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PNLE : Medical Surgical Nursing Exam 1 (PM)
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Question 1
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
When caring for Mr. Batumbakal, Jet teaches the client to avoid
A
Bending at the waist
B
Going out in the sun
C
Watching large screen TVs
D
Reading books
Question 2
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except
A
23 Year old athlete taking long term Decadron therapy and anabolic steroids
B
Undernourished and Underweight individual who undergone gastrectomy
C
23 Year old athlete with diabetes insipidus
D
23 Year old athlete taking illegal drugs and abusing substances
Question 3
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse should insert the colostomy tube for irrigation at approximately
A
1-2 inches
B
3-4 inches
C
12-18 inches
D
6-8 inches
Question 4
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Stat appendectomy was indicated. Pre op care would include all of the following except?
A
Remove the jewelries
B
Enema STAT
C
Consent signed by the father
D
Skin prep of the area including the pubis
Question 5
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Why is Mantoux test not routinely done in the Philippines?
A
Chest X Ray Can diagnose the specific microorganism responsible for the lesions
B
The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
C
It requires a highly skilled nurse to perform a Mantoux test
D
Almost all Filipinos will test positive for Mantoux Test
Question 6
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse notes that a positive result for Alfred is
A
5 mm wheal
B
10 mm Induration
C
5 mm Induration
D
10 mm Wheal
Question 7
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
A
The affected lobe in the patient is the Right lobe
B
The affected lobe in the patient is the Right lobe
C
Expressive aphasia is prominent on clients with right sided weakness
D
Clients orientation to time and space will be much affected
Question 8
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
The nurse is aware that in communicating with an elderly client, the nurse will
A
Use a low-pitched voice
B
Open mouth wide while talking to the client
C
Lean and shout at the ear of the client
D
Use a medium-pitched voice
Question 9
The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to
A
Infection
B
Inflammation
C
Degenerative disease
D
Thrombophlebitis
Question 10
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?
A
Irreversible vision loss
B
There is an increase in IOP
C
Pain
D
Loss of peripheral vision
Question 11
Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?
A
I will not eat turnips, red meat and raddish
B
I must drink atleast 3,000 ml of fluids per day
C
I will try to eat foods that are low in sodium and limit my fluid intake
D
I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
Question 12
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Approximately how much fluid is lost in acute weight loss of .5kg?
A
500 ml
B
750 ml
C
75 ml
D
50 ml
Question 13
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
A
A narrow and flattened stoma
B
Protruding stoma with swollen appearance
C
A sunken and hidden stoma
D
A dusky and bluish stoma
Question 14
The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except
A
Taking Furosemide and Phenytoin.
B
Hypothyroidism
C
Cushing’s Disease
D
End stage renal disease
Question 15
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him
A
Leans on the cane when the right leg swings through.
B
Holds the cane on the right side.
C
keeps the cane 6 Inches out to the side of the right foot.
D
Moves the cane when the right leg is moved.
Question 16
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
The main difference between chronic and organic brain syndrome is that the former
A
Occurs suddenly and reversible
B
tends to be progressive and irreversible
C
Is progressive and reversible
D
Occurs suddenly and irreversible
Question 17
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse jet knew that Acute close angle glaucoma is caused by
A
Obstruction in trabecular meshwork
B
An abrupt rise in IOP from 8 to 15 mmHg
C
Sudden blockage of the anterior angle by the base of the iris
D
Gradual increase of IOP
Question 18
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Common anesthesia for appendectomy is
A
Spinal
B
Caudal
C
General
D
Hypnosis
Question 19
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is
A
Relaxes the Ciliary muscle
B
Reduce production of CSF
C
Constrict the pupil
D
Reduce production of Aquesous Humor
Question 20
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
You also told Mr. Rojas to hold the cane
A
12 Inches at the lateral side of the foot.
B
3 Inches at the lateral side of the foot.
C
6 Inches at the lateral side of the foot.
D
1 Inches in front of the foot.
Question 21
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?
A
Hemorrhage
B
Intussusception
C
Ruptured colon
D
Paralytic Ileus
Question 22
Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?
A
He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
B
He might have a sensory hearing loss in the left ear
C
Conductive hearing loss is possible in the right ear
D
He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
Question 23
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
This is the name of the program of the DOH to control TB in the country
A
Expanded Program for Immunization
B
DOTS
C
National Tuberculosis Control Program
D
Short Coursed Chemotherapy
Question 24
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as
A
PDP
B
DPP
C
PDD
D
PPD
Question 25
Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?
A
Food, Diet and Nutrition
B
Air, Breathing, Circulation
C
Safety
D
Love and Belongingness
Question 26
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
The nurse will assess a loss of ability in which of the following areas?
A
Balance
B
Endurance
C
Speech
D
Judgment
Question 27
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
A
5-10 mmHg
B
20-25 mmHg
C
2-5 mmHg
D
10-15 mmHg
Question 28
Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?
A
Instill an antibiotic ear drops
B
Use a flashlight to coax the insect out of peachy’s ear
C
Irrigate the ear
D
Pick out the insect using a sterile clean forceps
Question 29
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Which of the following is the appropriate nursing diagnosis?
A
Fluid volume deficit R/T uncontrolled vomiting
B
Dehydration R/T subnormal body temperature
C
Dehydration R/T incessant vomiting
D
Fluid volume deficit R/T furrow tongue
Question 30
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?
A
IRIS
B
RODS [RETINA]
C
PUPIL
D
CONES [RETINA]
Question 31
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by
A
Death of brain cells due to old age
B
Impairment of dopamine producing cells in the brain
C
Injurious chemical substances
D
Hereditary factors
Question 32
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
A
Fr. 10
B
Fr. 12
C
Fr. 5
D
Fr. 18
Question 33
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse knew that the normal color of Michiel’s stoma should be
A
Pale Pink
B
Gray
C
Blue
D
Brick Red
Question 34
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
Which behavior results from organic psychoses?
A
Disorientation
B
Inappropriate affect
C
Impaired Judgement
D
Memory deficit
Question 35
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?
A
Gonioscopy
B
Slit lamp
C
Wood’s light
D
Snellen’s Chart
Question 36
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
As a registered nurse, Arthur knew that the first thing that he will do at the scene is
A
Leave the person for a few moments to call for help.
B
Reduce the fracture manually.
C
Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance.
D
Move the person to a safer place.
Question 37
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
When do you think the NGT tube be removed?
A
Abdomen is soft and patient asks for water
B
When patient requests for it
C
Abdomen is soft and flatus has been expelled
D
B and C only
Question 38
Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?
