nsg. le reviewer

8/13/2019 Nsg. LE Reviewer

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300-Item NLE Practice Exam

Situation Richard has a nursing diagnosis of ineffective airway clearance related to excessivesecretions and is at risk for infection because of retained secretions. Part of Nurse Marios nursingcare plan is to loosen and reove excessive secretions in the airway.

!. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of thelungs. "he appropriate position to drain the anterior and posterior apical segents of the lungswhen Mario does percussion would be#

$. %lient lying on his back then flat on his abdoen on "rendelenburg position&. %lient seated upright in bed or on a chair then leaning forward in sitting position then flat on hisback and on his abdoen%. %lient lying flat on his back and then flat on his abdoen'. %lient lying on his right then left side on "rendelenburg position

(. )hen docuenting outcoe of Richards treatent Mario should include the following in hisrecording *+%*P"#

$. %olor, aount and consistency of sputu&. %haracter of breath sounds and respiratory rate before and after procedure%. $ount of fluid intake of client before and after the procedure'. Significant changes in vital signs

-. )hen assessing Richard for chest percussion or chest vibration and postural drainage, Mariowould focus on the following *+%*P"#

$. $ount of food and fluid taken during the last eal before treatent&. Respiratory rate, breath sounds and location of congestion%. "eaching the clients relatives to perfor the procedure'. 'octors order regarding position restrictions and clients tolerance for lying flat

. Mario prepares Richard for postural drainage and percussion. )hich of the following is a specialconsideration when doing the procedure/

$. Respiratory rate of !0 to (1 per inute&. %lient can tolerate sitting and lying positions%. %lient has no signs of infection'. "ie of last food and fluid intake of the client

2. "he purpose of chest percussion and vibration is to loosen secretions in the lungs. "he differencebetween the procedures is#

$. Percussion uses only one hand while vibration uses both hands

&. Percussion delivers cushioned blows to the chest with cupped pals while vibration gentlyshakes secretion loose on the exhalation cycle%. 3n both percussion and vibration the hands are on top of each other and hand action is in tunewith clients breath rhyth'. Percussion slaps the chest to loosen secretions while vibration shakes the secretions alongwith the inhalation of air

Situation $ 0! year old an, Mr. Regalado, is aditted to the private ward for observation aftercoplaints of severe chest pain. 4ou are assigned to take care of the client.

0. )hen doing an initial assessent, the best way for you to identify the clients priority proble is

to#$. 3nterview the client for chief coplaints and other syptos&. "alk to the relatives to gather data about history of illness%. 'o auscultation to check for chest congestion'. 'o a physical exaination while asking the client relevant 5uestions

6. Nancy blaes 7od for her situation. She is easily provoked to tears and wants to be left alone,refusing to eat or talk to her faily. $ religious person before, she now refuses to pray or go tochurch stating that 7od has abandoned her. "he nurse understands that Nancy is grieving for herself and is in the stage of#


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$. bargaining&. denial%. anger'. acceptance

8. )hich of the following ethical principles refers to the duty to do good/$. &eneficence&. 9idelity

%. :eracity'. Nonaleficence

;. 'uring which step of the nursing process does the nurse analy


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$. "ake the blood pressure reading on both ars for coparison&. Aisten to and identify the phases of Borotkoffs sound%. Pup the cuff to around 21 ?g above the point where the pulse is obliterated'. Cbserve procedures for infection control

!0.$ pulse oxieter is attached to Mr. 'i


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%. ! tbsp of saltFday with soe patis and toyo'. ! tsp of saltFday but no patis and toyo

(2.)hich of the following ethods is the best ethod for deterining nasogastric tube placeent inthe stoach/

$. +>ray&. Cbservation of gastric aspirate%. "esting of p? of gastric aspirate

'. Placeent of external end of tube under water

(0.)hich of the following is the ost iportant risk factor for developent of %hronic CbstructivePulonary 'isease/

$. %igarette soking&. Cccupational exposure%. $ir pollution'. 7enetic abnoralities

(6.)hen perforing endotracheal suctioning, the nurse applies suctioning while withdrawing andgently rotating the catheter -01 degrees for which of the following tie periods/

$. !1>!2 seconds %. (1>(2 seconds&. -1>-2 seconds '. 1>2 seconds

(8."he nurse auscultates the apex beat at which of the following anatoical locations/$. 9ifth intercostal space, idclavicular line&. Mid>sternu%. (E to the left of the lower end of the sternu'. !E to the left of the xiphoid process

(;.)hich of the following ters describes the aount of blood e@ected per heartbeat/$. Stroke volue

&. %ardiac output%. *@ection fraction'. $fterload

-1.4ou are to apply a transderal patch of nitoglycerin to your client. "he following are iportantguidelines to observe *+%*P"#

$. $pply to hairless clean area of the skin not sub@ect to uch wrinkling&. Patches ay be applied to distal part of the extreities like forear%. %hange application and site regularly to prevent irritation of the skin'. )ear gloves to avoid any edication on your hand

-!."he 7$G7* si


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-.)hich priority nursing diagnosis is applicable for a patient with indwelling urinary catheter/$. Self estee disturbance&. 3paired urinary eliination%. 3paired skin integrity'. Risk for infection

-2.$n incontinent elderly client fre5uently wets his bed and eventually develop redness and skinexcoriation at the perianal area. "he best nursing goal for this client is to#

$. Make sure that the bed linen is always dry&. 9re5uently check the bed for wetness and always keep it dry%. Place a rubber sheet under the clients buttocks'. Beep the patient clean and dry

-0.$s a Nurse Manager, 'MAM en@oys her staff of talented and self otivated individuals. She knewthat the leadership style to suit the needs of this kind of people is called#

$. $utocratic&. Participative%. 'eocratic'. Aaisse< 9aire

-6.$ fire has broken in the unit of 'MAM R.N. "he best leadership style suited in cases ofeergencies like this is#

$. $utocratic&. Participative%. 'eocratic'. Aaisse< 9aire

-8.)hich step of the anageent process is concerned with Policy aking and Stating the goalsand ob@ective of the institution/

$. Planning

&. Crgani


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'. 'urable Power of $ttorney

