DRILL 3 Flashcards
Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
- The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as
A. PPD B. PDP C. PDD D. DPP
A. PPD
Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
A. IM B. IV C. ID D. SC
C. ID
- The nurse notes that a positive result for Alfred is
a. 5 mm wheal c. 10 mm Wheal
b. 5 mm Induration d. 10 mm Induration
D. 10 mm Induration
- The nurse told Alfred to come back after
a. a week b. 48 hours c. 1 day d. 4 days
B. 48hours
- Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?
a. Call the Physician
b. Notify the radiology dept. for CXR evaluation
c. Isolate the patient
d. Order for a sputum exam
A. Call the physician
- Why is Mantoux test not routinely done in the Philippines?
a. It requires a highly skilled nurse to perform a Mantoux test
b. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
c. Chest X Ray Can diagnose the specific microorganism responsible for the lesions
d. Almost all Filipinos will test positive for Mantoux Test
D. Almost all Filipinos will test positive for Mantoux Test
- Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
a. I b. II c. III d. IV
A. I
- How long is the duration of the maintenance phase of his treatment?
a. 2 months c. 4 months
b. 3 months d. 5 months
C. 4 months
- Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?
a. Rifampicin c. Ethambutol
b. Isoniazid d. Pyrazinamide
C. Ethambutol
- According to the DOH, the most hazardous period for development of clinical disease is during the first
a. 6-12 months after c. 1-2 months after
b. 3-6 months after d. 2-4 weeks after
A. 6-12 months after
- This is the name of the program of the DOH to control TB in the country
a. DOTS (Directly Observed Therapy short course)
b. National Tuberculosis Control Program
c. Short Coursed Chemotherapy
d. Expanded Program for Immunization
B. National Tuberculosis Control Program
- Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except
a. 23 Year old athlete with diabetes insipidus
b. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
c. 23 Year old athlete taking illegal drugs and abusing substances
d. Undernourished and Underweight individual who undergone gastrectomy
a. 23 Year old athlete with diabetes insipidus
- Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?
a. Primary c. Tertiary
b. Secondary d. Quarterly
b. Secondary
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
14. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
a. Look at the ostomy site
b. Participate with the nurse in his daily ostomy care
c. Ask for leaflets and contact numbers of ostomy support groups
d. Talk about his ostomy openly to the nurse and friends
b. Participate with the nurse in his daily ostomy care
- The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
a. Plain NSS / Normal Saline
b. K-Y Jelly
c. Tap water
d. Irrigation sleeve
a. Plain NSS / Normal Saline
- The nurse should insert the colostomy tube for irrigation at approximately
a. 1-2 inches c. 6-8 inches
b. 3-4 inches d. 12-18 inches
b. 3-4 inches
- The maximum height of irrigation solution for colostomy is
a. 5 inches c. 18 inches
b. 12 inches d. 24 inches
b. 12 inches
- Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
a. Ask to defer colostomy care to another individual
b. Promises he will begin to listen the next day
c. Agrees to look at the colostomy
d. States that colostomy care is the function of the nurse while he is in the hospital
c. Agrees to look at the colostomy
- While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
a. Stop the irrigation by clamping the tube
b. Slow down the irrigation
c. Tell the client that cramping will subside and is normal
d. Notify the physician
a. Stop the irrigation by clamping the tube
- The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
a. A sunken and hidden stoma
b. A dusky and bluish stoma
c. A narrow and flattened stoma
d. Protruding stoma with swollen appearance
d. Protruding stoma with swollen appearance
- Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
a. Eat eggs
b. Eat cucumbers
c. Eat beet greens and parsley
d. Eat broccoli and spinach
c. Eat beet greens and parsley
- The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
a. Use 500 ml to 1,000 ml NSS
b. Suspend the irrigant 45 cm above the stoma
c. Insert the cone 4 cm in the stoma
d. If cramping occurs, slow the irrigation
b. Suspend the irrigant 45 cm above the stoma
- The nurse knew that the normal color of Michiel’s stoma should be
a. Brick Red c. Blue
b. Gray d. Pale Pink
a. Brick Red
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
24. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
a. Hyperventilating James with 100% oxygen before and after suctioning
b. Instilling 3 to 5 ml normal saline to loosen up secretion
c. Applying suction during catheter withdrawal
d. Suction the client every hour
d. Suction the client every hour
- What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
a. Fr. 5 b. Fr. 10 c. Fr. 12 d. Fr. 18
d. Fr. 18
- Wilma is using a portable suction unit at home, what is the amount of suction required by James using this unit?
a. 2-5 mmHg c. 10-15 mmHg
b. 5-10 mmHg d. 20-25 mmHg
c. 10-15 mmHg
- If a Wall unit is used, what should be the suctioning pressure required by James?
