Recalls 4 - NP4

Question 1

Situation 1

Nurse Alex cares for a terminally ill client with cancer

1. Nurse Yolan assesses the client for depression. Which of the following is a key indicator for clinical depression?

A. Anger due to pain experience
B. Feeling of excessive guilt
C. Anorexia and weight loss
D. Inability to care for one’s physical self

Answer 1

D. Inability to care for one’s physical self

Question 2

2. The client has difficulty sleeping. Which of the following interventions is LEAST helpful for Nurse Yolan to incorporate in her care plan?

A. Instruct the client to drink herbal tea.
B. Give warm milk at bedtime
C. Perform relaxation routine such as massage, imagery or music
D. Instruct the client to drink black tea

Answer 2

D. Instruct the client to drink black tea

Question 3

3. The care plan for the client includes family support. Which of the following is MOST appropriate for the family to establish a relationship with the health care team? Nurse Yolan should ___________:

A. Give permission to the family to take time to maintain friendship with the health care team.
B. Discuss the roles of the family members to the health care team.
C. Explain the roles of all members of the interdisciplinary team.
D. Provide a brief explanation to the family member about the care being delivered to the client.

Answer 3

C. Explain the roles of all members of the interdisciplinary team.

Question 4

4. The client appears to be dehydrated. The family members are discussing whether their loved one should be given intravenous fluid. Which of the following concepts about dehydration in terminally ill clients should guide Nurse Yolan?

A. Peripheral edema occurs because of fluid overload.
B. Thirst is an indication of dehydration.
C. Terminally ill clients are hydrated through oral and intravenous routes.
D. All interventions for terminally ill client should be directed towards comfort and reduction of symptoms.

Answer 4

D. All interventions for terminally ill client should be directed towards comfort and reduction of symptoms.

Question 5

5. The client show signs of imminent death. Nurse Yolan recognizes cardiovascular indicators of imminent death which are the following EXCEPT __________:

A. bradycardia
B. Irregular heart rate
C. tachycardia
D. lowered blood pressure

Answer 5

C. tachycardia

Question 6

Situation 2

A 65-year old male is admitted for prostate cancer. On assessment, the nurse
determines that the patient has experienced incontinence. The nurse knows that incontinence is the
first most common symptom of prostate cancer.

6. Based on information gathered, the nurse writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate?

A. Deficient knowledge related to self-care and risk prevention.
B. Fear secondary to the diagnosis of cancer.
C. Risk for urinary infection
D. Risk for impaired urinary elimination

Answer 6

D. Risk for impaired urinary elimination

Question 7

7. To help manage incontinence, the nurse instructs the patients to do which of the following:

A. Eat foods rich in fiber
B. Increase fluid intake.
C. Take in medications to manage pain.
D. Perform perineal muscle exercises

Answer 7

D. Perform perineal muscle exercises

Question 8

8. The patient asks for treatment option for his condition. The Nurse explains that treatment options are based on which of the following:

A. gender
B. ability of the patient to manage physical and emotional implications of incontinence
C. Socio-economic status
D. grade and stage of the disease

Answer 8

B. ability of the patient to manage physical and emotional implications of incontinence

Question 9

9. The patient asks the nurse what the physician meant about his prostate cancer as Stage C or T3. The nurse explains that the tumor is ______________:

A. palpable and has spread to other organs and often to distant sites such as bones and lymph nodes.
B. palpable and has spread beyond the prostate but not to other organs.
C. confined to the prostate and was not palpable during digital rectal examination.
D. confined to the prostate and was not palpable during digital rectal examination.

Answer 9

B. palpable and has spread beyond the prostate but not to other organs.

Question 10

10. The nurse recalls the staging and classification of prostate cancer. Which of the following statements is TRUE?

A. the gleason grading system is usually used for hematological cancers but not prostate cancer.
B. the normal prostate specific antigen (PSA) range under 40 years of age is less than 4 to 6 ng/mL.
C. at least two separate biopsy specimens are graded based on their differentiation from normal prostate cells.
D. A score of D is less invasive than a score of B in the cancer staging system.

Answer 10

B. the normal prostate specific antigen (PSA) range under 40 years of age is less than 4 to 6 ng/mL.

Question 11

Situation 3

You are newly promoted charge nurse of a department in a tertiary hospital. You review
management concepts to prepare you for the position. The following questions pertain to
management of resources.

11. You are oriented on health care economics. The study of economics focuses on how choices are made to overcome a scarcity of resources. Which of the following statements BEST illustrates health care economics __________:
12. Providing less health care services that is optimal in order to contain costs.
13. Using individuals with less knowledge and skill to perform health care services usually performed by people with advanced knowledge and training.
14. Taking economic risks as a health care provider.
15. Providing adequate or appropriate care minimize risk of expensive utilization.

A. 1 and 2
B. 3 and 4
C. 1 and 4
D. 2 and 3

Answer 11

B. 3 and 4

Question 12

12. Which of the following statement is TRUE regarding health care economics?

A. Contemporary health care is characterized as a business struggling to balance cost and quality.
B. Profit in health care is synonymous with billing privileges.
C. Health care economics is a new concept in nursing.
D. Health care is becoming affordable and clients are demanding quality care.