-.Mang %arlos has a standing 'NR order. ?e then suddenly stopped breathing and you are at hisbedside. 4ou would#

$. 7ive extraordinary easures to save Mang %arlos&. Stay with Mang %arlos and 'o nothing%. %all the physician'. $ctivate %ode &lue

.3t is not a legally binding docuent but nevertheless, :ery iportant in caring for the patients.$. &CN Resolution No. ((1 Series of (11(&. Patients &ill of Rights%. Nurses %ode of *thics'. Philippine Nursing $ct of (11(

2.3n onitoring the patient in P$%G, the nurse correctly identify that checking the patients vitalsigns is done every#

$. ! hour

&. 2 inutes%. !2 inutes'. -1 inutes

Situation# 'ianne May 'ee, R.N., is conducting a research on her unit about the effects of effectivenurse>patient counication in decreasing anxiety of post operative patients.0.)hich of the following step in nursing research should she do next/

$. Review of related literature&. $sk perission fro the hospital adinistrator%. 'eterine the research proble

'. 9orulate ways on collecting the data

6.&efore 'ianne perfors the foral research study, what do you call the pre testing, sall scaletrial run to deterine the effectiveness of data collection and ethodological proble that ightbe encountered/

$. Sapling&. Pre>testing%. Pre>Study'. Pilot Study

8.Cn the study Deffects of effective nurse>patient counication in decreasing anxiety of post

operative patientsE )hat is the 3ndependent variable/$. *ffective Nurse>patient counication&. %ounication%. 'ecreasing $nxiety'. Post operative patient

;.Cn the study Deffects of effective nurse>patient counication in decreasing anxiety of postoperative patientsE )hat is the 'ependent variable/

$. *ffective Nurse>patient counication&. %ounication%. $nxiety level

'. Post operative patient

21.3n the recent technological innovations, which of the following describe researches that are adeto iprove and ake huan life easier/

$. Pure research&. &asic research%. $pplied research'. *xperiental research


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2!.)hich of the following is not true about a Pure *xperiental research/$. "here is a control group&. "here is an experiental group%. Selection of sub@ects in the control group is randoi


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is unethical

01.)ho aong the following can work as a practicing nurse in the Philippines without taking theAicensure exaination/

$. 3nternationally well known experts which services are for a fee&. "hose that are hired by local hospitals in the country%. *xpert nurse clinicians hired by prestigious hospitals'. "hose involved in edical ission whos services are for free

0!.3n signing the consent for, the nurse is aware that what is being observed as an ethicalconsideration is the patients

$. $utonoy&. Justice%. $ccountability'. &eneficence

0(.Nurse &uddy gave 3napsine instead of 3nsulin to a patient in severe hyperglyceia. ?e reportedthe incident as soon as he knew there was an error. $ nurse that is always ready to answer for allhis actions and decision is said to be#

$. $ccountable %. %ritical thinker&. Responsible '. $ssertive

0-.)hich of the following best describes Priary Nursing/$. 3s a for of assigning a nurse to lead a tea of registered nurses in care of patient froadission to discharge&. $ nurse is responsible in doing certain tasks for the patient%. $ registered nurse is responsible for a group of patients fro adission to discharge'. $ registered nurse provides care for the patient with the assistant of nursing aides

0."he best and ost effective ethod in ties of staff and financial shortage is#

$. 9unctional Method %. "ea Nursing&. Priary Nursing '. Modular Method

02.4ou are doing bed bath to the client when suddenly, "he nursing assistant rushed to the roo andtell you that the client fro the other roo was in Pain. "he best intervention in such case is#

$. Raise the side rails, cover the client and put the call bell within reach and then attend to theclient in pain to give the PRN edication&. "ell the nursing assistant to give the pain edication to the client coplaining of pain%. "ell the nursing assistant to go the clients roo and tell the client to wait'. 9inish the bed bath 5uickly then rush to the client in Pain

00.$ngie is a disoriented client who fre5uently falls fro the bed. $s her nurse, which of the followingis the best nursing intervention to prevent future falls/

$. "ell $ngie not to get up fro bed unassisted&. Put the call bell within her reach%. Put bedside coode at the bedside to prevent $ngie fro getting up'. Put the bed in the lowest position ever

06.)hen in@ecting subcutaneous in@ection in an obese patient, 3t should be angled at around#$. 2 K&. ;1 K

%. !81 K'. Parallel to the skin

08."he following stateents are all true about L>"rack techni5ue except#$. L track in@ection prevent irritation of the subcutaneous tissues&. "he techni5ue involve creating a Lig Lag like pattern of edication%. 3t forces the edication to be contained at the subcutaneous tissues'. 3t is used when adinistering Parenteral 3ron


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0;.%ounication is best undertaken if barriers are first reoved. %onsidering this stateent, whichof the following is considered as deterrent factor in counication/

$. Not universally accepted abbreviations&. )rong 7raar%. Poor Penanship'. Cld age of the client

61.Nurse 'MAM is correct in identifying the correct se5uence of events during abdoinal

assessent if she identifies which of the following/$. 3nspection, $uscultation, Percussion, Palpation&. 3nspection, Percussion, Palpation, $uscultation%. 3nspection, Palpation, Percussion, $uscultation'. 3nspection, $uscultation, Palpation, Percussion

6!."o prevent in@ury and strain on the uscles, the nurse should observe proper body echanics.$ong the following, which is a principle of proper body echanics/$. &roaden the space between the feet&. Push instead of pull%. Move the ob@ect away fro the body when lifting

'. &end at the waist, not on the knees

6(.3n taking the clients blood pressure, the nurse should position the clients ar#$. $t the level of the heart&. Slightly above the level of the heart%. $t the 2th intercostals space idclavicular line'. &elow the level of the heart

6-.)hat principle is used when the client with fever loses heat through giving cooling bed bath tolower body teperature/

$. Radiation %. *vaporation

&. %onvection '. %onduction

6."he ost effective way in liiting the nuber of icroorganis in the hospital is#$. Gsing strict aseptic techni5ue in all procedures&. )earing ask and gown in care of all patients with counicable diseases%. Sterili


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%. 'isconnect the drainage bag, obtain a sterile syringe and draw the specien fro the drainagebag'. 'isconnect the tube, obtain a sterile syringe and draw the specien fro the tube