A
A high calorie, high protein dietary intake
B
low fat, low sodium and high calorie intake
C
low sodium and restricted fluid intake
D
A low sodium , high fluid intake
Question 39
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
A
Theophylline and Epinephrine
B
New set of tracheostomy tubes and Oxygen tank
C
Obturator and Kelly clamp
D
Sterile saline dressing
Question 40
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
A
States that colostomy care is the function of the nurse while he is in the hospital
B
Ask to defer colostomy care to another individual
C
Promises he will begin to listen the next day
D
Agrees to look at the colostomy
Question 41
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
One day, the patient complained of difficulty in walking. Your response would be
A
Don’t force yourself to walk
B
You will need a cane for support
C
I’ll get you a wheelchair
D
Walk erect with eyes on horizon
Question 42
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
If a Wall unit is used, What should be the suctioning pressure required by James?
A
155-175 mmHg
B
95-110 mmHg
C
50-95 mmHg
D
100-120 mmHg
Question 43
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
A
Insert the cone 4 cm in the stoma
B
Use 500 ml to 1,000 ml NSS
C
Suspend the irrigant 45 cm above the stoma
D
If cramping occurs, slow the irrigation
Question 44
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
Arthur suspects a hip fracture when he noticed that the old woman’s leg is
A
Shortened, Abducted and Externally Rotated.
B
Shortened, Adducted and Externally Rotated.
C
Lengthened, Abducted and Internally Rotated.
D
Shortened, Adducted and Internally Rotated.
Question 45
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?
A
Order for a sputum exam
B
Call the Physician
C
Isolate the patient
D
Notify the radiology dept. for CXR evaluation
Question 46
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Which of the following is most important discharge teaching for Mr. Dela Isla
A
Emergency Numbers
B
Drug Compliance
C
Relaxation technique
D
Dietary prescription
Question 47
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?
A
Pindolol [Visken]
B
Mesoridazine Besylate [Serentil]
C
Atropine Sulfate
D
Naloxone Hydrochloride [Narcan]
Question 48
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
What is the rationale for giving Mr. Franco frequent mouth care?
A
Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
B
He will be thirsty considering that he is doesn’t drink enough fluids
C
To remove dried blood when tongue is bitten during a seizure
D
The tactile stimulation during mouth care will hasten return to consciousness
Question 49
Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?
A
Fever and Bradycardia
B
Fever and Hypertension
C
Tachycardia and Hypotension
D
Bradycardia and Hypertension
Question 50
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
A
Use special water mattress
B
Keep skin clean and dry
C
Massage reddened areas with lotion or oils
D
Turn frequently every 2 hours
Question 51
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?
A
Lying down
B
Watching TV
C
Listening to the music
D
Reading newsprint
Question 52
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
Which of the following drugs are not compatible when taking Probanthine?
A
Acetaminophen
B
Alcohol
C
Caffeine
D
NSAID
Question 53
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse would inject the solution in what route?
A
IV
B
ID
C
SC
D
IM
Question 54
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
A
I know the hallucinations are parts of the disease
B
Ill turn off the TV when we go to another room
C
I help her do some tasks he cannot do for himself
D
I told her she is wrong and I explained to her what is right
Question 55
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet knows that Aqueous Humor is produce where?
A
In the sub arachnoid space of the meninges
B
In the Ciliary Body
C
In the Choroids
D
In the Lateral ventricles
Question 56
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures
A
Determines the Tone of the eye in response to the sudden increase in IOP.
B
Measures the Client’s Visual Acuity
C
It measures the peripheral vision remaining on the client
D
Measures the Intra Ocular Pressure
Question 57
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?
A
Quarterly
B
Tertiary
C
Secondary
D
Primary
Question 58
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
How long is the duration of the maintenance phase of his treatment?
A
2 months
B
3 months
C
5 months
D
4 months
Question 59
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
A
Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
B
The tracheotomy can be pulled slightly away from the neck
C
Wilma places 2 fingers between the tie and neck
D
James’ neck veins are not engorged
Question 60
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
A
Footboard and splint
B
Hand bell and extra bed linen
C
Sandbag and trochanter rolls
D
Footboard and splint
Question 61
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to
A
Relax the Ciliary muscle
B
Dilate the pupils
C
Contract the Ciliary muscle
D
Decrease production of Aqueous Humor
Question 62
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What is the action of this drug?
A
Dissolve blockage of the urinary tract due to obstruction of cystine stones
B
Increases glandular secretion for clients affected with cystic fibrosis
C
Stimulate peristalsis for treatment of constipation and obstruction
D
Reduces secretion of the glandular organ of the body
Question 63
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :
A
Reduce pain
B
Relax abdominal muscle
C
Allay anxiety and apprehension
D
Prevent vomiting
Question 64
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Which of the following measures will not help correct the patient’s condition
A
Give small volumes of fluid at frequent interval
B
Frequent oral care
C
Offer large amount of oral fluid intake to replace fluid lost
D
Give enteral or parenteral fluid
Question 65
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
A
Look at the ostomy site
B
Talk about his ostomy openly to the nurse and friends
C
Participate with the nurse in his daily ostomy care
D
Ask for leaflets and contact numbers of ostomy support groups
Question 66
Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?
A
This indicates an intact and working vestibular branch of CN VIII
B
The test should be repeated again because the result is vague
C
This is Grossly abnormal and should be reported to the neurosurgeon
D
Indicating a Cranial Nerve VIII Dysfunction
Question 67
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The maximum height of irrigation solution for colostomy is
A
24 inches
B
5 inches
C
18 inches
D
12 inches
Question 68
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse told Alfred to come back after
A
a week
B
1 day
C
48 hours
D
4 days
Question 69
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
The patient was prescribed with levodopa. What is the action of this drug?
A
Decrease acetylcholine availability
B
Decrease acetylcholine availability
C
Activates dopaminergic receptors in the basal ganglia
D
Increase dopamine availability
Question 70
Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is
A
Pull the pinna up and back and direct the solution towards the eardrum
B
Pull the pinna up and back and direct the solution onto the wall of the canal
C
Pull the pinna down and back and direct the solution onto the wall of the canal
D
Pull the pinna down and back and direct the solution towards the eardrum
Question 71
The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?
A
Diazepam [Valium]
B
Out of bed activities and ambulation
C
Dipenhydramine [Benadryl]
D
Atropine sulfate
Question 72
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma knew that the maximum time when suctioning James is
A
20 seconds
B
10 seconds
C
30 seconds
D
45 seconds
Question 73
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Postural Hypotension is
A
A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
B
A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
C
A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
D
A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Question 74
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.
Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
A
Indicates a CN VIII Dysfunction
B
Inconclusive
C
Abnormal
D
Normal
Question 75
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
A
Plain NSS / Normal Saline
B
K-Y Jelly
C
Tap water
D
Irrigation sleeve
Question 76
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
Which of the following is a characteristic of a patient with advanced Parkinson’s disease?
