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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

busy

c. Report this behaviour to the nurse

incharge

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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S

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

sedated

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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

temperature

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

higher.

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

system

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

down

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:

a.Disconnectedb.Closed

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

b.Anaesthesiologistc.Surgeon

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

measurement

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 clients

except:a.a client with proliferative

retinopathy

b.unstable diabetesc.hypoglycaemia without warning

d.abdominal renal glucose threshold

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25. it is necessary for diabetic

clients to exercise regularly. What is

the effect of regular exercise to adiabetic client?

a.It burns excess glucose

b.It improves insulin utilization andlowers blood glucose

c.It lowers glucose, improves insulin

utilization decreases totaltriglyceride level

d.It will fit and energized

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26. Following a fracture of the

forearm or tibia, complaints of sharp,deep, unrelenting pain in the hand or

foot unrelieved by analgesics or

elevation of the extremity indicatewhich complication?

a. cast syndrome b. compartment

syndrome c. gangrene d. fat embolism

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28. Circulation must be restored

within 4 minutes of cardiopulmonaryarrest because:

a. the lungs fill with fluid

b. the blood begins to coagulatec. brain cells begin to die

d. irreversible kidney failure develops

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29. Benny elaborated on the concept of informed

consent. He determines that the nurses need

more explanation if theirresponse is one of the following:

a. the consent should provide a description of

alternative treatments or procedures

b. the consent should offer a thorough explanation ofthe procedures to be done and

the

consequences of it.

c. the consent should include the medical diagnosisand explanation of the patients condition

d. the consent should describe the prognosis if the

recommended care is refused.

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30. Which of the assessment findingswould indicate a need for possible

glaucoma testing?

a. intermittent loss of vision c. halosaround lights

b. presence of floaters d. pruritus and

erythema of the conjunctiva

31 Th di b i i k f

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31. The diabetic patient asks for a

snack and something to drink. The

MOST appropriate choicefor this client to meet

nutritional needs would be which of

the following:a. crackers with cheese and tea

b. toast with peanut butter and cocoa

c. vanilla wafers and coffee with

cream

d. graham crackers and warm milk

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32. The patient demonstrates

knowledge of the psychological

response to the operation and

other invasive procedure

when she asks about:a. Who will be with me in the OR?b. How is the post operative pain over the

site like?c. Will I be naked during the operation?

d. Is it cold inside the OR?

33 hi h h h

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33. In teaching the mother the proper

administration of tetracycline eye

ointment, which of thefollowing is MOST crucial?a. squirt a small amount on the inside of the

infected eyes lower lidb. use clean, wet cloth to gently wipe away the

pus

c. wash hands before medication

administration

d. do not use other eye ointments or drops or

put anything else in eyes.

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34. The primary goal of nursinginterventions after a craniotomy is:

a. avoiding need for secondary

surgeryb. ensuring patient comfort

c. preventing increased intracranial

pressure

d. prevention of infection

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35. Mr. Salvo, a 35 year old male, has

been admitted with the diagnosis of

peptic ulcers. The

nurse recognizes which

drugs as those MOST commonly used in

these patients to decrease acid

secretions?

a. erythromycin and flagyl

b. Tagamet and zantac

c. Maalox and kayexalate

d. Dyazide and carafate

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36. When reading the urinalysis

report, the nurse recognizes this

result as abnormal:a. red blood cells 15-20 c. Glucose

negative

b. turbid d. ph 6.0

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37. Mr. Hizon has had cataract

surgery. Discharge teaching wouldinclude:

a. wearing eye patches for the first 72

hoursb. bending at the waist acceptable if

done slowly

c. bending at the knees and keepingthe head straight

d. lifting light objects is acceptable

38 d i i i ll i i

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38. Endoscopic minimally invasive

surgery has evolved from diagnostic

modality to a widespreadsurgical technique. What

department should the nurse

collaborate which is unusual inconventional surgery?

a. engineering department c. Blood

bank services

b. x-ray department d. linen

section

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39. When the client is discharged

from the hospital and is not capableof doing the needed care

services, the following

can assume the role, EXCEPT:

a. family members c. significant

othersb. chaplain d. responsible

caregiver

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40. R.N. denotes that a nurse:

a. has satisfactorily completed with

the requirements to practice nursing

as set by the

state.b. has a baccalaureate degree in

nursing

c. is professionally ready to practicenursing

d. just a title

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Situation 7 - Joint Commission onAccreditation of Hospital Organization

(JCAHP) patient safety goals and

requirements include the care andefficient use of technology in the OR

arid elsewhere in the healthcare

facility.

