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RN 2023 cutie > PREBOARDS 2_NP 3 > Flashcards

PREBOARDS 2_NP 3 Flashcards

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1
Q

Situation
Nurse Eve is assigned in the morning shift of the Post-Anesthesia Care Unit (PACU) and has a patient for admission.
1. After abdominal surgery, Nurse Eve’s initial priority assessment should focus on?
*
1 punto
A. surgical site for drainage and hemorrhage
B. skin color and temperature
C. responsiveness to painful stimuli and noise
D. respiratory function and airway

A

D. respiratory function and airway

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2
Q
  1. A patient is drowsy and still under the effect of anesthesia post-operatively, in what position should Nurse Eve place the patient?
    *
    1 punto
    A Supine position with head bed slightly elevated.
    B. Prone position with a pillow under the abdomen
    C. Semi-Fowler’s position with the head turned to the right.
    D. Left lateral position with a pillow supporting the head.’
A

C. Semi-Fowler’s position with the head turned to the right. = it can relieve post op wound pain, reduce severe coughing and bucking after extubation

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3
Q
  1. A patient is reported to have bleeding from an arterial source post-operatively, what color of blood should Nurse Eve expect?
    *
    1 punto
    A. Darkly -colored, blood flows fast.
    B. Bright red and spurts with the heartbeat.
    C. Slow, dark-colored, generally ooze.
    D. Pinkish colored- slowly flowing.
A

B. Bright red and spurts with the heartbeat.

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4
Q
  1. The PRIMARY goal of the health care team is to maintain ventilation after surgery. Hypoxemia is the result of?
    *
    1 punto
    A. Excess carbon dioxide in the blood.
    B. Increasing ammonia in the blood.
    C. Decreased oxygen saturation
    D. Reduction of blood PH.
A

C. Decreased oxygen saturation

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5
Q
  1. A patient is undergoing blood transfusion after an abdominal surgery and develops a temperature of 39.5C. Nurse Eve should immediately refer the situation to the physician as this may indicate ____.
    *
    1 punto
    A. abdominal tissue injury
    B. ongoing potential infection
    C. post-anesthesia drug reaction
    D. allergic reaction from blood transfusion
A

D. allergic reaction from blood transfusion

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6
Q

Situation
Nurse Ricky, a nurse researcher, is studying one of the research priority problems in the cardiovascular unit which is the Effects of Personalized Care Management Strategies on Stress after an acute myocardial infarction (MI).
6. Nurse Ricky is planning to use a framework which states that humans are in constant relationship with stressors in the environment. In this framework, nursing is viewed as interventions focused on helping the patient adjust to the environment/stress. This framework is in which of the following?
*
1 punto
A. Parse’ Human becoming theory
B. Neuman’s adaptation model
C. Peplau’s psychodynamic theory
D. Swanson’s theory of caring

A

B. Neuman’s adaptation model

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7
Q
  1. The research team decided to get their sample by choosing every 5th patient who recently had MI, what sample method is used?
    *
    1 punto
    A. Simple random
    B. Systematic
    C. Stratified
    D. Cluster
A

B. Systematic

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8
Q
  1. The questionnaires were given to the respondents of the study without their names on it. Nurse Ricky is employing which ethical safeguard?
    *
    1 punto
    A. Confidentiality
    B. Truthfulness
    C. Trustworthiness
    D. Anonymity
A

D. Anonymity

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9
Q
  1. Nurse Ricky learned that the findings of their study is applicable to all patients with MI under stress. What criteria of research does it meet?
    *
    1 punto
    A. Reliability
    B. Validity
    C. Generalizability
    D. Transferability
A

C. Generalizability

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10
Q
  1. Nurse Ricky made a short but concise summary of their whole research paper. This is known as the ____.
    *
    1 punto
    A. narrative
    B. abstract
    C. critical appraisal
    D. monograph
A

B. abstract

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11
Q

Situation
One of the basic skills that should be acquired by nurses is therapeutic communication. As nurses, we use this to establish rapport and build a trusting/helping relationship with clients.2`12
11. A 62-year old patient who has been in the hospital for a week came up to the nurse and said “I wish that my children will visit me today”. As a competent nurse, what would be your response?
*
1 punto
A. “do you have their cell phones, If you want I can call them”
B. “just relax, I am sure they will come and visit you today”
C. “you sound to be lonely, do you want me to be with you for a while”.
D. there is so much traffic anyway it is not yet time for visiting hours”

A

C. “you sound to be lonely, do you want me to be with you for a while”.

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12
Q
  1. Nurse Lily has a patient who was just admitted for abdominal pain. While the nurse is doing her assessment the patient tells “I am afraid to undergo the physical examination”. Nurse Lily’s response is the most appropriate when she tells the patient which of the following statement?
    *
    1 punto
    A. “ I will inform the physician that you are afraid to undergo the physical examination”
    B. “there are several patients waiting for me, the examination has to be done now”
    C. “ I will call your relative to be with you, while you are being examined”
    D. “the examination will not hurt, would you like to sit down first and rest”
A

