PRACTICE TESTS 1

RN > charge nurse > nursing supervisor > chief nurse

What is the correct nursing hierarchy in reporting a situation?

Droplet precaution

A client is diagnosed with AIDS. He then had an opportunistic infection of pneumocystis jeroveci. What precaution should you implement?

150,000-400,00/mL

normal platelet count

"How do you feel about the lifestyle changes you are planning to make?"

You are trying to determine client's adjustment to his new diagnosis. What question would elicit the most useful info from client?

- Open capsule & sprinkle into orange juice

- Ask pharmacy for liquid form of med

- Give med w/ soft foods

- Crush meds and mix with water

An 88 yr old client has difficulty swallowing. What nursing actions are appropriate in administering tablets by mouth?

Shakiness, cold, clammy skin

Orange juice is needed if what symptoms develop?

Calf pain

Tenderness

Increased girth of leg

Homan's sign

Signs of DVT

Brudzinki's sign

A positive sign of meningitis, in which there is an involuntary flexion of the HIP & KNEE when the patient's NECK is passively flexed

Sweaty skin

Client is diagnosed w/ Graves' dss. What manifestation will you expect?

Imbalanced nutrition: less than body requirements r/t hypermetabolism

What is an approp nursing diagnosis for hyperthyroidism?

hepatosplenomegaly

Client has pulmonic stenosis. What symptom will you expect?

Wear long-sleeved clothing when going outside (antipsychotics = hypothermia)

What health teaching should you include for a client on neuroleptic ttt?

"Tell me when you feel anxious"

You observe that the px is agitated. What is an appropriate therapeutic communication?

"How do you feel about having a male nurse?"

Client states, "I've never had a male nurse before". How should you respond?

88-92%

normal COPD O2 sat

Manage joint pain and fatigue to perform ADLs

What is an appropriate expected outcome for px with rheumatoid arthritis?

Client does not drink water DURING meals

What assessment finding indicates effective mgmt of client w/ anorexia nervosa?

Steamed mix veggies, lean beef, rice

What should chronic renal failure patient's diet be?

N&V

Hypertension

Dizziness

Client underwent hemodialysis for the first time. What s/s suggest disequilibrium syndrome?

Low sodium, high K, high protein

A client is receiving Prednisone. What should his diet be?

Raisins

Banana

Watermelon

Papaya

Tomatoes

Orange juice

Which foods are high in potassium?

Apple/pineapple

Strawberries

Which fruits are low in potassium?

Taping tube to the bridge of the nose

What is your last step in inserting NGT?

inspection, palpation, percussion, auscultation

order of physical assessment

Px is able to attend conference on time

What indicates effectiveness of lithium?

endocardial cushion defect

cardiac abnormality that is commonly observed in children with Down Syndrome (trisomy 21)

Terminal

At which stage of the natural history of dss is tertiary prevention required?

2-8 C

appropriate storage temp of DPT

hemophilus influenzae

microorganism responsible for the most common type of meningitis in children aged 2 mos to 3 years

morbillivirus

etiological agent of Rubeola (Measles) "9-day Measles"

RA 7160

= Local Government Code of 1991

= law that devolved basic health services to LGUs

Amebic dysentery

identified by the presence of blood and/or mucus in the stool

giardiasis

characterized by fat malabsorption, resulting in the production of oily stools (steatorrhea)

severe dehydration

Which of the ff severe conditions may not always require urgent referral to a hospital?

IV fluid therapy

Oresol or NGT

Hospital referral

What is the mgmt for severe dehydration?

myoglobin elevation

early indicator of myocardial damage

Creatine Phosphokinase (CPK), Troponin T & I, myoglobin

Which laboratory studies evaluate myocardial damage?

t-wave inversion

You reviewed the ECG of a px during an episode of chest pain. You find out he has myocardial ischemia. How is this displayed in an ECG?

increased QRS duration

You reviewed the ECG of a px during an episode of chest pain. You find out he has a bundle-branch block. How is this displayed in an ECG?

shortened PR interval

You reviewed the ECG of a px during an episode of chest pain. You find out he has a junctional rhythm. How is this displayed in an ECG?

pathological q waves

You reviewed the ECG of a px during an episode of chest pain. You find out he has a myocardial infarction. How is this displayed in an ECG?

hemorrhagic shock

Patient who is 4 hrs PP has weak and thready pulse of 100 bpm. This may indicate __.

amount of lochia (determine the extent of uterine bleeding)

Patient who is 4 hrs PP has weak and thready pulse of 100 bpm. What do you check for?

due to dehydrating effects of labor

Why is high temp normal after birth?

community of solution

If a nurse chooses to volunteer in a community of indigenous people and help them lobby against environmental degradation of their ancestral land, the nurse is part of a?

Epidemiological surveillance

What public health function according to WHO focuses on CONTROL OF COMMUNICABLE DSS?

PHC Strategy

= made by the World Health Organization

= adopted in the PH by virtue of Letter of Instruction No. 949 by President Marcos

= defined by Alma Ata Declaration as "essential health care at a cost that the community CAN AFFORD"

PHC Strategy

= health services made available to all age groups

= socially acceptable, scientifically sound services of healthcare given to the poor

= a strategy of healthcare delivery among developing & first-world countries

Alma Ata Declaration

= made on Sept. 6-12, 1978 in Union of Soviet Socialist Republics (USSR)

= defines PHC strategy as "essential health care at a cost that the community CAN AFFORD"

= listed 8 essential health services to achieve the goal of "health for all"

Report the situation to the nursing supervisor

Incoming male RN smells of alcohol. What is your most appropriate action?

