,000mm/dL

SITUATION: Nurse Dianne is caring for patients with sickle cell anemia. The following questions apply.

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While nurse Dianne is also a clinical instructor, student nurse Daven asks "what is sickle cell anemia?" Nurse Dianne would be correct if she answered ___________________

A. "There is a pamphlet about the disease you are asking about in the nurses' station."

B. "It is an in-born disease that causes the blood to not clot."

C. "The client has little to no synovial fluid, thus increasing joint pain."

D. "The blood clumps especially if the patient is deprived of oxygen."

D. "The blood clumps especially if the patient is deprived of oxygen."

SITUATION: Nurse Dianne is caring for patients with sickle cell anemia. The following questions apply.

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Nurse Dianne is caring for an african-american patient with sickle cell crisis. What assessment data below is the most pertinent for assessing cyanosis to her patient?

A. Assess the client's metatarsals

B. Assess the client's mucosa

C. Assess the client's capillary refill time

D. Assess the sclera of the patient's eyes

B. Assess the client's mucosa

SITUATION: Nurse Dianne is caring for patients with sickle cell anemia. The following questions apply.

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Which of the following would Nurse Dianne expect to assess in a client diagnosed with an acute vaso-occlusive sickle cell crisis?

A. Lordosis

B. Epistaxis

C. Hematuria

D. Petechiae

C. Hematuria

blood clot

no blood flow

ischemia

kidney endothelial damage

SITUATION: Nurse Dianne is caring for patients with sickle cell anemia. The following questions apply.

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Nurse Dianne is caring for patient Gab, who was diagnosed with sickle cell anemia. During her shift, Gab experienced a vaso-occlusive sickle cell crisis secondary to infection. Among the interventions listed, which should the nurse anticipate that the HCP would be ordering for Gab?

A. Give demerol IV

B. Admit the patient in a private room with reverse isolation

C. Infuse D5W 0.33% NSS at 150mL/hr via infusion pump

D. Insert a 22-French Foley catheter with a urimeter

C. Infuse D5W 0.33% NSS at 150mL/hr via infusion pump

to increase blood volume and decrease clumping of sickled RBCs

SITUATION: Nurse Dianne is caring for patients with sickle cell anemia. The following questions apply.

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After the crisis, patient Gab is concerned with the potential complication that occurs specifically to male patients with SCA during a sickle cell crisis. Which among the following would Nurse Dianne inform the patient about the potential complication to males with SCA?

A. Chest syndrome

B. Priapism

C. Compartment syndrome

D. Hypertensive crisis

B. Priapism

SITUATION: ice, 38 year old female, presents to the OPD complaining of pain in the gastric area that occurs 30mins to 1hr after eating. She also said that eating more food does not help, but also increases the pain. The following questions apply.

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As patient Vice is seen by the HCP, a suspected diagnosis of peptic ulcer disease is made. Which of the following would confirm this diagnosis?

A. Esophagogastroduodenoscopy (EGD)

B. Magnetic Resonance Imaging (MRI)

C. Occult blood test

D. Gastric acid stimulation

A. Esophagogastroduodenoscopy (EGD)

SITUATION: ice, 38 year old female, presents to the OPD complaining of pain in the gastric area that occurs 30mins to 1hr after eating. She also said that eating more food does not help, but also increases the pain. The following questions apply.

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As Vice is admitted to the hospital for further management, which nursing diagnosis should observe physiological complications?

A. Alteration in bowel elimination patterns

B. Knowledge deficits in the causes of ulcers

C. Inability to cope with changing family roles

D. Potential for alteration in gastric emptying

D. Potential for alteration in gastric emptying

SITUATION: ice, 38 year old female, presents to the OPD complaining of pain in the gastric area that occurs 30mins to 1hr after eating. She also said that eating more food does not help, but also increases the pain. The following questions apply.

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The HCP ordered the following medications to Vice. Nurse Chin would question which of the following?

A. Erythromycin

B. Prilosec

C. Flagyl

D. Tylenol

A. Erythromycin

antibiotics are irritating to the stomach

antibiotics destroy stomach lining further causing more ulcers

SITUATION: ice, 38 year old female, presents to the OPD complaining of pain in the gastric area that occurs 30mins to 1hr after eating. She also said that eating more food does not help, but also increases the pain. The following questions apply.

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Nurse Chin is assigned to monitor her patient, Vice. Which among the assessment findings would indicate that the patient's gastric ulcer has perforated?

A. Complaints of sudden, sharp, substernal pain

B. Rigid, boardlike abdomen with rebound tenderness

C. Frequently, clay-colored, liquid stool

D. Complaints of vague abdominal pain in the right upper quadrant

B. Rigid, boardlike abdomen with rebound tenderness

SITUATION: ice, 38 year old female, presents to the OPD complaining of pain in the gastric area that occurs 30mins to 1hr after eating. She also said that eating more food does not help, but also increases the pain. The following questions apply.

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Nurse Chin administered all the medications ordered by the HCP to Vice. which assessment data would indicate that the medications given by the HCP are effective?

A. A decrease in alcohol intake

B. Maintaining a bland diet

C. A return to previous activities

D. A decrease in gastric distress

D. A decrease in gastric distress

SITUATION: Francis, a newly registered nurse, is working in the medicine ward where he is assigned patients with gastrointestinal disorders. The following questions apply.

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As nurse Francis is being trained, his supervisor asked him who among the following are at risk for developing diverticulosis?

