NURSING PRACTICE IV part 2

51. The MOST effective method of delivering pain

medication during the emergent phase is:

a. intramuscularly

b. orally

c. subcutaneously

d. intravenously

52. When a client accidentally splashes chemicals to

his eyes, The initial priority care following the

chemical burn is to:

a. irrigate with normal saline for 1 to 15

minutes

b. transport to a physician immediately

c. irrigate with water for 15 minutes or

longer

d. cover the eyes with a sterile gauze

53. Which of the following can be a fatal

complication of upper airway burns?

a. stress ulcers

b. shock

c. hemorrhage

d. laryngeal spasms and swelling

54. When a client will rush towards you and he has a

burning clothes on, It is your priority to do which

of the following first?

a. log roll on the grass/ground

b. slap the flames with his hands

c. Try to remove the burning clothes

d. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most

important to:

a. cover clientwith a warm blanket

b. give him sips of water

c. calculate the extent of his burns

d. assess the Sergio’s breathing

56. During the first 24 hours after the thermal injury,

you should asses Sergio for:

a. hypokalemia and hypernatremia

b. hypokalemia and hyponatremia

c. hyperkalemia and hyponatremia

d. hyperkalemia and hypernatremia

57. A client who sustained deep partial thickness

and full thickness burns of the face, whole

anterior chest and both upper extremities two

days ago begins to exhibit extreme restlessness.

You recognize that this most likely indicates that

the client is developing:

a. Cerebral hypoxia

b. metabolic acidosis

c. Hypervolemia

d. Renal failure

58. A 165 lbs trauma client was rushed to the

emergency room with full thickness burns on the

whole face, right and left arm, and at the

anterior upper chest sparing the abdominal area.

He also has superficial partial thickness burn at

the posterior trunk and at the half upper portion

of the left leg. He is at the emergent phase of

burn. Using the parkland’s formula, you know

that during the first 8 hours of burn, the amount

of fluid will be given is:

a. 5,400 ml

b. 9, 450 ml

c. 10,800 ml

d. 6,750 ml

59. The doctor incorporated insulin on the client’s

fluid during the emergent phase. The nurse

knows that insulin is given because:

a. Clients with burn also develops

Metabolic acidosis

b. Clients with burn also develops hyperglycemia

c. Insulin is needed for additional energy

and glucose burning after the stressful

incidence to hasten wound healing,

regain of consciousness and rapid return

of hemodynamic stability

d. For hyperkalemia

60. The IV fluid of choice for burn as well as

dehydration is:

a. 0.45% NaCl

b. Sterile water

c. NSS

d. D5LR

Situation: ENTEROSTOMAL THERAPY is now considered a

specialty in nursing. You are participating in the OSTOMY

CARE CLASS.

61. You plan to teach Fermin how to irrigate the

colostomy when:

a. The perineal wound heals And Fermin

can sit comfortably on the commode

b. Fermin can lie on the side comfortably,

about the 3rd postoperative day

c. The abdominal incision is closed and

contamination is no longer a danger

d. The stools starts to become formed,

around the 7th postoperative day

62. When preparing to teach Fermin how to irrigate

colostomy, you should plan to do the procedure:

a. When Fermin would have normal bowel

movement

b. At least 2 hours before visiting hours

c. Prior to breakfast and morning care

d. After Fermin accepts alteration in body image

63. When observing a return demonstration of a

colostomy irrigation, you know that more

teaching is required if Fermin:

a. Lubricates the tip of the catheter prior to

inserting into the stoma

b. Hangs the irrigating bag on the

bathroom door cloth hook during fluid

insertion

c. Discontinues the insertion of fluid after

500 ml of fluid has been instilled

d. Clamps of the flow of fluid when felling

uncomfortable

64. You are aware that teaching about colostomy

care is understood when Fermin states, “I will

contact my physician and report:

a. If I have any difficulty inserting the

irrigating tub into the stoma.”

b. If I noticed a loss of sensation to touch in

the stoma tissue.”

c. The expulsion of flatus while the

irrigating fluid is running out.”

d. When mucus is passed from the stoma

between the irrigations.”

65. You would know after teaching Fermin that

dietary instruction for him is effective when he

states, “It is important that I eat:

a. Soft food that is easily digested and

absorbed by my large intestines.”

b. Bland food so that my intestines do not

become irritated.”

c. Food low in fiber so that there are fewer

stools.”

d. Everything that I ate before the

operation, while avoiding foods that

cause gas”.

Situation: Based on studies of nurses working in special

units like the intensive care unit and coronary care unit,

it is important for nurses to gather as much information

to be able to address their needs for nursing care.

