Medical-Surgical Nursing Exam 11: Musculoskeletal Care (60 Items)  - Challenge your nursing knowledge with this Medical-Surgical Nursing Examination! This is a 50-item examination that can help you improve, review and challenge your knowledge about Medical-Surgical Nursing through these challenging questions. If you are taking the board examination or nurse board examination or even the NCLEX, then this practice exam is for you.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

a. Supine
b. Semi Fowler’s
c. Orthopneic
d. Trendelenburg

2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?

a. Observe the color of the fingers
b. Palpate the radial pulse under the cast
c. Check the cast for odor and drainage
d. Evaluate the response to analgesics

3. After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:

a. An anaphylactic reaction to the dye
b. Inflammation from the extravasation of fluid during injection.
c. Fluid overload from the volume of the infusions
d. A normal reaction to the stress of the diagnostic procedure.

4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immedite notification of the physician?

a. Moderate pain, as reported by the client
b. Report, by client, the heat is being felt under the cast
c. Presence of slight edema of the toes of the casted foot
d. Onset of paralysis in the toes of the casted foot

5. Which of these nursing actions will best promote independence for the client in skeletal traction?

a. Instruct the client to call for an analgesic before pain becomes severe.
b. Provide an overhead trapeze for client use
c. Encourage leg exercise within the limits of traction
d. Provide skin care to prevent skin breakdown.

6. A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.

a. The client reports pain in the affected leg
b. A large hematoma is visible in the affected extremity
c. The affected extremity is shortenend, adducted, and extremely rotated
d. The affected extremity is edematous.

7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?

a. Order a trapeze to increase the client’s ambulation
b. Maintain the client in a flat, supine position at all times.
c. Provide pin care at least every hour
d. Remove traction weights for 20 minutes every two hours.

8. To prevent foot drop in a client with Buck’s traction, the nurse should:

a. Place pillows under the client’s heels.
b. Tuck the sheets into the foot of the bed
c. Teach the client isometric exercises
d. Ensure proper body positioning.

9. Which nursing intervention is appropriate for a client with skeletal traction?

a. Pin care
b. Prone positioning
c. Intermittent weights
d. 5lb weight limit

10. In order for Buck’s traction applied to the right leg to be effective, the client should be placed in which position?

a. Supine
b. Prone
c. Sim’s
d. Lithotomy

11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:

a. It will be very painful for the client
b. The soft tissue around the site will be damaged
c. Displacement can occur with flexion
d. It will pull the hip out of alignment

12. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:

a. Trochanter roll by the knee
b. Sandbag to the lateral calf
c. Trochanter roll to the thigh
d. Footboard

13. A client has just returned from surgery after having his left leg amputated below the knee. Physician’s orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client’s amputated limb. The nursing action is to:

a. Leave the pillow as his stump is elevated
b. Remove the pillow and elevate the foot of the bed
c. Leave the pillow and elevate the foot of the bed
d. Check with the physician and clarify the orders

14. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:

a. Protect the skin with lotion
b. Keep the client pulled up in bed
c. Pad the top of the splint with washcloths
d. Provide a footplate in the bed

15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to:

a. Reduce fever
b. Reduce the inflammation of the joints
c. Assist the client’s range of motion activities without pain
d. Prevent extension of the disease process

16. Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

a. Ability to ambulate sooner
b. Less change of phantom limb sensation
c. Dressing changes are not necessary
d. Better fit of the prosthesis

17. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:

a. Cough and deep breathe
b. Turn himself in bed
c. Perform biceps exercise
d. Wiggle his toes

18. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is to:

a. Get the client up in a chair after dangling at the bedside.
b. Use a walker for balance when getting the client out of bed
c. Have the client put minimal weight on the affected side when getting up
d. Practice getting the client out of bed by having her slightly flex her hips

19. A young client is in the hospital with his left leg in Buck’s traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:

a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot

20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the:

a. Client’s position
b. Rope/pulley system
c. Amount of weight
d. Point of friction

21. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:

a. Elevating the foot of the bed
b. Elevating the head of the bed
c. Application of the pelvic girdle
d. Lowering the head of the bed

22. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client’s toes for:

a. Increase in the temperature
b. Change in color
c. Edema
d. Movement

23. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse’s priority assessment should be to observe for:

a. Urinary retention
b. Bladder distention
c. Weight gain
d. Bower evacuation

24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client’s drug therapy is whether she has

a. Headaches
b. Tarry stools
c. Blurred vision
d. Decreased appetite

25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to

a. Read a story and act out the part
b. Watch a puppet show
c. Watch television
d. Listen to the radio

26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses:

a. Limited motion of joints
b. Deformed joints of the hands
c. Early morning stiffness
d. Rheumatoid nodules

27. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

a. History of Epstein-Barr virus infection
b. Female gender
c. Adults between the ages 60 to 75 years
d. Positive testing for human leukocyte antigen (HLA) DR4 allele

28. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?

a. Proper body alignment
b. Elevating the part
c. Prone lying positions
d. Positions of flexion

29. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching?

a. “I will take my vitamins while I am on this drug”
b. “I must not drink any alcohol while I’m taking this drug”
c. I should brush my teeth after every meal”
d. “I will continue taking my birth control pills”

30. When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess?

a. Anemia
b. Osteoporosis
c. Weight loss
d. Local joint pain

31. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

a. At bedtime
b. On arising
c. Immediately after meal
d. On an empty stomach

32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?

a. Hepatotoxicity
b. Renal toxicity
c. Gastrointestinal bleeding
d. Nausea and vomiting

33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?

a. A developing infection
b. Bleeding in the operative site
c. Joint dislocation
d. Glue seepage into soft tissue

