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6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should youcollect 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 containerC. Disconnect the tubing from the urinary catheter and let urine floe into a sterile containerD. Wipe the self sealing aspirations port with antiseptic solution and insert a sterile needle into the selfsealing 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 containerB. Cough after pursed lip breathingC. Save sputum for two days in covered containerD. After respiratory treatment, expectorate into a container

8. The best time for collecting the sputum specimen for culture: A. Before retiring at nightB. Upon waking up in the morningC. Anytime of the day.D. Before meal

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 Withdrawn using twisting motion.

B. Insert catheter until resistance is met; then withdraw slightly, applying suction intermittently ascatheter is withdrawn.C. Hyperoxygenate client insert catheter using back and forth motionD. Insert suction, catheter four inches into the tube, suction 30 seconds using twirling motion as catheter iswithdrawn.

10. The purpose of NGT IMMEDIATELY after operation is:A. For feeding or gavageB. For gastric decompressionC. For lavage, or the cleansing of the stomach contentD. For the rapid return of peristalsis

Situation 3 Mr. Santos, 50, is to undergo cytoscopy due to multiple problems like scantly urination, hematuria,and dysuria.

11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy,you will enumerate as follows:A. Urethra, Kidney, BladderB. Urethra, Bladder wall, trigone, urethral openingC. Bladder wall, uterine wall and urethral openingD. Urethral opening, urethral opening bladder.

12. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopyin:A. SupineB. LithotomyC. Semi-fowlerD. Trendelenburg

13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you yell him?

A. Cystoscopy is direct visualization and examination by urologistB. Cystoscopy is done by x-ray visualization of the urinary tactC. Cystoscopy is done by using lasers on the urinary tractD. Cystoscopy is an endoscopic procedure of the unrinarytract

14. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:A. Pink-tinged urineB. Distended bladderC. Signs of infection

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23. Which government agency is responsible for testing the melamine content of foods and food products?A. DOHB. MMDAC. NBID. 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, UrolithiasisB. High blood pressure, feverC. Anuria, Oliguria or HematuriaD. Fever, Irritability and a large output of diluted urine

25. What kind of renal failure from melamine poisoning cause?A. Chronic Pre-renalB. Acute, PostrenalC. Chronic, IntrarenalD. Acute, Prerenal

Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause ofalmost 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. Whrereas acute nonlymphoid leukaemia has survival rate of:A. 25 %B. 40 %C. 75 %D. 95 %

28. The three main consequence of leukaemia that cause the most danger is:A. Neutropenia causing infection, anemia causing impaired oxygenationand thrombocytopenia leadingto bleeding tendencies.B. Central nervous system infiltration, anemia causing impaired oxygenationand thrombocytopenia leading tobleeding tendencies.C. Splenomegaly, hepatomegaly, fracturesD. Invasion by the leukemic cells to the bone causing severe bone pain

29. Gold standard in the diagnosis of leukaemia is by which of the following?A. Blood culture and sensitivityB. Bone marrow biopsyC. Blood biopsy

30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the client for long term therapy. Onecommon side effect, especially of adriamycin is alopecia. The child asks: Will I get my hair back once again? Thenurse respond is by saying:A. Dont be silly, of course you will get your hair back.B. We are not sure, lets hope itll grow.

C. This side effect is usually permanent, but I will get the doctor todiscuss it for you.D. Your hair will regrow in 3 -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 inwoman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in thehigh 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 children after age30.

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B. GeneticsC. Increasing ageD. Prolonged intake of Tamoxifen (Nolvadex)

32. Protective factors for the development of breast cancer includes which of the following EXCEPT:A. ExerciseB. Prophylactic Tamoxifen

C. Breast FeedingD. Alcohol intake

33. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgerywith radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurseinforms the patients that the lumpectomy with radiation.A. Reduces the fear and anxiety that accompany the diagnosis and treatment of cancerB. Has about the same 10 years survival rate as the modified radical mastectomyC. Provides shorter treatment period with a fewer long term complicationsD. Preserves the normal appearance and sensitivity of the breast

34. Carmen, is asking the nurse the most appropriate time of the month to do her self-examination of the breast.The MOST appropriate reply by the nurse would be:A. the 26th day of menstrual cycleB. 7 8 days after conclusion of the menstrual period

C. During her menstruationD. the same day each month

35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skindamage from the radiation therapy?A. Cover the areas with thick clothing materialsB. Apply a heating pad to the siteC. Wash skin with water after therapyD. Avoid applying creams and powder to the area.