66. Critically ill patients frequently complain about

which of the following when hospitalized?

a. Hospital food

b. Lack of privacy

c. Lack of blankets

d. Inadequate nursing staff

67. Who of the following is at greatest risk of

developing sensory problem?

a. Female patient

b. Transplant patient

c. Adoloscent

d. Unresponsive patient

68. Which of the following factors may inhibit

learning in critically ill patients?

a. Gender

b. Educational level

c. Medication

d. Previous knowledge of illness

69. Which of the following statements does not

apply to critically ill patients?

a. Majority need extensive rehabilitation

b. All have been hospitalized previously

c. Are physically unstable

d. Most have chronic illness

70. Families of critically ill patients desire which of

the following needs to be met first by the nurse?

a. Provision of comfortable space

b. Emotional support

c. Updated information on client’s status

d. Spiritual counselling

Situation: Johnny, sought consultation to the hospital

because of fatigability, irritability, jittery and he has been

experiencing this sign and symptoms for the past 5

months.

71. His diagnosis was hyperthyroidism, the following

are expected symptoms except:

a. Anorexia

b. Fine tremors of the hand

c. Palpitation

d. Hyper alertness

72. She has to take drugs to treat her

hyperthyroidism. Which of the following will you

NOT expect that the doctor will prescribe?

a. Colace (Docusate)

b. Tapazole (Methimazole)

c. Cytomel (Liothyronine)

d. Synthroid (Levothyroxine)

73. The nurse knows that Tapazole has which of the

following side effect that will warrant immediate

withholding of the medication?

a. Death

b. Hyperthermia

c. Sore throat

d. Thrombocytosis

74. You asked questions as soon as she regained

consciousness from thyroidectomy primarily to

assess the evidence of:

a. Thyroid storm

b. Damage to the laryngeal nerve

c. Mediastinal shift

d. Hypocalcaemia tetany

75. Should you check for haemorrhage, you will:

a. Slip your hand under the nape of her

neck

b. Check for hypotension

c. Apply neck collar to prevent

haemorrhage

d. Observe the dressing if it is soaked with

blood

76. Basal Metabolic rate is assessed on Johnny to

determine his metabolic rate. In assessing the

BMR using the standard procedure, you need to

tell Johnny that:

a. Obstructing his vision

b. Restraining his upper and lower

extremities

c. Obstructing his hearing

d. Obstructing his nostrils with a clamp

77. The BMR is based on the measurement that:

a. Rate of respiration under different

condition of activities and rest

b. Amount of oxygen consumption under

resting condition over a measured

period of time

c. Amount of oxygen consumption under

stressed condition over a measured

period of time

d. Ratio of respiration to pulse rate over a

measured period of time

78. Her physician ordered lugol’s solution in order

to:

a. Decrease the vascularity and size of the

thyroid gland

b. Decrease the size of the thyroid gland only

c. Increase the vascularity and size of the

thyroid gland

d. Increase the size of the thyroid gland only

79. Which of the following is a side effect of Lugol’s

solution?

a. Hypokalemia

b. Enlargement of the Thryoid gland

c. Nystagmus

d. Excessive salivation

80. In administering Lugol’s solution, the

precautionary measure should include:

a. Administer with glass only

b. Dilute with juice and administer with a

straw

c. Administer it with milk and drink it

d. Follow it with milk of magnesia

Situation: Pharmacological treatment was not effective

for Johnny’s hyperthyroidism and now, he is scheduled

for Thyroidectomy.

81. Instruments in the surgical suite for surgery is

classified as either CRITICAL, SEMI CRITICAL and

NON CRITICAL. If the instrument are introduced

directly into the blood stream or into any

normally sterile cavity or area of the body it is

classified as:

a. Critical

b. Non Critical

c. Semi Critical

d. Ultra Critical

82. Instruments that do not touch the patient or

have contact only to intact skin is classified as:

a. Critical

b. Non Critical

c. Semi Critical

d. Ultra Critical

83. If an instrument is classified as Semi Critical, an

acceptable method of making the instrument

ready for surgery is through:

a. Sterilization

b. Disinfection

c. Decontamination

d. Cleaning

84. While critical items and should be:

a. Clean

b. Sterilized

c. Decontaminated

d. Disinfected

85. As a nurse, you know that intact skin acts as an

effective barrier to most microorganisms.