34. Which of the following would the nurse assess in a client with an intracapsular hip fracture?

a. Internal rotation
b. Muscle flaccidity
c. Shortening of the affected leg
d. Absence of pain the fracture area

35. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?

a. Informing the client that the procedure is painless
b. Taking a thorough history of past surgeries
c. Checking for previous complaints of claustrophobia
d. Starting an intravenous line at keep-open rate

36. Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site?

a. Elevate the stump
b. Reinforcing the dressing
c. Calling the surgeon
d. Drawing a mark around the site

37. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

a. Tell the client it is impossible to feel the pain
b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic

38. The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises

39. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?

a. Axillae
b. Elbows
c. Upper arms
d. Hands

40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following?

a. Hemorrhage
b. Infection
c. Deformity
d. Shock

41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug’s primary effect?

a. Killing of microorganisms
b. Reduction in itching
c. Relief of muscle spasms
d. Decrease in nervousness

42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?

a. Expected common side effects
b. Hypersensitivity reactions
c. Possible habituating effects
d. Hemorrhage from GI irritation

43. When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?

a. The area proximal to the fracture
b. The actual fracture site
c. The area distal to the fracture
d. The opposite extremity for baseline comparison

44. A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure?

a. Rales
b. Jaundice
c. Generalized edema
d. Dark, scanty urine

45. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

a. Acute respiratory distress syndrome
b. Migraine like headaches
c. Numbness in the right leg
d. Muscle spasms in the right thigh

46. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?

a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection

47. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?

a. Formation of scar tissue interfering with absorption
b. Development of pus leading to ischemia
c. Production of bacterial growth by avascular tissue
d. Antibiotics not being instilled directly into the bone

48. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

a. Homan’s sign
b. Pain
c. Tenderness
d. Leg girth

49. The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority?

a. Allergy to iodine or shellfish
b. Ability of the client to remain still during the procedure
c. Whether the client has any remaining questions about the procedure
d. Whether the client wishes to void before the procedure

50. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

a. Divertional activity deficit
b. Powerlessness
c. Self care deficit
d. Impaired physical mobility

51. The nurse is teaching the client who is to have a gallium scan about the procedure. The nurse includes which of the following items as part of the instructions?

a. The gallium will be injected intravenously 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan

52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection?

a. Coolness and pallor of the extremity
b. Presence of a “hot spot” on the cast
c. Diminished distal pulse
d. Dependent edema

53. The client has Buck’s extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device?

a. Massage the skin of the right leg with lotion every 8 hours
b. Give pin care once a shift
c. Inspect the skin on the right leg at least once every 8 hours
d. Release the weights on the right leg for range of motion exercises daily

54. The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

a. Left leg and right crutch then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the left leg
d. Crutches and the left leg then advance the right leg

55. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

a. Left hand and placing the cane in front of the left foot
b. Right hand and placing the cane in front of the right foot
c. Left hand and 6 inches lateral to the left foot
d. Right hand and 6 inches lateral to the left foot

56. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:

a. Pillow to keep the right leg abducted during turning
b. Pillow to keep the right leg adducted during turning
c. Trochanter roll to prevent external rotation while turning
d. Trochanter roll to prevent abduction while turning

57. The nurse has an order to get the client out of bed to a chair on the first postoperative day after a total knee replacement. The nurse plans to do which of the following to protect the knee joint:

a. Apply a knee immobilizer before getting the client up and elevate the client’s surgical leg while sitting
b. Apply an Ace wrap around the dressing and put ice on the knee while sitting
c. Lift the client to the bedside change leaving the CPM machine in place
d. Obtain a walker to minimize weight bearing by the client on the affected leg

58. The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb was wrapped with an elastic compression bandage which has come off. The nurse immediately:

a. Calls the physician
b. Rewrap the stump with an elastic compression bandage
c. Applies ice to the site
d. Applies a dry sterile dressing and elevates it on a pillow

59. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to:

a. Wear a clean nylon stump sock daily
b. Toughen the skin of the stump by rubbing it with alcohol
c. Prevent cracking of the skin of the stump by applying lotion daily
d. Using a mirror to inspect all areas of the stump each day

60. The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse expect to note in the client?

a. Uric acid level of 8 mg/dl
b. Calcium level of 9 mg/dl
c. Phosphorus level of 3 mg/dl
d. Uric acid level of 5 mg/dl

The post Medical-Surgical Nursing Exam 11: Musculoskeletal Care (60 Items) appeared first on Nurseslabs.

Medical-Surgical Nursing Exam 13: Burns (40 Items) -Challenge your nursing knowledge with this Medical-Surgical Nursing Examination! This is a 50-item examination that can help you improve, review and challenge your knowledge about Medical-Surgical Nursing through these challenging questions. If you are taking the board examination or nurse board examination or even the NCLEX, then this practice exam is for you.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

3. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.

4. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

5. Which client factors should alert the nurse to potential increased complications with a burn injury?

A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.

6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

7. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase

8. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum

9. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the extremity.

10. What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis

11. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells

12. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

13. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?

A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.

14. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

15. On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning

16. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.

17. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit

18. What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image

19. All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%

20. The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?

A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities

21. In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”

22. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

23. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

24. The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”

25. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month

26. The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?

A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.

27. Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

A. Handwashing on entering the client’s room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas

28. In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?

A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.

29. The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

A. Place a towel roll under the client’s neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.

30. The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat

31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level

32. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?

A. Nothing, because the findings are normal for clients during the acute phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.

33. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A. Changing gloves between wound care on different parts of the client’s body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

34. When should ambulation be initiated in the client who has sustained a major burn?

A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift

35. What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
C. “I will have some scarring in the area when the skin is removed for grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was before I was burned.”