a. 50-95 mmHg c. 100-120 mmHg
b. 95-110 mmHg d. 155-175 mmHg
c. 100-120 mmHg
- Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
a. New set of tracheostomy tubes and Oxygen tank
b. Theophylline and Epinephrine
c. Obturator and Kelly clamp
d. Sterile saline dressing
c. Obturator and Kelly clamp
- Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
a. Wilma places 2 fingers between the tie and neck
b. The tracheotomy can be pulled slightly away from the neck
c. James’ neck veins are not engorged
d. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
a. Wilma places 2 fingers between the tie and neck
- Wilma knew that James have an adequate respiratory condition if she notices that
a. James’ respiratory rate is 18
b. James’ Oxygen saturation is 91%
c. There are frank blood suction from the tube
d. There are moderate amount of tracheobronchial secretions
a. James’ respiratory rate is 18
- Wilma knew that the maximum time when suctioning James is
a. 10 seconds c. 30 seconds
b. 20 seconds d. 45 seconds
a. 10 seconds
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
32. Which of the following is the appropriate nursing diagnosis?
a. Fluid volume deficit R/T furrow tongue
b. Fluid volume deficit R/T uncontrolled vomiting
c. Dehydration R/T subnormal body temperature
d. Dehydration R/T incessant vomiting
b. Fluid volume deficit R/T uncontrolled vomiting
- Approximately how much fluid is lost in acute weight loss of 0.5kg?
a. 50 ml b. 750 ml c. 500 ml d. 75 ml
c. 500 ml
- Postural Hypotension is
a. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
b. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
c. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
d. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
b. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- Which of the following measures will not help correct the patient’s condition
a. Offer large amount of oral fluid intake to replace fluid lost
b. Give enteral or parenteral fluid
c. Frequent oral care
d. Give small volumes of fluid at frequent interval
Offer large amount of oral fluid intake to replace fluid lost
- After nursing intervention, you will expect the patient to have
- Maintain body temperature at 36.5 C
- Exhibit return of BP and Pulse to normal
- Manifest normal skin turgor of skin and tongue
- Drinks fluids as prescribed
a. 1,3 B. 2,4 C. 1,3,4
D. 2,3,4
D. 2,3,4
SITUATION: Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
37. What is the action of this drug?
a. Increases glandular secretion for clients affected with cystic fibrosis
b. Dissolve blockage of the urinary tract due to obstruction of cystine stones
c. Reduces secretion of the glandular organ of the body
d. Stimulate peristalsis for treatment of constipation and obstruction
c. Reduces secretion of the glandular organ of the body
- What should the nurse caution the client when using this medication
a. Avoid hazardous activities like driving, operating machineries etc.
b. Take the drug on empty stomach
c. Take with a full glass of water in treatment of Ulcerative colitis
d. I must take double dose if I missed the previous dose
a. Avoid hazardous activities like driving, operating machineries etc.
- Which of the following drugs are not compatible when taking Probanthine?
a. Caffeine c. Acetaminophen
b. NSAID d. Alcohol
d. Alcohol
- What should the nurse tell clients when taking Probanthine?
a. Avoid hot weathers to prevent heat strokes
b. Never swim on a chlorinated pool
c. Make sure you limit your fluid intake to 1L a day
d. Avoid cold weathers to prevent hypothermia
a. Avoid hot weathers to prevent heat strokes
- Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?
a. Urinary retention
b. Peptic Ulcer Disease
c. Ulcerative Colitis
d. Glaucoma
b. Peptic Ulcer Disease
SITUATION: a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
42. Which result of the lab test will be significant to the diagnosis?
a. RBC : 4.5 TO 5 Million / cu. mm.
b. Hgb : 13 to 14 gm/dl.
c. Platelets : 250,000 to 500,000 cu.mm.
d. WBC : 12,000 to 13,000/cu.mm
d. WBC : 12,000 to 13,000/cu.mm
- Stat appendectomy was indicated. Pre op care would include all of the following except?
a. Consent signed by the father
b. Enema STAT
c. Skin prep of the area including the pubis
d. Remove the jewelries
b. Enema STAT
- Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :
a. Allay anxiety and apprehension
b. Reduce pain
c. Prevent vomiting
d. Relax abdominal muscle
a. Allay anxiety and apprehension
- Post op care for appendectomy include the following except
a. Early ambulation
b. Diet as tolerated after fully conscious
c. Nasogastric tube connect to suction
d. Deep breathing and leg exercise
b. Diet as tolerated after fully conscious
- Common anesthesia for appendectomy is
a. Spinal
b. General
c. Caudal
d. Hypnosis
a. Spinal
- Peritonitis may occur in ruptured appendix and may cause serious problems which are
- Hypovolemia, electrolyte imbalance
- Elevated temperature, weakness and diaphoresis
- Nausea and vomiting, rigidity of the abdominal wall
- Pallor and eventually shock
a. 1 and 2 B. 2 and 3 C. 1,2,3
d. All of the above
d. All of the above
- If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?
a. Intussusception
b. Paralytic Ileus
c. Hemorrhage
d. Ruptured colon
b. Paralytic Ileus
- NGT was connected to suction. In caring for the patient with NGT, the nurse must
a. Irrigate the tube with saline as ordered
b. Use sterile technique in irrigating the tube
c. advance the tube every hour to avoid kinks
d. Offer some ice chips to wet lips
a. Irrigate the tube with saline as ordered
- When do you think the NGT tube be removed?
a. When patient requests for it
b. Abdomen is soft and patient asks for water
c. Abdomen is soft and flatus has been expelled
d. B and C only
c. Abdomen is soft and flatus has been expelled