Therefore, items that come in contact with the

intact skin or mucus membranes should be:

a. Disinfected

b. Clean

c. Sterile

d. Alcoholized

86. You are caring for Johnny who is scheduled to

undergo total thyroidectomy because of a

diagnosis of thyroid cancer. Prior to total

thyroidectomy, you should instruct Johnny to:

a. Perform range and motion exercise on

the head and neck

b. Apply gentle pressure against the

incision when swallowing

c. Cough and deep breathe every 2 hours

d. Support head with the hands when

changing position

87. As Johnny’s nurse, you plan to set up emergency

equipment at her bedside following

thyroidectomy. You should include:

a. An airway and rebreathing tube

b. A tracheostomy set and oxygen

c. A crush cart with bed board

d. Two ampules of sodium bicarbonate

88. Which of the following nursing interventions is

appropriate after a total thyroidectomy?

a. Place pillows under your patient’s

shoulders.

b. Raise the knee-gatch to 30 degrees

c. Keep you patient in a high-fowler’s

position.

d. Support the patient’s head and neck

with pillows and sandbags.

89. If there is an accidental injury to the parathyroid

gland during a thyroidectomy which of the

following might Leda develops postoperatively?

a. Cardiac arrest

b. Respiratory failure

c. Dyspnea

d. Tetany

90. After surgery Johnny develops peripheral

numbness, tingling and muscle twitching and

spasm. What would you anticipate to

administer?

a. Magnesium sulfate

b. Potassium iodide

c. Calcium gluconate

d. Potassium chloride

Situation: Budgeting is an important part of a nurse

managerial activity. The correct allocation and

distribution of resources is vital in the harmonious

operation of the financial balance of the agency.

91. Which of the following best defines Budget?

a. Plan for the allocation of resources for

future use

b. The process of allocating resources for future use

c. Estimate cost of expenses

d. Continuous process in seeing that the

goals and objective of the agency is met

92. Which of the following best defines Capital

Budget?

a. Budget to estimate the cost of direct

labour, number of staff to be hired and

necessary number of workers to meet

the general patient needs

b. Includes the monthly and daily expenses

and expected revenue and expenses

c. These are related to long term planning

and includes major replacement or

expansion of the plant, major

equipment and inventories.

d. These are expenses that are not

dependent on the level of production or

sales. They tend to be time-related, such

as salaries or rents being paid per month

93. Which of the following best described

Operational Budget?

a. Budget to estimate the cost of direct

labour, number of staff to be hired and

necessary number of workers to meet

the general patient needs

b. Includes the monthly and daily

expenses and expected revenue and

expenses

c. These are related to long term planning

and includes major replacement or

expansion of the plant, major

equipments and inventories.

d. These are expenses that are not

dependent on the level of production or

sales. They tend to be time-related, such as rent

94. Which of the following accurately describes a

Fixed Cost in budgeting?

a. These are usually the raw materials and

labour salaries that depend on the

production or sales

b. These are expenses that change in

proportion to the activity of a business

c. These are expenses that are not

dependent on the level of production or

sales. They tend to be time-related,

such as rent

d. This is the summation of the Variable

Cost and the Fixed Cost

95. Which of the following accurately describes

Variable Cost in budgeting?

a. These are related to long term planning

and include major replacement or

expansion of the plant, major

equipments and inventories.

b. These are expenses that change in

proportion to the activity of a business

c. These are expenses that are not

dependent on the level of production or

sales. They tend to be time-related, such

as rent

d. This is the summation of the Variable

Cost and the Fixed Cost

Situation – Andrea is admitted to the ER following an

assault where she was hit in the face and head. She was

brought to the ER by a police woman. Emergency

measures were started.

96. Andrea’s respiration is described as waxing and

waning. You know that this rhythm of respiration

is defined as:

a. Biot’s

b. Cheyne stokes

c. Kussmaul’s

d. Eupnea

97. What do you call the triad of sign and symptoms

seen in a client with increasing ICP?

a. Virchow’s Triad

b. Cushing’s Triad

c. The Chinese Triad

d. Charcot’s Triad

98. Which of the following is true with the Triad

seen in head injuries?

a. Narrowing of Pulse pressure, Cheyne

stokes respiration, Tachycardia

b. Widening Pulse pressure, Irregular

respiration, Bradycardia

c. Hypertension, Kussmaul’s respiration,

Tachycardia

d. Hypotension, Irregular respiration,

Bradycardia

99. In a client with a Cheyne stokes respiration,

which of the following is the most appropriate

nursing diagnosis?

a. Ineffective airway clearance

b. Impaired gas exchange

c. Ineffective breathing pattern

d. Activity intolerance

100. You know the apnea is seen in client’s with

cheyne stokes respiration, APNEA is defined as:

a. Inability to breathe in a supine position

so the patient sits up in bed to breathe

b. The patient is dead, the breathing stops

c. There is an absence of breathing for a

period of time, usually 15 seconds or more

d. A period of hypercapnea and hypoxia

due to the cessation of respiratory effort

inspite of normal respiratory functioning