36. Which statement by the client indicates correct understanding of rehabilitation after burn injury?

A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”

37. Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”

38. What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?

A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements

39. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:

a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules

40. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:

a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees

The post Medical-Surgical Nursing Exam 13: Burns (40 Items) appeared first on Nurseslabs.

Preboard Exam C — Test 5: Psychiatric Nursing. This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Mental Health Nursing & Psychiatric Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

a. Observations
b. Restating
c. Exploring
d. Focusing

2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to:

a. Check the client’s medical record for an order for an as-needed I.M. dose of medication for agitation.
b. Place the client in full leather restraints.
c. Call the attending physician and report the behavior.
d. Remove all other clients from the dayroom.

3. Tina who is manic, but not yet on medication, comes to the drug treatment center. The nurse would not let this client join the group session because:

a. The client is disruptive.
b. The client is harmful to self.
c. The client is harmful to others.
d. The client needs to be on medication first.

4. Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:

a. Inform the mother that she and the father can work through this problem themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
d. Suggest that the father and son work things out.

5. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.

6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do?

a. Withhold the drug.
b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.

7. Dervid, an adolescent has a history of truancy from school, running away from home and “barrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the:

a. Id
b. Ego
c. Superego
d. Oedipal complex

8. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?

a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.

9. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:

a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.

10.What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?

a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.

11.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior?

a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.

12.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?

a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.

13.Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, “Why has this happened to me?” What is the nurse’s best response?

a. “You’ve developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
b. “It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical.”
c. “Your problem is real but there is no physical basis for it. We’ll work on what is going on in your life to find out why it’s happened.”
d. “It isn’t uncommon for someone with your personality to develop a conversion disorder during times of stress.”

14.Nurse Krina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD):

a. benztropine (Cogentin) and diphenhydramine (Benadryl).
b. chlordiazepoxide (Librium) and diazepam (Valium)
c. fluvoxamine (Luvox) and clomipramine (Anafranil)
d. divalproex (Depakote) and lithium (Lithobid)

15.Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following?

a. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.
b. A warning about the incidence of neuroleptic malignant syndrome (NMS).
c. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug.
d. A warning that immediate sedation can occur with a resultant drop in pulse.

16.Richard with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include:

a. Insomnia and an inability to concentrate.
b. Severe anxiety and fear.
c. Depression and weight loss.
d. Withdrawal and failure to distinguish reality from fantasy.

17.Which medications have been found to help reduce or eliminate panic attacks?

a. Antidepressants
b. Anticholinergics
c. Antipsychotics
d. Mood stabilizers

18.A client seeks care because she feels depressed and has gained weight. To treat her atypical depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical depression, what is its onset of action?

a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
d. 10 to 14 days

19. A 65 years old client is in the first stage of Alzheimer’s disease. Nurse Patricia should plan to focus this client’s care on:

a. Offering nourishing finger foods to help maintain the client’s nutritional status.
b. Providing emotional support and individual counseling.
c. Monitoring the client to prevent minor illnesses from turning into major problems.
d. Suggesting new activities for the client and family to do together.

20.The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent?

a. Combativeness, sweating, and confusion
b. Agitation, hyperactivity, and grandiose ideation
c. Emotional lability, euphoria, and impaired memory
d. Suspiciousness, dilated pupils, and increased blood pressure

21.The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?

a. History of gainful employment
b. Frequent expression of guilt regarding antisocial behavior
c. Demonstrated ability to maintain close, stable relationships
d. A low tolerance for frustration

22.Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

a. Barbiturates
b. Amphetamines
c. Methadone
d. Benzodiazepines

23.Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

a. Delusions
b. Hallucinations
c. Loose associations
d. Neologisms

24. Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

a. Restricts visits with the family and friends until the client begins to eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.

25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis reflects a belief that one is:

a. Highly important or famous.
b. Being persecuted
c. Connected to events unrelated to oneself
d. Responsible for the evil in the world.

26.Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic state would include:

a. Offering a high-calorie meals and strongly encouraging the client to finish all food.
b. Insisting that the client remain active through the day so that he’ll sleep at night.
c. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
d. Listening attentively with a neutral attitude and avoiding power struggles.

27.Ramon is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?

a. Withdrawal
b. Logical thinking
c. Repression
d. Denial

28.Richard is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

a. Aggressive behavior
b. Paranoid thoughts
c. Emotional affect
d. Independence needs

29. Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

a. Avoid shopping for large amounts of food.
b. Control eating impulses.
c. Identify anxiety-causing situations
d. Eat only three meals per day.

30.Rudolf is admitted for an overdose of amphetamines. When assessing the client, the nurse should expect to see:

a. Tension and irritability
b. Slow pulse
c. Hypotension
d. Constipation

31.Nicolas is experiencing hallucinations tells the nurse, “The voices are telling me I’m no good.” The client asks if the nurse hears the voices. The most appropriate response by the nurse would be:

a. “It is the voice of your conscience, which only you can control.”
b. “No, I do not hear your voices, but I believe you can hear them”.
c. “The voices are coming from within you and only you can hear them.”
d. “Oh, the voices are a symptom of your illness; don’t pay any attention to them.”

32.The nurse is aware that the side effect of electroconvulsive therapy that a client may experience:

a. Loss of appetite
b. Postural hypotension
c. Confusion for a time after treatment
d. Complete loss of memory for a time

33.A dying male client gradually moves toward resolution of feelings regarding impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to use nonverbal interventions when assessment reveals that the client is in the:

a. Anger stage
b. Denial stage
c. Bargaining stage
d. Acceptance stage

34.The outcome that is unrelated to a crisis state is:

a. Learning more constructive coping skills
b. Decompensation to a lower level of functioning.
c. Adaptation and a return to a prior level of functioning.
d. A higher level of anxiety continuing for more than 3 months.