A
Mask like facial expression
B
Forgetfulness
C
Disturbed vision
D
Muscle atrophy
Question 77
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Which result of the lab test will be significant to the diagnosis?
A
Hgb : 13 to 14 gm/dl.
B
WBC : 12,000 to 13,000/cu.mm
C
RBC : 4.5 TO 5 Million / cu. mm.
D
Platelets : 250,000 to 500,000 cu.mm.
Question 78
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
What do you call a STROKE that manifests a bizarre behavior?
A
Organic Psychoses
B
Inorganic Stroke
C
Inorganic Psychoses
D
Organic Stroke
Question 79
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
A
Slow down the irrigation
B
Tell the client that cramping will subside and is normal
C
Notify the physician
D
Stop the irrigation by clamping the tube
Question 80
A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?
A
Knowledge deficit R/T the pre operative and post operative self care
B
Anxiety R/T to the operation and its outcome
C
Body Image disturbance R/T the eye packing after surgery
D
Sensory perceptual alteration R/T Lens extraction and replacement
Question 81
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
A
Patency of airway and adequacy of respiration
B
Level of awareness and response to pain
C
Papillary reflexes and response to sensory stimuli
D
Coherence and sense of hearing
Question 82
Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?
A
Rifampicin
B
Pyridoxine
C
Isoniazid
D
Ethambutol
Question 83
Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?
A
I will use straw for drinking
B
Activities are resumed within 5 days
C
I will make sure that I will clean my hair and face to prevent infection
D
I should avoid air travel for a while
Question 84
After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is
A
CN VI
B
CN II
C
CN VII
D
CN I
Question 85
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What should the nurse tell clients when taking Probanthine?
A
Avoid cold weathers to prevent hypothermia
B
Make sure you limit your fluid intake to 1L a day
C
Avoid hot weathers to prevent heat strokes
D
Never swim on a chlorinated pool
Question 86
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What should the nurse caution the client when using this medication
A
Take the drug on empty stomach
B
Avoid hazardous activities like driving, operating machineries etc.
C
Take with a full glass of water in treatment of Ulcerative colitis
D
I must take double dose if I missed the previous dose
Question 87
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Post op care for appendectomy include the following except
A
Diet as tolerated after fully conscious
B
Deep breathing and leg exercise
C
Nasogastric tube connect to suction
D
Early ambulation
Question 88
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?
A
Urinary retention
B
Peptic Ulcer Disease
C
Ulcerative Colitis
D
Glaucoma
Question 89
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma knew that James have an adequate respiratory condition if she notices that
A
There are frank blood suction from the tube
B
There are moderate amount of tracheobronchial secretions
C
James’ Oxygen saturation is 91%
D
James’ respiratory rate is 18
Question 90
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
You are discussing with the dietician what food to avoid with patients taking levodopa?
A
Thiamine rich food
B
Vitamin E rich food
C
Vitamin B6 rich food
D
Vitamin C rich food
Question 91
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane
A
On his right hand, because only his right leg is weak.
B
On his right hand, to support the right leg.
C
On his left hand, because his right side is weak.
D
On his left hand, because of reciprocal motion.
Question 92
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
A
Eat cucumbers
B
Eat eggs
C
Eat beet greens and parsley
D
Eat broccoli and spinach
Question 93
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
A
I
B
III
C
IV
D
II
Question 94
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
A
Agnosia
B
Aphraxia
C
Aphasia
D
Insomnia
Question 95
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
After nursing intervention, you will expect the patient to have
Maintain body temperature at 36.5 C
Exhibit return of BP and Pulse to normal
Manifest normal skin turgor of skin and tongue
Drinks fluids as prescribed
A
2,4
B
1,3,4
C
2,3,4
D
1,3
Question 96
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
According to the DOH, the most hazardous period for development of clinical disease is during the first
A
2-4 weeks after
B
6-12 months after
C
1-2 months after
D
3-6 months after
Question 97
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Peritonitis may occur in ruptured appendix and may cause serious problems which are
Hypovolemia, electrolyte imbalance
Elevated temperature, weakness and diaphoresis
Nausea and vomiting, rigidity of the abdominal wall
Pallor and eventually shock
A
All of the above
B
2 and 3
C
1,2,3
D
1 and 2
Question 98
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
NGT was connected to suction. In caring for the patient with NGT, the nurse must
A
Offer some ice chips to wet lips
B
advance the tube every hour to avoid kinks
C
Irrigate the tube with saline as ordered
D
Use sterile technique in irrigating the tube
Question 99
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet knows that the normal IOP is
A
8-21 mmHg
B
2-7 mmHg
C
31-35 mmHg
D
15-30 mmHg
Question 100
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
A
Instilling 3 to 5 ml normal saline to loosen up secretion
B
Applying suction during catheter withdrawal
C
Suction the client every hour
D
Hyperventilating James with 100% oxygen before and after suctioning
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PNLE : Medical Surgical Nursing Exam 1 (EM)
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Question 1
After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is
A
CN VII
B
CN II
C
CN VI
D
CN I
Question 2
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Stat appendectomy was indicated. Pre op care would include all of the following except?
A
Skin prep of the area including the pubis
B
Consent signed by the father
C
Remove the jewelries
D
Enema STAT
Question 3
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
A
5-10 mmHg
B
2-5 mmHg
C
20-25 mmHg
D
10-15 mmHg
Question 4
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane
A
On his left hand, because of reciprocal motion.
B
On his right hand, because only his right leg is weak.
C
On his left hand, because his right side is weak.
D
On his right hand, to support the right leg.
Question 5
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse jet knew that Acute close angle glaucoma is caused by
A
Obstruction in trabecular meshwork
B
Sudden blockage of the anterior angle by the base of the iris
C
An abrupt rise in IOP from 8 to 15 mmHg
D
Gradual increase of IOP
Question 6
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
A
Irrigation sleeve
B
K-Y Jelly
C
Plain NSS / Normal Saline
D
Tap water
Question 7
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
A
I help her do some tasks he cannot do for himself
B
I told her she is wrong and I explained to her what is right
C
I know the hallucinations are parts of the disease
D
Ill turn off the TV when we go to another room
Question 8
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Approximately how much fluid is lost in acute weight loss of .5kg?
A
50 ml
B
750 ml
C
75 ml
D
500 ml
Question 9
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Which result of the lab test will be significant to the diagnosis?
A
WBC : 12,000 to 13,000/cu.mm
B
Hgb : 13 to 14 gm/dl.
C
Platelets : 250,000 to 500,000 cu.mm.
D
RBC : 4.5 TO 5 Million / cu. mm.
Question 10
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Why is Mantoux test not routinely done in the Philippines?