6;.)hich of the following is an exaple of secondary prevention/$. "eaching the diabetic client on obtaining his blood sugar level using a glucoeter&. Screening patients for hypertension

%. 3uni


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'. Make a nursing diagnosis

88.7ina, $ client in prolong labor said she cannot go on anyore. "he health care tea decided thatboth the child and the other cannot anyore endure the process. "he baby is preature andhas a little chance of surviving. %aesarian section is not possible because 7ina already lostenough blood during labor and additional losses would tend to be fatal. "he husband decided that7ina should survive and gave his consent to terinate the fetus. "he principle that will be used bythe health care tea is#

$. &eneficence&. Non alfeasance%. Justice'. 'ouble effect

Situation "here are various developents in health education that the nurse should know about#

8;."he provision of health inforation in the rural areas nationwide through television and radioprogras and video conferencing is referred to as#

$. %ounity health progra&. "elehealth progra

%. )ellness progra'. Red %ross progra

;1.3n teaching the sister of a diabetic client about the proper use of a glucoeter in deterining theblood sugar level of the client, "he nurse is focusing in which doain of learning according tobloo/

$. %ognitive&. $ffective%. Psychootor'. $ffiliative

;!.$ nearby counity provides blood pressure screening, height and weight easureent,soking cessation classes and aerobics class services. "his type of progra is referred to as

$. outreach progra&. hospital extension progra%. barangay health progra'. wellness progra

;(.$fter cleaning the abrasions and applying antiseptic, the nurse applies cold copress to theswollen ankle as ordered by the physician. "his stateent shows that the nurse has correctunderstanding of the use of cold copress#

$. %old copress reduces blood viscosity in the affected area&. 3t is safer to apply than hot copress%. %old copress prevents edea and reduces pain'. 3t eliinates toxic waste products due to vasodilation

;-.$fter receiving prescription for pain edication, Ronnie is instructed to continue applying -1inute cold at hoe and start -1 inute hot copress the next day. 4ou explain that the use ofhot copress#

$. Produces anesthetic effect&. 3ncreases nutrition in the blood to proote wound healing%. 3ncrease oxygenation to the in@ured tissues for better healing

'. 3nduces vasoconstriction to prevent infection

Situation $ nursing professor assigns a group of students to do data gathering by interviewing theirclassates as sub@ects.

;.She instructed the interviewees not to tell the interviewees that the data gathered are for her ownresearch pro@ect for publication. "his teacher has violated the students right to#

$. Not be hared&. 'isclosure%. Privacy


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'. Self>deterination

;2.&efore the nurse researcher starts her study, she analyaking power is called#

$. uasi>Judicial Power&. Regulatory Power%. uasi>Aegislative Power'. *xecutiveFProulgating Power

;;.$nita is perforing &S* and she stands in front of the Mirror. "he rationale for standing in front ofthe irror is to check for#

$. Gnusual discharges coing out fro the breast&. $ny obvious alignancy%. "he Si


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%. Prevent cervical lacerations'. Stiulate uterine contractions

Situation# Nurse Aorena is a 9aily Planning and 3nfertility Nurse Specialist and currently attends to9$M3A4 PA$NN3N7 %A3*N"S $N' 3N9*R"3A* %CGPA*S. "he following conditions pertain toeeting the nursing needs of this particular population group.

!1. 'ina, !6 years old, asks you how a tubal ligation prevents pregnancy. )hich would be the best

answer/$. Prostaglandins released fro the cut fallopian tubes can kill sper&. Sper cannot enter the uterus because the cervical entrance is blocked.%. Sper can no longer reach the ova, because the fallopian tubes are blocked'. "he ovary no longer releases ova as there is no where for the to go.

!12. "he 'ators are a couple undergoing testing for infertility. 3nfertility is said to exist when#$. a woan has no uterus&. a woan has no children%. a couple has been trying to conceive for ! year'. a couple has wanted a child for 0 onths

!10. "he correct teperature to store vaccines in a refrigerator is#$. between > deg % and 8 deg %&. between ( deg % and 8 deg %%. between >8 deg % and 1 deg %'. between >8 deg % and deg %

!16. )hich of the following vaccines is not done by intrauscular H3MI in@ection/$. Measles vaccine %. ?epa>& vaccine&. 'P" '. "etanus toxoids

!18. "his vaccine content is derived fro RN$ recobinants.$. Measles %. ?epatitis & vaccines&. "etanus toxoids '. 'P"

!1;. "his special for is used when the patient is aditted to the unit. "he nurse copletes theinforation in this record particularly hisFher basic personal data, current illness, previous healthhistory, health history of the faily, eotional profile, environental history as well as physicalassessent together with nursing diagnosis on adission. )hat do you call this record/

$. Nursing Bardex&. Nursing ?ealth ?istory and $ssessent )orksheet%. Medicine and "reatent Record

'. 'ischarge Suary

!!1. "hese are sheetsFfors which provide an efficient and tie saving way to record inforationthat ust be obtained repeatedly at regular andFor short intervals of tie. "his does not replacethe progress notesO instead this record of inforation on vital signs, intake and output, treatent,postoperative care, post partu care, and diabetic regien, etc. "his is used whenever specificeasureents or observations are needed to be docuented repeatedly. )hat is this/

$. Nursing Bardex&. 7raphic 9low Sheets%. 'ischarge Suary'. Medicine and "reatent Record

!!!. "hese records show all edications and treatent provided on a repeated basis. )hat do youcall this record/

$. Nursing ?ealth ?istory and $ssessent )orksheet&. 'ischarge Suary%. Nursing Bardex'. Medicine and "reatent Record


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!!(. "his flip>over card is usually kept in a portable file at the Nurses Station. 3t has (>parts# theactivity and treatent section and a nursing care plan section. "his carries inforation about basicdeographic data, priary edical diagnosis, current orders of the physician to be carried out bythe nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safetyprecautions in patient care and factors related to daily living activities. "his record is used in thecharge>of>shift reports or during the bedside rounds or walking rounds. )hat record is this/