Answer 12

C. Health care economics is a new concept in nursing.

Question 13

13. You understand that a key factor that influence client care is the cost involved in the delivery of health services. Which of the following resources is NOT required to support the services delivered by nurses?

A. Time
B. Client’s environment
C. People
D. Equipment

Answer 13

B. Client’s environment

Question 14

14. You are aware that there is a need for you to understand how to manage the cost of client care as it relates to clinical practice. Which of the following are nurses accountable for?

A. Decision regarding cost effective practices.
B. The Client’s hospital charges
C. Distribution and consumption of resources such as time, supplies, drugs, staff and personnel.
D. Financial viability of nursing department.

Answer 14

C. Distribution and consumption of resources such as time, supplies, drugs, staff and personnel.

Question 15

15. While touring the department where you are assigned, you noticed that the supply room is stacked with medical supplies and equipment. Which of the following is the BEST action you will take?

A. Create a task force to assess the situation and report the findings.
B. Take an inventory of the supplies and equipment.
C. Request maintenance to sort out the supplies and check the medical equipment to determine if they are still functional.
D. Call for a staff meeting and discuss how best to utilize the available resources.

Answer 15

D. Call for a staff meeting and discuss how best to utilize the available resources.

Question 16

Situation 4

A 34 year old female client complains of experiencing double vision and frequent
headaches. The client claims to be forgetful and has mood swings. A diagnosis of right frontal lobe
lesion was made and the client was admitted for craniotomy.

16. The client claims to have a diagnostics work up in the outpatient unit before she was admitted. The admitting nurse prepares the client for which of the procedure that will MOST likely confirm the presence of brain tumor?

A. Myelogram
B. CT Scan
C. Lumbar puncture
D. Skull x-ray

Answer 16

B. CT Scan

Question 17

17. While the client is being interviewed, she had a seizure. The initial intervention of the nurse must be directed towards:

A. Protecting the client
B. Controlling the Seizure
C. Reducing circulation to the brain
D. Restraining the client

Answer 17

A. Protecting the client

Question 18

18. After surgery, it is important for the nurse to position the head of the client properly to:

A. Facilitate venous drainage
B. Prevent hemorrhage on the suture line.
C. Provide for client comfort
D. Maintain patent airway

Answer 18

A. Facilitate venous drainage

Question 19

19. The Nurse is aware that one of the measures listed below is contraindicated in post-operative pulmonary toilet.

A. Suctioning
B. Deep Breathing
C. Turning
D. Coughing

Answer 19

A. Suctioning

Question 20

20. The surgeon orders glucocorticoid Dexamethasone (Decadron) to be given following craniotomy. The nurse recognizes that this drug:

A. Creates a feeling of euphoria, which is beneficial in the early post-operative period.
B. Promotes excretion of water which aids in reducing ICP.
C. Enhances venous return and thus reduce ICP
D. Reduces cerebral edema thus reducing ICP.

Answer 20

D. Reduces cerebral edema thus reducing ICP.

Question 21

Situation 5

A Nurse in the intensive care unit attends to a 20 – year old female who was involved in
a vehicular accident three days prior to admission. The prognosis is very poor. No brain activity was
detected after two electro encephalograms (EEGs) were taken.

21. The family decides to wean the patient from the ventilator support. The family talks to the nurse about their decision to get the nurses’ support. Which of the following actions is NOT appropriate? The Nurse ___________

A. Checks the physician’s orders for sedation and analgesia and make sure that the anticipated death is comfortable and dignified.
B. Explains to the family what will happen each phase of the weaning and offer support.
C. Tells the family that death will occur almost immediately after the patient is removed from the ventilator support.
D. Participates in the decision-making process by offering the family information

Answer 21

C. Tells the family that death will occur almost immediately after the patient is removed from the ventilator support.

Question 22

22. Two hours after the ventilator support was discontinued, the patient dies. The nurse discusses with the family the possibility of donating the deceased person’s organs. The following are guidelines in organ or tissue donation.
23. Religious beliefs in organ donation and transplantation must be respected.
24. Donors must be free of infectious disease and cancer.
25. Consent or written orders by the physician are necessary for referral to an organ procurement organization.
26. The family of the deceased should be offered an opportunity to speak with a knowledge organ procurement coordinator.
27. The person requesting for organ donation does not have to believe in the benefits of organ donation but should support the process with a positive attitude.

Which of the guidelines should the nurse observe?

A. 1, 2, 3, 4, 5
B. 1, 2, 4
C. 2, 3, 4
D. 1, 3, 5

Answer 22

B. 1, 2, 4

Question 23

23. The legal definition of death that facilitate organ donation is the cessation of ________ :

A. Function of the entire brain
B. Pulse
C. Circulatory and respiratory functions
D. Respiration

Answer 23

C. Circulatory and respiratory functions

Question 24

25. The family goes through the stages of grieving. What are the stages in the grieving process?
26. Acceptance
27. Depression
28. Denial
29. Bargaining
30. Anger

A. 3, 5, 1, 4, 2
B. 3, 5, 4, 2, 1
C. 1, 5, 3, 4, 2
D. 1, 2, 5, 4, 3

Answer 24

B. 3, 5, 4, 2, 1

Question 24

24. The patient is pronounced dead by the physician. Which of the following nursing actions VIOLATES the standards of care for a dead person?