A. A 60-year-old male spending 5-6 hours watching the TV

B. A 72-year-old female with history of giving birth to twins

C. A 63-year-old female with hemorrhoids

D. A 40-year-old male with a family history of diverticulosis

C. A 63-year-old female with hemorrhoids

constipation

inc. intraluminal pressure in sigmoid colon

weak intestinal lining

outpuching

SITUATION: Francis, a newly registered nurse, is working in the medicine ward where he is assigned patients with gastrointestinal disorders. The following questions apply.

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Nurse Francis is teaching a client diagnosed with diverticulosis. Which instruction should he not include in his teaching session?

A. Discuss the importance of drinking at least 2000mL of water

B. Instruct the patient of exercising daily

C. Teach the client of eating a low-residue diet

D. Emphasize the importance of regular bowel movements

C. Teach the client of eating a low-residue diet

LOW RESIDUE = LOW FIBER

CONSTIPATION = HIGH FIBER

SITUATION: Francis, a newly registered nurse, is working in the medicine ward where he is assigned patients with gastrointestinal disorders. The following questions apply.

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Nurse Francis is aware that which of the following is an expected laboratory finding to a patient with diverticulitis?

A. Elevated red blood cell count

B. Decreased platelet count

C. Elevated white blood cell count

D. Elevated serum blood urea nitrogen concentration

C. Elevated white blood cell count

SITUATION: Francis, a newly registered nurse, is working in the medicine ward where he is assigned patients with gastrointestinal disorders. The following questions apply.

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One of the diagnostic procedures to diagnose diverticulitis is Barium enema. As a competent nurse, nurse Francis knows why it is not prescribed because this procedure:

A. Can perforate an intestinal abscess

B. Would increase client's pain immensely

C. Has minimal usefulness for diverticulitis

D. Is a long procedure and the patient may not be able to tolerate it.

A. Can perforate an intestinal abscess

SITUATION: Francis, a newly registered nurse, is working in the medicine ward where he is assigned patients with gastrointestinal disorders. The following questions apply.

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After teaching the patient with diverticulitis about appropriate activities he can perform, which of the following statements of the patient indicates a need for additional teaching?

A. "My diverticulitis can be cured if I adhere to the diet regimen strictly."

B. "It is important for me to drink at least 2000mL of fluid everyday"

C. "I should include exercise in my daily routine."

D. "Using stool softeners as prescribed by my doctor is okay for controlling my bowel movements."

A. "My diverticulitis can be cured if I adhere to the diet regimen strictly."

SITUATION: Nurse Faith is assigned in the Surgical Unit of Hospital Twice. The following questions apply.

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Informed consent is a vital document for patients that will undergo surgery. Nurse Faith is correct when she identifies that who among the following cannot give consent?

A. A 55-year-old women who cannot read and write

B. A 44-year-old male who can't speak or understand english

C. A 16-year-old client who has a fractured ankle

D. An 80-year-old patient who is not oriented to the day.

C. A 16-year-old client who has a fractured ankle

SITUATION: Nurse Faith is assigned in the Surgical Unit of Hospital Twice. The following questions apply.

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Nurse Faith is correct when she delegates which of the following activities to the unlicensed nursing assistant?

A. Complete pre-operative checklist

B. Assess the client's pre-operative vital signs

C. Teach the client how to do deep breathing and deep breathing

D. Assist the client on removing clothing and jewelry

D. Assist the client on removing clothing and jewelry

SITUATION: Nurse Faith is assigned in the Surgical Unit of Hospital Twice. The following questions apply.

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Nurse Faith is knowledgeable of the different tasks of each surgical personnel in the operating room. Which of the following describes the task of a circulating nurse?

A. Monitor client's position, ensure client's safety, coordinates activities in the OR

B. Give preoperative medication in the holding area and monitor the client's response to anesthesia

C. Prepare sutures, set-up sterile field, counting of all needles, sponges, and instruments

D. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

A. Monitor client's position, ensure client's safety, coordinates activities in the OR

SITUATION: Nurse Faith is assigned in the Surgical Unit of Hospital Twice. The following questions apply.

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Nurse Faith administered Narcan, an opioid antagonist, to a patient post-operative in PACU. She then asked you, a Registered nurse, what would be an appropriate nursing diagnosis for the patient?

A. Alteration in comfort

B. Risk for depressed respiratory pattern

C. Potential for infection

D. Fluid and electrolyte imbalance

B. Risk for depressed respiratory pattern

SITUATION: Nurse Faith is assigned in the Surgical Unit of Hospital Twice. The following questions apply.

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Nurse Faith was promoted to be the head nurse in her unit. Which of the following case should she assign to the new nurse?

A. Noynoy, a patient that is to undergo an open-heart surgery

B. Beshy, scheduled for laparoscopic knee repair

C. Emy, that is scheduled for breast biopsy

D. Onse, to undergo laser eye surgery

C. Emy, that is scheduled for breast biopsy

SITUATION: A nurse is caring for patients with rheumatoid arthritis. The following questions apply.

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Jose, a patient with rheumatoid arthritis, expressed his frustration to nurse Jepoy. He has difficulties with activities of daily living getting fatigued easily. Nurse Jepoy is correct when he prioritizes which of the following goals?

A. Conserve energy

B. Adapting self-care skills

C. Developing coping skills

D. Adapting good body image

A. Conserve energy

SITUATION: A nurse is caring for patients with rheumatoid arthritis. The following questions apply.

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Nurse Jepoy included adequate rest periods in his teaching plan for his patient. While resting, what should be avoided?