A
It requires a highly skilled nurse to perform a Mantoux test
B
Almost all Filipinos will test positive for Mantoux Test
C
Chest X Ray Can diagnose the specific microorganism responsible for the lesions
D
The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
Question 11
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
If a Wall unit is used, What should be the suctioning pressure required by James?
A
100-120 mmHg
B
95-110 mmHg
C
155-175 mmHg
D
50-95 mmHg
Question 12
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
After nursing intervention, you will expect the patient to have
Maintain body temperature at 36.5 C
Exhibit return of BP and Pulse to normal
Manifest normal skin turgor of skin and tongue
Drinks fluids as prescribed
A
1,3
B
2,3,4
C
1,3,4
D
2,4
Question 13
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Peritonitis may occur in ruptured appendix and may cause serious problems which are
Hypovolemia, electrolyte imbalance
Elevated temperature, weakness and diaphoresis
Nausea and vomiting, rigidity of the abdominal wall
Pallor and eventually shock
A
2 and 3
B
All of the above
C
1,2,3
D
1 and 2
Question 14
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse knew that the normal color of Michiel’s stoma should be
A
Blue
B
Gray
C
Brick Red
D
Pale Pink
Question 15
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?
A
Intussusception
B
Hemorrhage
C
Ruptured colon
D
Paralytic Ileus
Question 16
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What should the nurse tell clients when taking Probanthine?
A
Avoid cold weathers to prevent hypothermia
B
Avoid hot weathers to prevent heat strokes
C
Never swim on a chlorinated pool
D
Make sure you limit your fluid intake to 1L a day
Question 17
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Post op care for appendectomy include the following except
A
Deep breathing and leg exercise
B
Diet as tolerated after fully conscious
C
Nasogastric tube connect to suction
D
Early ambulation
Question 18
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
Which of the following is a characteristic of a patient with advanced Parkinson’s disease?
A
Forgetfulness
B
Mask like facial expression
C
Disturbed vision
D
Muscle atrophy
Question 19
Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is
A
Pull the pinna up and back and direct the solution onto the wall of the canal
B
Pull the pinna down and back and direct the solution onto the wall of the canal
C
Pull the pinna up and back and direct the solution towards the eardrum
D
Pull the pinna down and back and direct the solution towards the eardrum
Question 20
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to
A
Dilate the pupils
B
Contract the Ciliary muscle
C
Relax the Ciliary muscle
D
Decrease production of Aqueous Humor
Question 21
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
How long is the duration of the maintenance phase of his treatment?
A
3 months
B
4 months
C
5 months
D
2 months
Question 22
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
A
Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
B
The tracheotomy can be pulled slightly away from the neck
C
James’ neck veins are not engorged
D
Wilma places 2 fingers between the tie and neck
Question 23
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse notes that a positive result for Alfred is
A
10 mm Induration
B
5 mm wheal
C
5 mm Induration
D
10 mm Wheal
Question 24
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
The nurse will assess a loss of ability in which of the following areas?
A
Endurance
B
Balance
C
Speech
D
Judgment
Question 25
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
Arthur suspects a hip fracture when he noticed that the old woman’s leg is
A
Lengthened, Abducted and Internally Rotated.
B
Shortened, Adducted and Externally Rotated.
C
Shortened, Abducted and Externally Rotated.
D
Shortened, Adducted and Internally Rotated.
Question 26
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma knew that James have an adequate respiratory condition if she notices that
A
There are moderate amount of tracheobronchial secretions
B
There are frank blood suction from the tube
C
James’ respiratory rate is 18
D
James’ Oxygen saturation is 91%
Question 27
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
A
Obturator and Kelly clamp
B
Theophylline and Epinephrine
C
New set of tracheostomy tubes and Oxygen tank
D
Sterile saline dressing
Question 28
The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to
A
Thrombophlebitis
B
Infection
C
Degenerative disease
D
Inflammation
Question 29
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
This is the name of the program of the DOH to control TB in the country
A
Expanded Program for Immunization
B
DOTS
C
Short Coursed Chemotherapy
D
National Tuberculosis Control Program
Question 30
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
A
Agrees to look at the colostomy
B
Ask to defer colostomy care to another individual
C
States that colostomy care is the function of the nurse while he is in the hospital
D
Promises he will begin to listen the next day
Question 31
Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?
A
Irrigate the ear
B
Instill an antibiotic ear drops
C
Pick out the insect using a sterile clean forceps
D
Use a flashlight to coax the insect out of peachy’s ear
Question 32
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
A
Fr. 5
B
Fr. 12
C
Fr. 10
D
Fr. 18
Question 33
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse would inject the solution in what route?
A
SC
B
ID
C
IV
D
IM
Question 34
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
A
Footboard and splint
B
Footboard and splint
C
Hand bell and extra bed linen
D
Sandbag and trochanter rolls
Question 35
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
NGT was connected to suction. In caring for the patient with NGT, the nurse must
A
advance the tube every hour to avoid kinks
B
Use sterile technique in irrigating the tube
C
Irrigate the tube with saline as ordered
D
Offer some ice chips to wet lips
Question 36
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures
A
Determines the Tone of the eye in response to the sudden increase in IOP.
B
Measures the Client’s Visual Acuity
C
Measures the Intra Ocular Pressure
D
It measures the peripheral vision remaining on the client
Question 37
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
A
Level of awareness and response to pain
B
Coherence and sense of hearing
C
Patency of airway and adequacy of respiration
D
Papillary reflexes and response to sensory stimuli
Question 38
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
A
Insomnia
B
Agnosia
C
Aphasia
D
Aphraxia
Question 39
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is
A
Reduce production of Aquesous Humor
B
Reduce production of CSF
C
Constrict the pupil
D
Relaxes the Ciliary muscle
Question 40
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
The patient was prescribed with levodopa. What is the action of this drug?
A
Increase dopamine availability
B
Decrease acetylcholine availability
C
Activates dopaminergic receptors in the basal ganglia
D
Decrease acetylcholine availability
Question 41
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
You are discussing with the dietician what food to avoid with patients taking levodopa?
A
Vitamin C rich food
B
Vitamin E rich food
C
Vitamin B6 rich food
D
Thiamine rich food
Question 42
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Which of the following measures will not help correct the patient’s condition
A
Frequent oral care
B
Offer large amount of oral fluid intake to replace fluid lost
C
Give enteral or parenteral fluid
D
Give small volumes of fluid at frequent interval
Question 43
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
The nurse is aware that in communicating with an elderly client, the nurse will
A
Use a medium-pitched voice
B
Lean and shout at the ear of the client
C
Use a low-pitched voice
D
Open mouth wide while talking to the client
Question 44
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
A
IV
B
III
C
II
D
I
Question 45
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
A
Eat eggs
B
Eat broccoli and spinach
C
Eat cucumbers
D
Eat beet greens and parsley
Question 46
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?