D. “the examination will not hurt, would you like to sit down first and rest”

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13
Q
  1. What is the nurse’s best response when a student with bronchial asthma, who has been going back and forth to the hospital, asks her, “Do you think I should stop attending my classes?” ?
    *
    1 punto
    A. “Well to me, that is a good decision for now, especially with your asthma.
    B. “You said, you are thinking of stopping from attending your classes?”
    C. “Let us consult your physician, which one im better for you”
    D. “Do you feel that is a good decision for you and your parents”
A

B. “You said, you are thinking of stopping from attending your classes? = Restating

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14
Q
  1. The nurse notices that the elderly patient who has been admitted a week ago looks depressed. While the nurse is taking the patient’s blood pressure, the patient suddenly says “Go away, leave me alone, I don’t want to talk to you anymore”. The nurse’s most therapeutic response is __.
    *
    1 punto
    A. “don’t say that, otherwise I will not come and see you anymore”
    B. “I will be back in an hour, by that time, you might want to talk to me”
    C. “If you need me, just inform your watcher for some help.”
    D. “don’t say that, I will just attend to the other patients in the ward”
A

B. “I will be back in an hour, by that time, you might want to talk to me”

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15
Q
  1. A patient who is receiving his insulin injection tells the nurse, “I don’t want to have that insulin injection anymore.” The most appropriate response of the nurse is _____.
    *
    1 punto
    A. you need the insulin injection, otherwise your diabetes will not be controlled.
    B. just have your insulin injection now, I will refer you later to your attending physician.”
    C. your physician will get mad, if you will not have your insulin injection.
    D. let us sit down, I will explain to you, why you have to receive the insulin injection.”
A

D. let us sit down, I will explain to you, why you have to receive the insulin injection.” = offer self/ giving info

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16
Q

Situation
Diane, a 54-year-old accountant, is admitted to the General Ward. According to their family physician, she is suspected to have Crohn’s disease.
16. Which of the following manifestations are expected of Crohn’s disease?
I. left lower quadrant abdominal pain
II. diarrhea, unrelieved by defecation
III. abdominal tenderness and spasm
IV. increase in weight
V. excessive fat in the feces
*
1 punto
A. II & III
B. II, III & IV
C. II, III & V
D. I & II

A

A. II & III

C. II, III & V

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17
Q
  1. In order to confirm the diagnosis, the nurse knows that the examination conclusive of the presence of Crohn’s disease is which of the following?
    *
    1 punto
    A. Upper GI series
    B. Proctosigmoidoscopy
    C. Barium enema
    D. Abdominal radiography
A

B. Proctosigmoidoscopy

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18
Q
  1. One day, while at the hospital, Diane is experiencing fever, loose bowel movement with foul smelling odor with abdominal pain. Considering these manifestations, the nurse should expect what specific condition?
    *
    1 punto
    A. Hypercalcemia
    B. Thrombocytopenia
    C. Hyperbulemia
    D. Hypokalemia
A

D. Hypokalemia

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19
Q
  1. Diane is going to undergo total parenteral nutrition (TPN) to help with her body’s hydration and nutrition. The nurse should implement which of the following measures to achieve positive patient outcomes?
    I. Weighing the patient daily
    II. Measure intake and output
    III. Provide relief of pain & discomforts
    IV. Monitor IV infusion rate daily
    *
    1 punto
    A. I, II and III
    B. I, II and IV
    C. I, II, III, & IV
    D. II and III
A

A. I, II and III

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20
Q
  1. Considering the level of education of the patient, the nurse must include the following in her health teaching for home parenteral nutrition, EXCEPT?
    *
    1 punto
    A. Use of aseptic technique in changing the dressing.
    B. How to store and preparing the solution properly.
    C. Setting up of the infusion pump safely.
    D. Flushing the parenteral nutrition line with antibiotics.
A

D. Flushing the parenteral nutrition line with antibiotics.

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21
Q

Situation
Newly hired nurses in Pangasinan General Hospital are being oriented with the legal responsibilities and accountabilities in their workplace.
21. Nurse Kyla, an ER nurse, is very busy in the morning which resulted to the administration of a penicillin injection to the wrong patient. Keeping the error of nurse Kyla in mind, she can be charged of ___.
*
1 punto
A. malpractice
B. negligence
C. assault
D. battery

A

A. malpractice

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22
Q
  1. In order for nurses to perform a doctor’s order, nurses will need to transcript the order. All of the following are considered transcription errors, EXCEPT?
    *
    1 punto
    A. Illegible handwriting of the physician
    B. Misinterpretation of the directions ordered
    C. Use of unapproved abbreviation in the chart.
    D. Wrong route of medication administration.
A

D. Wrong route of medication administration.

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23
Q
  1. According to the 7 Rights of Drug Administration under the category of “Right Drug”, The label of the drug should be read_______.