$. 'ischarge Suary&. Medicine and "reatent Record

%. Nursing ?ealth ?istory and $ssessent )orksheet'. Nursing Bardex

!!-. Most nurses regard this conventional recording of the date, tie, and ode by which thepatient leaves a healthcare unit but this record includes iportantly, directs of planning fordischarge that starts soon after the person is aditted to a healthcare institution. 3t is acceptedthat collaboration or ultidisciplinary involveent Hof all ebers of the health teaI in dischargeresults in coprehensive care. )hat do you call this/

$. 'ischarge Suary&. Nursing Bardex%. Medicine and "reatent Record

'. Nursing ?ealth ?istory and $ssessent )orksheet

!!. &ased on the %ode of *thics for 9ilipino Nurses, what is regarded as the hallark of nursingresponsibility and accountability/

$. ?uan rights of clients, regardless of creed and gender&. "he privilege of being a registered professional nurses%. ?ealth, being a fundaental right of every individual'. $ccurate docuentation of actions and outcoes

!!2. $ nurse should be cogni


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%. 9ast breathing'. 'ifficulty to awaken

!(1. $ child with ear proble should be assessed for the following, *+%*P"#$. is there any fever/&. *ar discharge%. 3f discharge is present for how long/'. *ar pain

!(!. 3f the child does not have ear proble, using 3M%3, what should you as the nurse do/$. %heck for ear discharge&. %heck for tender swellings behind the ear%. %heck for ear pain'. 7o to the next 5uestion, check for alnutrition

!((. $ll of the following are treatent for a child classified with no dehydration except#$. !,111 l to !,11 l be given within hours&. %ontinue feeding

%. ?ave the child takes as uch fluid as he wants'. Return the child to the doctor if condition worsens

!(-. $n ear infection that persists but still less than ! days is classified as#$. Mastoiditis&. %hronic *ar 3nfection%. $cute *ar 3nfection'. Ctitis Media

!(. 3f a child has two or ore pink signs, you would classify the child as having#$. No disease

&. Mild for of disease%. Grgent Referral'. :ery severe disease

!(2. "he nurse knows that the ost coon coplication of Measles is#$ Pneuonia and larynigotracheitis&. *ncephalitis%. Ctitis Media'. &ronchiectasis

!(0. $ client scheduled for hysterosalpingography needs health teaching before the procedure. "he

nurse is correct in telling the patient that#$. She needs to void prior to the procedure&. $ full bladder is needed prior to the procedure%. Painful sensation is felt as the needle is inserted'. 9lushing sensation is felt as the dye in in@ected

!(6. 3n a population of ;,211. )hat is your estiate of the population of pregnant woan needingtetanus toxoid vaccination/

$. 0-(.2 %. 21.2&. 2!(.2 '. --(.2

!(8. $ll of the following are seen in a child with easles. )hich one is not/$. Reddened eyes %. Pustule&. %ory


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'. Nursing Process

!-1. Prevention of work related accidents in factories and industries are responsibilities of whichfield of nursing/

$. School health nursing&. Private duty nursing%. Cccupational health nursing'. 3nstitutional nursing

!-!. 3n one of your hoe visit to Mr. JGN, you found out that his son is sick with cholera. "here is agreat possibility that other eber of the faily will also get cholera. "his possibility is aFan#

$. 9oreseeable crisis&. ?ealth threat%. ?ealth deficit'. %risis

!-(. )hy is bleeding in the leg of a pregnant woan considered as an eergency/$. &lood volue is greater in pregnant woanO therefore, blood loss is increased&. "here is an increase blood pressure during pregnancy increasing the likelihood of heorrhage

%. Pregnant woan are aneic, all fors of blood loss should be considered as an eergencyespecially if it is in the lower extreity'. "he pressure of the gravid uterus will exert additional force thus, increasing the blood loss inthe lower extreities

!--. $ling Maria is nearing enopause. She is habitually taking cola and coffee for the past (1years. 4ou should tell $ling Maria to avoid taking caffeinated beverages because#

$. 3t is stiulating

&. 3t will cause nervousness and insonia%. 3t will contribute to additional bone deinerali


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!-8. )hat is the rationale in the use of bag techni5ue during hoe visits/$. 3t helps render effective nursing care to clients or other ebers of the faily&. 3t saves tie and effort of the nurse in the perforance of nursing procedures%. 3t should inii


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%. )hen it is issing'. )hen the edical record is inaccurate, incoplete, and inade5uate

!8. 'isposal of edical records in governent hospitalsFinstitutions ust be done in closecoordination with what agency/

$. 'epartent of 3nterior and Aocal 7overnent H'3A7I&. Metro Manila 'evelopent $uthority HMM'$I%. Records Manageent $rchives Cffice HRM$CI

'. 'epartent of ?ealth H'C?I

!;. 3n the hospital, when you need the edical record of a discharged patient for research you willre5uest perission through#

$. 'octor in charge&. "he hospital director%. "he nursing service'. Medical records section

!21. 4ou will give health instructions to %arlo, a case of bronchial astha. "he health instruction willinclude the following, *+%*P"#

$. $void eotional stress and extree teperature&. $void pollution like soking%. $void pollens, dust, seafood'. Practice respiratory isolation

!2!. $s the head nurse in the CR, how can you iprove the effectiveness of clinical alarsystes/

$. Aiit suppliers to a few so that 5uality is aintained&. 3pleent a regular inventory of supplies and e5uipent%. $dherence to anufacturers recoendation'. 3pleent a regular aintenance and testing of alar systes

!2(. Cverdosage of edication or anesthetic can happen even with the aid of technology likeinfusion pups, sphygoanoeter and siilar devicesFachines. $s a staff, how can youiprove the safety of using infusion pups/

$. %heck the functionality of the pup before use&. Select your brand of infusion pup like you do with your cellphone%. $llow the technician to set the infusion pup before use'. :erify the flow rate against your coputation

!2-. )hile tea effort is needed in the CR for efficient and 5uality patient care delivery, we shouldliit the nuber of people in the roo for infection control. )ho coprise this tea/

$. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly&. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist%. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist'. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

!2. )hen surgery is on>going, who coordinates the activities outside, including the faily/$. CrderlyFclerk %. %irculating Nurse&. Nurse Supervisor '. $nesthesiologist

