NURSING PRACTICE IV
Situation: After an abdominal surgery, the circulating
and scrub nurses have critical responsibility about
sponge and instrument count.
1. Counting is performed thrice: During the
preincision phase, the operative phase and
closing phase. Who counts the sponges, needles
and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating nurse
2. The layer of the abdomen is divided into 5.
Arrange the following from the first layer going
to the deepest layer:
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/Fat
5. Skin
a. 5,4,3,2,1
b. 5,4,1,3,2
c. 5,4,2,1,3
d. 5,4,1,2,3
3. When is the first sponge/instrument count
reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
4. Like any nursing interventions, counts should be
documented. To whom does the scrub nurse
report any discrepancy of counts so that
immediate and appropriate action is instituted?
a. Anaesthesiologists
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse
5. Which of the following are 2 interventions of the
surgical team when an instrument was
confirmed missing?
a. MRI and Incidence report
b. CT Scan, MRI, Incidence report
c. X-RAY and Incidence report
d. CT Scan and Incidence report
Situation: An entry level nurse should be able to apply
theoretical knowledge in the performance of the basic
nursing skills.
6. A client has an indwelling urinary catheter and
she is suspected of having urinary infection. How
should you collect a urine specimen for culture
and sensitivity?
a. clamp tubing for 60 minutes and insert a
sterile needle into the tubing above the
clamp to aspirate urine
b. drain urine from the drainage bag into
the sterile container
c. disconnect the tubing from the urinary
catheter and let urine flow into a sterile
container
d. wipe the self-sealing aspiration port
with antiseptic solution and insert a
sterile needle into the self-sealing port
7. To obtain specimen for sputum culture and
sensitivity, which of the following instruction is
best?
a. Upon waking up, cough deeply and
expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate
into a container
8. The best time for collecting the sputum
specimen for culture and sensitivity is:
a. Before retiring at night
b. Anytime of the day
c. Upon waking up in the morning
d. Before meals
9. When suctioning the endotracheal tube, the
nurse should:
a. Explain procedure to patient; insert
catheter gently applying suction.
Withdrawn using twisting motion
b. Insert catheter until resistance is met,
and then withdraw slightly, applying
suction intermittently as catheter is withdrawn
c. Hyperoxygenate client insert catheter
using back and forth motion
d. Insert suction catheter four inches into
the tube, suction 30 seconds using
twirling motion as catheter is withdrawn
10. The purpose of NGT IMMEDIATELY after an
operation is:
a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of the
stomach content
d. For the rapid return of peristalsis
Situation - Mr. Santos, 50, is to undergo cystoscopy due
to multiple problems like scantly urination, hematuria
and dysuria.
11. You are the nurse in charge in Mr. Santos. When
asked what are the organs to be examined
during cystoscopy, you will enumerate as
follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral
opening
c. Bladder wall, uterine wall, and urethral opening
d. Urethral opening, ureteral opening
bladder
12. In the OR, you will position Mr. Santos who is
cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to
explain why there is no incision of any kind.
What do you tell him?
a. “Cystoscopy is direct visualization and
examination by urologist”.
b. “Cystoscopy is done by x-ray
visualization of the urinary tract”.
c. “Cystoscopy is done by using lasers on
the urinary tract”.
d. “Cystoscopy is an endoscopic procedure
of the urinary tract”.
14. Within 24-48 hours post cystoscopy, it is normal
to observe one the following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
15. Leg cramps are NOT uncommon post cystoscopy.
Nursing intervention includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath
Situation – Mang Felix, a 79 year old man who is brought
to the Surgical Unit from PACU after a transurethral
resection. You are assigned to receive him. You noted
that he has a 3-way indwelling urinary catheter for
continuous fast drip bladder irrigation which is
connected to a straight drainage.
16. Immediately after surgery, what would you
expect his urine to be?
a. Light yellow
b. Bright red
c. Amber
d. Pinkish to red
17. The purpose of the continuous bladder irrigation
is to:
a. Allow continuous monitoring of the fluid
output status
b. Provide continuous flushing of clots and
debris from the bladder
c. Allow for proper exchange of electrolytes and fluid
d. Ensure accurate monitoring of intake and output
18. Mang Felix informs you that he feels some
discomfort on the hypogastric area and he has to
void. What will be your most appropriate action?
a. Remove his catheter then allow him to void on his own
b. Irrigate his catheter
c. Tell him to “Go ahead and void. You
have an indwelling catheter.”
d. Assess color and rate of outflow, if
there is changes refer to urologist for
possible irrigation.