A. Proper body alignment

B. Elevating the part

C. Prone lying position

D. Positions of flexion

D. Positions of flexion

SITUATION: A nurse is caring for patients with rheumatoid arthritis. The following questions apply.

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Nurse Jepoy is assigned to the following patients. Who among them is not at risk for developing RA?

I. Adults between 20-50 years old

II. Adults who have had an infectious disease with EBV

III. Male adults

IV. Adults who possess a genetic link of HLA-DR4

V. Adults who also have osteoarthritis

A. I, III

B. I, IV

C. V, II

D. III, V

D. III, V

SITUATION: A nurse is caring for patients with rheumatoid arthritis. The following questions apply.

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A patient of nurse Jepoy with severe RA is prescribed methotrexate. The following statements do not need further teaching, except?

A. "I will continue to take my vitamins while I'm taking this drug"

B. "I must not drink any alcohol while I'm taking this drug"

C. "I should brush my teeth after every meal"

D. "I will continue taking my birth control pills"

A. "I will continue to take my vitamins while I'm taking this drug"

methotrexate is a folic acid antagonist

SITUATION: A nurse is caring for patients with rheumatoid arthritis. The following questions apply.

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One of Nurse Jepoy's patients complained of difficulty seeing on the left eye. He is taking hydroxychloroquine for his RA. What is the correct interpretation for this?

A. Development of a Cataract

B. Possible retinal degeneration

C. Part of the disease process

D. A coincidental occurrence

B. Possible retinal degeneration

SITUATION: You are a newly registered nurse who is assigned to the medicine ward. The following questions apply.

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One of your patients with pulmonary embolism is on thrombolytic therapy. Which nursing interventions should you implement?

I. Keep protamine sulfate readily available

II. Avoid applying pressure to venipuncture sites

III. Assess for overt and covert signs of bleeding

IV. Avoid invasive procedures and injections

V. Administer stool softeners as ordered

A. I, II, III, IV

B. II, III, IV, V

C. I, III, IV, V

D. I, II, V

C. I, III, IV, V

heparin = antidote: protamin sulfate

apply pressure to venipuncture sites = to increase clotting ability and decrease bleeding

SITUATION: You are a newly registered nurse who is assigned to the medicine ward. The following questions apply.

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You have a patient that is suspected to have a pulmonary embolism. Which diagnostic test is the gold standard to confirm this diagnosis?

A. Plasma D-Dimer test

B. CT Pulmonary Angiography

C. Chest X-ray

D. Magnetic Resonance imaging (MRI)

B. CT Pulmonary Angiography

SITUATION: You are a newly registered nurse who is assigned to the medicine ward. The following questions apply.

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As a newly registered nurse, you know that which among the assessment data would indicate that the client has experienced a pulmonary embolism?

A. Calf pain with dorsiflexion of the foot

B. Sudden onset of chest pain with dyspnea

C. Left-sided chest pain and diaphoresis

D. Bilateral crackles and low-grade fever

B. Sudden onset of chest pain with dyspnea

SITUATION: You are a newly registered nurse who is assigned to the medicine ward. The following questions apply.

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Knowing the pathophysiology of a pulmonary embolism, which among the interventions should you anticipate implementing to a patient newly diagnosed with pulmonary embolism?

A. Administer oral anticoagulants

B. Assess client's bowel sounds

C. Prepare the client for a thoracentesis

D. Institute and maintain bed rest

D. Institute and maintain bed rest

SITUATION: You are a newly registered nurse who is assigned to the medicine ward. The following questions apply.

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You identified a patient's problem with pulmonary embolism as a "decreased cardiac output." Which of the following should you implement?

A. Monitor client's arterial blood gas

B. Assess skin color and temperature

C. Check signs for bleeding

D. Keep the client in the Trendelenburg position

B. Assess skin color and temperature

monitor client's ABG = ineffective breathing pattern

check signs for bleeding = risk for bleeding

trendelenburg = causes more DOB

SITUATION: Niño is assigned to be the head nurse of their unit. While he is still on training, the supervisor wants to test his leadership and management skills, as well as in research. The following questions apply.

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A relative of the patient approached Niño, and complained that she heard one of the staff nurses talking badly about the patient. Head nurse Niño would be correct is he identified that this is an act of:

A. Defamation

B. Negligence

C. Battery

D. Malpractice

A. Defamation

SITUATION: Niño is assigned to be the head nurse of their unit. While he is still on training, the supervisor wants to test his leadership and management skills, as well as in research. The following questions apply.

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While head nurse Niño is reviewing the theories of leadership, he encounters the theory that mostly talks about leadership being flexible depending on the need. What theory of leadership describes this?

A. Great Man theory

B. Charismatic theory

C. Path-goal theory

D. Contingency theory

D. Contingency theory

SITUATION: Niño is assigned to be the head nurse of their unit. While he is still on training, the supervisor wants to test his leadership and management skills, as well as in research. The following questions apply.

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Head nurse Niño received a memorandum from the top level management about policy changes. What type of lines of communication is this?

A. Upward communication

B. Grapevine communication

C. Downward communication

D. Horizontal communication

C. Downward communication

SITUATION: Niño is assigned to be the head nurse of their unit. While he is still on training, the supervisor wants to test his leadership and management skills, as well as in research. The following questions apply.

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Head nurse Niño is conducting a study on pressure ulcers. He would like to select his sample by asking the earlier respondents of his study. Which sampling method best describes this?