35.Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against:

a. Driving at night
b. Staying in the sun
c. Ingesting wines and cheeses
d. Taking medications containing aspirin

36.Jen a nursing student is anxious about the upcoming board examination but is able to study intently and does not become distracted by a roommate’s talking and loud music. The student’s ability to ignore distractions and to focus on studying demonstrates:

a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety

37.When assessing a premorbid personality characteristics of a client with a major depression, it would be unusual for the nurse to find that this client demonstrated:

a. Rigidity
b. Stubbornness
c. Diverse interest
d. Over meticulousness

38.Nurse Krina recognizes that the suicidal risk for depressed client is greatest:

a. As their depression begins to improve
b. When their depression is most severe
c. Before nay type of treatment is started
d. As they lose interest in the environment

39.Nurse Kate would expect that a client with vascular dementis would experience:

a. Loss of remote memory related to anoxia
b. Loss of abstract thinking related to emotional state
c. Inability to concentrate related to decreased stimuli
d. Disturbance in recalling recent events related to cerebral hypoxia.

40.Josefina is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include:

a. Advising the client to watch the diet carefully
b. Suggesting that the client take the pills with milk
c. Reminding the client that a CBC must be done once a month.
d. Encouraging the client to have blood levels checked as ordered.

41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teaching about the side effects of this drug were understood when the client state, “I will call my doctor immediately if I notice any:

a. Sensitivity to bright light or sun
b. Fine hand tremors or slurred speech
c. Sexual dysfunction or breast enlargement
d. Inability to urinate or difficulty when urinating

42.Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a critical care area is:

a. Privacy
b. Respect
c. Empathy
d. Presence

43.When establishing an initial nurse-client relationship, Nurse Hazel should explore with the client the:

a. Client’s perception of the presenting problem.
b. Occurrence of fantasies the client may experience.
c. Details of any ritualistic acts carried out by the client
d. Client’s feelings when external; controls are instituted.

44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, “I will avoid:

a. Citrus fruit, tuna, and yellow vegetables.”
b. Chocolate milk, aged cheese, and yogurt’”
c. Green leafy vegetables, chicken, and milk.”
d. Whole grains, red meats, and carbonated soda.”

45.Nurse John is a aware that most crisis situations should resolve in about:

a. 1 to 2 weeks
b. 4 to 6 weeks
c. 4 to 6 months
d. 6 to 12 months

46. Nurse Judy knows that statistics show that in adolescent suicide behavior:

a. Females use more dramatic methods than males
b. Males account for more attempts than do females
c. Females talk more about suicide before attempting it
d. Males are more likely to use lethal methods than are females

47. Dervid with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?

a. “Your behavior won’t be tolerated. Go to your room immediately.”
b. “You’re just doing this to get back at me for making you come to therapy.”
c. “Your cursing is interrupting the activity. Take time out in your room for 10 minutes.”
d. “I’m disappointed in you. You can’t control yourself even for a few minutes.”

48.Nurse Maureen knows that the nonantipsychotic medication used to treat some clients with schizoaffective disorder is:

a. phenelzine (Nardil)
b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane)
d. imipramine (Tofranil)

49.Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)?

a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.

50.Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which lifethreatening reaction:

a. Tardive dyskinesia.
b. Dystonia.
c. Neuroleptic malignant syndrome.
d. Akathisia.

51.Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)?

a. Consulting with the physician about substituting a different type of antidepressant.
b. Advising the client to sit up for 1 minute before getting out of bed.
c. Instructing the client to double the dosage until the problem resolves.
d. Informing the client that this adverse reaction should disappear within 1 week.

52.Mr. Cruz visits the physician’s office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low selfesteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Tyfany suspects:

a. Cyclothymic disorder.
b. Atypical affective disorder.
c. Major depression.
d. Dysthymic disorder.

53. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal?

a. 5 g mixed in 250 ml of water
b. 15 g mixed in 500 ml of water
c. 30 g mixed in 250 ml of water
d. 60 g mixed in 500 ml of water

54.What herbal medication for depression, widely used in Europe, is now being prescribed in the United States?

a. Ginkgo biloba
b. Echinacea
c. St. John’s wort
d. Ephedra

55.Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

a. Calcium
b. Sodium
c. Chloride
d. Potassium

56.Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?

a. It’s characterized by an acute onset and lasts about 1 month.
b. It’s characterized by a slowly evolving onset and lasts about 1 week.
c. It’s characterized by a slowly evolving onset and lasts about 1 month.
d. It’s characterized by an acute onset and lasts hours to a number of days.

57.Edward, a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for:

a. Occasional irritable outbursts.
b. Impaired communication.
c. Lack of spontaneity.
d. Inability to perform self-care activities.

58.Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that:

a. This medication may be habit forming and will be discontinued as soon as the client feels better.
b. This medication has no serious adverse effects.
c. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication.
d. This medication may initially cause tiredness, which should become less bothersome over time.

59.Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client’s physical health, the nurse should plan to:

a. Severely restrict the client’s physical activities.
b. Weigh the client daily, after the evening meal.
c. Monitor vital signs, serum electrolyte levels, and acid-base balance.
d. Instruct the client to keep an accurate record of food and fluid intake.