!22. "he breakdown in teawork is often ties a failure in#$. *lectricity

&. 3nade5uate supply%. Aeg work'. %ounication

!20. "o prevent recurrent attacks on client with gloerulonephritis, the nurse instructs the client to#$. "ake a shower instead of tub baths&. $void situations that involve physical activity%. %ontinue the sae restriction on fluid intake'. Seek early treatent for respiratory infection


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!26. )hen adinistering "apa


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$. Bnee chest position&. Side lying position%. Sis position'. 7enopectoral position

!06. 4ou would expect that after an abdoinal perineal resection, the type of colostoy that will beuse is/

$. 'ouble barrel colostoy

&. "eporary colostoy%. Peranent colostoy'. $n 3leostoy

!08. 4ou are an ostoy nurse and you know that colostoy is defined as#$. 3t is an incision into the colon to create an artificial opening to the exterior of the abdoen&. 3t is end to end anastoosis of the gastric stup to the duodenu%. 3t is end to end anastoosis of the gastric stup to the @e@unu'. 3t is an incision into the ileu to create an artificial opening to the exterior of the abdoen

!0;. Aarry, 22 years old, who is suspected of having colorectal cancer, is aditted to the %3. $ftertaking the history and vital signs the physician does which test as a screening test for colorectalcancer.

$. &ariu enea&. %arcinoebryonic antigen%. $nnual digital rectal exaination'. Proctosigoidoscopy

!61. Syptos associated with cancer of the colon include#$. constipation, ascites and ucus in the stool&. diarrhea, heart burn and eructation

%. blood in the stools, aneia, and Dpencil shapedE stools'. anorexia, heateesis, and increased peristalasis

!6!. ( ?ours after creation of colostoy, Nurse :ioly is correct if she identify that the noralappearance of the stoa is #

$. Pink, oist and slightly protruding fro the abdoen&. 7ray, oist and slightly protruding fro the the abdoen%. Pink, dry and slightly protruding fro the abdoen'. Red, oist and slightly protruding fro the abdoen

!6(. 3n cleaning the stoa, the nurse would use which of the following cleaning edius/

$. ?ydrogen Peroxide, water and ild soap&. Providone 3odine, water and ild soap%. $lcohol, water and ild soap'. Mild soap and water

!6-. )hen observing a return deonstration of a colostoy irrigation, you know that ore teachingis re5uired if pt#

$. Aubricates the tip of the catheter prior to inserting into the stoa&. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion%. 'iscontinues the insertion of fluid after only 211 l of fluid has been instilled'. %laps of the flow of fluid when felling uncofortable

!6. )hat does a saple group represent/$. %ontrol group %. 7eneral population&. Study sub@ects '. Gniverse

!62. $s a nurse, you can help iprove the effectiveness of counication aong healthcare giversby#

$. Gse of reinders of what to do&. Gsing standardion>one oral endorseent


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'. "ext essaging and e>ail

!60. Myxedea coa is a life threatening coplication of long standing and untreatedhypothyroidis with one of the following characteristics.

$. ?yperglyceia %. ?ypertheria&. ?ypotheria '. ?ypoglyceia

!66. Mang *dgardo has a chest tube inserted in place after a Aobectoy. "he nurse knows that

that %hest tube after this procedure will#$. Prevents ediastinal shift&. Proote chest expansion of the reaining lung%. 'rain fluids and blood accuulated post operatively'. Reove the air in the lungs to proote lung expansion

!68. Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions,*+%*P"#

$. straddling a chair with ars and head resting on the back of the chair&. lying on the unaffected side with the bed elevated -1>1 degrees%. lying prone with the head of the bed lowered !2>-1 degrees

'. sitting on the edge of the bed with her feet supported and ars and head on a paddedoverhead table

!6;. %hest x>ray was ordered after thoracentesis. )hen your client asks what is the reason foranother chest x>ray, you will explain#

$. to rule out pneuothorax&. to rule out any possible perforation%. to decongest'. to rule out any foreign body

!81. "he RR nurse should onitor for the ost coon postoperative coplication of#$. heorrhage&. endotracheal tube perforation%. osopharyngeal edea'. epiglottis

!8!. "he P$%G nurse will aintain postoperative " and $ client in what position/$. Supine with neck hyperextended and supported with pillow&. Prone with the head on pillow and turned to the side%. Sei>fowlers with neck flexed'. Reverse trendelenburg with extended neck

!8(. "ony is to be discharged in the afternoon of the sae day after tonsillectoy andadenoidectoy. 4ou as the RN will ake sure that the faily knows to#

$. offer osteri


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%. $llowing the client cheese, canned foods and other processed food'. &ananas, cantaloupe, orange and other fresh fruits can be included in the diet

!82. "he ost coon causative agent of Pyelonephritis in hospitali


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!;-. )hen observing a return deonstration of a colostoy irrigation, you know that ore teachingis re5uired if pt#

$. Aubricates the tip of the catheter prior to inserting into the stoa&. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion%. 'iscontinues the insertion of fluid after only 211 l of fluid has been instilled'. %laps of the flow of fluid when felling uncofortable

!;. )hich of the four phases of eergency anageent is defined as Dsustained action that

reduces or eliinates long>ter risk to people and property fro natural ha


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(1(. 3n adinistering blood transfusion, what needle gauge is used/$. !8 %. (-&. (( '. (

(1-. &efore adinistration of blood and blood products, the nurse should first#$. %heck with another R.N the clients nae, 3dentification nuber, $&C and R? type.&. *xplain the procedure to the client

%. $ssess baseline vital signs of the client'. %heck for the &" order

(1. "he only 3: fluid copatible with blood products is#$. '2AR %. NSS&. '2NSS '. Plain AR

(12. 3n any event of an adverse heolytic reaction during blood transfusion, Nursing interventionshould focus on#

$. Slow the infusion, %all the physician and assess the patient&. Stop the infusion, $ssess the client, Send the reaining blood to the laboratory and call the

physician%. Stop the infusion, %all the physician and assess the client'. Slow the confusion and keep a patent 3: line open for adinistration of edication

(10. "he nurse knows that after receiving the blood fro the blood bank, it should be adinisteredwithin#

$. ! hour %. hours&. ( hours '. 0 hours

(16. 'uring blood adinistration, the nurse should carefully onitor adverse reaction. "o onitorthis, it is essential for the nurse to#

$. Stay with the client for the first !2 inutes of blood adinistration&. Stay with the client for the entire period of blood adinistration%. Run the infusion at a faster rate during the first !2 inutes'. "ell the client to notify the staff iediately for any adverse reaction

(18. $s Aedas nurse, you plan to set up an eergency e5uipent at her beside followingthyroidectoy. 4ou should include#

$. $n airway and rebreathing tube&. $ tracheostoy set and oxygen%. $ crush cart with bed board'. "wo apules of sodiu bicarbonate

(1;. )hich of the following nursing interventions is appropriate after a total thyroidectoy/$. Place pillows under your patients shoulders.&. Raise the knee>gatch to -1 degrees%. Beep you patient in a high>fowlers position.'. Support the patients head and neck with pillows and sandbags.