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41. As the head nurse in the OR, how can you

improve the effectiveness of clinical alarm

systems?

a. limit suppliers to a few so that quality is

maintained

b. implement a regular inventory of supplies

and equipment

c. Adherence to manufacturer's

recommendationd. Implement a regular maintenance and

testing of alarm systems

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44. You identified a potential risk of pre and

post operative clients. To reduce the risk of

patient harm resulting from fall, you canimplement the following EXCEPT:

a. Assess potential risk of fail associated with

the patient's the following EXCEPT: medication

regimen

b. Take action to address any identified risks

through Incident Report (IR)c. Allow client to walk with relative to the OF?

d. Assess and periodically reassess individual

client's risk for falling

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45. As a nurse you know you can improve

on accuracy of patient's identification by 2

patient identifiers, EXCEPT:

a. identify the client by his/her wrist tag and

verify with family membersb. identify client by his/her wrist tag and call

his/her by name

c. call the client by his/her case and bed

number

d. call the patient by his/her name and bed

number

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Situation 8 - Team efforts is

best demonstrated in the OR

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46. If you are the nurse in charge for

scheduling surgical cases, what important

information do you need to ask thesurgeon?

a. Who is your internistb. Who is your assistant and anesthesiologist,

and what is your preferred time and type of

surgery?c. Who are your anesthesiologist, internist, and

assistant

d. Who is your anesthesiologist.

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47. In the OR, the nursing tandem for

every surgery is:

a. Instrument technician and

circulating nurseb. Nurse anesthetist, nurse assistant,

and instrument technician

c. Scrub nurse and nurse anesthetist

d. Scrub and circulating nurses

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48. While team effort is needed in the OR for

efficient and quality patient care delivery, we

should limit the number of people in the roomfor infection control. Who comprise this team?

a. Surgeon, anesthesiologist, scrub nurse,

radiologist, orderly

b. Surgeon, assistants, scrub nurse, circulating

nurse, anesthesiologist

c. Surgeon, assistant surgeon, anesthesiologist,scrub nurse, pathologist

d. Surgeon, assistant surgeon, anesthesiologist,

intern, scrub nurse

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ki d h i

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51. Skin care around the stoma is

critical. Which of the following is not

indicated as a skin care barriers?a. Apply liberal amount of mineral oil

to the area

b. Use karaya paste and rings around

the stoma

c. Clean the area daily with soap andwater before applying bag

d. Apply talcum powder twice a day

52 Wh h l h i i ill

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52. What health instruction will

enhance regulation of a colostomy

(defecation) of clients?

a. Irrigate after lunch everyday

b. Eat fruits and vegetables in all

three meals

c. Eat balanced meals at regularintervals

d. Restrict exercise to walking only

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53. After ileostomy, which of the

following condition is NOT expected?

a. increased weight

b. Irritation of skin around the stoma

c. Liquid stool

d. Establishment of regular bowel

movement

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54. The following are appropriate nursing

interventions during colostomy irrigation

EXCEPT:

a. Increase the irrigating solution flow rate

when abdominal cramps is felt

b. Insert 2-4 inches of an adequately lubricated

catheter to the stoma

c. Position client in semi-Fowlerd. Hand the solution 18 inches above the stoma

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55. What sensation is used as a gauge

so that patients with ileostomy can

determine how often their pouch

should be drained?

a. Sensation of taste

b. Sensation of pressure

c. Sensation of smelld. Urge to defecate

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Situation 12 - As a nurse, you should

be aware and prepared of thedifferent roles you play.

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56. What role do you play, when you

hold all clients information entrusted

to you in the strictest confidence?

a. Patient's advocate

b. Educator

c. Patient's Liaisond. Patient's arbiter

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58. As a nurse, your primary focus in the

workplace is the client's safety. However,

personal safety is also a concern. You can

communicate hazards to your co-workers

through the use of the following EXCEPT:

a. Formal training

b. Posters

c. Posting IR in the bulletin board

d. Use of labels and signs

59 As a nurse what is one of the best

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59. As a nurse, what is one of the best

way to reconcile medications across

the continuum of care?

a. Endorse on a case-to-case basis

b. Communication a complete list of thepatient's medication to the next provider

of service

c. Endorse in writingd. Endorse the routine and 'stat'

medications every shift

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60. As a nurse, you protect yourself and

co-workers from misinformation andmisrepresentations through the following

EXCEPT:a. Provide information to clients about a variety of

services that can help alleviate the client's pain and

other conditions

b. Advising the client, by virtue of your expertise, that

which can contribute to the client's well-being

c. Health education among clients and significant

others regarding the use of chemical disinfectant

d. Endorsement thru trimedia to advertise your

favorite disinfectant solution

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Situation 14 - You were on duty at the medical

ward when Zeny came in for admission for

tiredness, cold intolerance, constipation, andweight gain. Upon examination, the doctor's

diagnosis was hypothyroidism.