A. Removing soiled dressing and tubes.
B. Keeping the dead person in a sitting position until the family has arrived and said their goodbyes.
C. Placing identification tags on both the shroud and ankle.
D. Preparing to transfer the body to the morgue.

Answer 24

B. Keeping the dead person in a sitting position until the family has arrived and said their goodbyes.

Question 25

Situation 6

A male teenager was wheeled in the Emergency Department (ED) for injured.

26. The nurse assesses the patient for complications. Which are the MOST COMMON complications?
27. Urinary leakage
28. Delayed bleeding from damage
29. Abscess formation
30. Paralytic ileus
31. Renal failure

A. 4 & 5
B. 3 & 4
C. 1 & 2
D. 2 & 3

Answer 25

A. 4 & 5

Question 26

27. The nurses knows that with renal trauma, further complications may occur such as: .
28. Secondary hemorrhage usually due to infection
29. Renal artery stenosis
30. Renal atrophy
31. Hypotension
32. Hydronephrosis

Which are the POSSIBLE complications?

A. 2, 3, 4, 5
B. 1, 2, 3, 4, 5
C. 1, 2, 3, 5
D. 1, 3, 4, 5

Answer 26

C. 1, 2, 3, 5

Question 26

28. The nurse assesses the patient to determine the extent of injury. Which of the following signs is a CARDINAL sign of renal trauma?

A. Shock
B. Lumbar pain
C. Abdominal pain
D. Hematuria

Answer 26

D. Hematuria

Question 27

29. The nurse writes a nursing diagnosis for the patient with stab wound. The MOST appropriate nursing diagnosis is ____________.

A. Nutrition imbalance, less than body requirements, related to nausea from renal trauma
B. Deficient fluid volume related to blood in the urine
C. Acute pain in the abdominal area related to renal trauma
D. Acute pain in the lumbar area related to renal trauma

Answer 27

D. Acute pain in the lumbar area related to renal trauma

Question 28

30. The physician prescribes Magnetic Resonance Imaging (MRI) of both kidneys to confirm clinical suspicion and determine the severity of the injury. Which of the following activities is a PRIMARY nursing consideration in preparing the patient for MRI?

A. Administer all medications scheduled before the test.
B. Report findings of metal screening ; sedate the patient before sending him for MRI.
C. Coordinate the MRI with other patient care activities and inform the patient about the test.
D. Ensure the patient is on NPO and hold all medications until test is completed.

Answer 28

C. Coordinate the MRI with other patient care activities and inform the patient about the test.

Question 29

Situation 7

Nurse Ashley is a staff nurse in the oncology unit of a tertiary hospital. She reads
literature on antineoplastic medications.

31. Nurse Ashley understands the importance of continuing professional development. Which of the following is the MAIN purpose of continuing professional development? To ____________.

A. Update one’s professional knowledge and competence
B. Acquire a certificate of attendance to add to one’s curriculum vitae
C. Establish networking within the nursing profession
D. Fulfill requirements for an advanced degree in nursing

Answer 29

A. Update one’s professional knowledge and competence

Question 30

33. Nurse Ashley reads in the literature that a patient with breast cancer taking Cytoxan should observe the following. Given a case what should nurse Ashley instruct a patient to do?

A. Decrease sodium intake while on medication.
B. Take the medication with food.
C. Increase potassium intake while on medication.
D. Increase fluid intake 2000 to 3000 mL daily.

Answer 30

D. Increase fluid intake 2000 to 3000 mL daily.

Question 30

32. Nurse Ashley reads that the drug Cyclophosphamide ( Cytoxan ) is given to patients with breast cancer. Nurse Ashley understand that this drug is ______:

A. Cell cycle phase-non-specific
B. A hormonal medication
C. An antimetabolite
D. Cell cycle phase-specific

Answer 30

A. Cell cycle phase-non-specific

Question 31

34. Nurse Ashley understands that patients receiving antineoplastic medications should do which of the following?
35. Drinks beverages containing alcohol in moderate amounts.
36. Consult with the physician before receiving immunizations.
37. Be sure to receive flu and pneumonia immunizations.
38. Take aspirin (Acetylsalicylic Acid, ASA) as for headache.

A. 2 only
B. 3 & 4
C. All of the options
D. 1 & 2

Answer 31

A. 2 only

Question 32

35. An incident was described in the literature where a patient developed stomatitis after receiving a course od antineoplastic medications. Which of the following actions would be BEST for a nurse to do?

A. Swab the mouth daily with lemon and glycerine.
B. Avoid foods and fluids for the next 24 hours.
C. Brush the teeth and use waxed dental floss 3x a day.
D. Rinse the mouth with diluted baking soda or saline.

Answer 32

D. Rinse the mouth with diluted baking soda or saline.

Question 33

Situation 8

The head nurse of a trauma unit introduce changes to improve the quality of care
of trauma patients.