36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection methodfor 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 assayC. an annual mammogram

D. a physician conduct a breast clinical examination every 2 years

37. The purpose of performing the breast self examination (BSE) regularly is to discover:A. fibrocystic massesB. cancerous lumpsC. areas of thickness or fullnessD. 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 monthB. right after the menstrual periodC. on the first day of her menstruationD. 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 tissueB. axillaryC. lumps in the breast tissueD. change in size and contour

40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towelunder the clients left shoulder is to:A. bring the breast closer to the examiners right handB. tense the pectoral muscleC. balance the breast tissue more evenly on the chest wall

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D. facilitate lateral positioning of the breast

Situation Radiation therapy is another modality of cancer management. With emphasis on multidisciplinarymanagement you have important responsibilities as a nurse

41. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the followingnursing interventions would be most helpful for Albert?A. Tell him that sometimes these feelings can be psychogenic B. Refer him to the physicianC. Reassures him that these feelings are normalD. Help him plan his activities

42. Immediately following the radiation teletherapy, Albert is:A. Considered radioactive fro 24hoursB. Given a complete bathC. Placed on isolation for 6 hoursD. Free from Radiation

43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the followingsymptoms:A. Petechiae, ecchymosis, epistaxisB. Weakness, easy fatigability, pallorC. Headache, dizziness, blurred visionD. Severe sore throat, bacteremia, hepatomegaly

44. What nursing diagnosis should be the highest priority?A. Knowledge deficit regarding thrombocytopenia precautionsB. Activity intoleranceC. Impaired tissue integrityD. 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 regularlyB. Place Albert on strict isolation precautionC. Provide rest in between activitiesD. Administer antipyretics if his temperature exceeds 38 C

Situation: Burn is 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 exposed and painlessness:A. Superficial partial thickness burnB. Deep partial thickness burnC. Full thickness burnD. Deep full thickness burn

47. Which of the following BEST describes superficial partial thickness burn or first degrees burn?A. Structures beneath the skin and damageB. Dermis is partially damagedC. Epidermis and dermis are both damagedD. Epidermis is damaged

48. A burn that is said to be WEEPING is classified as:A. Superficial partial thickness burnB. Deep partial thickness burnC. Full thickness burnD. Deep full thickness burn

49. During the Acute Phase of the burn injury, which of the following is a priority?A. Wound healingB. Reconstructive surgeryC. Emotional supportD. Fluid resuscitation

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50. While in the emergent phase, the nurse knows that the priority is to:A. Prevent infectionB. Control painC. Prevent deformities and contracturesD. Return the hemodynamic stability via fluid resuscitation

NP4 Nursing Board Exam November Answer Key 'Nursing Care of Client with

Physiological and Psychosocial Alteration'

100 Nursing Board Exam test questions of November 2008 Nurse Licensure Examination (NLE)

Nursing Practice IVNursing Care of Client with Physiological and Psychosocial AlterationMedical and Surgical Nursing / Psychology

PART 2 Board Exam test questions 51 - 100

51. The MOST effective method of delivering pain medication during the emergent phase is:

A. intramuscularlyB. subcutaneouslyC. orallyD. intravenously

52. When a client accidentally splashes chemicals to his eyes. The initial priority care of the following the chemicalburns is to:A. irrigate with normal saline for 1 to 15 minutesB. transport to a physician immediatelyC. irrigate with water for 15 minutes or longerD. cover the eyes with a sterile gauze

53. Which of the following can be fatal complication of upper airway burns?A. stress ulcersB. hemorrhage

C. shockD. laryngeal spasm and swelling

54. When a client will rush towards you and he has burning clothes on, it is your priority to do which of thefollowing first?A. log roll on the grass/groundB. slap the flames with his handsC. Try to remove the burning clothesD. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most important: A. cover client with warm blanketB. Give him sips of waterC. Calculate the extent of this burnsD. Assess the Sergios breathing

56. During the first 24 hours after thermal injury, you should assess Sergio for:A. hypokalemia and hypernatremiaB. hypokalemia and hyponatremiaC. hyperkalemia and hyponatremiaD. hyperkalemia and hypernatremia

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57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and bothupper extremities two days ago begins to exhibit extreme restlessness . You recognize that this most likelyindicates that the client is developing:A. Cerebral hypoxiaB. HypervolemiaC. Metabolic acidosisD. Renal failure

58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, rightand left arm, and at the anterior chest sparing the abdominal area. He also has superficial partial thickness burn atthe posterior trunk and at the half upper portion of the left leg. He the emergent phase of burns using theparklands formula, you know that during the first 8 hours of burn the amount of fluid will be given is:A. 5, 400mlB. 10,500 mlC. 9,450 mlD. 6,750 ml

59. The doctor incorporated insulin on the clients fluid during the emergent phase. The nurse knows that insulin isgiven because:A. Clients with burn also develops Metabolic AcidosisB. Clients with burn also develops hyperglycemiaC. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten woundhealing, 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% NaClB. NSSC. Sterile waterD. D5LR

Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMYCARE 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 commodeB. Fermin can lie on the side comfortably, about the 3rd postoperative day

C. The abdominal incision is closed and contamination is no longer a dangerD. 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 movementB. At least 2 hours before visiting hoursC. Prior to breakfast and morning careD. After Fermin accepts alteration in body image

63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required ifFermin:A. Lubricates the tip of the catheter prior to inserting into the stomaB. Hangs the irrigating bag on the bathroom door cloth hook during fluidinsertionC. Discontinues the insertion of fluid after only 500 ml of fluid has been instilledD. Clamps of the flow of fluid when felling uncomfortable

64. You are aware that teaching about colostomy care is understood when Fermin states, I wil l contact myphysician 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.