A
Reading newsprint
B
Listening to the music
C
Lying down
D
Watching TV
Question 47
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
The main difference between chronic and organic brain syndrome is that the former
A
tends to be progressive and irreversible
B
Occurs suddenly and irreversible
C
Occurs suddenly and reversible
D
Is progressive and reversible
Question 48
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?
A
Snellen’s Chart
B
Wood’s light
C
Slit lamp
D
Gonioscopy
Question 49
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet knows that Aqueous Humor is produce where?
A
In the Ciliary Body
B
In the Choroids
C
In the Lateral ventricles
D
In the sub arachnoid space of the meninges
Question 50
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What is the action of this drug?
A
Stimulate peristalsis for treatment of constipation and obstruction
B
Increases glandular secretion for clients affected with cystic fibrosis
C
Dissolve blockage of the urinary tract due to obstruction of cystine stones
D
Reduces secretion of the glandular organ of the body
Question 51
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Which of the following is the appropriate nursing diagnosis?
A
Dehydration R/T incessant vomiting
B
Fluid volume deficit R/T furrow tongue
C
Fluid volume deficit R/T uncontrolled vomiting
D
Dehydration R/T subnormal body temperature
Question 52
Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?
A
Fever and Bradycardia
B
Bradycardia and Hypertension
C
Tachycardia and Hypotension
D
Fever and Hypertension
Question 53
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
When caring for Mr. Batumbakal, Jet teaches the client to avoid
A
Watching large screen TVs
B
Reading books
C
Going out in the sun
D
Bending at the waist
Question 54
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
When do you think the NGT tube be removed?
A
B and C only
B
When patient requests for it
C
Abdomen is soft and flatus has been expelled
D
Abdomen is soft and patient asks for water
Question 55
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
A
Notify the physician
B
Slow down the irrigation
C
Stop the irrigation by clamping the tube
D
Tell the client that cramping will subside and is normal
Question 56
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?
A
Ulcerative Colitis
B
Urinary retention
C
Glaucoma
D
Peptic Ulcer Disease
Question 57
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
According to the DOH, the most hazardous period for development of clinical disease is during the first
A
2-4 weeks after
B
6-12 months after
C
3-6 months after
D
1-2 months after
Question 58
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Common anesthesia for appendectomy is
A
General
B
Spinal
C
Caudal
D
Hypnosis
Question 59
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by
A
Impairment of dopamine producing cells in the brain
B
Death of brain cells due to old age
C
Injurious chemical substances
D
Hereditary factors
Question 60
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
You also told Mr. Rojas to hold the cane
A
12 Inches at the lateral side of the foot.
B
3 Inches at the lateral side of the foot.
C
6 Inches at the lateral side of the foot.
D
1 Inches in front of the foot.
Question 61
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as
A
PDD
B
DPP
C
PDP
D
PPD
Question 62
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
A
Use special water mattress
B
Turn frequently every 2 hours
C
Massage reddened areas with lotion or oils
D
Keep skin clean and dry
Question 63
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?
A
Irreversible vision loss
B
There is an increase in IOP
C
Pain
D
Loss of peripheral vision
Question 64
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
As a registered nurse, Arthur knew that the first thing that he will do at the scene is
A
Reduce the fracture manually.
B
Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance.
C
Leave the person for a few moments to call for help.
D
Move the person to a safer place.
Question 65
Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?
A
I will try to eat foods that are low in sodium and limit my fluid intake
B
I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
C
I will not eat turnips, red meat and raddish
D
I must drink atleast 3,000 ml of fluids per day
Question 66
Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?
A
He might have a sensory hearing loss in the left ear
B
He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
C
He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
D
Conductive hearing loss is possible in the right ear
Question 67
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
What do you call a STROKE that manifests a bizarre behavior?
A
Organic Psychoses
B
Organic Stroke
C
Inorganic Stroke
D
Inorganic Psychoses
Question 68
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma knew that the maximum time when suctioning James is
A
45 seconds
B
10 seconds
C
30 seconds
D
20 seconds
Question 69
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
Which behavior results from organic psychoses?
A
Impaired Judgement
B
Inappropriate affect
C
Memory deficit
D
Disorientation
Question 70
Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?
A
Air, Breathing, Circulation
B
Safety
C
Love and Belongingness
D
Food, Diet and Nutrition
Question 71
Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?
A
This indicates an intact and working vestibular branch of CN VIII
B
This is Grossly abnormal and should be reported to the neurosurgeon
C
The test should be repeated again because the result is vague
D
Indicating a Cranial Nerve VIII Dysfunction
Question 72
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Postural Hypotension is
A
A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
B
A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C
A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
D
A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Question 73
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?
A
Quarterly
B
Primary
C
Secondary
D
Tertiary
Question 74
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The maximum height of irrigation solution for colostomy is
A
24 inches
B
5 inches
C
18 inches
D
12 inches
Question 75
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.
Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
A
Normal
B
Inconclusive
C
Indicates a CN VIII Dysfunction
D
Abnormal
Question 76
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
Which of the following drugs are not compatible when taking Probanthine?
A
NSAID
B
Acetaminophen
C
Caffeine
D
Alcohol
Question 77
A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?
A
Knowledge deficit R/T the pre operative and post operative self care
B
Body Image disturbance R/T the eye packing after surgery
C
Anxiety R/T to the operation and its outcome
D
Sensory perceptual alteration R/T Lens extraction and replacement
Question 78
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
What is the rationale for giving Mr. Franco frequent mouth care?
A
To remove dried blood when tongue is bitten during a seizure
B
The tactile stimulation during mouth care will hasten return to consciousness
C
Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
D
He will be thirsty considering that he is doesn’t drink enough fluids
Question 79
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
A
Clients orientation to time and space will be much affected
B
Expressive aphasia is prominent on clients with right sided weakness
C
The affected lobe in the patient is the Right lobe
D
The affected lobe in the patient is the Right lobe
Question 80
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse should insert the colostomy tube for irrigation at approximately
A
12-18 inches
B
3-4 inches
C
6-8 inches
D
1-2 inches
Question 81
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
Nurse Jet knows that the normal IOP is
A
2-7 mmHg
B
15-30 mmHg
C
8-21 mmHg
D
31-35 mmHg
Question 82
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
A
Protruding stoma with swollen appearance
B
A narrow and flattened stoma
C
A dusky and bluish stoma
D
A sunken and hidden stoma
Question 83
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?
A
Pindolol [Visken]
B
Naloxone Hydrochloride [Narcan]
C
Mesoridazine Besylate [Serentil]
D
Atropine Sulfate
Question 84
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
A
Participate with the nurse in his daily ostomy care
B
Ask for leaflets and contact numbers of ostomy support groups
C
Talk about his ostomy openly to the nurse and friends
D
Look at the ostomy site
Question 85
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
What should the nurse caution the client when using this medication
A
I must take double dose if I missed the previous dose
B
Take the drug on empty stomach
C
Avoid hazardous activities like driving, operating machineries etc.
