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  • 8/6/2019 simu 20 test 3


    Nursing Practice III

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    SituationOne learns by doing

    especially when you practice the bestmethod.

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    1. Which action by a new nurse signifies

    a need for further teaching in infectioncontrol?

    a. The nurse places the side rails to an

    unconscious patient

    b. The nurse elevate the head of the bed

    to check the BP

    c. The nurse uses her bare hands to

    change the dressingd. The nurse applies oxygen catheter to

    the mouth

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    . ou are on s an a ou

    patients are discharged. You noted that

    the orderly was looking through the

    items of one of the patients. Which action

    should you pursue?

    a. Call the attention of the orderly in

    privateb. Ignore the situation because you are


    c. Report this behaviour to the nurse


    d. Monitor the situation and note whether

    any other items are reported missing

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    3. What appropriate action should you do

    when you overhear the nursing attendantspeaking harshly to an elderly patient?

    a. Try to explore the interaction with the

    nursing attendant concerned

    b. Change the attendants assignment

    c. Initiate group discussion with all the

    other nursing attendant

    d. Discuss the matter with the patientsfamily

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    4. Disposal of medical records inthe government hospitals need

    collaboration with the following

    department except:a. DOH

    b. MMDA

    c. DILGd. RMAO

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    5. You saw one colleague charting

    medication administration that she has

    not administered. after talking to her, you

    also report the incident to the charge

    nurse. The charge nurse should:

    a. Require the staff to submit an incidentreport

    b. Terminate the nurse

    c. Charge the erring nurse withdishonesty

    d. Report to the board of nursing

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    ituationYou are assigned at thePACU

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    6. Which nursing diagnosis has priority

    among clients in PACU?a. Acute pain related to discomfort of

    wound and immobility

    b. Body image disturbance due to wound

    dressing and drainsc. Ineffective airway clearance related to

    general anesthesia

    d. Knowledge deficit related to lack ofinformation because patients are


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    7. Which of the following clients in PACU

    demonstrate the effectiveness of thenurse teaching?

    a. The client demonstrate deep

    breathing, coughing, splinting andleg exercise

    b. The client manifest normal


    c. The client sleeps welld. The client has good balance and I and O

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    8. Which of the following remark

    indicates that the clients relative

    understood the discharge instructionsfor wound care?

    a. If the wound is painful, I would say

    that it is normalb. It is alright to use adhesive tape over

    the wound to keep it intact

    c. It is okay for his pet to remain at his

    bedside to keep him company

    d. I will report any redness or swelling

    of the wound

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    9. You must transfer out a post-op

    client to her room. Whatinstructions to the family should

    you include to avoid accident?

    a.Report when the IV infusion isalmost finished

    b.Test the call system if functioning

    c.Keep the room lights on for24hours

    d.Make sure the side rails are up

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    10. One of your post-op patients has a

    temperature of27.9 degree Celsius and was

    shivering. You covered him with a blanket and

    later took his temperature and it is now 38.9.

    The nursing student asked you to explain the

    absence of shivering even if the temperature is


    a.The patient is no longer febrile thus he is no

    longer chilling

    b.Shivering normally disappears as

    temperatures becomes higher

    c.The body has reached its new set point thus

    the absence of shivering

    d.The patient is feeling better

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    SituationPatients with chest tube

    can be very challenging to newnurses.

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    11. The chest tube drainage system of

    Tirso has continuous bubbling in the

    water seal drainage. After an hour, you

    noticed that the bubbling stops. Which of

    the following condition is the possible

    cause of malfunctioning sealeddrainage?

    a.A suction being too high

    b.An air leak

    c.A tube being too small

    d.A tension pneumothorax

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    12. While you were making your

    endorsement, you found out that the

    chest tube of a client was disconnected.What would be your appropriate action?

    a.Assist the client back to his bed and

    place him on the affected sideb.Cover the end of the chest tube with

    sterile gauze

    c.Reconnect the tube to the chest tube


    d.Put the end of the chest tube to the cup

    of sterile NSS

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    13. Dr. Reyes asked you to assist him

    with the removal of Tirsos chest tube.You would instruct the client to:

    a.Continuously breathe normally during

    the removal of the chest tubeb.Take a deep breath, exhale and bear


    c.Exhale upon actual removal of the tube

    d.Hold breath until the chest tube ispulled out

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    14. Chest tube diameter is

    measured is expressed in:

    a. Frenchb. Gauge

    c. Millimetres

    d. Inches

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    15. When transporting client

    with a chest tube, the

    system should be:


    c.Placed lower than the

    patients chest

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    SituationThe preoperative nurse

    collaborates with the clients

    significant others and healthcareproviders.

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    16. To control environmental

    hazards in the OR, the nursecollaborates with the following

    departments EXCEPT:

    a. Biomedical divisionb. DOH

    c. Infection control committee

    d. DILG

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    18. Tess, the PACU nurse, discovered

    that Malou, who weighs 110 lbs prior tosurgery is in severe pain 8 hours after

    cholecystectomy. Upon checking the

    chart ,Tess found out that Malou has an

    order of Demerol 100 mg prn for pain.Tess should verify the order with:

    a.Nurse supervisor


    d.Intern on duty

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    19. Rose, 57, who is diabetic is for debridement

    of incision wound. When the circulating nurse

    checked the present IV fluid, she found out that

    there is no insulin incorporated as ordered.

    What should the circulating nurse do?

    a.Double check the doctors order and call theattending MD

    b.Communicate with the ward nurse to verify if

    insulin was incorporated or not

    c.Communicate with the client to verify ifinsulin was incorporated

    d.Incorporate insulin as ordered

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    20. The documentation of all nursing activities

    performed is legally and professionally vital.

    Which of the following should not be includedin the patients chart?

    a. Presence of prosthetic devices such as

    dentures, artificial limbs, hearing aids,etc

    b. Baseline physical, emotional andpsychological data

    c. Arguments between nurses and residents

    regarding treatment

    d. Observed untoward signs and symptomsand interventions including contaminant

    intervening factors

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    SituationTechnology and patients

    education has dramatically improvedthe management of diabetic clients.

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    21. the current insulin pumps available in themarket have the following capabilities, except:

    a.prevent unexpected saving in blood glucose


    b.detect sign and symptoms of hypoglycaemiaand hypercalcemia

    c.deliver a pre-meal bolus dose of insulin

    before each meal

    d.deliver a continuous basal rate of insulin at0.5 units to 2 units per hour

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    22. discharge plan of diabetic clientsinclude injection site rotation. You

    should emphasize that the space

    between sites should be:a. 6 cm

    b. 5 cm

    c. 2.5 cmd. 4 cm

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    23. it is also critical that a diabetic

    client should be educated in the

    possible sites of regular insulin

    injection. The fastest absorption rate

    happens at the tissue areas of:

    a.gluteal area

    b.deltoid area

    c.anterior aread.abdominal area

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    24. self-monitoring of blood glucose

    is recommended for patients used.You will recommend this

    technology to diabetic clien