60.Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?

a. Alcohol withdrawal
b. Cannibis withdrawal
c. Cocaine withdrawal
d. Opioid withdrawal

61.Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm’s employee assistance program. Nurse Beatriz knows that the client’s behavior most likely represents the use of which defense mechanism?

a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization

62.Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe:

a. Abnormal movements and involuntary movements of the mouth, tongue, and face.
b. Abnormal breathing through the nostrils accompanied by a “thrill.”
c. Severe headache, flushing, tremors, and ataxia.
d. Severe hypertension, migraine headache,

63.Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms?

a. Weakness
b. Diarrhea
c. Blurred vision
d. Fecal incontinence

64.Nurse Jannah is monitoring a male client who has been placed inrestraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:

a. The client verbalizes the reasons for the violent behavior.
b. The client apologizes and tells the nurse that it will never happen again.
c. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
d. The administered medication has taken effect.

65.Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse:

a. Increased attention span and concentration
b. Increase in appetite
c. Sleepiness and lethargy
d. Bradycardia and diarrhea

66.Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:

a. Profound
b. Mild
c. Moderate
d. Severe

67.The therapeutic approach in the care of Armand an autistic child include the following EXCEPT:

a. Engage in diversionary activities when acting -out
b. Provide an atmosphere of acceptance
c. Provide safety measures
d. Rearrange the environment to activate the child

68.Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.

a. Heroin
b. Cocaine
c. LSD
d. Marijuana

69.Nurse Pauline is aware that Dementia unlike delirium is characterized by:

a. Slurred speech
b. Insidious onset
c. Clouding of consciousness
d. Sensory perceptual change

70.A 35 year old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from:

a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia

71.Nurse Myrna develops a counter-transference reaction. This is evidenced by:

a. Revealing personal information to the client
b. Focusing on the feelings of the client.
c. Confronting the client about discrepancies in verbal or non-verbal behavior
d. The client feels angry towards the nurse who resembles his mother.

72.Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in-charge do first:

a. Recognize this as a drug interaction
b. Give the client Cogentin
c. Reassure the client that these are common side effects of lithium therapy
d. Hold the next dose and obtain an order for a stat serum lithium level

73.Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu?

a. A therapy that rewards adaptive behavior
b. A cognitive approach to change behavior
c. A living, learning or working environment.
d. A permissive and congenial environment

74.Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting:

a. Splitting
b. Transference
c. Countertransference
d. Resistance

75.Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis:
a. Situational
b. Adventitious
c. Developmental
d. Internal

76. Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is:

a. Obesity
b. Borderline personality disorder
c. Major depression
d. Hypertension

77.Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena?

a. Intellectualization
b. Transference
c. Triangulation
d. Splitting

78.An 83year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders?

a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
d. Sublimation

79. Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder

80. Nurse Daisy is aware that the following pharmacologic agents are sedativehypnotic medication is used to induce sleep for a client experiencing a sleep disorder is:

a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)

81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?

a. It brings some stability to the family
b. It decreases the preoccupation with the physical illness
c. It enables the client to avoid some unpleasant activity
d. It promotes emotional support or attention for the client

82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response?

a. “I went to the mall with my friends last Saturday”
b. “I’m hyperventilating only when I have a panic attack”
c. “Today I decided that I can stop taking my medication”
d. “Last night I decided to eat more than a bowl of cereal”

83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in client with posttraumatic stress disorder can be demonstrated by which of the following client self –reports?

a. “I’m sleeping better and don’t have nightmares”
b. “I’m not losing my temper as much”
c. “I’ve lost my craving for alcohol”
d. I’ve lost my phobia for water”

84. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication?

a. Stopping the drug may cause depression
b. Stopping the drug increases cognitive abilities
c. Stopping the drug decreases sleeping difficulties
d. Stopping the drug can cause withdrawal symptoms

85. Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect?

a. Anxiety disorder
b. Behavioral difficulties
c. Cognitive impairment
d. Labile moods

86. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true?

a. It involves a mood range from moderate depression to hypomania
b. It involves a single manic depression
c. It’s a form of depression that occurs in the fall and winter
d. It’s a mood disorder similar to major depression but of mild to moderate severity

87. The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:

a. Vascular dementia has more abrupt onset
b. The duration of vascular dementia is usually brief
c. Personality change is common in vascular dementia
d. The inability to perform motor activities occurs in vascular dementia

88. Loretta, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions?

a. Infection
b. Metabolic acidosis
c. Drug intoxication
d. Hepatic encephalopathy

89. Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate?

a. The client is experiencing aphasia
b. The client is experiencing dysarthria
c. The client is experiencing a flight of ideas
d. The client is experiencing visual hallucination

90. Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion?

a. The client tries to hit the nurse when vital signs must be taken
b. The client says, “I keep hearing a voice telling me to run away”
c. The client becomes anxious whenever the nurse leaves the bedside
d. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.

91. During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder?

a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association

92. Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorder?

a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal

93. Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine (Zyprexa)?

a. Explain effects of serotonin syndrome
b. Teach the client to watch for extrapyramidal adverse reaction
c. Explain that the drug is less affective if the client smokes
d. Discuss the need to report paradoxical effects such as euphoria

94. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers?

a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention

95. Tommy, with dependent personality disorder is working to increase his selfesteem. Which of the following statements by the Tommy shows teaching was successful?

a. “I’m not going to look just at the negative things about myself”
b. “I’m most concerned about my level of competence and progress”
c. “I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should be doing”

96. Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first?

a. Talk about his hallucinations and fears
b. Refer him for anticholinergic adverse reactions
c. Assess for possible physical problems such as rash
d. Call his physician to get his medication increased to control his psychosis

97. Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, “I thought the nurse was my mirror. I felt connected only when I saw my nurse.” This behavior is known by which of the following terms?

a. Modeling
b. Echopraxia
c. Ego-syntonicity
d. Ritualism

98. Jun approaches the nurse and tells that he hears a voice telling him that he’s evil and deserves to die. Which of the following terms describes the client’s perception?

a. Delusion
b. Disorganized speech
c. Hallucination
d. Idea of reference

99. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by mike?

a. Projection
b. Rationalization
c. Regression
d. Repression

100. Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol?

a. Should report feelings of restlessness or agitation at once
b. Use a sunscreen outdoors on a year-round basis
c. Be aware you’ll feel increased energy taking this drug
d. This drug will indirectly control essential hypertension

The post Preboard Exam C — Test 5: Psychiatric Nursing appeared first on Nurseslabs.