I. three (3) times.
II. before removing from the shelf.
III, before measuring actual dose
IV. before opening a unit dose-container
*
1 punto
A. II and III
B. I and II
C. I, II and III
D. I, II, III and IV

A

D. I, II, III and IV

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24
Q
  1. The nurse is handling a restless patient admitted to the medical ward and decided to put the patient into a body restraint without the doctor’s order. Which of the following torts could the nurse be liable for?
    *
    1 punto
    A. invasion of privacy
    B. assault
    C. battery
    D. neglect
A

C. battery

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25
Q
  1. Due to a Jeepney strike, a lot of the nurses during the night shift was absent. The nurse supervisor decides to allocate most nurses to the PRIORITY wards to address this concern. What type of ethical principle is the nurse supervisor using?
    *
    1 punto
    A. Beneficence
    B. Non-maleficence
    C. Justice
    D. Fidelity
A

C. Justice

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26
Q

Situation
Ricky, a 50-year-old patient is having episode of Bronchial asthma and was examined in the ER by the physician and ordered to be admitted.
26. The watcher of Ricky observes that he is having difficulty breathing. The watcher immediately called Nurse Berna. Upon auscultation, Ricky’s breath sounds are diminished. The first nursing action she should implement is?
*
1 punto
A. Position him on bed in semi-fowler’s position.
B. Administer oxygen therapy as order.
C. Instruct patient to nebulize self if available.
D. Administer bronchodilator as ordered.

A

A. Position him on bed in semi-fowler’s position.

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27
Q
  1. Nurse Berna interviews Ricky for a comprehensive health history. The nurse discovers that he worked in a cement factory. Which occupational hazard can bring about an asthmatic trigger to Ricky?
    *
    1 punto
    A. contactant
    B. inhalant
    C. infiltrant
    D. ingestant
A

B. inhalant

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28
Q
  1. Theophylline was administered to the patient in order to relieve the patient’s asthmatic attack. Among the following mechanisms of action of the drug (Theophylline), which is INCORRECT?
    *
    1 punto
    A. Regulating the immune system of the body
    B. Relaxing the smooth tissue of the bronchial airways.
    C. reducing inflammation of the airways of the lungs
    D. relaxing the skeletal muscle of the bronchial airways.
A

A. Regulating the immune system of the body

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29
Q

Situation
Rica, a 66-year -old patient was admitted to the medical ward due to chronic back pain, general weakness and difficulty of breathing. One day, Nurse Susan observed the patient being anxious and restless. He was tentatively diagnosed with impending respiratory insufficiency secondary to hypoxia.
30. The patient is about to be discharged with bronchodilator drugs. The nurse informs him that the bronchodilator drug is considered effective if it lessens what symptom?
*
1 punto
A. allergic reaction
B. breath sounds
C. body temperature
D. wheezing

A

D. Wheezing

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30
Q
  1. The nurse should observe the patient taking Theophylline by mouth for what adverse effect of the drug?
    *
    1 punto
    A. dry mucosal membrane
    B. inability to sleep
    C. irregular heartbeat
    D. increased blood pressure
A

C. irregular heartbeat

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31
Q
  1. Nurse Susan is trying to correctly record restlessness caused by pain and that of hypoxia. Nurse Susan knows that restlessness caused by pain should be accurately recorded as _________?
    *
    1 punto
    A. Difficulty of breathing.
    B. Increased respiratory rate and blood pressure.
    C. Increased heart rate
    D. Increased perspiration and change of position.
A

D. Increased perspiration and change of position.
Pain causes restlessness and can be manifested by increased sweating and frequent change position

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32
Q

32.Nurse Susan documented: “Refused to eat and fell from bed” in the nurse’s notes. The statement is incomplete because it lacks which of the following?
*
1 punto
A. Time of complaint, foods missed and reaction on fall incurred.
B. Referrals made on fall, medications given and reasons of falling.
C. Contents of complaints, reasons of refusing meal and nature of fall.
D. Time of eating, medications for back pain and intense of pain.

A

C. Contents of complaints, reasons of refusing meal and nature of fall.

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33
Q
  1. The patient’s chart is sometimes used in court proceedings. Which of the following entries recorded would be MOST justifiable in court?
    *
    1 punto
    A. Large bruises on thigh upon assessment.
    B. Patient fell out of bed when reaching out for medication.
    C. Burn on the back area observed upon auscultation.
    D. Patient drunk when seen in the emergency room.
A

A. Large bruises on thigh upon assessment.

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34
Q
  1. Which of the following charting rules are considered to make documentation legally safe? Select all that apply.
    I. Documenting worries and all concerns as verbalized by the patient.
    II. Charting at the end of the shift only.
    III. Discussing recorded cases and diagnosis of the patient.
    IV. Recording all information verbalized by patient and family
    *
    1 punto
    A. III, IV
    B. I, III
    C. I
    D. II
A

A. III, IV

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35
Q
  1. Patient Rica was reading his own chart and she asks the nurse why “(-) smoking and (-) liquor” were recorded when she does not smoke or drink alcohol. The nurse knows that the MOST accurate response is?
    *
    1 punto
    A. Get the chart from him and reprimand him from reading the chart
    B. The sign of negative before the word means he is not drinking alcohol or smoking cigarette.
    C. Ask patient Miko to apologize for reading the chart.
    D. Tell Noel that alcohol and liquor are important factors in diagnosing his ailment
A

B. The sign of negative before the word means he is not drinking alcohol or smoking cigarette.

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36
Q

Situation
Ethical dilemma is becoming a common scenario in the health care delivery system brought about by the advanced technological changes in health care.
36. A competent nurse knows that which of the following situations is considered to be an ethical dilemma?
*
1 punto
A. A nurse providing demonstration of the possible risk if a chest tube drainage of a patient is pulled out.
B. Family members having ambivalent feelings whether their father will undergo amputation of a diabetic leg.
C. A nurse is overheard by the daughter that if her mother will not take her insulin injection she will not serve her food tray.
D. The physician signs the medical directives of terminally-ill patient admitted in the hospital with his spouse.