19. You decided to check on Mang Felix’s IV fluid
infusion. You noted a change in flow rate, pallor
and coldness around the insertion site. What is
your assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic reaction
d. Air embolism
20. Knowing that proper documentation of
assessment findings and interventions are
important responsibilities of the nurse during
first post-operative day, which of the following is
the LEAST relevant to document in the case of
Mang Felix?
a. Chest pain and vital signs
b. Intravenous infusion rate
c. Amount, color, and consistency of
bladder irrigation drainage
d. Activities of daily living started
Situation: Melamine contamination in milk has brought
worldwide crisis both in the milk production sector as
well as the health and economy. Being aware of the
current events is one quality that a nurse should possess
to prove that nursing is a dynamic profession that will
adapt depending on the patient’s needs.
21. Melamine is a synthetic resin used for
whiteboards, hard plastics and jewellery box
covers due to its fire retardant properties. Milk
and food manufacturers add melamine in order
to:
a. It has a bacteriostatic property leading
to increase food and milk life as a way of
preserving the foods
b. Gives a glazy and more edible look on
foods
c. Make milks more tasty and creamy
d. Create an illusion of a high protein
content on their products
22. Most of the milks contaminated by Melamine
came from which country?
a. India
b. China
c. Philippines
d. Korea
23. Which government agency is responsible for
testing the melamine content of foods and food
products?
a. DOH
b. MMDA
c. NBI
d. BFAD
24. Infants are the most vulnerable to melamine
poisoning. Which of the following is NOT a sign
of melamine poisoning?
a. Irritability, Back ache, Urolithiasis
b. High blood pressure, fever
c. Anuria, Oliguria or Hematuria
d. Fever, Irritability and a large output of
diluted urine
25. What kind of renal failure will melamine
poisoning cause?
a. Chronic, Prerenal
b. Chronic, Intrarenal
c. Acute, Postrenal
d. Acute, Prerenal
Situation: Leukemia is the most common type of
childhood cancer. Acute Lymphoid Leukemia is the cause
of almost 1/3 of all cancer that occurs in children under
age 15.
26. The survival rate for Acute Lymphoid Leukemia is
approximately:
a. 25%
b. 40%
c. 75%
d. 95%
27. Whereas acute nonlymphoid leukemia has a
survival rate of:
a. 25%
b. 40%
c. 75%
d. 95%
28. The three main consequence of leukemia that
cause the most danger is:
a. Neutropenia causing infection, anemia
causing impaired oxygenation and
thrombocytopenia leading to bleeding
tendencies
b. Central nervous system infiltration,
anemia causing impaired oxygenation
and thrombocytopenia leading to
bleeding tendencies
c. Splenomegaly, hepatomegaly, fractures
d. Invasion by the leukemic cells to the
bone causing severe bone pain
29. Gold standard in the diagnosis of leukemia is by
which of the following?
a. Blood culture and sensitivity
b. Bone marrow biopsy
c. Blood biopsy
d. CSF aspiration and examination
30. Adriamycin,Vincristine,Prednisone and L
asparaginase are given to the client for long
term therapy. One common side effect,
especially of adriamycin is alopecia. The child
asks: “Will I get my hair back once again?” The
nurse best respond is by saying:
a. “Don’t be silly, ofcourse you will get your
hair back”
b. “We are not sure, let’s hope it’ll grow”
c. “This side effect is usually permanent,
But I will get the doctor to discuss it for
you”
d. “Your hair will regrow in 3 to 6 months
but of different color, usually darker
and of different texture”
Situation: Breast Cancer is the 2nd most common type of
cancer after lung cancer and 99% of which, occurs in
woman. Survival rate is 98% if this is detected early and
treated promptly. Carmen is a 53 year old patient in the
high risk group for breast cancer was recently diagnosed
with Breast cancer.
31. All of the following are factors that said to
contribute to the development of breast cancer
except:
a. Prolonged exposure to estrogen such as
an early menarche or late menopause,
nulliparity and childbirth after age 30
b. Genetics
c. Increasing Age
d. Prolonged intake of Tamoxifen
(Nolvadex)
32. Protective factors for the development of breast
cancer includes which of the following except:
a. Exercise
b. Breast feeding
c. Prophylactic Tamoxifen
d. Alcohol intake
33. A patient diagnosed with breast cancer has been
offered the treatment choices of breast
conservation surgery with radiation or a
modified radical mastectomy. When questioned
by the patient about these options, the nurse
informs the patient that the lumpectomy with
radiation:
a. reduces the fear and anxiety that
accompany the diagnosis and treatment of cancer
b. has about the same 10-year survival rate
as the modified radical mastectomy
c. provides a shorter treatment period with
a fewer long term complications
d. preserves the normal appearance and
sensitivity of the breast.