D
Take with a full glass of water in treatment of Ulcerative colitis
Question 86
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him
A
keeps the cane 6 Inches out to the side of the right foot.
B
Leans on the cane when the right leg swings through.
C
Holds the cane on the right side.
D
Moves the cane when the right leg is moved.
Question 87
Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?
A
low sodium and restricted fluid intake
B
low fat, low sodium and high calorie intake
C
A low sodium , high fluid intake
D
A high calorie, high protein dietary intake
Question 88
The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except
A
Taking Furosemide and Phenytoin.
B
End stage renal disease
C
Cushing’s Disease
D
Hypothyroidism
Question 89
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
One day, the patient complained of difficulty in walking. Your response would be
A
You will need a cane for support
B
I’ll get you a wheelchair
C
Walk erect with eyes on horizon
D
Don’t force yourself to walk
Question 90
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
A
Use 500 ml to 1,000 ml NSS
B
If cramping occurs, slow the irrigation
C
Insert the cone 4 cm in the stoma
D
Suspend the irrigant 45 cm above the stoma
Question 91
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
The nurse told Alfred to come back after
A
4 days
B
a week
C
48 hours
D
1 day
Question 92
The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?
A
Out of bed activities and ambulation
B
Atropine sulfate
C
Dipenhydramine [Benadryl]
D
Diazepam [Valium]
Question 93
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :
A
Relax abdominal muscle
B
Reduce pain
C
Prevent vomiting
D
Allay anxiety and apprehension
Question 94
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Which of the following is most important discharge teaching for Mr. Dela Isla
A
Relaxation technique
B
Drug Compliance
C
Emergency Numbers
D
Dietary prescription
Question 95
Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?
A
Rifampicin
B
Pyridoxine
C
Ethambutol
D
Isoniazid
Question 96
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except
A
23 Year old athlete taking long term Decadron therapy and anabolic steroids
B
23 Year old athlete taking illegal drugs and abusing substances
C
Undernourished and Underweight individual who undergone gastrectomy
D
23 Year old athlete with diabetes insipidus
Question 97
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?
A
CONES [RETINA]
B
IRIS
C
PUPIL
D
RODS [RETINA]
Question 98
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
A
Instilling 3 to 5 ml normal saline to loosen up secretion
B
Applying suction during catheter withdrawal
C
Suction the client every hour
D
Hyperventilating James with 100% oxygen before and after suctioning
Question 99
Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?
A
I should avoid air travel for a while
B
I will use straw for drinking
C
Activities are resumed within 5 days
D
I will make sure that I will clean my hair and face to prevent infection
Question 100
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?
A
Call the Physician
B
Order for a sputum exam
C
Isolate the patient
D
Notify the radiology dept. for CXR evaluation
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Text Mode
Text Mode – Text version of the exam
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is
Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance.
Leave the person for a few moments to call for help.
Reduce the fracture manually.
Move the person to a safer place.
2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is
A. Lengthened, Abducted and Internally Rotated.
Shortened, Abducted and Externally Rotated.
Shortened, Adducted and Internally Rotated.
Shortened, Adducted and Externally Rotated.
3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to
Infection
Thrombophlebitis
Inflammation
Degenerative disease
4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except
Hypothyroidism
End stage renal disease
Cushing’s Disease
Taking Furosemide and Phenytoin.
5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?
Tachycardia and Hypotension
Fever and Bradycardia
Bradycardia and Hypertension
Fever and Hypertension
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane
On his left hand, because his right side is weak.
On his left hand, because of reciprocal motion.
On his right hand, to support the right leg.
On his right hand, because only his right leg is weak.
7. You also told Mr. Rojas to hold the cane
1 Inches in front of the foot.
3 Inches at the lateral side of the foot.
6 Inches at the lateral side of the foot.
12 Inches at the lateral side of the foot.
8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him
Moves the cane when the right leg is moved.
Leans on the cane when the right leg swings through.
keeps the cane 6 Inches out to the side of the right foot.
Holds the cane on the right side.
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as
PPD
PDP
PDD
DPP
10. The nurse would inject the solution in what route?
IM
IV
ID
SC
11. The nurse notes that a positive result for Alfred is
5 mm wheal
5 mm Induration
10 mm Wheal
10 mm Induration
12. The nurse told Alfred to come back after
a week
48 hours
1 day
4 days
13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?
Call the Physician
Notify the radiology dept. for CXR evaluation
Isolate the patient
Order for a sputum exam
14. Why is Mantoux test not routinely done in the Philippines?
It requires a highly skilled nurse to perform a Mantoux test
The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
Chest X Ray Can diagnose the specific microorganism responsible for the lesions
Almost all Filipinos will test positive for Mantoux Test
15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
I
II
III
IV
16. How long is the duration of the maintenance phase of his treatment?
2 months
3 months
4 months
5 months
17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?
Rifampicin
Isoniazid
Ethambutol
Pyridoxine
18. According to the DOH, the most hazardous period for development of clinical disease is during the first
6-12 months after
3-6 months after
1-2 months after
2-4 weeks after
19. This is the name of the program of the DOH to control TB in the country
DOTS
National Tuberculosis Control Program
Short Coursed Chemotherapy
Expanded Program for Immunization
20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except
23 Year old athlete with diabetes insipidus
23 Year old athlete taking long term Decadron therapy and anabolic steroids
23 Year old athlete taking illegal drugs and abusing substances
Undernourished and Underweight individual who undergone gastrectomy
21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?
Primary
Secondary
Tertiary
Quarterly
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
22. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
Look at the ostomy site
Participate with the nurse in his daily ostomy care
Ask for leaflets and contact numbers of ostomy support groups
Talk about his ostomy openly to the nurse and friends
23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
Plain NSS / Normal Saline
K-Y Jelly
Tap water
Irrigation sleeve
24. The nurse should insert the colostomy tube for irrigation at approximately
1-2 inches
3-4 inches
6-8 inches
12-18 inches
25. The maximum height of irrigation solution for colostomy is
5 inches
12 inches
18 inches
24 inches
26. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
Ask to defer colostomy care to another individual
Promises he will begin to listen the next day
Agrees to look at the colostomy
States that colostomy care is the function of the nurse while he is in the hospital
27. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
Stop the irrigation by clamping the tube
Slow down the irrigation
Tell the client that cramping will subside and is normal
Notify the physician
28. The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
A sunken and hidden stoma
A dusky and bluish stoma
A narrow and flattened stoma
Protruding stoma with swollen appearance
29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
Eat eggs
Eat cucumbers
Eat beet greens and parsley
Eat broccoli and spinach
30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
Use 500 ml to 1,000 ml NSS
Suspend the irrigant 45 cm above the stoma
Insert the cone 4 cm in the stoma
If cramping occurs, slow the irrigation
31. The nurse knew that the normal color of Michiel’s stoma should be
Brick Red
Gray
Blue
Pale Pink
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
Hyperventilating James with 100% oxygen before and after suctioning
Instilling 3 to 5 ml normal saline to loosen up secretion
Applying suction during catheter withdrawal
Suction the client every hour
33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
Fr. 5
Fr. 10
Fr. 12
Fr. 18
34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
2-5 mmHg
5-10 mmHg
10-15 mmHg
20-25 mmHg
35. If a Wall unit is used, What should be the suctioning pressure required by James?
50-95 mmHg
95-110 mmHg
100-120 mmHg
155-175 mmHg
36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
New set of tracheostomy tubes and Oxygen tank
Theophylline and Epinephrine
Obturator and Kelly clamp
Sterile saline dressing
37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
Wilma places 2 fingers between the tie and neck
The tracheotomy can be pulled slightly away from the neck
James’ neck veins are not engorged
Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
38. Wilma knew that James have an adequate respiratory condition if she notices that
James’ respiratory rate is 18
James’ Oxygen saturation is 91%
There are frank blood suction from the tube
There are moderate amount of tracheobronchial secretions
39. Wilma knew that the maximum time when suctioning James is
10 seconds
20 seconds
30 seconds
45 seconds
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?
Loss of peripheral vision
Irreversible vision loss
There is an increase in IOP
Pain
41. Nurse jet knew that Acute close angle glaucoma is caused by
Sudden blockage of the anterior angle by the base of the iris
Obstruction in trabecular meshwork
Gradual increase of IOP
An abrupt rise in IOP from 8 to 15 mmHg
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures
It measures the peripheral vision remaining on the client
Measures the Intra Ocular Pressure
Measures the Client’s Visual Acuity
Determines the Tone of the eye in response to the sudden increase in IOP.
43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?
IRIS
PUPIL
RODS [RETINA]
CONES [RETINA]
44. Nurse Jet knows that Aqueous Humor is produce where?
In the sub arachnoid space of the meninges
In the Lateral ventricles
In the Choroids
In the Ciliary Body
45. Nurse Jet knows that the normal IOP is
8-21 mmHg
2-7 mmHg
31-35 mmHg
15-30 mmHg
46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?
Slit lamp
Snellen’s Chart
Wood’s light
Gonioscopy
47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to
Contract the Ciliary muscle
Relax the Ciliary muscle
Dilate the pupils
Decrease production of Aqueous Humor
48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is
Reduce production of CSF
Reduce production of Aquesous Humor
Constrict the pupil
Relaxes the Ciliary muscle
49. When caring for Mr. Batumbakal, Jet teaches the client to avoid
Watching large screen TVs
Bending at the waist
Reading books
Going out in the sun
50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?
Reading newsprint
Lying down
Watching TV
Listening to the music
51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?
Atropine Sulfate
Pindolol [Visken]
Naloxone Hydrochloride [Narcan]
Mesoridazine Besylate [Serentil]
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.
52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
Indicates a CN VIII Dysfunction
Abnormal
Normal
Inconclusive
53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is
Pull the pinna up and back and direct the solution towards the eardrum
Pull the pinna down and back and direct the solution onto the wall of the canal
Pull the pinna down and back and direct the solution towards the eardrum
Pull the pinna up and back and direct the solution onto the wall of the canal
54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?
Air, Breathing, Circulation
Love and Belongingness
Food, Diet and Nutrition
Safety
55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is
CN I
CN II
CN VII
CN VI
56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?
Dipenhydramine [Benadryl]
Atropine sulfate
Out of bed activities and ambulation
Diazepam [Valium]
57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?
I will try to eat foods that are low in sodium and limit my fluid intake
I must drink atleast 3,000 ml of fluids per day
I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
I will not eat turnips, red meat and raddish
58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?
Use a flashlight to coax the insect out of peachy’s ear
Instill an antibiotic ear drops
Irrigate the ear
Pick out the insect using a sterile clean forceps
59. Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?
Activities are resumed within 5 days
I will make sure that I will clean my hair and face to prevent infection
I will use straw for drinking
I should avoid air travel for a while
60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?
Indicating a Cranial Nerve VIII Dysfunction
The test should be repeated again because the result is vague
This is Grossly abnormal and should be reported to the neurosurgeon
This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?
Anxiety R/T to the operation and its outcome
Sensory perceptual alteration R/T Lens extraction and replacement
Knowledge deficit R/T the pre operative and post operative self care
Body Image disturbance R/T the eye packing after surgery
62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?
He might have a sensory hearing loss in the left ear
Conductive hearing loss is possible in the right ear
He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?
A low sodium , high fluid intake
A high calorie, high protein dietary intake
low fat, low sodium and high calorie intake
low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
64. Which of the following is the appropriate nursing diagnosis?
Fluid volume deficit R/T furrow tongue
Fluid volume deficit R/T uncontrolled vomiting
Dehydration R/T subnormal body temperature
Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute weight loss of .5kg?
50 ml
750 ml
500 ml
75 ml
66. Postural Hypotension is
A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
67. Which of the following measures will not help correct the patient’s condition
Offer large amount of oral fluid intake to replace fluid lost
Give enteral or parenteral fluid
Frequent oral care
Give small volumes of fluid at frequent interval
68. After nursing intervention, you will expect the patient to have
Maintain body temperature at 36.5 C
Exhibit return of BP and Pulse to normal
Manifest normal skin turgor of skin and tongue
Drinks fluids as prescribed
1,3
2,4
1,3,4
2,3,4
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?
Disturbed vision
Forgetfulness
Mask like facial expression
Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by
Injurious chemical substances
Hereditary factors
Death of brain cells due to old age
Impairment of dopamine producing cells in the brain
71. The patient was prescribed with levodopa. What is the action of this drug?
Increase dopamine availability
Activates dopaminergic receptors in the basal ganglia
Decrease acetylcholine availability
Release dopamine and other catecholamine from neurological storage sites
72. You are discussing with the dietician what food to avoid with patients taking levodopa?
Vitamin C rich food
Vitamin E rich food
Thiamine rich food
Vitamin B6 rich food
73. One day, the patient complained of difficulty in walking. Your response would be
You will need a cane for support
Walk erect with eyes on horizon
I’ll get you a wheelchair
Don’t force yourself to walk
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
74. The nurse will assess a loss of ability in which of the following areas?
Balance
Judgment
Speech
Endurance
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
Insomnia
Aphraxia
Agnosia
Aphasia
76. The nurse is aware that in communicating with an elderly client, the nurse will
Lean and shout at the ear of the client
Open mouth wide while talking to the client
Use a low-pitched voice
Use a medium-pitched voice
77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
I know the hallucinations are parts of the disease
I told her she is wrong and I explained to her what is right
I help her do some tasks he cannot do for himself
Ill turn off the TV when we go to another room
78. Which of the following is most important discharge teaching for Mr. Dela Isla
Emergency Numbers
Drug Compliance
Relaxation technique
Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
79. What is the action of this drug?
Increases glandular secretion for clients affected with cystic fibrosis
Dissolve blockage of the urinary tract due to obstruction of cystine stones
Reduces secretion of the glandular organ of the body
Stimulate peristalsis for treatment of constipation and obstruction
80. What should the nurse caution the client when using this medication
Avoid hazardous activities like driving, operating machineries etc.