A. Simple random sampling

B. Chain Sampling

C. Systematic sampling

D. Stratified random sampling

B. Chain Sampling

SNOWBALL

SITUATION: Niño is assigned to be the head nurse of their unit. While he is still on training, the supervisor wants to test his leadership and management skills, as well as in research. The following questions apply.

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One of the eligibility criteria of Head Nurse Niño for his study is the age of the patient. Age will fall on which level of measurement?

A. Nominal

B. Interval

C. Ratio

D. Ordinal

C. Ratio

interval = has negative values

ratio = positive values, weight height age

SITUATION: Peppa is a telemetry nurse in Ospital ng Sulu in Mindanao. She is assigned to care for patients with cardiac conditions.

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A patient of Nurse Peppa suddenly records a chaotic irregular deflections in a cardiac monitor with no identifiable P wave, QRS Complexes, and T wave. She identified the rate to be at 150 bpm. What should nurse Pepa do first?

A. Administer epinephrine IV

B. Prepare to defibrillate the patient

C. Start CPR

D. Call a code

D. Call a code

SITUATION: Peppa is a telemetry nurse in Ospital ng Sulu in Mindanao. She is assigned to care for patients with cardiac conditions.

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What should nurse Peppa implement next when defibrillating the patient above?

A. Defibrillate the patient at 50, 100, 200 joules

B. Do not remove the oxygen source during defibrillation

C. Shout "all clear" prior to defibrillation

D. Place petroleum jelly on the defibrillator pads

C. Shout "all clear" prior to defibrillation

MONO = 200-300-360 joules

BIPHASIC = 120-200

SITUATION: Peppa is a telemetry nurse in Ospital ng Sulu in Mindanao. She is assigned to care for patients with cardiac conditions.

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Another patient of Nurse Peppa has cardiac dysrhythmia. Which problem listed below should receive the highest priority?

A. Alteration in comfort

B. Decreased cardiac output

C. Impaired gas exchange

D. Activity intolerance

B. Decreased cardiac output

SITUATION: Peppa is a telemetry nurse in Ospital ng Sulu in Mindanao. She is assigned to care for patients with cardiac conditions.

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While monitoring the telemetry, nurse Peppa saw one ECG tracing of a patient that shows a P-wave before each QRS complex and the rate is 62 bpm. What should nurse Peppa do?

A. Documents as a Normal sinus rhythm

B. Request a 12-lead ECG

C. Prepare to administer digoxin PO

D. Assess the client's cardiac enzyme

A. Documents as a Normal sinus rhythm

SITUATION: Peppa is a telemetry nurse in Ospital ng Sulu in Mindanao. She is assigned to care for patients with cardiac conditions.

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Another patient of Nurse Peppa has a complete heart block. Among the interventions listed, which should she implement first?

A. Prepare to insert a pacemaker

B. Administer atropine, an antidysrhythmic

C. Obtain a STAT ECG

D. Notify HCP

B. Administer atropine, an antidysrhythmic

Situation

Nurse Pathy is working in a public tertiary hospital in Manila where she is assigned in the Thyroid and Endocrine Disorders unit. Under her current care are patients Maricris, a 35-year-old female, diagnosed with adrenocortical insufficiency, Jojie, a 46-year-old male, diagnosed with pheochromocytoma, and Rosemae, a 38-year-old female with Cushing's disease.

Nurse Pathy is assessing Jojie with pheochromocytoma. Which finding would alert Nurse Pathy that a potential complication associated with Jojie's disorder is arising?

a. A blood urea nitrogen level of 18 mg/dL

b. A heart rate of 90 bpm and is irregular

c. An hourly urine output of 60 mL/hr

d. A coagulation time of 5 minutes

b. A heart rate of 90 bpm and is irregular

Nurse Pathy is providing Maricris, the client with adrenocortical insuffiency, information on how to adjust glucocorticoid doses. Nurse Pathy should explain that Maricris may need an increased amount of the drug in which of the following situations?

a. Undergoing a root canal

b. Completing her master's degree in business administration

c. Gaining 2 kilograms

d. Getting married

a. Undergoing a root canal

Bone resorption, as Nurse Pathy tells Rosemae, is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help Rosemae prevent this complication?

a. Modify the diet so that there is increased potassium intake

b. Perform isometric exercises

c. Do weight-bearing exercises regularly

d. Limit daily intake of Vitamin D

c. Do weight-bearing exercises regularly

Maricris complains to Nurse Pathy on how her skin has "turned darker than it used to." Nurse Pathy should teach Maricris that the bronze-colored skin from having adrenocortical insufficiency is thought to be due to which of the following?

a. Sun exposure hypersensitivity

b. Increased serum bilirubin levels

c. An adverse effect of the glucocorticoid therapy

d. Increased secretion of the adrenocorticotropic hormone (ACTH)

d. Increased secretion of the adrenocorticotropic hormone (ACTH)

inc. melanocyte stimulating hormone

Rosemae verbalized to Nurse Pathy that she was a former beauty queen when she was in her twenties. She also won numerous awards and was a Binibining Pilipinas candidate in the nineties. She says that she is upset regarding her current appearance due to her moon face and buffalo hump. She adds that her husband may not love her just as much anymore because she "isn't as pretty" as she once was. What would be the most appropriate nursing diagnosis for Rosemae?

a. Disturbed body image related to altered physical appearance

b. Risk for injury related to weakness

c. Disturbed thought processes related to mood swings

d. Impaired skin integrity related to edema

a. Disturbed body image related to altered physical appearance

Situation

Teresing, a 45-year-old woman, comes to the clinic as she was called in due to her abnormal Papanicolau (Pap) smear test. Her history identifies that she has had a long-standing, chronic HPV infection due to her having multiple sexual partners starting when she was 19. She is accompanied to the clinic by her loving husband, Torong. Nurse Drink Water is assigned to her.