Preboard Exam C — Test 2: Community, Maternal & Child Health Nursing. This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Maternal & Child Health Nursing & Community Health Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?

a. Inevitable
b. Incomplete
c. Threatened
d. Septic

2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion?

a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus

3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?

a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature

4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require:

a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin

5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?

a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:

a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:

a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

a. Contractions every 1 ½ minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:

a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:

a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

11.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:

a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?

a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.

13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

a. Skim milk and baby food.
b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.

15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant
would be:

a. 6 months
b. 4 months
c. 8 months
d. 10 months

16.Which of the following is the most prominent feature of public health nursing?

a. It involves providing home care to sick people who are not confined in the hospital.
b. Services are provided free of charge to people within the catchments area.
c. The public health nurse functions as part of a team providing a public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.

17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating

a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness

18.Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply?

a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit

19.Tony is aware the Chairman of the Municipal Health Board is:

a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician

20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need?

a. 1
b. 2
c. 3
d. The RHU does not need any more midwife item.

21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement?

a. The community health nurse continuously develops himself personally and professionally.
b. Health education and community organizing are necessary in providing community health services.
c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease.
d. The goal of community health nursing is to provide nursing services to people in their own places of residence.

22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is?

a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus

23.May knows that the step in community organizing that involves training of potential leaders in the community is:

a. Integration
b. Community organization
c. Community study
d. Core group formation

24.Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?

a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the community’s resources in dealing with health problems.
d. To maximize the community’s resources in dealing with health problems.

25.Tertiary prevention is needed in which stage of the natural history of disease?

a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal

26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?

a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.

27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:

a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute

28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to:

a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infant’s fluid intake to decrease saturating diapers.

29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is:

a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect

30.Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is:

a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate

31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by:

a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea

32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be:

a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium

33.Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:

a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia

34.Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is:

a. A crying 5 year old child with a laceration on his scalp.
b. A 4 year old child with a barking coughs and flushed appearance.
c. A 3 year old child with Down syndrome who is pale and asleep in
his mother’s arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.

35.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected?

a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease

36.A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:

a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning

37.In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning?

a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria

38.To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching?

a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”
c. “The diaphragm must be left in place for atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.

39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for:

a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever

40.How should Nurse Michelle guide a child who is blind to walk to the playroom?

a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the child’s hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child’s hand.

41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an:

a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper extremities
d. Increased BP reading in the upper extremities.

42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires:

a. Less oxygen, and the newborn’s metabolic rate increases.
b. More oxygen, and the newborn’s metabolic rate decreases.
c. More oxygen, and the newborn’s metabolic rate increases.
d. Less oxygen, and the newborn’s metabolic rate decreases.

43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:

a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided

44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:

a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch

45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula?

a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches

46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct?

a. The older one gets, the more susceptible he becomes to the complications of chicken pox.
b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles.
c. To prevent an outbreak in the community, quarantine may be imposed by health authorities.
d. Chicken pox vaccine is best given when there is an impending outbreak in the community.

47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy?

a. Advice them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.

48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is:

a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects

49.A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect?

a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis

50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition?

a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery

51.The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism?

a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis

52.The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting the:

a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck

53.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds?

a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds

54.In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?

a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease

55.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. The estimated number of infants in the barangay would be:

a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants

56.The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer?

a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR

57.It is the most effective way of controlling schistosomiasis in an endemic area?

a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots

58.Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy?

a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear

59.Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of
leprosy?

a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge

60.Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do?

a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present everyday.

61.Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days

62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage Jimmy?

a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding program.
c. Make a teaching plan for the mother, focusing on menu planning for her child.
d. Assess and treat the child for health problems like infections and intestinal parasitism.

63.Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to:

a. Bring the child to the nearest hospital for further assessment.
b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more slowly.

64.Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?

a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.

65.Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as:

a. Fast
b. Slow
c. Normal
d. Insignificant

66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for

a. 1 year
b. 3 years
c. 5 years
d. Lifetime

67.Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?

a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day

68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to:

a. 5 months
b. 6 months
c. 1 year
d. 2 years

69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is:

a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks

70.When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following?

a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)

71.Which finding might be seen in baby James a neonate suspected of having an infection?

a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level

72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication?

a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia

73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which physical finding is expected?

a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body

74.After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate?

a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia

75.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without difficulty?

a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute

76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information?

a. Apply peroxide to the cord with each diaper change
b. Cover the cord with petroleum jelly after bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each day during a tub bath.

77.Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in the healthy neonate?

a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle

78.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons?

a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.

79.Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?

a. The parents’ willingness to touch and hold the new born.
b. The parent’s expression of interest about the size of the new born.
c. The parents’ indication that they want to see the newborn.
d. The parents’ interactions with each other.

80.Following a precipitous delivery, examination of the client’s vagina reveals

a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.

81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she’s in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first?

a. “Do you have any chronic illnesses?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”

82.A neonate begins to gag and turns a dusky color. What should the nurse do first?

a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe.