Take the drug on empty stomach
Take with a full glass of water in treatment of Ulcerative colitis
I must take double dose if I missed the previous dose
81. Which of the following drugs are not compatible when taking Probanthine?
Caffeine
NSAID
Acetaminophen
Alcohol
82. What should the nurse tell clients when taking Probanthine?
Avoid hot weathers to prevent heat strokes
Never swim on a chlorinated pool
Make sure you limit your fluid intake to 1L a day
Avoid cold weathers to prevent hypothermia
83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?
Urinary retention
Peptic Ulcer Disease
Ulcerative Colitis
Glaucoma
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
Level of awareness and response to pain
Papillary reflexes and response to sensory stimuli
Coherence and sense of hearing
Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Hand bell and extra bed linen
Sandbag and trochanter rolls
Footboard and splint
Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care?
He will be thirsty considering that he is doesn’t drink enough fluids
To remove dried blood when tongue is bitten during a seizure
The tactile stimulation during mouth care will hasten return to consciousness
Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
Massage reddened areas with lotion or oils
Turn frequently every 2 hours
Use special water mattress
Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
Expressive aphasia is prominent on clients with right sided weakness
The affected lobe in the patient is the Right lobe
The client will have problems in judging distance and proprioception
Clients orientation to time and space will be much affected
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
89. Which result of the lab test will be significant to the diagnosis?
RBC : 4.5 TO 5 Million / cu. mm.
Hgb : 13 to 14 gm/dl.
Platelets : 250,000 to 500,000 cu.mm.
WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the following except?
Consent signed by the father
Enema STAT
Skin prep of the area including the pubis
Remove the jewelries
91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :
Allay anxiety and apprehension
Reduce pain
Prevent vomiting
Relax abdominal muscle
92. Common anesthesia for appendectomy is
Spinal
General
Caudal
Hypnosis
93. Post op care for appendectomy include the following except
Early ambulation
Diet as tolerated after fully conscious
Nasogastric tube connect to suction
Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious problems which are
Hypovolemia, electrolyte imbalance
Elevated temperature, weakness and diaphoresis
Nausea and vomiting, rigidity of the abdominal wall
Pallor and eventually shock
1 and 2
2 and 3
1,2,3
All of the above
95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?
Intussusception
Paralytic Ileus
Hemorrhage
Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the nurse must
Irrigate the tube with saline as ordered
Use sterile technique in irrigating the tube
advance the tube every hour to avoid kinks
Offer some ice chips to wet lips
97. When do you think the NGT tube be removed?
When patient requests for it
Abdomen is soft and patient asks for water
Abdomen is soft and flatus has been expelled
B and C only
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
98. What do you call a STROKE that manifests a bizarre behavior?
Inorganic Stroke
Inorganic Psychoses
Organic Stroke
Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that the former
Occurs suddenly and reversible
Is progressive and reversible
tends to be progressive and irreversible
Occurs suddenly and irreversible
100. Which behavior results from organic psychoses?
Memory deficit
Disorientation
Impaired Judgement
Inappropriate affect
Answers
D. Move the person to a safer place.
D. Shortened, Adducted and Externally Rotated.
C. Inflammation
A. Hypothyroidism
A. Tachycardia and Hypotension
B. On his left hand, because of reciprocal motion.
c. 6 Inches at the lateral side of the foot.
A. Moves the cane when the right leg is moved.
A. PPD
C. ID
D. 10 mm Induration
B. 48 hours
A. Call the Physician
D. Almost all Filipinos will test positive for Mantoux Test
A. I
C. 4 months
C. Ethambutol
A. 6-12 months after
B. National Tuberculosis Control Program
A. 23 Year old athlete with diabetes insipidus
B. Secondary
B. Participate with the nurse in his daily ostomy care
A. Plain NSS / Normal Saline
B. 3-4 inches
C. 18 inches
C. Agrees to look at the colostomy
A. Stop the irrigation by clamping the tube
D. Protruding stoma with swollen appearance
C. Eat beet greens and parsley
B. Suspend the irrigant 45 cm above the stoma
A. Brick Red
D. Suction the client every hour
D. Fr. 18
C. 10-15 mmHg
C. 100-120 mmHg
C. Obturator and Kelly clamp
A. Wilma places 2 fingers between the tie and neck
A. James’ respiratory rate is 18
A. 10 seconds
D. Pain
A. Sudden blockage of the anterior angle by the base of the iris
B. Measures the Intra Ocular Pressure
D. CONES [RETINA]
D. In the Ciliary Body
A. 8-21 mmHg
B. Snellen’s Chart
A. Contract the Ciliary muscle
B. Reduce production of Aquesous Humor
B. Bending at the waist
A. Reading newsprint
A. Atropine Sulfate
C. Normal
B. Pull the pinna down and back and direct the solution onto the wall of the canal
D. Safety
C. CN VII
C. Out of bed activities and ambulation
A. I will try to eat foods that are low in sodium and limit my fluid intake
A. Use a flashlight to coax the insect out of peachy’s ear
D. I should avoid air travel for a while
D. This indicates an intact and working vestibular branch of CN VIII
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. low sodium and restricted fluid intake
B. Fluid volume deficit R/T uncontrolled vomiting
C. 500 ml
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
A. Offer large amount of oral fluid intake to replace fluid lost
D. 2,3,4
C. Mask like facial expression
D. Impairment of dopamine producing cells in the brain
A. Increase dopamine availability
D. Vitamin B6 rich food
A. You will need a cane for support
B. Judgment
D. Aphasia
D. Use a medium-pitched voice
B. I told her she is wrong and I explained to her what is right
B. Drug Compliance
C. Reduces secretion of the glandular organ of the body
A. Avoid hazardous activities like driving, operating machineries etc.
D. Alcohol
A. Avoid hot weathers to prevent heat strokes
B. Peptic Ulcer Disease
D. Patency of airway and adequacy of respiration
D. Suction machine and gloves
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
B. Turn frequently every 2 hours
A. Expressive aphasia is prominent on clients with right sided weakness