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64. Myxedema coma is a life

threatening complication of long

standing and untreated

hypothyroidism with one of the

following characteristics.

a. Hyperglycemia

b. hypothermiac. hyperthermia

d. hypoglycemia

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65. As a nurse, you know that themost common type of goiter is

related to a deficiency

a. thyroxine

b. thyrotropin

c. iron

d. iodine

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SituationMr. Santos, 50, is to

undergo cystoscopy due to multipleproblems like scanty urination.

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67. In the OR, you will position Mr.

Santos who is for cystoscopy in :

a. supineb. lithotomy

c. semi-fowlers

d. Trendelenburg

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68. After cystoscopy, Mr. Santos asked

you to explain why there is noincision of any kind. What do you tell

him?

a. cystoscopy is direct visualization andexamination by urologist

b. cystoscopy is done by x-ray visualization of

the urinary tract

c. cystoscopy is done by using lasers in the

urinary tract

d. cystoscopy is an endoscopic procedure of the

urinary tract

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69. Within 24-48 hrs after hours

postcystoscopy, it is normal to

observe one of the following:a) pink tinged urine

b) distended bladder

c) signs of infectiond) prolonged hematuria

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70. leg cramps are not uncommon

post cystoscopy. Nursing

interventions includes:a. bed rest

b. warm moist soak

c. early ambulationd. hot sitz bath

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71. Carmen is suspected to have left

breast CA. She is scheduled in yourroom on 5 for frozen section. How

will you prepare the specimen for

laboratory?a)Refrigerate and send it along with the days

specimen

b)Send to pathology immediately withoutsoaking solution

c)Send it in NSS

d)Soak it in formalin

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74. A post dilation and curettage

client is for discharge. Follow-up lab

result should be part of the discharge

plan. You will instruct client to followup result at the :

a)Medical records

b)Laboratoryc)Doctors clinic

d)Nurses station

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75. are the circulating nurse in OR 2.

You have 4 thyroidectomy cases for

the day. How do you prevent

switching of specimens?a) send specimens to laboratory right away after the

operation with the proper labels

b) collect all specimens and send to laboratory at the

end of the day

c) label specimen at onced) prepare for specimen vials first thing in the morning

76. Ms. F.X.. has been admitted with

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right upper quadrant pain and has

been placed on a low fatdiet. Which of the

following trays would be acceptable

for her?a. liver, fried potatoes and avocado

b. whole milk, rice and pastry

c. ham, mashed potatoes, cream peas

d. skim milk, lean fish, tapioca

pudding

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77. Negligence in the practice of

nursing can be a ground for:a. revocation of license by the

Ombudsman

b. revocation of license by the BON

c. revocation of license by the DOH

revocation of license by the Nursing

Department

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78. One way of verifying that the right

message/doctors order wascommunicated effectively is

by:

a. phrasing intelligentlyb. repeating the order message

c. documenting

d. speaking distinctly using enough

volume

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79. Maria is administering a cleansing enema to

a patient with fecal impaction. Before

administering the enema, she

should place the patient in which of the

following positions?

a. on the right side of the body with the headof the bed elevated 45 degrees

b. left Sims position

c. on the left side of the body with the head of

the bed elevated 45 degree

d. right Sims position

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80. The functionality and integrity of

instruments and medical devices used

in surgical procedure,

is the responsibility of

the:

a. surgeon c. OR nurseb. bio-med technician d. scrub nurse

81 Maria will be preparing a patient

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81. Maria will be preparing a patient

for thoracentesis. She should assist

the patient to which of

the following positions for

the procedure?a. prone with the head turned to the side andsupported by a pillow

b. lying in bed on the affected side with the head of

the bed elevated 45

degreesc. Sims position with the head of the bed flat

d. Lying in bed on the unaffected side with the head of

the bed elevated 45 degrees

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82. When a patient comes to the

clinic for an eye examination, theophthalmologists administers

phenylephrine 2.5%

drops to:a. dilate retinal blood vessels

b. anesthetize the cornea

c. dilate the pupild. removed any obstruction on the

cornea

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84. Patients undergoing surgery display differentlevels of anxiety. This is researchable. At

present, it has been found out

that music can decreases anxiety. What other factors

can reduce anxiety that is currently doneamong postoperative

cases?