(!1. 3f there is an accidental in@ury to the parathyroid gland during a thyroidectoy which of thefollowing ight Aeda develop postoperatively/

$. %ardiac arrest %. Respiratory failure&. 'yspnea '. "etany

(!!. $fter surgery Aeda develops peripheral nubness, tingling and uscle twitching and spas.)hat would you anticipate to adinister/

$. Magnesiu sulfate %. Potassiu iodide&. %alciu gluconate '. Potassiu chloride

Situation# NGRS*S are involved in aintaining a safe and healthy environent. "his is part of 5ualitycare anageent.


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(!(. "he first step in decontaination is#$. to iediately apply a cheical decontaination foa to the area of containation&. a through soap and water wash and rinse of the patient%. to iediately apply personal protective e5uipent'. reoval of the patients clothing and @ewelry and then rinsing the patient with water

(!-. 9or a patient experiencing pruritus, you recoend which type of bath.$. water %. saline

&. colloidal HoatealI '. sodiu bicarbonate

(!. 3nduction of voiting is indicated for the accidental poisoning patient who has ingested.$. Rust reover %. toilet bowl cleaner&. 7asoline '. aspirin

Situation# &ecause severe burn can affect the persons totality it is iportant that>you applyinterventions focusing on the various diensions of an. 4ou also have to understand the rationaleof the treatent.

(!2. $ client was rushed in the *.R showing a whitish, leathery and painless burned area on his

skin. "he nurse is correct in classifying this burn as#$. 9irst degree burn %. "hird degree burn&. Second degree burn '. Partial thickness burn

(!0. 'uring the first ( hours of burn, nursing easures should focus on which of the following/$. 3 and C hourly&. Strict aseptic techni5ue%. 9orced oral fluids'. 3solate the patient

(!6. 'uring the $cute phase of burn, the priority nursing intervention in caring for this client is#$. Prevention of infection&. Pain anageent%. Prevention of &leeding'. 9luid Resuscitation

(!8. "he nurse knows that the ost fatal electrolyte ibalance in burned client during the *ergentphase of burn is#

$. ?ypokaleia&. ?yperkaleia%. ?ypernatreia

'. ?yponatreia

(!;. ?ypokaleia is reflected in the *%7 by which of the following/$. "all " waves %. Pathologic wave&. )idening RS %oplex '. G wave

((1. Pain edications given to the burn clients are best given via what route/$. 3: %. Cral&. 3M '. S

((!. )hat type of debrideent involves proteolytic en


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((-. ?ypertrophic burn scars are caused by#$. exaggerated contraction&. rando layering of collagen%. wound ischeia'. delayed epithelialiPatient interaction is#

$. Gnderstanding&. $cceptance%. Aistening'. "eaching

(-1. Selective inattention is seen in what level of anxiety/$. Mild&. Moderate%. Severe'. Panic

(-!. Cbsessive copulsive disorder is characteri


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$. "ell e ore about being the :irgin Mary&. So, 4ou are the :irgin Mary/%. *xcuse e but, you are not anyore a :irgin so you cannot be the &lessed :irgin Mary.'. 4ou are Maria Salvacion

(--. Marias stateent D&ow down before eQ 3 a the holy other of %hristQ 3 a the blessed:irgin MaryQE is an exaple of#

$. 'elusion of grandeur

&. :isual ?allucination%. Religious delusion'. $uditory ?allcucination

(-. "he nurse interprets the stateent D&ow down before eQ 3 a the holy other of %hristQ 3 athe blessed :irgin MaryQE as iportant in docuenting in which of the following areas of entalstatus exaination/

$. "hought content&. Mood%. $ffect'. $ttitude

(-2. Mang 'avid, $ (6 year old psychiatric client was aditted with a diagnosis of schi


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$. "aste the food in front of hi and tell hi that the food is not poisoned&. Cffer other types of food until the client eats%. Siply state that the food is not poisoned'. Cffer sealed foods

((. "oilet training occurs in the anal stage of 9reuds psychosexual task. "his is e5uivalent to*riksons#

$. "rust vs. Mistrust

&. $utonoy vs. Shae and 'oubt%. 3nitiative vs. 7uilt'. 3ndustry vs. 3nferiority

(-. 'uring the phallic stage, the child ust identify with the parent of#$. "he sae sex&. "he opposite sex%. "he other or the priary caregiver'. &oth sexes

(. Ms. $N$ had a car accident where he lost her boyfriend. $s a result, she becae passive and

subissive. "he nurse knows that the type of crisis Ms. $N$ is experiencing is#$. 'evelopental crisis&. Maturational crisis%. Situational crisis'. Social %risis

(2. Persons experiencing crisis becoes passive and subissive. $s a nurse, you know that thebest approach in crisis intervention is to be#

$. $ctive and 'irective&. Passive friendliness%. $ctive friendliness

'. 9ir kindness

(0. "he psychosocial task of a 22 year old adult client is#$. 3ndustry vs. 3nferiority&. 3ntiacy vs. 3solation%. 3ntegrity vs. 'espair'. 7enerativity vs. Stagnation

(6. "he stages of grieving identified by *liRoss are#$. Nubness, anger, resolution and reorgani


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(2!. )hich of the following ters refers to weakness of both legs and the lower part of the trunk/$. Paraparesis&. ?eiplegia%. uadriparesis'. Paraplegia