A

C. A nurse is overheard by the daughter that if her mother will not take her insulin injection she will not serve her food tray.

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37
Q
  1. The physician suggested that a pacemaker be inserted to correct the symptoms of a 78-year-old patient with bradycardia and palpitation, but the patient voluntarily decided not to have it inserted. The family respects the decision of the patient. Which ethical principle is being applied?
    *
    1 punto
    A. Beneficence
    B. Autonomy
    C. Fidelity
    D. Justice
A

B. Autonomy

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38
Q
  1. A physician ordered pain medication for a pediatric patient. The nurse clarifies the prescription of the physician. The ethical principle being observed by the nurse is _______?
    *
    1 punto
    A. Fidelity
    B. Truthfulness
    C. Justice
    D. Non-maleficence
A

D. Non-maleficence

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39
Q
  1. Which ethical principle is being used when a nurse promises a post- surgical patient that he would come back to assist in the patient’s ambulation after carrying out a physician’s order?
    *
    1 punto
    A. Beneficence
    B. Justice
    C. Autonomy
    D. Fidelity
A

D. Fidelity

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40
Q
  1. Which ethical principle is being observed by a nurse who aids for the patient’s welfare in relation to health, safety and personal rights?
    *
    1 punto
    A. Responsibility
    B. Accountability
    C. Confidentiality
    D. Advocacy
A

D. Advocacy

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41
Q

Situation
In the Philippines, endocrine disorders are of high prevalence. Cynthia is a 48-year-old patient who was diagnosed with Graves’ disease. Based on her health history she has been having insomnia, palpitation and heat intolerance.
41. Which of the following manifestations is a classic finding expected of Cynthia’s diagnosis?
*
1 punto
A. Decreased libido
B. Exophthalmos
C. Infertility
D. Hoarseness of the voice

A

B. Exophthalmos

42
Q
  1. Which of the following laboratory findings will confirm Cynthia’s diagnosis?
    I. Decreased TSH levels
    II. Elevated free thyroxin levels
    III. Increased TSH levels
    IV. Decreased free thyroxin levels
    *
    1 punto
    A. II and IV
    B. III and IV
    C. I and II
    D. II and III
A

C. I and II

43
Q
  1. One of the managements for Graves’ disease is through medication. In order to inhibit the synthesis of thyroid hormones and block the conversion of T3 and T4, which of the following drugs should be given?
    *
    1 punto
    A. adrenergic blockers (Inderal)
    B. radioactive iodine (RAI)
    C. sevothyroxine (Synthroid)
    D. propyl thiouracil (Propyl Thyracil)
A

D. propyl thiouracil (Propyl Thyracil)

44
Q
  1. The nurse is teaching Cynthia about hyperthyroidism and her nutritional needs that require attention. The nurse knows that the diet MOST appropriate for Cynthia is?
    *
    1 punto
    A. high fibrous, low protein, high CHO
    B. high caloric, high CHO and high protein
    C. high caloric, high CHO and low protein
    D. high protein, low Vitamin A and C
A

B. high caloric, high CHO and high protein

45
Q
  1. Numbness of the fingers, toes and twitching of the mouth is felt by Cynthia 7 hours after her thyroid is removed. This manifestations are MOST probably caused by?
    *
    1 punto
    A. thyrotoxic crisis
    B. hypoparathyroidism
    C. hypo thyroidism
    D. infection
A

B. hypoparathyroidism

46
Q

Situation
Ely was rushed in the emergency room appearing with jaundice, dyspnea and an enlarged abdomen. The physician suspects that he has a liver disorder and beginning esophageal varices. Based on history acquired, Ely was a smoker and alcoholic.
46. All of the following signs/symptoms indicates a hepatic disorder, EXCEPT?
*
1 punto
A. Indigestion
B. Diarrhea
C. Nausea and vomiting
D. Abdominal bloating

A

A. Indigestion

47
Q
  1. The physician ordered a liver function test for Ely. Which of the following is/are the expected results for a patient with damaged liver?
    I. Prothrombin time is prolonged.
    II. Albumin level is increased.
    III. Globulin level is decreased.
    IV. Ammonia level is decreased.
    1 punto
    A. I and II
    B. I, II and III
    C. I only
    D. I, II, II and IV
A

C. I only

48
Q
  1. Ely has developed esophageal varices and it began bleeding, the doctor immediately ordered Sengstaken-Blakemore tube to stop bleeding. After a few hours, the patient is observed to have difficulty breathing. What is the priority action of the nurse?
    *
    1 punto
    A. Monitor vital signs
    B. Asked client to take a deep breath
    C. Deflate the esophageal balloon
    D. Call the physician at once
A