36. The head nurse presented a set of goals to the staff nurses. Which of the following goals is NOT relevant to improving quality of care? No_______:

A. Legal suits.
B. Needless deaths.
C. Waste of resources.
D. Needless pain or suffering.

Answer 33

A. Legal suits.

Question 34

37. The head nurse reviews reports on nurse staffing. The following findings result to better patient outcomes EXCEPT: A higher _______:

A. Nurse to patient ratio shortens lengths of patient stay in the hospital.
B. Nurse to patient ratio results to reduced patient mortality.
C. Number of nurses, infection rates fall.
D. Nurse to patient ratio increases costs.

Answer 34

D. Nurse to patient ratio increases costs.

Question 35

38. The head nurse determines to reduce medication errors in the trauma unit. She recognizes that medication errors often occur in relation to the following EXCEPT:

A. Preparing the wrong concentration and administering the medication via the correct route.
B. Failure to question unclear medication errors.
C. Lack of knowledge about medication.
D. Failure to identify non-therapeutic client responses.

Answer 35

D. Failure to identify non-therapeutic client responses.

Question 36

39. The head nurse suggests that to reduce medication errors, several measures will be instituted. Which of the following is MOST appropriate?

A. Use point-of-care technology to access drug reference information.
B. Use of drug index
C. Nurses must help educate patients and their families regarding proper medication
administration.
D. Patients must become more involved in managing their care.

Answer 36

A. Use point-of-care technology to access drug reference information.

Question 37

40. The head nurse is aware that managing and improving quality care in the trauma unit requires which of the following?

A. Personalized attention to patient’s needs and their families.
B. A blame – free environment.
C. All of the choices.
D. A clean and orderly trauma unit.

Answer 37

C. All of the choices.

Question 38

Situation 9

Nurse Mirasol is the attending nurse of a 40-year old female admitted in the medical unit
with a probable diagnosis of Scleroderma.

41. The patient complains of pain in her fingertips and pallor followed by blanching of the extremities and redness. Nurse Mirasol knows that these symptoms are characteristic of which of the following disorders?

A. Swan-neck deformity
B. Raynaud’s phenomenon
C. Joint swelling and effusion
D. Symmetric Polyarthritis

Answer 38

B. Raynaud’s phenomenon

Question 39

43. Nurse Mirasol writes a nursing diagnosis for the patient. Which of the following is a PRIORITY nursing diagnosis?

A. Social isolation
B. Impaired skin integrity
C. Disturbed body image
D. Low self-esteem

Answer 39

B. Impaired skin integrity

Question 39

42. Nurse Mirasol assesses the skin of the patient. Which phase of skin changes occur FIRST and are usually painless and symmetrical?

A. Indurative
B. Primary
C. Curative
D. Edematous

Answer 39

D. Edematous

Question 40

44. Nurse Mirasol assists the patient in coping with the disorder. During the early stages of a chronic disease, patients tend to focus on which of the following behaviors?

A. Understanding the disease process
B. Impact on lifestyle changes
C. Interpretations of symptoms
D. Schedule of medications

Answer 40

B. Impact on lifestyle changes

Question 41

45. Nurse Mirasol prepares a discharge plan of care for the patient. Which of the following objectives are MOST appropriate? The patient should _______________.
46. Try to prevent breakdown of the skin and ulceration
47. Avoid activities that trigger pain
48. Modify diet to include legumes
49. Avoid exposure to extreme cold temperature

A. 1, 2, 3, 4
B. 1, 2, 3
C. 1, 2, 4
D. 2, 3, 4

Answer 41

C. 1, 2, 4

Question 42

Situation 10

Nurse Bessie is a nurse manager of trauma unit. She supervises the staff nurses and
regularly holds conferences with them and other unit personnel. In one meeting she reorients the staff
nurses on their various functions. She cites clinical situations related to a nurses dependent,
interdependent, and collaborative functions.

46. An interdependent function of nurse is when the nurse _______:

A. Irrigates a feeding tube that appears obstructed.
B. Gives ice chips to a client who has an order of NPO.
C. Applies a dry sterile dressing to an abdominal incision.
D. Helps a client choose foods rich in protein from an ordered diet.

Answer 42

B. Gives ice chips to a client who has an order of NPO.

Question 43

47. A nurse decides to give a partial bath to a client instead of a complete bath. The nurse is working __________:

A. Independently
B. Interdependently
C. Dependently
D. Collaboratively

Answer 43

A. Independently

Question 44

49. A nurse initiates a visit from member of the clergy for a terminally ill client. The nurse is functioning ___________:

A. Interdependently
B. Collegially
C. Independently
D. Dependently

Answer 44

A. Interdependently

Question 45

48. A nurse works with a skin care team. The nurse is functioning _________:

A. Dependently
B. Interdependently
C. Collaboratively
D. Independently

Answer 45

C. Collaboratively

Question 46

50. When a nurse uses a straight catheter to obtain a urine specimen for laboratory test, the nurse is functioning ________:

A. Dependently
B. Interdependently
C. Independently
D. Collegially

Answer 46

C. Independently

Question 47

55.Patient Cena tells Nurse Marie “How did I acquire breast cancer?” Nurse Marie explains that there are risk factors that may have contributed to her condition. Which of the following statements is TRUE concerning the risk factors for breast cancer?

A. Hormones are not a risk factor for breast cancer.
B. Other types of cancer history have no correlation with breast cancer.
C. Ethnicity is a risk factor.
D. Environment is not a risk factor for breast cancer.