(2(. Cf the following neurotransitters, which deonstrates inhibitory action, helps control oodand sleep, and inhibits pain pathways/

$. Serotonin&. *nkephalin%. Norepinephrine'. $cetylcholine

(2-. "he lobe of the brain that contains the auditory receptive areas is the lobe.$. teporal&. frontal%. parietal

'. occipital

(2. 3n preparation for *%", the nurse knows that it is alost siilar to that of#$. *%7 %. **7&. 7eneral $nesthesia '. MR3

(22. "he expected side effect after *%" is coonly associated with#$. "ransient loss of eory, confusion and disorientation&. Nausea and voiting%. 9ractures'. ?ypertension and increased in cardiac rate

(20. "he purpose of *%" in clients with depression is to#$. Stiulation in the brain to increase brain conduction and counteract depression&. Mainly &iologic, increasing the norepinephrine and serotonin level%. %reates a teporary brain daage that will increase blood flow to the brain'. 3nvolves the conduction of electrical current to the brain to charge the neurons and cobatdepression

(26. "he priority nursing diagnosis for a client with a@or depression is#$. $ltered nutrition&. $ltered thought process

%. Self care deficit'. Risk for in@ury

(28. $ patient tells the nurse D3 a depressed to talk to you, leave e aloneE )hich of the followingresponse by the nurse is ost therapeutic/

$. 3ll be back in an hour&. )hy are you so depressed/%. 3ll seat with you for a oent'. %all e when you feel like talking to e

(2;. Cne of the following stateents is true with regards to the care of clients with depression#

$. Cnly entally ill persons coit suicide&. $ll depressed clients are considered potentially suicidal%. Most suicidal person gives no warning'. "he chance of suicide lessens as depression lessens

(01. $n adolescent client has bloodshot eyes, a voracious appetite and dry outh. )hich drugabuse would the nurse ost likely suspect/

$. Mari@uana&. $phetaines%. &arbiturates


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'. $nxiolytics

(0!. 'uring which phase of therapeutic relationship should the nurse infor the patient forterination of therapy/

$. Pre>orientation&. Crientation%. )orking'. "erination

(0(. $ client says to the nurse D3 a worthless person, 3 should be deadE "he nurse best replies#$. D'ont say you are worthless, you are not a worthless personE&. D)e are going to help you with your feelingsE%. D)hat akes you feel youre worthless/E'. D)hat you say is not trueE

(0-. "he nurses ost uni5ue tool in working with the eotionally ill client is hisFher$. theoretical knowledge&. personality ake up%. eotional reactions

'. counication skills

(0. "he entally ill person responds positively to the nurse who is war and caring. "his is adeonstration of the nurses role as#

$. counselor&. other surrogate%. therapist'. sociali


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(61. 3n a therapeutic relationship, the nurse ust understand own values, beliefs, feelings,pre@udices how these affect others. "his is called#

$. "herapeutic use of self&. Psychotherapy%. "herapeutic counication'. Self awareness

(6!. )hile on &ryants traction, which of these observations of 7raciela and her traction apparatus

would indicate a decrease in the effectiveness of her traction/$. 7racielas buttocks are resting on the bed.&. "he traction weights are hanging !1 inches above the floor.%. 7racielas legs are suspended at a ;1 degree angle to her trunk.'. "he traction ropes ove freely through the pulley.

(6(. "he nurse notes that the fall ight also cause a possible head in@ury. She will be observed forsigns of increased intracranial pressure which include#

$. Narrowing of the pulse pressure&. :oiting%. Periorbital edea

'. $ positive Bernigs sign

(6-. "his is a tricyclic antidepressant drug#$. :enlafaxine H*ffexorI&. 9louxetine HPro


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(6;. Aifestyle>related diseases in general share areas coon risk factors. "hese are the followingexcept#

$. physical activity&. soking%. genetics'. nutrition

(81. "he following echaniss can be utili


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$. Place June on an upright lateral position&. Perfor range of otion exercises%. $pply antiebolic stockings'. Gse hand rolls or pillows for support

(80. Saloe was fitted a hearing aid. She understood the proper use and wear of this device whenshe says that the battery should be functional, the device is turned on and ad@usted to a#

$. therapeutic level

&. cofortable level%. prescribed level'. audible level

(86. Mebership dropout generally occurs in group therapy after a eber#$. $ccoplishes his goal in @oining the group&. 'iscovers that his feelings are shared by the group ebers%. *xperiences feelings of frustration in the group'. 'iscusses personal concerns with group ebers

(88. )hich of the following 5uestions illustrates the group role of encourager/

$. )hat were you saying/&. )ho wants to respond next/%. )here do you go fro here/'. )hy havent we heard fro you/

(8;. "he goal of reotivation therapy is to facilitate#$. 3nsight %. Sociali


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'. .1 c.

(;0. )hich of the ff. colors would you expect a tank containing nitrous oxide Hlaughing gasI to have,based on the universally>accepted color codes/

$. Red&. &lue%. 7reenD. Crange

(;6. 9ro an *%7 reading, a RS %oplex represents#$. $trial depolari


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ANSWER KEY

!. &. %lient seated upright in bed or on a chair then leaning forward in sitting position then flat on hisback and on his abdoen

(. %. $ount of fluid intake of client before and after the procedure-. %. "eaching the clients relatives to perfor the procedure. &. %lient can tolerate sitting and lying positions2. &. Percussion delivers cushioned blows to the chest with cupped pals while vibration gently

shakes secretion loose on the exhalation cycle0. '. 'o a physical exaination while asking the client relevant 5uestions

6. %. anger8. $. &eneficence;. $. $ssessent!1.$. nurses anage collaborative probles using physician>prescribed interventions.!!.$. ?old urine as long as she can before eptying the bladder to strengthen her sphincter uscles!(.%. loss of tone of the sooth uscles of the colon!-.'. prolonged use of laxatives!.%. the distance fro the tip of the nose to the tip of the ear lobe!2.%. Pup the cuff to around 21 ?g above the point where the pulse is obliterated!0.'. 'etect oxygen saturation of arterial blood before syptos of hypoxeia develops!6.$. 'istributive