C. Deflate the esophageal balloon

49
Q
  1. A competent nurse knows which intervention to anticipate when a patient develops esophageal varices?
    *
    1 punto
    A. Monitoring progression of anxiety
    B. Observing signs of epistaxis
    C. Monitoring urine output
    D. Preparing client for blood transfusion
A

B. Observing signs of epistaxis

50
Q
  1. The nurse anticipates which of the following drugs to be ordered by the physician to help stop the bleeding caused by esophageal varices?
    *
    1 punto
    A. Neperidine
    B. Furosemide
    C. Aldactone
    D. Vasopressin
A

D. Vasopressin

51
Q
  1. Patient Bennett’s basilar fracture would present with what is known as Battle’s sign. Nurse Barbara would be correct if she notes this as?
    *
    1 punto
    A. Blood leaks from the patient’s nose
    B. Bruising in the periorbital region
    C. Swelling in the periorbital region
    D. The area behind the ear is bruised
A

D. The area behind the ear is bruised - seen in patients with traumatic brain injury

52
Q
  1. Fischl, patient Bennett’s guardian, asks nurse Barbara about the purpose of inserting a nasogastric tube. Nurse Barbara would be correct if she states that the primary purpose of a nasogastric tube is?
    *
    1 punto
    A. Administration of medication
    B. Decompression of the stomach
    C. Collection of gastric specimen for further testing
    D. Administration of nutritional requirements
A

B. Decompression of the stomach - decrease ICP

53
Q
  1. Which of the following actions is the most appropriate for Nurse Barbara to perform for the patient?
    *
    1 punto
    A. Place the patient in semi-Fowler’s position with a pillow for head support
    B. Assess the patency of the patient’s airway before inserting the nasogastric tube
    C. Check the gastric aspirate for blood
    D. Advance the tube with its natural curve upward the nostril of the patient
A

B. Assess the patency of the patient’s airway before inserting the nasogastric tube

NGT insertion: High Fowler’s
NGT feeding: Semi Fowler’s

NEX: Tip of the nose, earlobe, xiphoid process

54
Q
  1. Nurse Barbara further establishes her knowledge regarding NGT insertion when she considers which of the following actions as most appropriate?
    *
    1 punto
    A. Ask the physician for the use of an oral gastric tube instead
    B. Advance the NGT to reach the duodenum
    C. Check the gastric aspirate for blood
    D. Ensure extra lubrication upon the insertion of the nasogastric tube
A

A. Ask the physician for the use of an oral gastric tube instead

Pt has basilar skull fracture > risk of introducing the tube to the cranial cavity, ngt is not indicated for them.

55
Q
  1. As nurse Barbara carefully proceeds with each step of NGT insertion, she knows that which of the following actions is not a part of the procedure? Select all that apply.
    I. Identify the patient through his name and birthday
    II. Measure the tube length to be inserted and mark the location
    III. Elevate the patient’s head to 45 degrees
    IV. Instruct the patient to breathe and swallow throughout the procedure
    V. Assess the amount of gastric residual during tube feeding
    *
    1 punto
    A. II, III, V
    B. II, IV
    C. III, V
    D. III only
A

C. III, V

56
Q
  1. In what position should nurse Barbara place the patient upon insertion of the NGT?
    *
    1 punto
    A. Low-Fowler’s
    B. Semi-Fowler’s
    C. Fowler’s
    D. High-Fowler’s
A

D. High-Fowler’s

57
Q
  1. Resistance is met as the nasogastric tube is being inserted into the patient. Which of the following actions would be most appropriate for the nurse to do?
    *
    1 punto
    A. Pull the tube slightly then carefully advance the tube forward
    B. Advance the tube more slowly and as much as the client can tolerate
    C. Withdraw, relubricate, and reinsert the NGT in another nostril
    D. Withdraw the tube and repeat insertion when no resistance is met
A

C. Withdraw, relubricate, and reinsert the NGT in another nostril

58
Q
  1. The patient coughs and presents difficulty of breathing as the nasogastric tube is being inserted. Which of the following is the best nursing action?
    *
    1 punto
    A. Withdraw the tube completely and reinserting it when difficulty of breathing has subsided
    B. Advance the tube more slowly and as much as the client can tolerate since this is normal
    C. Stop advancing the tube for a few seconds then continue as tolerated
    D. Pull the tube slightly then carefully advance forward
A

A. Withdraw the tube completely and reinserting it when difficulty of breathing has subsided

59
Q
  1. Nurse Barbara knows that she can confirm a correct placement of a nasogastric tube by checking the gastric aspirate of its pH. What pH value should nurse Barbara obtain?
    *
    1 punto
    A. pH 6.7
    B. pH 5.7
    C. pH 8.7
    D. pH 7.7
A

B. pH 5.7

Acidic: 1-6

60
Q
  1. Before removing a nasogastric tube, which of the following actions would be the priority?
    *
    1 punto
    A. Push 50mL of air into the tube
    B. Slowly and carefully withdraw the tube
    C. Ask the client to take a deep breath and hold it
    D. Disconnect the nasogastric tube from the suction apparatus
A