Answer 47

C. Ethnicity is a risk factor.

Question 47

Situation 11

Marie, an oncology nurse assists in the care of patients with cancer.

51. One of her patients is a 50-year old female named Marcela is in the terminal stage of breast cancer. She tells Nurse Marie. “I have given responses of Nurse Marie is MOST therapeutic?

A. “You have given up hope?”
B. “You should talk to your physician about your fears of dying.”
C. “You should talk about dying with your spiritual adviser.”
D. “You should not give up hope. There are research studies being done to cure cancer.”

Answer 47

A. “You have given up hope?”

Question 48

53. Marcela tells Nurse Marie that her younger sister was recently diagnosed with cancer. She is concerned because she is aware that breast cancer “ runs in the family” but she could not recall any family member diagnosed with bone or lung cancer. Nurse Marie’s BEST response would be:

A. “ I am sorry to hear about your sister. I think you should meet with all of your family members and share with them their increased risk for developing lung and bone cancer.”
B. “ Apparently your sister is so unfortunate . it is rare to have three such unrelated cancers at one time.”
C. “ I think it is important for you to be tested for lung cancer as soon as possible , because it has hereditary link.”
D. “ I am sorry to hear about your sister’s recant diagnosis. Most probably your sister has a breast cancer that has metastasized or spread to the bone and lungs.”

Answer 48

D. “ I am sorry to hear about your sister’s recant diagnosis. Most probably your sister has a breast cancer that has metastasized or spread to the bone and lungs.”

Question 49

52. Marcela says to Nurse Marie. “ I don’t like to spend my final days on earth in a hospital.” The BEST response of Nurse Marie would be :

A. “Can you please tell me more how you are feeling right now?”
B. “I know how you feel. It must be hard to know that you are dying.”
C. “If I were in your place, I should have refused being admitted to the hospital knowing that I will die soon.
D. “What is it that you don’t like being in the hospital?”

Answer 49

D. “What is it that you don’t like being in the hospital?”

Question 50

54. Nurse Marie has another patient, Cena who was recently diagnosed with ductal cell carcinoma of the breast. Her oncologist described Cena’s cancer as T2, N1, Mx. Cena asked Nurse Marie to repeat to her what “ all those letters and numbers mean.” Nurse Marie replies that it means the following:

A. Two tumours present, one lymph node involved, and many sites of metastasis.
B. One large tumour present, nodal involvement in one region, and metastasis was present.
C. Two tumours present, one lymph node involved and metastasis was present.
D. One tumor present, which is larger than 2.5 centimeters, nodal involvement in one region, and metastasis was unable to be determined.

Answer 50

D. One tumor present, which is larger than 2.5 centimeters, nodal involvement in one region, and metastasis was unable to be determined.

Question 51

Situation 12

A 35-year old female client presents herself in the outpatient Department with
complaints of rashes particularly on the face, across the bridge of the nose and on the cheeks. The
client is suspected of having systematic lupus erythematous (SLE). She is admitted to the female
medical unit.

56.The nurse writes a care plan for the client. The Nurse is aware that this disorder is a/an ________.

A. disease caused by over exposure to sunlight
B. Local rash that occurs as a result of allergy.
C. inflammatory disease of collagen contained in connective tissues.
D. disease caused by the continuous release of histamine in the body.

Answer 51

C. inflammatory disease of collagen contained in connective tissues.

Question 52

57.The nurse includes in the care plan dietary instructions. Which of the food items should the nurse instruct the client to AVOID?

A. steak
B. broccoli
C. legumes
D. fish

Answer 52

A. steak

Question 53

58.The nurse is aware that fatigue is experienced by patients with SLE. Which of the following activities should be a component in the care plan for the client to manage fatigue? To ________.

1. sit whenever possible
2. take a hot shower in the morning
3. avoid long periods of rest
4. engage in moderate low impact exercise when not fatigued
5. maintain a balance diet

A. 2, 3, 5
B. 1, 2, 3
C. 1, 2, 3, 4, 5
D. 1, 4, 5

Answer 53

D. 1, 4, 5

Question 54

59.The physician schedules the client for plasmapheresis. The client asks the nurse what is plasmapheresis. The nurse explains that it is a method that will __________.

A. prevent foreign antibodies from damaging various body tissues
B. decrease the damage to organs caused by attacking T-lymphocytes
C. eliminate eosinophils and basophils from the blood
D. remove antibody-antigen complexes from circulation

Answer 54

D. remove antibody-antigen complexes from circulation

Question 55

60.The nurse monitors the client undergoing plasmapheresis. Which of the following reactions should the nurse observe?

A. shortness of breath
B. numbness and tingling
C. transfusion reactions
D. high blood pressure

Answer 55

A. shortness of breath

Question 56

Situation 13

The nurse assists in the care of clients with chronic obstructi pulmonary disease
(COPD).

61.The nurse is aware that clients with COPD are at risk for ineffective respirations EXCEPT which of the following _________?