Nurse Drink Water is preparing Teresing for a vaginal examination. What position should she place her in?

a. High fowler's position

b. Genupectoral position

c. Lithotomy position

d. Dorsal recumbent position

c. Lithotomy position

Torong tells Nurse Drink Water, "Her doctor told us that Teresing's type of cancer is curable. I know for a fact that cancers usually aren't. Was that doctor just trying to lighten up the situation?" Which answer from the nurse would be the most accurate?

a. "Cancers arising from the female reproductive tract tend to be slow growing and generally respond very well to treatment programs."

b. "Her saying that cancer is curable means that 50% of all women with cervical cancer survive for at least 10 more years."

c. "The 5-year survival rate is around 75%, which means that the odds are pretty good."

d. "When cervical cancer is detected in its early stages and is treated as soon as possible, the cure rate is almost at 100%."

d. "When cervical cancer is detected in its early stages and is treated as soon as possible, the cure rate is almost at 100%."

Teresing is to undergo brachytherapy. There is a lead-lined container and a pair of long forceps kept inside her hospital room. What are these used for?

a. For handling dislodged radiation source

b. Disposal of the client's eating utensils

c. Storage of the radiation dose

d. Disposal of emesis or other contaminated body secretions

a. For handling dislodged radiation source

While Teresing has the internal radiation implant, what principles should Nurse Drink Water follow in providing her care?

a. Take off the dosimeter film badge when going into the client's room.

b. Limit the time with the client to only 2 hours per shift.

c. Never allow children younger than 16 years old to enter the client's room.

d. Pregnant women are allowed to go into the client's room if they stay 6 feet away.

c. Never allow children younger than 16 years old to enter the client's room.

30 mins/shift

Nurse Drink Water should carefully observe Teresing for typical adverse effects associated with brachytherapy. These include:

a. Severe vaginal itching

b. Confusion

c. Nausea and foul vaginal discharge

d. High fever in the afternoon or evening

c. Nausea and foul vaginal discharge

Situation

As a newly hired nurse, Nurse Nobita must adhere to the hospital's policies and guidelines, including safety, infection control, and environmental sanitation.

61. Nurse Nobita is currently completing a blood draw from a patient whose HIV status is not yet known. Which of the following methods is the correct way of disposing the needle?

a. Place the needle into any biohazard disposal container if there is no puncture-resistant container nearby.

b. Do the fishing method of recapping the needle and place it in a puncture-resistant container.

c. Break the needle then place it in a puncture-resistant container in the nurse's station.

d. Place the needle in the nearest puncture resistant container.

d. Place the needle in the nearest puncture resistant container.

Nurse Nobita knows that the different colored waste containers in their facility serve different purposes. All except which one of the following are commonly used colors in waste segregation?

a. Red

b. Black

c. Yellow

d. Pink

d. Pink

RED = SHARPS

BLACK = NON-BIODEGRADABLE

YELLOW = INFECTIOUS

GREEN = BIODEGRADABLE

ORANGE = RADIOACTIVE

While attending to another patient in recovery from surgery, Nurse Nobita realizes that he has unintentionally administered the wrong dose of antibiotic. What should be Nurse Nobita's appropriate action when documenting this incident in the patient's medical record?

a. The nurse should inform the pt about the incident and inquire about their preference regarding the creation of an IR. If the pt requests 1, it should be duly included in their medical record.

b. The nurse should record the administered dosage in the pt's chart w/o the need for an incident report, as it was solely a case of an incorrect drug dosage being prescribed.

c. The nurse should generate an IR and document the facts of the event in the medical record, but there is no requirement to include an actual copy of the IR or make reference to its existence.

d. The nurse should generate an IR and place a copy of it in the pt's medical record.

c. The nurse should generate an IR and document the facts of the event in the medical record, but there is no requirement to include an actual copy of the IR or make reference to its existence.

While caring for a patient undergoing intravenous drug therapy with the aid of an infusion pump, Nurse Nobita encounters a situation where the pump consistently emits an alarm, and he is uncertain if the drug administration is proceeding correctly. What is the appropriate course of action for Nurse Nobita to take in this scenario?

a. Continue in attempting to resolve the issue with the pump to ensure the patient's drug therapy stays on schedule.

b. Stop the infusion, replace the malfunctioning pump with a functional one, restart the infusion, and properly label the broken pump before placing it in the designated area for faulty equipment.

c. Discontinue the infusion, replace it with a functioning pump, and leave the malfunctioning pump outside of the patient's room for maintenance to try.

d. Turn off the alarm, resume the infusion, and closely monitor the patient for any additional issues.

b. Stop the infusion, replace the malfunctioning pump with a functional one, restart the infusion, and properly label the broken pump before placing it in the designated area for faulty equipment.

Nurse Nobita is helping a client, who has a history of falls and hearing difficulty, get ready to leave the hospital's assistive care facility and go home. As the client prepares for discharge, Nurse Nobita goes over fall prevention strategies. Which statement by the client suggests a need for further education?

a. "I'll position rugs at my doorways and the top of the stairs."

b. "If I'm unable to clean up a spill on the floor, I should place a marker around it until someone can come and take care of it to prevent any accidents."

c. "I need to wear my hearing aids throughout the day."

d. "I must refrain from using a step stool or ladder, even if it's just to get an item from a shelf."

a. "I'll position rugs at my doorways and the top of the stairs."