Do not eat raw food

Practice handwashing before & after using bathroom

Avoid crowded places

Avoid refrigerated foods

Avoid exposure to cold & dampness

Px has a WBC count of 3,000/cumm. What would you give as health teachings?

glycosylated hemoglobin

most accurate lab test for the diagnosis of DM

Prothrombin time

Lab test for client receiving Warfarin (Coumadin)

Position the elbows flexed at 30-degree angle at the crossbar of the crutches

What should you tell the px regarding use of crutches after his knee amputation?

20/15 vision (the lower the R number, the more farsighted)

Px is diagnosed with hyperopia. What do you expect to note in his Snellen's chart test?

Kussmaul's breathing

What breathing pattern do you observe in a px with diabetic ketoacidosis?

Apple (has low potassium)

A patient has a serum K level of 5.8 mEq/L. Which fruit can be included in his diet based on this finding?

70-110 mg/dL

normal fasting blood glucose

10-20 mg/dL

Normal BUN levels

3.5-5.0 mEq/L

normal potassium levels

below 1.010 (diluted)

A patient has diabetes insipidus. The nurse would expect to find that his specific gravity is __.

respiratory acidosis

Patient has the ff arterial blood gas results: pH 7.32, PaCO2 50mmHg, HCO3 26 mEq/L. His results indicated __.

Inform charge nurse about suspected child abuse

A 3 yr old child was brought to ER for limb fractures. His mother is uncooperative in giving info. What is your next action?

Suctioning for 15-20 secs (should be

When suctioning a client with tracheostomy, what will be an inappropriate action?

Palpate pedal artery of affected leg

How will you assess neurovascular status of an extremity casted from ankle to thigh?

SOB

Client is receiving blood transfusion. What symptom indicates that client is experiencing Transfusion Reaction Acute Lung Injury (TRALI)?

Urinary bag is full

Client is diagnosed with ruptured intervertebral discs T6 to T12. What assessment finding will concern you the most several hrs after surgery?

He is eating green salad

What observation in an immunocompromised patient requires health teaching?

Client who is HIV positive

Client has AIDS. What client can be safely roomed-in with client?

"I know this is frightening for you, but I don't see any bugs crawling in your skin."

Client has tactile hallucinations due to Delirium Tremens. He states, "There are bugs crawling under my skin!" What's your most appropriate response?

Prone

Best position for a child with myelomeningocele

Sitting upright leaning forward

Position for thoracentesis

Lithotomy

Position for cystoscopy

Prone

Position for renal biopsy

Tetralogy of Fallot

congenital malformation involving four distinct heart defects

patent ductus arteriosus (PDA)

passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth

Can perform personal self-care activities with no chest pain

What is an appropriate expected outcome for px with MI on her second day hospitalization?

inspection, auscultation, percussion, palpation

order of abdominal assessment

headache (increased ICP)

What finding is most concerning for a px who will undergo lumbar puncture?

The client's spouse turns on the TV 1 hour in the afternoon & 2 hrs in the evening

Px has closed head injury. What situation needs intervention by the nurse?

Wear long sleeve shirt (antipsychotics = hypothermia)

A client is taking Chlorpromazine (Thorazine). What should you include in the health teaching before letting client walk?

Measles

Which illness has been declared as the target for eradication in the PH through Presidential Proclamation no. 4?

early in the morning

Appropriate time for scheduling a stool specimen to confirm the diagnosis of a px suspected of having pinworms

total popu x 3%

How do we estimate the num of infants in a popu?

Tertiary prevention

= prevention that involves rehab, prevention of permanent disability and disability limitation

= for convalescents, disabled, complicated cases, and terminally ill

buccal mucosa

You know that the presence of Koplik's spots is a definitive sign of measles. These spots can be observed at what part of the body?

DPT (diphtheria, pertussis, tetanus)

= vaccine used in the Expanded Program Immunization (EPI) that should NOT BE STORED IN A FREEZER

= aka pentavalent vax

pentavalent vaccine

vaccine that protects against five potential killers: Diptheria, Tetanus, Pertusis, Hib, and Hepatitis B

rural health unit

As a new BSN graduate aspiring to be a public health nurse, where do you submit your application?

copious amount of watery stools

primary symptom of cholera

Oresol

oral rehydration solution for use to correct dehydration caused by diarrhea or correct fluid imbalance in dengue

Assess further because this may be a sign of infection

The client reports that his cast has a foul odor. How should you respond?

name, address, gender, info about living will, durable power of attorney for healthcare, location of advance directive

You need to collect the px's biographic details. What are examples of these data?

Info related to chief complaint, past health hx, hx of immunizations

You need to assess a patient's health and illness patterns. What info do you need?

flat sign of electrocardiogram

What health status indicates death of px?

lochia

After observing a PP client with temp of 101.4F, a tender uterus upon palpation, a uterus that remains unusually large and not descending as expected, what should you assess next?

Recognize this as normal first period of reactivity

After birth, you observe that the male newborn has an RR of 78, HR of 160, nostril flaring, mild intercostal retractions, and grunting. What action will you take next?

fractured clavicle

If infant has asymmetrical Moro reflex response, what do you assess for next?

Community

a group of people, a territory, with interaction and common issues

8 midwives (40,000/5,000=8)

According to the DOH, if a certain municipality has 40,000 population, how many midwives does the nurse expect that she will work with?