34. Carmen, who is asking the nurse the most
appropriate time of the month to do herself examination
of the breast. The MOST
appropriate reply by the nurse would be:
a. the 26th day of the menstrual cycle
b. 7 to 8 days after conclusion of the menstrual period
c. during her menstruation
d. the same day each month
35. Carmen being treated with radiation therapy.
What should be included in the plan of care to
minimize skin damage from the radiation
therapy?
a. Cover the areas with thick clothing
materials
b. Apply a heating pad to the site
c. Wash skin with water after the therapy
d. Avoid applying creams and powders to
the area
36. Based on the DOH and World Health
Organization (WHO) guidelines, the mainstay for
early detection method for breast cancer that is
recommended for developing countries is:
a. a monthly breast self-examination (BSE)
and an annual health worker breast
examination (HWBE)
b. an annual hormone receptor assay
c. an annual mammogram
d. a physician conduct a breast clinical
examination every 2 years
37. The purpose of performing the breast selfexamination
(BSE) regularly is to discover:
a. fibrocystic masses
b. areas of thickness or fullness
c. cancerous lumps
d. changes from previous BSE
38. If you are to instruct a postmenopausal woman
about BSE, when would you tell her to do BSE:
a. on the same day of each month
b. on the first day of her menstruation
c. right after the menstrual period
d. on the last day of her menstruation
39. During breast self-examination, the purpose of
standing in front of the mirror it to observe the
breast for:
a. thickening of the tissue
b. lumps in the breast tissue
c. axillary lymphnodes
d. change in size and contour
40. When preparing to examine the left breast in a
reclining position, the purpose of placing a small
folded towel under the client’s left shoulder is
to:
a. bring the breast closer to the examiner’s
right hand
b. tense the pectoral muscle
c. balance the breast tissue more evenly
on the chest wall
d. facilitate lateral positioning of the breast
Situation – Radiation therapy is another modality of
cancer management. With emphasis on multidisciplinary
management you have important responsibilities as
nurse.
41. Albert is receiving external radiation therapy and
he complains of fatigue and malaise. Which of
the following nursing interventions would be
most helpful for Albert?
a. Tell him that sometimes these feelings
can be psychogenic
b. Refer him to the physician
c. Reassure him that these feelings are
normal
d. Help him plan his activities
42. Immediately following the radiation teletherapy,
Albert is
a. Considered radioactive for 24 hrs
b. Given a complete bath
c. Placed on isolation for 6 hours
d. Free from radiation
43. Albert is admitted with a radiation induced
thrombocytopenia. As a nurse you should
observe the following symptoms:
a. Petechiae, ecchymosis, epistaxis
b. Weakness, easy fatigability, pallor
c. Headache, dizziness, blurred vision
d. Severe sore throat, bacteremia,
hepatomegaly
44. What nursing diagnosis should be of highest
priority?
a. Knowledge deficit regarding
thrombocytopenia precautions
b. Activity intolerance
c. Impaired tissue integrity
d. Ineffective tissue perfusion, peripheral,
cerebral, cardiovascular,
gastrointestinal, renal
45. What intervention should you include in your
care plan?
a. Inspect his skin for petechiae, bruising,
GI bleeding regularly
b. Place Albert on strict isolation
precaution
c. Provide rest in between activities
d. Administer antipyretics if his
temperature exceeds 38C
Situation: Burn are cause by transfer of heat source to
the body. It can be thermal, electrical, radiation or
chemical.
46. A burn characterized by Pale white appearance,
charred or with fat exposed and painlessness is:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
47. Which of the following BEST describes superficial
partial thickness burn or first degree burn?
a. Structures beneath the skin are damage
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged
48. A burn that is said to be “WEEPING” is classified
as:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
49. During the Acute phase of the burn injury, which
of the following is a priority?
a. wound healing
b. emotional support
c. reconstructive surgery
d. fluid resuscitation
50. While in the emergent phase, the nurse knows
that the priority is to:
a. Prevent infection
b. Prevent deformities and contractures
c. Control pain
d. Return the hemodynamic stability via
fluid resuscitation
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