Situation

Miss Jade So, 18 years old, was diagnosed last week with juvenile-onset diabetes mellitus. Nurse Sue aids her in understanding her condition and provides health teaching to alleviate her anxiety and fears.

Jade tells the nurse that sometimes she feels lightheaded a few hours before their lunch break in school and that when she checked her blood sugar levels like she was taught, the reading was at 50 mg/dL. Nurse Sue knows that using the 15-15 rule, she would teach Jade to:

a. Drink 15 oz of juice and retest in 15 minutes

b. Drink 15 mL of juice and give another 15 mL in 15 minutes.

c. Eat 15 g of carbohydrate and retest the blood sugar again in 15 minutes

d. Eat 15 g of carbohydrate and 15 g of protein

c. Eat 15 g of carbohydrate and retest the blood sugar again in 15 minutes

4 oz only

check for 3x

Nurse Sue provides information on the different types of insulin that can be used for a patient with juvenile onset diabetes. She determines that Jade needs no additional teaching when she states that which one of the following is classified as a rapid-acting insulin?

a. Apidra

b. Humulin R

c. Glargine

d. NPH

a. Apidra

Jade's parents ask Nurse Sue of the difference between the diabetes that Jade has as compared to that of her uncle. Upon further questioning, Nurse Sue finds out that the uncle has diabetes insipidus. Nurse Sue is correct in differentiating the two when she states that?

a. "Type 1 diabetes mellitus is sometimes called adult-onset diabetes whereas diabetes insipidus is known as juvenile onset diabetes."

b. "Diabetes mellitus is a pancreatic disorder while diabetes insipidus is a hypothalamic disorder."

c. "Urine is diluted in both diabetes mellitus and insipidus.

d. "Blood glucose levels are increased in both."

b. "Diabetes mellitus is a pancreatic disorder while diabetes insipidus is a hypothalamic disorder."

Jade suddenly comes down with the flu. Nurse Sue knows that during times of illness, the client needs to be provided with:

a. More calories

b. Less protein and fat

c. Less insulin

d. More insulin

d. More insulin

infxn > inc. body stress > inc. insulin resistance > inc. glucose

Which of the following would alert Nurse Sue that a complication of juvenile onset diabetes mellitus may be occurring?

a. Fecal odor breath

b. Oliguria

c. Glucose levels of 90 mg/dL

d. Serum potassium of 7.5 mEq/L

d. Serum potassium of 7.5 mEq/L

DKA complication

FRUITY not fecal odor breath (intestinal blockage)

POLYURIA not oliguria

Glucose levels = 200-250 mg/dL

Situation

Coviduvidapdap, 62 years old, is brought to Clearview General Hospital due recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. Other findings include jaundice and weight loss. Nurse Mirasol is conducting the initial interview when he admits that he has been a struggling alcoholic for 20 years and is fond of eating fatty meat. The physician suspects chronic pancreatitis.

The doctor orders some laboratory tests to be done to Coviduvidapdap. Which of the following is the most useful study in diagnosing chronic pancreatitis?

a. ERCP

b. Upper GI series

c. EGD

d. Proctoscopy

a. ERCP

endoscopic retrograde cholangiopancreatography

Nurse Mirasol observes Coviduvidapdap as the physician confirms the existence of chronic pancreatitis. She takes note of the client's occasional spontaneous twitching and spasms. How will she interpret the importance of these symptoms?

a. The symptoms may be due to the drug, Demerol.

b. Hypocalcemia may be developing.

c. Nutritional imbalance may be present.

d. Muscle relaxant may be needed to facilitate rest.

b. Hypocalcemia may be developing.

pancreatitis

calcium is being used to repair pancreas

Nurse Mirasol knows that diet is just as important as the control of the symptoms in Coviduvidapdap. She provides him with health teaching on the allowable foods that he can intake that will not cause further pain. Which of the following, if stated by the client, will prompt Nurse Mirasol to do reeducation measures?

a. Buttered vegetables with mayonnaise dip

b. Lean chicken breast and boiled rice

c. Fortified soya drink and frozen grapes

d. Sliced papaya and watermelon

a. Buttered vegetables with mayonnaise dip

Pancreatic enzymes are ordered for Coviduvidapdap. When should Nurse Mirasol instruct him to take them to increase its therapeutic effectiveness?

a. Every 4 hous, at specific times of the day

b. Once in the AM and once in the PM

c. Three times daily in between meals

d. With each meal and snack

d. With each meal and snack

Nurse Mirasol adds that Coviduvidapdap should monitor the effectiveness of the pancreatic enzyme replacement therapy by doing which of the following?

a. Performing regular glucose checks via a glucometer

b. Measuring fluid intake

c. Observing for fatty, frothy, foul-smelling stools

d. Testing urine for the presence of ketones

c. Observing for fatty, frothy, foul-smelling stools

Situation

Lei understands the importance of knowing the content of RA 9173 or the Philippine Nursing Act of 2002 and RA 10912 or the Continuing Professional Development Act of 2016 as an upcoming registered nurse.