A. Clients undergoing thoracic or abdominal surgery
B. Clients with rib fractures and kyphosis
C. Clients with neuromuscular disorders such as Guillain-Barre’ syndrome
D. Clients with fluid volume deficit

Answer 56

D. Clients with fluid volume deficit

Question 57

62.Nursing interventions for clients with respiratory acidosis include the following EXCEPT to __________.

A. monitor arterial blood gases (ABGs), pH, PCO2, and HCO3
B. administer oxygen and medication as ordered
C. monitor hourly vital signs and respiratory status
D. administer sedation as ordered by the physician to relax the client

Answer 57

D. administer sedation as ordered by the physician to relax the client

Question 58

63.The nurse understands that excess acid in the body acts as CNS depressant. Clients with acidosis may exhibit which of the following symptoms:

1. reduced level of consciousness
2. confusion
3. lethargy
4. coma

A. all of the options
B. 1, 3, & 4
C. 1, 2, 3
D. 1 & 3

Answer 58

A. all of the options

Question 59

64.The goal for treatment for respiratory acidosis is to improve ventilation. Which of the following measures is appropriate for clients with COPD experiencing respiratory acidosis?

A. Bronchodilators
B. Administer medications as ordered
C. Ambulation
D. Spirometers

Answer 59

B. Administer medications as ordered

Question 60

65.The nurse understands that respiratory acidosis occurs when __________:

A. the body retains too much carbon dioxide
B. the client is unable to exhale carbon dioxide
C. the client hyperventilates
D. there is loss of acid or retention of base in the body

Answer 60

B. the client is unable to exhale carbon dioxide

Question 61

67.What research design is the MOST suitable to gather data for the study?

A. Quasi Experimental
B. Correlational Study
C. Descriptive study
D. Developmental study

Answer 61

C. Descriptive study

Question 62

Situation 14

Nurse Mark is assigned in the oncology unit of a tertiary hospital. He is aware of the
increase in number of colorectal cancer patient in his unit. He and a colleague plan to conduct a study
of the incidence of colorectal cancer in the Philippines.

66.Nurse Mark formulates a possible title for the study. Which of the following is the MOST appropriate title?

A. “Incidence of Colorectal Cancer in the Philippines”
B. “Perceptions of the Filipinos on Colorectal Cancer”
C. “Colorectal Cancer in the Philippines: It’s Risk Factors and Interventions”
D. “A Comparative Study of Gastrointestinal Cancer Cases among Filipinos”

Answer 62

A. “Incidence of Colorectal Cancer in the Philippines”

Question 63

68.In gathering data for the study, ethical guidelines on basic human rights will be observed? Which of the ethical principles is applicable?

1. Justice
2. Privacy and dignity
3. Respect
4. Confidentiality

A. 1, 2, 3, 4
B. 2, 3, 4
C. 1, 2, 3
D. 2, 3

Answer 63

A. 1, 2, 3, 4

Question 63

69.Nurse Mark formulates an assumption for the study. Which of the following is MOST acceptable?

A. Liver cancer cases have decreased in 2017 due to intensive public awareness
B. More Filipinos regardless of gender are diagnosed with colorectal cancer.
C. Male Filipinos are prone to colorectal cancer than liver cancer.
D. The leading cause of colorectal cancer among Filipinos is high consumption of alcohol.

Answer 63

B. More Filipinos regardless of gender are diagnosed with colorectal cancer.

Question 64

70. Which of the following is the MOST appropriate recommendation Nurse Mark should propose?

A. Warning signs of the effects of alcohol should be printed on bottles and cans of alcoholic beverages.
B. Health professionals should educate the public on the risk factors of CRC.
C. DOH only should intensify its campaign on colorectal cancer awareness.
D. Congress should pass a bill banning all cancer-producing foods and beverages.

Answer 64

B. Health professionals should educate the public on the risk factors of CRC.

Question 65

Situation 15

The nurses cares for a 30 year old patient who is admitted for severe vomiting. The
diagnosis of the patient is hypernatremia.

71.The nurse reads the laboratory results. Which of the following values indicate that the patient is experiencing hypernatremia?

A. Potassium level of 5.5mEg/L
B. Urine specific gravity below 1.0008
C. Serum osmolality below 280mOsm/kg
D. Serum osmolality above 295mOsm/kg

Answer 65

D. Serum osmolality above 295mOsm/kg

Question 66

72.The nurse monitors the patient for signs and symptoms of complications. The nurse knows that one of the PRIMARY risks when treating hypernatremia is ___________:

A. renal shutdown
B. cerebral edema
C. cellular dehydration
D. RBC destruction

Answer 66

B. cerebral edema

Question 67

73.In planning the care for this patient the nurse includes the following interventions. Which of the following actions should the nurse NOT include in the plan of care?

A. observe for possible increase in temperature
B. observe and prepare for possible seizure attack.
C. monitor intake and output
D. restrict fluids to 1,200 mL per day.

Answer 67

A. observe for possible increase in temperature

Question 68

74.The nurse understands that a patient with hyperatremia is at high risk for seizure. Which of the following safety measures is MOST appropriate? Use of _________.

A. pillows placed at the head
B. padded tongue blades
C. padded restraints
D. padded side rails

Answer 68

D. padded side rails

Question 69

75.The nurse formulates a nursing diagnosis for the patient. Which of the following nursing diagnoses is NOT appropriate for this patient?