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65. You would know after teaching Fermin that dietary instruction for him is effective when he states, It isimportant that I eat:A. Soft food that are 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 is less stool.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 itis important for nurses to gather as much information to be able to address their needs for nursing care.

66. Critically ill patient frequently complain about which of the following when hospitalized?A. Hospital reportB. Lack of blanketsC. Lack of privacyD. Inadequate nursing staff

67. Who of the following is at greatest risk of developing sensory problem?A. Female patientB. AdolescentC. Transplant patientD. Unresponsive patient

68. Which of the following factors may inhibit learning in critically ill patients?A. GenderB. MedicationC. Educational levelD. Previous knowledge of illness

69. Which of the following statements does not apply to critically ill patients?A. Majority need extensive rehabilitationB. All have been hospitalized previouslyC. Are physically unstableD. 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 spaceB. Emotional supportC. Updated information on the clients statusD. Spiritual counselling

Situatuon: Johnny, sought consultation to the hospital before

71. His diagnosis was hyperthyroidism, the following are expected symptoms except:A. AnorexiaB. PalpitationC. Fine tremors of the handD. Hyper alertness

72. He has to take drugs to treat hyperthyroidism, which of the following will you not expect that the doctor willprescribe?

A. Colace (Docusate)B. Cytomel (Llothyronine)C. Tapazole (D. (Levothyroxine)

73. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding ofthe medication?A. DeathB. Sore throatC. HyperthermiaD. Thrombocytosis

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74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess theevidence of:A. Thyroid stormB. Mediastinal shiftC. Damage to the laryngeal nerveD. Hypocalcemia tetany

75. Should you check for haemorrhage, you will:A. Slip your hand under the nape of her neckB. Check for hypotensionC. Apply neck collar to prevent haemorrhageD. Observe the dressing if is soaked with blood

76. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using thestandard procedure, you need to tell Johnny that: A. Obstructing his visionB. Restraining his upper and lower extremitiesC. Obstructing his hearingD. Obstructing his nostril with a clamp

77. The BMR is based on the measurement that:A. Rate of respiration under different condition of activities and restB. 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 timeD. Ratio of respiration to pulse rate over a measured period of time

78. Her physician ordered lugols solution in order to:A. Decrease the vascularity and size of the thyroid glandB. Decrease the size of the thyroid gland onlyC. Increase the vascularity and size of the thyroid glandD. Increase the size of the thyroid gland only

79. Which of the following is a side effect of lugols solution?A. HypokalemiaB. NystagmusC. Enlargement of the Thyroid glandD. Excessive salivation

80. In administering Lugols solution, the precautionary measure should include:A. Administer with glass onlyB. Dilute with juice and administer with a strawC. Administer it with milk and drink itD. Follow it with milk of magnesia

Situation: Pharmacological treatment was not effective for Johnnys hyperthyroidism and now he is scheduled forThyroidectomy.

81. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NONCRITICAL. If the instrument are introduced directly into the blood stream or into any normally sterile cavity or areaof the body it is classified as:

A. CriticalB. Semi criticalC. Non criticalD. Ultra critical

82. Instruments that do not touch the patient or have contact only to the intact skin is classified as:A. CriticalB. Semi criticalC. Non criticalD. Ultra critical

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83. If an instrument is classified as Semi Critical an acceptable method of making the instrument ready for surgeryis through:A. SterilizationB. DecontaminationC. DisinfectionD. Cleaning

84. While critical items and should be:A. CleanB. DecontaminatedC. SterilizedD. Disinfected

85. As a nurse, you know that intact skin as an effective barrier to most microorganisms. Therefore, items thatcome in contact with the intact skin or mucous membranes should be:A. DisinfectedB. SterileC. CleanD. Alcoholized

86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroidcancer. Prior to total thyroidectomy, you should instruct Johnny to:

A. Perform range and motion exercise on the head or neckB. Apply gentle pressure against the incision when swallowingC. Cough and deep breathe every hoursD. Support head with the hands when changing position

Situation Andrea is admitted to the ER following an assault where she was hit on the face and head. She wasbrought to the ER by a police woman. Emergency measures were stated.

96. Andreas respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:A. BiotsB. KussmaulsC. Cheyne StokesD. Eupnca

97. What do you call the triad of sign and symptoms seen in a client with increasing ICP?A. Virchows TriadB. The Chinese triadC. Cuschings TriadD. Charcots Triad

98. Which of the following is true with the Cushings Triad seen in head injuries?A. Narrowing of Pulse Pressure, Cheyne strokes respiration, TachycardiaB. Widening Pulse pressure, Irregular respiration, BradycardiaC. Hypertension, Kussmauls respiration, TachycardiaD. 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 clearanceB. Ineffective breathing patternC. Impaired gas exchange

D. Activity Intolerance

100. You know the apnea is seen in clients with cheyne stoke respiration, APNEA is defined as:A. Inability to breath in a supine position so the patient sits up in bed to breathe.B. The patient is dead, the breathing stopsC. 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 cessation of respiratory effort inspite of normalrespiratory functioning