Lei knows that the Professional Regulatory Board of Nursing are esteemed individuals tasked to supervise and regulate the practice of the nursing profession in the Philippines. The following are the qualifications to become part of the BON, except?

a. Natural born citizen and resident of the Philippines

b. Have at least ten (10) years of continuous practice of the profession prior to appointment with the last two (2) years being in the Philippines

c. Not have been convicted of any offense involving moral turpitude

d. Registered nurse and holder of a master's degree in nursing

b. Have at least ten (10) years of continuous practice of the profession prior to appointment with the last two (2) years being in the Philippines

last 5 YEARS not 2

Lei identifies that which of the following is true of the BON, except?

a. The membership to the Board shall represent the three (3) areas of nursing, namely: nursing education, medical surgical nursing and community health nursing.

b. Any person appointed as Chairperson or Member of the Board shall immediately resign from any teaching position

c. The Chairperson and Members of the Board shall hold office for a term of three (3) years and until their successors shall have been appointed and qualified

d. The BON shall issue, suspend or revoke certificates of registration for the practice of nursing

a. The membership to the Board shall represent the three (3) areas of nursing, namely: nursing education, medical surgical nursing and community health nursing.

NURSING SERVICE, NOT MSN

Lei recognizes that the Board has the responsibility to monitor schools or universities offering nursing courses. She knows that which authority is to open and close colleges of nursing and/or nursing education programs upon the written recommendation of the Board?

a. Department of Health

b. Commission on Higher Education

c. Professional Regulatory Commission

d. Department of Education

b. Commission on Higher Education

Lei, in preparation for her board exams on November 11 and 12 reviews the qualifications for admission to the licensure exam. Which of the following is not included?

a. Philippine citizen

b. Good moral character

c. An average board rating of 75%, with a rating of not below 60% per NP

d. Holder of a bachelor's degree in nursing from a college or university that complies with the standards of nursing education

c. An average board rating of 75%, with a rating of not below 60% per NP

QUALIFICATION FOR PASSING, NOT ADMISSION

Lei is aware that once she obtains her Professional Identification Card (PIC) from the PRC, she will need to renew it periodically, provided that she has complied with the required number of CPD units. She knows this will be every?

a. One Year

b. Two years

c. Three years

d. Four years

c. Three years

Situation

Nurse Tide conducts a health teaching session on first aid principles during emergency circumstances to a small team of student nurses. Some of the topics that he covered include snakebites, anaphylaxis, triage, and prioritization.

Nurse Tide places the students in a scenario where a client is accidentally bit by a snake as he was moving through a forest near their barangay. He should convey to them that the foremost priority intervention in such a situation is to take which action?

a. The affected extremity must be immobilized.

b. Place the extremity in a position that is below heart level.

c. Remove any constrictive items from the client's body.

d. Relocate the client to a safe area away from the snake and advise them to rest.

d. Relocate the client to a safe area away from the snake and advise them to rest.

2. Remove any constrictive items from the client's body.

3. a. The affected extremity must be immobilized.

3. b. Place the extremity in a position that is below heart level.

Nurse Tide presents another situation wherein a client is having a severe anaphylactic reaction to a drug. Drug administration has already been stopped and a rapid call response was initiated. The blood pressure reads 70/42, heart rate is 130, and oxygen saturation is 87%. The nurse observes audible wheezing, facial redness, and swelling. In this situation, what is the initial treatment for the patient's condition?

a. IV Diphenhydramine

b. SQ Epinephrine

c. Albuterol

d. IV 0.9% Sodium Chloride

b. SQ Epinephrine

Nurse Tide's student, Perla, asks about what a triage nurse would first do if she found a man collapsing in the emergency department waiting room. Nurse Tide correctly responds:

a. Feel the presence of air movement from the man's nose or mouth.

b. Perform head tilt-chin lift maneuver to open the airway

c. Gently shake the man and observe for responsive

d. Observe the chest for respirations

c. Gently shake the man and observe for responsive

Nurse Tide quizzes his students about managing emergency situations and challenges them to arrange the following individuals based on triage principles. The first person in the order should be the one to be transported to the hospital first. What would be the correct sequence?

i. A 15-year-old with a fractured arm

ii. A 67-year-old who has an abdominal wound but has already been stabilized

iii. A 26-year-old with HR of 130 bpm, RR of 25 cycles per minute, and BP 75/40

iv. A 30-year-old who has fixed, dilated pupils with a penetrating head injury

a. 3, 1, 2, 4

b. 4, 3, 2, 1

c. 2, 1, 3, 4

d. 3, 2, 1, 4

a. 3, 1, 2, 4

Since there was a confusion on color triaging, Nurse Tide asks another question on the topic. He asked his students as to how they will tag a patient with a spinal cord injury at C3 and has agonal respirations. He determines that the student has understood the teaching when they answer:

a. Black

b. Red

c. Yellow

d. Green

a. Black

HIGH QUADRIPLEGIA

PHRENIC NERVE PARALYSIS

DIAPHRAGM PARALYSIS

AGONAL RESPIRATION

Situation

Porco, a 27-year-old man, had been involved in a motor vehicular accident when his Ducati Desmosedici crashed against a speeding Ford Raptor that suddenly merged into his lane along SLEX Southbound. He was rushed to a nearby private hospital in the area. Fortunately, he survived the crash but now suffers from a head injury and has been diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH).