A. Impaired Electrolyte, Sodium related vomiting.
B. imbalanced Nutrition, more that body requirements, related to excess intake of foods rich in sodium.
C. Risk for injury, bleeding, related to the interference with blood coagulation secondary to sodium excess.
D. impaired skin integrity, related to peripheral edema secondary to sodium and water excess.

Answer 69

A. Impaired Electrolyte, Sodium related vomiting.

Question 70

77.You are oriented on the hospital policy that when a patient is readmitted, the patient’s file maybe retrieved from the hospital records department. From which file may be a readmitted patient’s record be retrieved?

A. physician’s ledger
B. master patient index file.
C. civil service file
D. hospital library records

Answer 70

B. master patient index file.

Question 70

Situation 16

You are a nurse manager of a tertiary hospital. One of your responsibilities is to keep a
record of all patients admitted in the hospital.

76.You are aware of the importance of keeping hospital records. Which of the following statements is NOT rue about hospital records? Hospital records _____________.

A. provide data on health information system
B. are a key source of data for medical research on statistical reports.
C. provide personal information about the physicians and nurses assigned to care for the patients.
D. provide evidence of a hospital’s accountability

Answer 70

C. provide personal information about the physicians and nurses assigned to care for the patients.

Question 71

78.You orient your staff on the common system used in recording nursing interventions. The system used is a nursing index card or Kardex. What information is NOT included in the Kardex?

A. Drug regimen of the patient.
B. Allergies if any of the patient.
C. Progress notes of the physician.
D. Dietary requirements of the patient.

Answer 71

C. Progress notes of the physician.

Question 72

79.A patient’s record contains information of the medications and treatments administered, and observations of the patient’s condition. Which of the following data MUST be filled up in the patient’s chart when he/she is discharged from the hospital?

A. Religion
B. Nursing Diagnosis
C. Final medical diagnosis
D. Educational attainment

Answer 72

C. Final medical diagnosis

Question 73

80.You are familiar with the ethical aspects of patients and hospital records. Which of the following statements is NOT true?

A. Health records are the property of the locality where the patient is treated.
B. Hospital records maybe released without the patient’s consent when required in investigation for serious criminal offense.
C. Confidential records must be protected against loss, damage, unauthorized access, modification and disclosure.
D. Patients have the right to confidential treatment of information they provide to health professionals.

Answer 73

A. Health records are the property of the locality where the patient is treated.

Question 74

Situation 17

Ms. Gina is a staff nurse in a medical unit of x hospital. She collaborate with other
members of the health team to provide safe and quality patient care.

81.Which of the following statements BEST explains the role of the nurse in collaborating with others to plan for the patient’s care? The nurse _____________.

A. collaborates with colleagues and the patient’s family to provide combined expertise in planning care.
B. works independently to plan and deliver care and does not depend on other staff for assistance.
C. consults the physician for direction in establishing goals for clients.
D. depends on the latest literature to complete an excellent plan of care.

Answer 74

A. collaborates with colleagues and the patient’s family to provide combined expertise in planning care.

Question 75

83.To initiate an intervention in collaboration with the health team, Nurse Gina must be competent in which of the following areas?

A. Leadership, autonomy, and skills
B. Experience, advanced education, and skills
C. Knowledge, function, and specific skills
D. Leadership, finances, and skills

Answer 75

A. Leadership, autonomy, and skills

Question 75

82.Nurse Gina is aware that collaborative interventions are therapies that require the following: Which of the collaborative interventions is the MOST therapeutic?

A. Nurse and patient intervention
B. Multiple health care professionals
C. Physician and nurse intervention
D. Patient and physician intervention

Answer 75

B. Multiple health care professionals

Question 76

84.Nurse Gina is aware that there are nursing activities that may be delegated to other health care team members. Which principle should guide the nurse in delegating tasks?

A. Delegation occurs only upon a physician’s order.
B. The delegated personnel is accountable for the care.
C. Delegation may reduce the patient’s cost of care.
D. The nurse has the primary responsibility for the quality of patient care.

Answer 76

D. The nurse has the primary responsibility for the quality of patient care.

Question 77

85.Nurse Gina is a potential team leader of the health team. Which of the following skills should she develop?

A. Collaborative skills
B. Management
C. Supervisory skills
D. Patient advocacy

Answer 77

A. Collaborative skills

Question 78

Situation 18

Nurse Rolly, a triage nurse admits clients in the Emergency Department (ED) of X
hospital. The following are situations in the ED Nurse Rolly encounters.

86.Four victims are brought to the ED after a motor vehicle crash. Who among the following victims require the HIGHEST priority for the treatment?

A. 21 year-old male with fracture of the face jaw.
B. 20 year-old female with misaligned right leg.
C. 35 year-old male complaining of abdominal pain.
D. 62 year-old female with palpitation and chest pain.

Answer 78

D. 62 year-old female with palpitation and chest pain.

Question 79

87.Four victims of a car crash are brought to the ED. Nurse Rolly assesses the victims. Select who among the following has the HIGHEST priority for treatment.