C. Ask the client to take a deep breath and hold it

61
Q

Situation
Nurse Jean comes into a patient’s room where she finds the latter lying on the floor next to the bed. Nurse Jean brought the client back to bed, assessed for any injuries, and notified the physician.
61. Nurse Jean who found the client lying on the floor knows that she should:
*
1 punto
A. Be suspended due to the incident
B. Report the incident to the nursing board
C. Record the incident in her employee file
D. Write an incident report

A

D. Write an incident report

Sentinel events

62
Q
  1. Nurse Jean knows that which of the following is the primary purpose of submitting an incident report?
    *
    1 punto
    A. Provide clients the treatment they need to stabilize their condition
    B. Measure the effectiveness of interventions relating to outcomes
    C. Immediate documentation of the incident
    D. It is the correct method of reporting to local, regional, and national units
A

C. Immediate documentation of the incident

Only Factual events should be recorded

63
Q
  1. Which of the following is an important principle when filing an incident report?
    *
    1 punto
    A. It is not included in the patient’s chart
    B. Record in the client’s chart that an incident report was accomplished
    C. Create a copy of the incident report for the healthcare provider
    D. Place the incident report with the client’s medical chart
A

A. It is not included in the patient’s chart - it’s just a way to minimize further risks for fall

64
Q
  1. The following are not appropriate for nurse Jean to include in the incident report except?
    *
    1 punto
    A. A suspicion of what might have caused the incident
    B. How the nurse saw the client and what she did for the client
    C. The statement of the client about the incident
    D. The extenuating circumstances involved in the situation.
A

B. How the nurse saw the client and what she did for the client

65
Q
  1. All of the following are to be included in the incident report except?
    *
    1 punto
    A. All witnesses to the incident
    B. The time, date, and place of incident
    C. The client’s own account of the incident
    D. Daily medications of the client
A

D. Daily medications of the client

66
Q
  1. The incident report must be completed within what time frame?
    *
    1 punto
    A. 24 hours
    B. 72 hours
    C. 1 week
    D. 2 weeks
A

A. 24 hours

67
Q
  1. What should Nurse Jean do next when she has accomplished the incident report?
    *
    1 punto
    A. Secure the incident report with the client’s chart
    B. Inform the family about the incident
    C. Avoid mentioning the incident in the chart documentation
    D. Submit the incident report to the head nurse
A

D. Submit the incident report to the head nurse

68
Q
  1. Head nurse Lisa receives the incident report from nurse Jean. Where should head nurse Lisa to store the incident report?
    *
    1 punto
    A. Physician’s record
    B. Secured cabinet
    C. Nurse’s notes
    D. Patient’s medical record
A

B. Secured cabinet - to secure the documentation of the sentinel event

69
Q
  1. What will prove that Nurse Jean’s interventions have been carried out?
    *
    1 punto
    A. Determining the nurse’s need for assistance
    B. Supervision over delegated or assigned care
    C. Implementation of the nursing interventions
    D. Documentation of the procedures
A

D. Documentation of the procedures

70
Q
  1. When obtaining factual information, which of the following will be the best source for the healthcare team?
    *
    1 punto
    A. The patient’s chart
    B. The nurse’s notes
    C. The physician’s records
    D. The nurse’s incident report
A

D. The nurse’s incident report

71
Q
  1. The following chart recordings violate the legal guidelines of proper documentation except?
    *
    1 punto
    A. Patient had a good day and moved around the room
    B. Patient’s condition unchanged
    C. The attending physician made an error
    D. Dr. Kaeya was called to clarify the order for antibiotics
A

D. Dr. Kaeya was called to clarify the order for antibiotics

72
Q
  1. A nurse makes an error while doing her documentation. Which of the following should the nurse not do?
    *
    1 punto
    A. Obtain a new nurse’s notes and rewrite the entries
    B. Write the word “error” above the error
    C. Draw a single line through the error
    D. Sign your name or initials and date of the error
A

A. Obtain a new nurse’s notes and rewrite the entries
B. Write the word “error” above the error

73
Q
  1. As the nurse reviews the progress notes, she notices that there is an unintentionally left blank space. The nurse should do the following except?
    *
    1 punto
    A. Place a signature at the end
    B. Draw a horizontal line through the space
    C. Input the nurse’s credentials in the last part
    D. Allow the space to be filled in later
A

D. Allow the space to be filled in later - there should be no space

74
Q
  1. A charting method consisting of written notes stating the routine care, findings and problems found in a client is known as narrative charting and is a traditional part of which documentation system?
    *
    1 punto
    A. PIE charting that includes progress notes and flow sheets
    B. Focus charting that utilizes the FDAR
    C. Source-oriented record where information about a particular problem is distributed throughout the record
    D. Problem-oriented record that consists of a list of problems, a care plan, progress notes, and a database
A

C. Source-oriented record where information about a particular problem is distributed throughout the record

D is for FDAR

75
Q
  1. A documentation system that documents only abnormal or significant findings related to the patient is known as Charting By Exception (CBE). It has three main elements which include the following except?
    *
    1 punto
    A. Standards of nursing care
    B. Nurse’s station access to chart forms
    C. Bedside access to chart forms
    D. Flow sheets
A