Nurse Gabi assesses Porco. What alteration in fluid and electrolyte balance will she expect to find?

a. Increased plasma osmolality

b. Decreased serum sodium

c. Decreased blood pressure

d. Increased urine output

b. Decreased serum sodium

Porco's current sodium levels are found to be at 114 mEqs/L. Which of the following orders from the primary health care provider would Nurse Gabi question?

a. Begin an infusion of 3% NaCl

b. Administer the prescribed vasopressin antagonist

c. Encourage fluid intake of at least 2L/day

d. Elevate HOB to high-Fowler's position

c. Encourage fluid intake of at least 2L/day

Nurse Gabi understands the basic pathophysiology of what occurs to a patient with SIADH and relays the information to Porco. Which of the following statements, if stated by Porco, indicates that teaching was effective?

a. There is decreased serum osmolarity as excess water is being retained by the kidneys

b. There is increased serum osmolarity as excess water is being excreted by the kidneys

c. There is decreased serum osmolarity as excess sodium is excreted by the kidneys

d. There is increased serum osmolarity as excess sodium is retained by the kidneys

a. There is decreased serum osmolarity as excess water is being retained by the kidneys

Due to the abnormal serum sodium levels, Nurse Gabi continues to monitor the client closely for which of the following abnormal signs/symptoms?

a. Confusion

b. Palpitations

c. Complaints of excessive thirst

d. Pupillary constriction to light

a. Confusion

Porco who was standing against the wall watching TV suddenly exhibited a seizure episode due to cerebral edema. Which priority nursing action would Nurse Gabi implement first?

a. Maintain a patent airway

b. Assist Porco to the floor and protect the head

c. Monitor vital signs

d. Monitor the seizure activity

b. Assist Porco to the floor and protect the head

Situation

Lolo Hubert, 63-years-old, had been diagnosed with Stage II stomach cancer. This led to him needing a total gastrectomy. On his 8th post-operative day, he was already being started on a light diet. Nurse Nemo observes him as he eats.

Nurse Nemo monitors Lolo Hubert for early signs of dumping syndrome. Which of the following findings would alert Nurse Nemo that this is occurring?

a. Tachycardia and pallor

b. Bradycardia and indigestion

c. Irritability and anxiety

d. Double vision and chest pain

a. Tachycardia and pallor

Which of the following instructions would Nurse Nemo include in his teaching plan for Lolo Hubert in assisting him to prevent dumping syndrome? Select all that apply.

i. Lie down for 20-30 minutes after meals.

ii. Limit the fluids taken with meals

iii. Modify the diet to high fiber and high protein

iv. Avoid sugary, high carbohydrate foods

a. 1, 2, 3

b. 1, 2, 4

c. 2, 3, 4

d. All of the above

d. All of the above

inc. fiber to delay gastric emptying

fiber is slowly digested in stomach

Lolo Hubert has gotten ahold of Nurse Nemo's teaching for dumping syndrome and is well for a few months. However, he returns complaining to the nurse that he has mouth sores, shortness of breath, and a red beefy tongue. His physician suspects pernicious anemia and orders a peripheral blood smear. Nurse Nemo knows that if pernicious anemia is present, the red blood cells will appear?

a. Small and hypochromic

b. With a crescent moon shape

c. Large and oval-shaped

d. Disc-shaped

c. Large and oval-shaped

Vitamin B12 Deficiency

Megalobastlic Anemia

a. Small and hypochromic

IRON

b. With a crescent moon shape

SICKLE

d. Disc-shaped

NORMAL

Lolo Hubert asks Nurse Nemo which vitamin is deficient in pernicious anemia. Nurse Nemo's senior nurse need not to intervene if Nurse Nemo states that Lolo Hubert lacks?

a. Vitamin B9

b. Vitamin B12

c. Vitamin C

d. Vitamin A

b. Vitamin B12

Nurse Nemo emphasizes the need to increase cyanocobalamin intake from Lolo Hubert. He asks the nurse as to how he can achieve this. Nurse Nemo correctly answers:

a. Increasing cyanocobalamin in the diet

b. Taking oral cyanocobalamin supplements

c. Chelation therapy

d. Taking cyanocobalamin injections

d. Taking cyanocobalamin injections

Situation

Tala works as a nurse in a provincial hospital. She is assigned to prepare the medications of 5 patients for her AM shift. The following questions apply.

The doctor has prescribed atropine sulfate 0.8 milligrams intramuscularly (IM) before surgery. The medication is supplied in a concentration of 1.6 milligrams per milliliter. What is the amount of medication that Nurse Tala should prepare for administration?

a. 0.25 mL

b. 0.5 mL

c. 1.0 mL

d. 1.50 mL

b. 0.5 mL

For a client with congestive heart failure (CHF), Nurse Tala is tasked with administering 60 mg of furosemide (Lasix). The vial holds 15 mg/mL. What is the accurate dose the nurse should administer?

a. 4.0 mL

b. 0.4 ml

c. 0.25 mL

d. 2.5 mL

a. 4.0 mL

One of Nurse Tala's clients needs to take 1 g of ascorbic acid daily by mouth. The medication is available in containers labeled as "Ascorbic Acid 500 mg tablets." What will be the amount of medication that Nurse will give?

a. 0.5 tablets

b. 1 tablet

c. 2 tablets

d. 5 tablets

c. 2 tablets

Nurse Tala regulates the IV fluids of some patients. For one patient, 250 mL of normal saline IV is administered over 4 hours, using tubing with a drip factor of 15 drops/mL. What should be the rate of delivery in drops per minute?

a. 16 gtts/min

b. 21 gtts/min

c. 13 gtts/min

d. 19 gtts/min

a. 16 gtts/min

Another patient is prescribed to receive 1,000 mL of NSS, administered at a rate of 125 mL per hour. How many hours will go by before Nurse Tala needs to change the IV bag?

a. 0.125 hours

b. 8 hours

c. 6 hours

d. 4 hours

b. 8 hours