!8.$. 3ntravenous!;.%. higher than what the reading should be(1.&. -1 inutes(!.%. %over the fingertip sensor with a towel or bedsheet((.'. inflated to -1 ?g above the estiated systolic &P based on palpation of radial or brachial

artery(-.&. blood should be wared to roo teperature for -1 inutes before blood transfusions is

adinistered(.'. ! tsp of saltFday but no patis and toyo(2.$. +>ray(0.$. %igarette soking

(6.$. !1>!2 seconds(8.$. 9ifth intercostal space, idclavicular line(;.$. Stroke volue-1.&. Patches ay be applied to distal part of the extreities like forear-!.&. "he internal diaeter of the tube-(.&. )ithdrawing of the suction catheter--.$. Separate the upper and lower airway-.'. Risk for infection-2.'. Beep the patient clean and dry-0.'. Aaisse< 9aire


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-6.$. $utocratic-8.$. Planning-;.&. *valuating1.$. Philosophy!.%. Next of Bin(.'. 'urable Power of $ttorney-.&. Stay with Mang %arlos and do nothing.&. Patients &ill of Rights

2.%. !2 inutes0.$. Review of related literature6.'. Pilot Study8.$. *ffective Nurse>patient counication;.%. $nxiety level21.%. $pplied research2!.'. "here is a careful selection of sub@ects in the experiental group2(.&. is assigning the responsibility to the aide but not the accountability for those tasks2-.%. collective bargaining2.&. 3n>service education22.$. R.$ ;!6-

20.%. Prudence26.%. Mitigating28.$. $utonoy2;.%. &ecause the patients right coincide with the nurses responsibility01.'. "hose involved in edical ission whos services are for free0!.$. $utonoy0(.$. $ccountable0-.%. $ registered nurse is responsible for a group of patients fro adission to discharge0.$. 9unctional Method02.$. Raise the side rails, cover, put the call bell within reach, and attend to the client in pain to give

the PRN edication

00.'. Put the bed in the lowest position ever06.&. ;1 K08.%. 3t forces the edication to be contained at the subcutaneous tissues

0;.$. Not universally accepted abbreviations61.$. 3nspection, $uscultation, Percussion, Palpation6!.$. &roaden the space between the feet6(.$. $t the level of the heart6-.'. %onduction

6.'. ?andwashing62.&. Natural passive iunity60.%. 3 ust choose another doctor if 3 withdrew fro this research66.%. "he water fluctuates during inhalation of the patient68.&. $lcoholi


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;(.%. %old copress prevents edea and reduces pain;-.%. 3ncrease oxygenation to the in@ured tissues for better healing;.&. 'isclosure;2.&. 9easibility;0.'. Mean;6.&. )ithin ( hours after discharge;8.%. uasi>Aegislative Power;;.%. "he Si


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!21. '. Practice respiratory isolation!2!. '. 3pleent a regular aintenance and testing of alar systes!2(. $. %heck the functionality of the pup before use!2-. &. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist!2. &. Nurse Supervisor!22. '. %ounication!20. '. Seek early treatent for respiratory infection!26. &. ?ypothyroidis

!28. $. 7ag reflex!2;. %. Grinary fre5uency!01. $. $pply liberal aount of ineral oil to the area!0!. %. *at balanced eals at regular intervals!0(. $. 3ncreased weight!0-. $. 3ncrease the irrigating solution flow rate when abdoinal craps is felt!0. &. Sensation of pressure!02. '. Aeft Sis position!00. &. Side>lying position!06. %. Peranent colostoy!08. $. 3t is an incision into the colon to create an artificial opening to the exterior of the abdoen

!0;. '. Proctosigoidoscopy!61. %. blood in the stools, aneia, and Dpencil shapedE stools!6!. '. Red, oist and slightly protruding fro the abdoen!6(. '. Mild soap and water!6-. &. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion!6. %. 7eneral population!62. &. Gsing standardi


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(!!. &. %alciu gluconate(!(. '. reoval of the patients clothing and @ewelry and then rinsing the patient with water(!-. &. colloidal HoatealI

(!. '. aspirin(!2. %. "hird degree burn(!0. $. 3 and C hourly

(!6. '. 9luid Resuscitation(!8. &. ?yperkaleia(!;. '. G wave((1. $. 3:((!. '. %heical(((. '. Sulfaylon((-. &. rando layering of collagen((. $. case study((2. %. $udio>visual recording((0. $. Nurses own beliefs and attitude about the entally ill((6. $. Self>awareness

((8. &. %ounter "ransference((;. %. Aistening(-1. &. Moderate(-!. &. Persistent thoughts and behavior(-(. '. 4ou are Maria Salvacion(--. %. Religious delusion(-. $. "hought content(-2. &. 'elusion(-0. $. Psychotherapy(-6. %. %risis(-8. &. Neurotic disorders

(-;. $. Risk for in@ury(1. &. Risk for in@ury directed to others(!. '. Cffer sealed foods((. &. $utonoy vs. Shae and 'oubt(-. $. "he sae sex(. %. Situational crisis(2. $. $ctive and 'irective(0. '. 7enerativity vs. Stagnation(6. $. Nubness, anger, resolution and reorganiawareness


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(6!. $. 7racielas buttocks are resting on the bed.(6(. &. :oiting(6-. '. 3ipraine H"ofranilI(6. &. %ohesiveness(62. '. includes characteristics of tolerance and withdrawal(60. '. $c5uire acadeic skills of 0th grade level(66. &. %odependent(68. &. "ype 33 is ore coon and is also preventable copared to "ype 3 diabetes which is

genetic in etiology(6;. %. genetics(81. '. Gse of Nursing 3nterventions %lassification(8!. '. "he Standards of %are includes the various steps of the NP and the standards of

professional perforance(8(. &. ?ave ( nurse validate the order, both nurses sign the order and the doctor should sign his

order within ( hrs(8-. &. a b are strong @ustifications(8. '. Speak softly then hold her hands gently(82. &. Perfor range of otion exercises(80. '. audible level

(86. %. *xperiences feelings of frustration in the group(88. &. )ho wants to respond next/(8;. $. 3nsight(;1. &. ego(;!. '. includes characteristics of tolerance and withdrawal(;(. '. proote hoeostasis and inii

nsg. le reviewer

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