a. pre-anesthetic drugs c. shower prior to surgery

b. pre-operative visit d. presence of any members ofthe family

85. a heavily researched topic in

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85. a heavily researched topic in

infection control is about the single

most important procedure forpreventing hospital acquired

infections. What is the procedure

called?

a. handwashing

b. use of scrub suitc. use of facemask

d. brain washing

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86. a most critical strategy in nursing

communication is:

a. non-verbal communication

b. giving stereotyped comments

c. verbal communications

d. active listening

87 Mr Tan has undergone surgery for

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87. Mr. Tan has undergone surgery for

lyses of adhesions. He is transferred

from the post anesthesia care unit to

the surgical floor. The nurse should

obtain blood pressure, pulse and

respiration every:

a. 3 minutes

b. 30 minutesc. 15 minutes

d. 20 minutes

88 Mr KAG GED age 13 diagnosed

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88. Mr. KAG GED age 13, diagnosed

with chronic bronchitis. He is very

dyspnoeic and must sit up to breath.

An abnormal condition in which there

is discomfort in breathing in any bed

or sitting position is:

A. cheyne stokes

b. orthopneac. eupnea

d. dyspnea

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89. the nurse recognizes that the

most common causative organism is

pyelonephritis is:

a. E. Coli

b. Klebsiella

c. candida albicansd. pseudomonas

90. Mr. Wat Tee is cleaning the garage

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and accidentally splashed a chemical

into his eyes. The initial priority carefollowing the chemical burn is to;

a,. Irrigate with normal saline for 1-15

minutesb. transport to a physician

immediately

c. employ in a private hospital

d. send to a medical mission where

services are free

91. Licensed nurses from foreign

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g

countries can practice nursing in the

Philippines with the followingcondition:

a. employed in state colleges and

universitiesb. special projects with hospitals with

a fixed fee

c. employees by private hospitals

d. medical mission whose services are

free

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93. the patient has a right to

information regarding the operationor other invasive procedures and

potential effects. This right is

achieved through:a. informed consent

b. preoperative visit

c. charting

d. doctors order

94. which statement about a persons

h t i id t i th OR t ?

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character is evident in the OR team?

a. it assists in the control of feelings

thoughts, emotions in the face of

difficulty

b. it reflects the moral values and beliefs

that are used as guides to personal

behaviour actions

c. it encourages the constructive use of

pleasure of the sense

d. it refers to the quality of being

righteous, correct, fair and impartial

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Situation 15 - Mrs. Pichay is admitted

to your ward. The MD ordered

"Prepared for thoracentesis this pmto remove excess air from the pleural

cavity."

96. Which of the following nursing

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96. Which of the following nursing

responsibility is essential in Mrs.

Pichay who will undergo

thoracentesis?

a. Support, and reassure client during the procedure

b. Ensure that informed consent has been signed

c. Determine if client has allergic reaction to local

anesthesiad. Ascertain if chest x-rays and other tests have been

prescribed and completed

97. Mrs. Pichay who is for thoracentesis is

i t d b th t f th f ll i

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assisted by the nurse to any of the following

positions, EXCEPT:

a. straddling a chair with arms and head resting

on the back of the chair

b. lying on the unaffected side with the bedelevated 30-40 degrees

c. lying prone with the head of the bed lowered

15-30 degrees

d. sitting on the edge of the bed with her feet

supported and arms and head on a padded

overhead table

98. During thoracentesis, which of the

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98. During thoracentesis, which of the

following nursing intervention will be most

crucial?

a. Place patient in a quiet and cool room

b. Maintain strict aseptic technique

c. Advice patient to sit perfectly still during

needle insertion until it has been withdrawn

from the chest

d. Apply pressure over the puncture site assoon as the needle is withdrawn

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99. To prevent leakage of fluid in the

thoracic cavity, how will you position

the client after thoracentesis?

a. Place flat in bed

b. Turn on the unaffected side

c. Turn on the affected sided. On bed rest

100. Chest x-ray was ordered after

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thoracentesis. When you client asks

what is the reason for another chestx-ray, you will explain:

a. to rule out pneumothorax

b. to rule out any possible perforation

c. to decongestd. to rule out any foreign: body