B. Nurse’s station access to chart forms - at bedside to make it part of CBE

76
Q

Situation
Student Nurse Eula is dedicating all of her time into studying in the library for the Philippine Nursing Licensure Examination. Her study buddy, Amber, asks Eula a few questions related to Maternal and Child nursing as this Amber’s weakest nursing subject. The following are the questions Amber asked to Eula:
76. What is the site of fertilization or conception?
*
1 punto
A. Ampulla
B. Uterus
C. Cervix
D. Isthmus

A

A. Ampulla in fallopian tube

77
Q
  1. What is the site of implantation?
    *
    1 punto
    A. Ampulla
    B. Uterus
    C. Cervix
    D. Isthmus
A

B. Uterus

78
Q
  1. Amber can’t remember what to call the lowest point of the pelvis and the site that is being assess during a culdoscopy. Eula is correct if she calls this the:
    *
    1 punto
    A. Cervix
    B. Isthmus
    C. Pouch of Douglas
    D. Ampulla
A

C. Pouch of Douglas (fold of peritoneum behind the uterus)

culdoscopy - examines the space for the presence of blood. Blood can indicate ectopic pregnancy

79
Q
  1. What is the site of tubal ligation or female sterilization?
    *
    1 punto
    A. Ampulla
    B. Pouch of Douglas
    C. Cervix
    D. Isthmus
A

D. Isthmus

80
Q
  1. What is the site for Pap Smears and Spinnbarkeit sampling?
    *
    1 punto
    A. Ampulla
    B. Pouch of Douglas
    C. Cervix
    D. Isthmus
A

C. Cervix

81
Q
  1. Nurse Sage palpates patient Jett’s edematous limbs and finds that upon palpation, a pit 6mm deep appears and disappears after a while. Nurse Sage knows that this pitting edema is under what grading?
    *
    1 punto
    A. 1+
    B. 2+
    C. 3+
    D. 4+
A

C. 3+

82
Q
  1. After an hour, nurse Sage conducts another assessment. She palpated the edematous limbs and found moderate indentation of the edema. Nurse Sage would interpret this is as what grading?
    *
    1 punto
    A. 1+
    B. 2+
    C. 3+
    D. 4+
A

B. 2+

83
Q
  1. Being a prudent nurse, nurse Sage knows that the cause and nature of edema is related to what mechanism?
    *
    1 punto
    A. There is an increase in kidney tubular reabsorption
    B. There is an increase in glomerular filtration rate
    C. There is a decrease in glomerular membrane permeability
    D. There will only be edema in the ankle
A

A. There is an increase in kidney tubular reabsorption > sodium retention > fluid retention (edema)

84
Q
  1. Client Jett’s ankle clonus has been observed to have 3 involuntary movements which would be interpreted as?
    *
    1 punto
    A. None
    B. Mild
    C. Moderate
    D. Severe
A

C. Moderate

Mild: 2
Mod: 3-5
Severe: over 6

Ankle clonus - to know if hypereflexia is present

85
Q
  1. Client Jett’s patellar reflex has been brisker than usual. Nurse Sage would be correct to grade this as?
    *
    1 punto
    A. 1+
    B. 2+
    C. 3+
    D. 4+
A

C. 3+

0 - no response, abnormal
1 - somewhat diminished but not abnormal
2 - average response
3+ - brisker than usual but not abnormal
4+ - hyperactive, very brisk, abnormal

Only 0 and 4+ are abnormal

86
Q

Situation
Student Nurse Sana has been reviewing Nursing Research in preparation for the NLE as this was the subject she almost failed in college. Today, she tries to differentiate deductive and inductive research.
86. Student Nurse Sana knows that the focus of inductive research is the following except?
*
1 punto
A. Interacting with the participants that results in findings
B. Knowing that reality is multiple and subjective
C. Building predictions for testing
D. Testing predictions that were already built

A

D. Testing predictions that were already built (Deductive)

Inductive - theory building > qualitative
Deductive - theory testing > quantitative

87
Q
  1. Student Nurse Sana also knows that the focus of deductive research is following except?
    *
    1 punto
    A. Building predictions for testing
    B. Being independent from the participants
    C. A real world exists that is driven by real natural causes
    D. Testing predictions that were already built
A

A. Building predictions for testing - inductive

88
Q

Situation
Patient Lyney comes into the clinic and states that he was diagnosed with a complicated UTI. Nurse Lynette assesses patient Lyney’s condition.
88. Patient Lyney asks about the difference between a complicated and an uncomplicated UTI. Nurse Lynette would be correct if she states that an uncomplicated UTI:
*
1 punto
A. Affects only the ureters
B. Is associated with an underlying disease
C. Occurs in a normal urinary tract
D. Occurs in a urinary tract with structural or functional problems

A

C. Occurs in a normal urinary tract

Complicated UTI: UTI secondary to AKI, CKD, DM
Uncomplicted UTI: infection that occurs in the ureters, bladder (normal urinary tract)

89
Q

Situation
During her rotation in the pediatric ward, nurse Ayaka is expected to be well-versed with the care and nutrition of pediatric clients.
90. On her first day, she cares for baby Kazuha who is 3-month-old infant. Nurse Ayaka is correct if she knows baby Kazuha can start eating solid foods at what month?
*
1 punto
A. 6 months
B. 7 months
C. 8 months
D. 9 months