A. Absence of peripheral pulses
B. A suckling chest wound
C. Severe bleeding of facial and head lacerations
D. An open femur fracture with profuse bleeding

Answer 79

B. A suckling chest wound

Question 80

88.Nurse Rolly performs primary assessment on one of the trauma victims, and determines that the client has a patent airway. The NEXT assessment by Nurse Rolly should be to ___________.

A. palpate for the presence of peripheral pulses
B. check the level of consciousness
C. examine the client for any external bleeding
D. observe/assess client’s breathing or respiratory effort

Answer 80

D. observe/assess client’s breathing or respiratory effort

Question 81

89. A 45 year-old male client was brought in the ED with head and neck trauma sustained in a motorcycle accident. The FIRST action of Nurse Rolly is to ___________.

A. suction of the mouth and oropharynx
B. obtain venous access
C. immobilize the cervical spine
D. administer supplemental oxygen

Answer 81

C. immobilize the cervical spine

Question 82

90.Jerome, 65 years old who works as a carpenter fell from a ladder while fixing the roof of a neighbor. He was brought to the ED by family members. He is unconscious. Nurse Rolly does a primary assessment on client Jerome which is to :

A. Ask the family about Jerome’s medical condition
B. Assess the vital signs
C. Attach a cardiac ECG monitor
D. Obtain a Glasgow Coma Scale Score

Answer 82

B. Assess the vital signs

Question 83

Situation 19

A 30 year-old female is admitted for fever, fatigue, lymphadenopathy, thrush, diarrhea
and muscle and joint pains. She also has a rash in her torso and arms.

91.The nurse assesses the client. What question should she ask to determine the client’s possible exposure to HIV?

A. “Do you use public toilet seats?”
B. Did you shake hands with a person infected with HIV?”
C. “Did you receive blood transfusion recently?”
D. “Do you practice safe sex?”

Answer 83

D. “Do you practice safe sex?”

Question 84

92.The nurse writes a care plan for the client. Included in the care plan is to provide health teachings. Before the nurse performs any teaching, what should the nurse do FIRST?

A. Evaluate the client’s existing level of knowledge about HIV infection.
B. Assess the client’s immediate clinical status.
C. Assess the emotional status of the client.
D. Focus on potential problems the client may encounter during the illness.

Answer 84

A. Evaluate the client’s existing level of knowledge about HIV infection.

Question 85

94.The client is being treated for thrush. The patient asks if there are any side effects of the medication she is receiving for thrush. Which of the following should the nurse include in her teaching?

A. “There are few side effects associated with the medications to treat thrush”
B. “Hepatitis can develop as a side effect.”
C. “Nausea, vomiting, and diarrhea are common side effects.”
D. “Skin discoloration is a common side effect.”

Answer 85

A. “There are few side effects associated with the medications to treat thrush”

Question 86

93.To determine whether the client is infected with HIV, the physician writes an order for HIV antibody testing. What test would confirm a positive ELISA test?

A. CD4 cell count
B. Easter Blot test
C. HIV antigen test
D. Western Blot test

Answer 86

D. Western Blot test

Question 87

95.The client complains of increasing pain in her feet and legs. The nurse realizes that the client is demonstrating a/an _________:

A. nervous system manifestation of the disease
B. reaction to a medication
C. opportunistic infection
D. secondary cancer

Answer 87

A. nervous system manifestation of the disease

Question 88

Situation 20

An adult male is wheeled in the Emergency Department with complaints of nausea and
vomiting, abdominal pain and lower back pain. The physician writes a medical diagnosis of abdominal
aortic aneurysm (AAA)

96.The nurse assesses the patient with AAA. Which of the assessment findings is related to the aneurysm?

1. Pulsatile abdominal mass
2. Hyperactive bowel sounds
3. Systolic bruit over the area of the mass
4. Subjective sensation of “heart beating” in the abdomen

A. 1, 3, 4
B. 1, 2, 3, 4
C. 2, 3, 4
D. 1, 2, 3

Answer 88

A. 1, 3, 4

Question 89

97.The nurse auscultates the abdominal area of the patient with AAA. Which of the following sounds can be DISTINCTLY heard over the area?

A. Dullness
B. Bruit
C. Friction rubs
D. Crackles

Answer 89

B. Bruit

Question 90

98.The nurse recalls specific anatomic sites for aneurysm. The most common sites are the aortic arch, thoracic aorta and abdominal aorta. Which of the following areas is an AAA most commonly located?

A. Proximal to the renal arteries
B. Distal to the iliac arteries
C. Distal to the renal arteries
D. Adjacent to the aortic arch

Answer 90

A. Proximal to the renal arteries

Question 91

99.The patient complains of severe lower back pain. Which of the following is the PRIORITY action by the nurse?

A. take the vital signs and document results
B. administer pain medication as prescribed
C. notify the physician
D. observe for signs of abdominal distention.

Answer 91

B. administer pain medication as prescribed

Question 92

100. The nurse is aware that rupture of the aneurysm is a life-threatening emergency. Which of the following groups of symptoms indicates a ruptured AAA?

A. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
B. Severe back pain, decreased blood pressure, decreased RBC count, increased WBC count.
C. Lower back pain, increased blood pressure, decreased RBC count, increased WBC count.
D. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

Answer 92

B. Severe back pain, decreased blood pressure, decreased RBC count, increased WBC count.