A

A. 6 months

90
Q
  1. Among the following table foods, nurse Ayaka would be correct if she selects which food to introduce last?
    *
    1 punto
    A. Scrambled eggs
    B. Whole-grain bread
    C. Steamed vegetables
    D. Cereals
A

A. Scrambled eggs - has protein, risk for allergies

91
Q
  1. Nurse Lynette asks the patient about the medications he uses for his condition. She would be correct to expect which medication for complicated UTI?
    *
    1 punto
    A. Amoxicillin
    B. Ampicillin
    C. Ciprofloxacin
    D. Trimethoprim/Sulfamethoxazole
A

C. Ciprofloxacin

The rest of the medications are for uncomplicated UTI

92
Q
  1. Nurse Ayaka recalls that toddlers have a tendency to only want the same foods prepared in the same way for every meal of the day but forgot what it was called. Her colleague, nurse Ayato, states that this is:
    *
    1 punto
    A. Pica
    B. Picky eating
    C. Food selectiveness
    D. Food jag
A

D. Food jag - phenomena when the toddler wants the same food in every meal

93
Q

Situation
Patient Peppa, an obese adolescent with type 1 diabetes mellitus, goes to the clinic and is assessed by nurse George.
93. Nurse George asks patient Peppa what she does in the administration of her insulin. Nurse George should correct her if she states that she:
*
1 punto
A. Injects the prepared insulin 5-15 minutes after preparation
B. Does not aspirate after inserting the needle to herself
C. Administer some her of insulin intravenously
D. Shakes the bottle of insulin

A

D. Shakes the bottle of insulin - shaking can cause bubbles which can be hard to aspirate = inaccurate measurement of insulin

94
Q
  1. As a result of her high total triglyceride, cholesterol, and LDL levels, a low-fat diet was prescribed for patient Peppa which unfortunately proved ineffective. Her physician then prescribed a cholesterol-reducing agent. Nurse George knows that if this medication therapy proves ineffective as well, patient Peppa will then be prescribed with what drug?
    *
    1 punto
    A. Atorvastatin (Lipitor)
    B. Bempedoic acid (Nexletol)
    C. Cholestyramine (Questran)
    D. Icosapent ethyl (Vascepa)
A

A. Atorvastatin (Lipitor)

Taken at night because cholesterol spikes at night

95
Q

Situation
Future nurse Dahyun is currently reviewing maternal and child nursing and tries to recall the different placental functions to the fetus.
95. Future Nurse Dahyun knows that the placenta is responsible for the “respiration” of the developing fetus by transferring oxygen and carbon dioxide to their respective places. She would also be correct if she states that these gases readily cross the placenta by?
*
1 punto
A. Active transport
B. Pinocytosis
C. Simple diffusion
D. Passive diffusion

A

D. Passive diffusion

96
Q
  1. Future Nurse Dahyun also knows that maternal IgG antibodies can cross placentally despite the fact that most proteins are too large to do this. She is correct if she states that these antibodies provide passive immunity and pass through the placenta by:
    *
    1 punto
    A. Active transport
    B. Pinocytosis
    C. Simple diffusion
    D. Passive diffusion
A

B. Pinocytosis - breaks down antibody to get into the placenta

97
Q
  1. Nurse Rosaria knows that post-partum hemorrhage often leads to hypovolemia and would present with early signs and symptoms such as?
    *
    1 punto
    A. Dizziness and lethargy
    B. Rapid weak pulses and falling blood pressure
    C. Pale mucous membranes
    D. Decreasing level of consciousness
A

B. Rapid weak pulses and falling blood pressure

98
Q
  1. One of nurse Rosaria’s patient was worried and asked nurse Rosaria if she was at risk for post-partum hemorrhage. Nurse Rosaria would be correct if she does not include which of the following as a risk factor?
    *
    1 punto
    A. Anteverted uterus
    B. Retained tissue
    C. Uterine atony
    D. Trauma
A

A. Anteverted uterus - normal

4 T’s Risk for Bleeding
Tone - Uterine Atony (boggy uterus)
Tissue - Retained Placental fragments
Thrombin - DIC
Trauma

99
Q
  1. Another patient of nurse Rosaria is one day post-partum and is having her uterus palpated. Nurse Rosaria is correct if she knows that at this time, the uterus is normally be located at:
    *
    1 punto
    A. At the level of the umbilicus
    B. 1 cm below the umbilicus
    C. 1 inch below the umbilis
    D. Midway of the umbilicus and symphysis pubis
A

B. 1 cm below the umbilicus

100
Q
  1. As nurse Rosaria is making rounds, one of her patients talks to her about post-partum discharges the patient has been having. All of the following statements requires no correction except?

A. This lochia is quite annoying to manage, but I know why it occurs
B. I should alert the nurse when there are color changes in my lochia
C. I use tampons to makes it easier to manage my lochia just like my period
D. If I change perineal pads, I make sure to wash my hands before handling the baby

A

B. I should alert the nurse when there are color changes in my lochia
C. I use tampons to makes it easier to manage my lochia just like my period

RN 2023 cutie (11 decks)

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