83. When a client states that her “water broke,” which of the following actions would be inappropriate for the nurse to do?

a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.

84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She’s diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby’s plan of care to
prevent retinopathy of prematurity?

a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.

85. Which of the following is normal newborn calorie intake?

a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg

86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks?

a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks

87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization?

a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins

88. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa?

a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound

89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal:

a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption

90. Emily has gestational diabetes and it is usually managed by which of the following therapy?

a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin

91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?

a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure

92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures?

a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain

93. Which of the following drugs is the antidote for magnesium toxicity?

a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)

94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results?

a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.

95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely?

a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)

96. Rh isoimmunization in a pregnant client develops during which of the following conditions?

a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal
antibodies.
b. Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating
maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.

97. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?

a. Lateral position
b. Squatting position
c. Supine position
d. Standing position

98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find:

a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.

99. The uterus returns to the pelvic cavity in which of the following time frames?

a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.

100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who’s caring for her should stay alert for:

a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort

The post Preboard Exam C — Test 2: Community, Maternal & Child Health Nursing appeared first on Nurseslabs.

This is a comprehensive examination which you can use for your Nurse Licensure Examination (NLE). This comprehensive exam ranges all topics of nursing.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. A woman in a child bearing age receives a rubella vaccination. Nurse Joy would give her which of the following instructions?

a. Refrain from eating eggs or egg products for 24 hours

b. Avoid having sexual intercourse

c. Don’t get pregnant at least 3 months

d. Avoid exposure to sun

2. Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been effective for a patient that has increased intracranial pressure?

a. Increased urinary output

b. Decreased RR

c. Slowed papillary response

d. Decreased level of consciousness

3. Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the Nurse Maureen is appropriate?

a. Incubation period is 6 months

b. Incubation period is 1 week

c. Incubation period is 1 month

d. Incubation period varies depending on the site of the bite

4. Which of the following should Nurse Cherry do first in taking care of a male client with rabies?

a. Encourage the patient to take a bath

b. Cover IV bottle with brown paper bag

c. Place the patient near the comfort room

d. Place the patient near the door

5. Which of the following is the screening test for dengue hemorrhagic fever?

a. Complete blood count

b. ELISA

c. Rumpel-leede test

d. Sedimentation rate

6. Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most important diagnostic test in malaria is:

a. WBC count

b. Urinalysis

c. ELISA

d. Peripheral blood smear

7. The Nurse supervisor is planning for patient’s assignment for the AM shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes zoster?

a. Nurse who never had chicken pox

b. Nurse who never had roseola

c. Nurse who never had german measles

d. Nurse who never had mumps

8. Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella. When would be the most appropriate for her to receive rubella immunization?

a. At once

b. During 2nd trimester

c. During 3rd trimester

d. After the delivery of the baby

9. A female child with rubella should be isolated from a:

a. 21 year old male cousin living in the same house

b. 18 year old sister who recently got married

c. 11 year old sister who had rubeola during childhood

d. 4 year old girl who lives next door

10. What is the primary prevention of leprosy?

a. Nutrition

b. Vitamins

c. BCG vaccination

d. DPT vaccination

11. A bacteria which causes diphtheria is also known as?

a. Amoeba

b. Cholera

c. Klebs-loeffler bacillus

d. Spirochete

12. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well?

a. I will come back later

b. I will come back next month

c. I will come back on Friday

d. I will come back on Wednesday, same time, to read the result

13. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as:

a. Negative

b. Uncertain and needs to be repeated

c. Positive

d. Inconclusive

14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to:

a. Use alcohol moderately

b. Avoid vitamin supplements while o therapy

c. Incomplete intake of dairy products

d. May be discontinued if symptoms subsides

15. Which is the primary characteristic lesion of syphilis?

a. Sore eyes

b. Sore throat

c. Chancroid

d. Chancre

16. What is the fast breathing of Jana who is 3 weeks old?

a. 60 breaths per minute

b. 40 breaths per minute

c. 10 breaths per minute

d. 20 breaths per minute

17. Which of the following signs and symptoms indicate some dehydration?

a. Drinks eagerly

b. Restless and irritable

c. Unconscious

d. A and B

18. What is the first line for dysentery?

a. Amoxicillin

b. Tetracycline

c. Cefalexin

d. Cotrimoxazole

19. In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter of water?

a. 1 tbsp. salt and 8 tbsp. sugar

b. 1 tbsp. salt and 8 tsp. sugar

c. 1 tsp. salt and 8 tsp. sugar

d. 8 tsp. salt and 8 tsp. sugar

20. Gentian Violet is used for:

a. Wound

b. Umbilical infections

c. Ear infections

d. Burn

21. Which of the following is a live attenuated bacterial vaccine?

a. BCG

b. OPV

c. Measles

d. None of the above

22. EPI is based on?

a. Basic health services

b. Scope of community affected

c. Epidemiological situation

d. Research studies

23. TT? provides how many percentage of protection against tetanus?

a. 100

b. 99

c. 80

d. 90

24. Temperature of refrigerator to maintain potency of measles and OPV vaccine is:

a. -3c to -8c

b. -15c to -25c

c. +15c to +25c

d. +3c to +8c

25. Diptheria is a:

a. Bacterial toxin

b. Killed bacteria

c. Live attenuated

d. Plasma derivatives

26. Budgeting is under in which part of management process?

a. Directing

b. Controlling

c. Organizing

d. Planning

27. Time table showing planned work days and shifts of nursing personnel is:

a. Staffing

b. Schedule

c. Scheduling

d. Planning

28. A force within an individual that influences the strength of behavior?

a. Motivation

b. Envy

c. Reward

d. Self-esteem

29. “To be the leading hospital in the Philippines” is best illustrate in:

a. Mission

b. Philosophy

c. Vision

d. Objective

30. It is the professionally desired norms against which a staff performance will be compared?

a. Job descriptions

b. Survey

c. Flow chart

d. Standards

31. Reprimanding a staff nurse for work that is done incorrectly is an example of what type of reinforcement?

a. Feedback

b. Positive reinforcement

c. Performance appraisal

d. Negative reinforcement

32. Questions that are answerable only by choosing an option from a set of given alternatives are known as?

a. Survey

b. Close ended

c. Questionnaire

d. Demographic

33. A researcher that makes a generalization based on observations of an individuals behavior is said to be which type of reasoning:

a. Inductive

b. Logical

c. Illogical

d. Deductive

34. The balance of a research’s benefit vs. its risks to the subject is:

a. Analysis

b. Risk-benefit ratio

c. Percentile

d. Maximum risk

35. An individual/object that belongs to a general population is a/an:

a. Element

b. Subject

c. Respondent

d. Author

36. An illustration that shows how the members of an organization are connected:

a. Flowchart

b. Bar graph

c. Organizational chart

d. Line graph

37. The first college of nursing that was established in the Philippines is:

a. Fatima University

b. Far Eastern University

c. University of the East

d. University of Sto. Tomas

38. Florence nightingale is born on:

a. France

b. Britain

c. U.S

d. Italy

39. Objective data is also called:

a. Covert

b. Overt

c. Inference

d. Evaluation

40. An example of subjective data is:

a. Size of wounds

b. VS

c. Lethargy

d. The statement of patient “My hand is painful”

41. What is the best position in palpating the breast?

a. Trendelenburg

b. Side lying

c. Supine

d. Lithotomy

42. When is the best time in performing breast self examination?

a. 7 days after menstrual period

b. 7 days before menstrual period

c. 5 days after menstrual period

d. 5 days before menstrual period

43. Which of the following should be given the highest priority before performing physical examination to a patient?

a. Preparation of the room

b. Preparation of the patient

c. Preparation of the nurse

d. Preparation of environment

44. It is a flip over card usually kept in portable file at nursing station.

a. Nursing care plan

b. Medicine and treatment record

c. Kardex

d. TPR sheet

45. Jose has undergone thoracentesis. The nurse in charge is aware that the best position for Jose is:

a. Semi fowlers

b. Low fowlers

c. Side lying, unaffected side

d. Side lying, affected side

46. The degree of patients abdominal distension may be determined by:

a. Auscultation

b. Palpation

c. Inspection

d. Percussion

47. A male client is addicted with hallucinogen. Which physiologic effect should the nurse expect?

a. Bradyprea

b. Bradycardia

c. Constricted pupils

d. Dilated pupils

48. Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck. What will be the priority nursing diagnosis?

a. Ineffective airway clearance related to edema

b. Impaired mobility related to pain

c. Impaired urinary elimination related to fluid loss

d. Risk for infection related to epidermal disruption

49. In assessing a client’s incision 1 day after the surgery, Nurse Betty expect to see which of the following as signs of a local inflammatory response?

a. Greenish discharge

b. Brown exudates at incision edges

c. Pallor around sutures

d. Redness and warmth

50. Nurse Ronald is aware that the amiotic fluid in the third trimester weighs approximately:

a. 2 kilograms

b. 1 kilograms

c. 100 grams

d. 1.5 kilograms

51. After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find a cord to:

a. Two arteries and two veins

b. One artery and one vein

c. Two arteries and one vein

d. One artery and two veins

52. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is

a. November 4

b. November 11

c. April 4

d. April 18

53. Which of the following is not a good source of iron?

a. Butter

b. Pechay

c. Grains

d. Beef

54. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate?

a. NPO

b. Bed rest

c. Immediate surgery

d. Enema

55. Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

a. Supine

b. Left side lying

c. Trendelinburg

d. Semi-fowlers

56. Nurse Hazel knows that Myrna understands her condition well when she remarks that urinary frequency is caused by:

a. Pressure caused by the ascending uterus

b. Water intake of 3L a day

c. Effect of cold weather

d. Increase intake of fruits and vegetables

57. How many ml of blood is loss during the first 24 hours post delivery of Myrna?

a. 100

b. 500

c. 200

d. 400

58. Which of the following hormones stimulates the secretion of milk?

a. Progesterone

b. Prolactin

c. Oxytocin

d. Estrogen

59. Nurse Carla is aware that Myla’s second stage of labor is beginning when the following assessment is noted:

a. Bay of water is broken

b. Contractions are regular

c. Cervix is completely dilated

d. Presence of bloody show

60. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the client’s membrane have ruptures when the paper turns into a:

a. Pink

b. Violet

c. Green

d. Blue

61. After amniotomy, the priority nursing action is:

a. Document the color and consistency of amniotic fluid

b. Listen the fetal heart tone

c. Position the mother in her left side

d. Let the mother rest

62. Which is the most frequent reason for postpartum hemorrhage?

a. Perineal lacerations

b. Frequent internal examination (IE)

c. CS

d. Uterine atomy

63. On 2nd postpartum day, which height would you expect to find the fundus in a woman who has had a caesarian birth?

a. 1 finger above umbilicus

b. 2 fingers above umbilicus

c. 2 fingers below umbilicus

d. 1 finger below umbilicus

64. Which of the following criteria allows Nurse Kris to perform home deliveries?

a. Normal findings during assessment

b. Previous CS

c. Diabetes history

d. Hypertensive history

65. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection?

a. Measles

b. OPV

c. BCG

d. Tetanus toxoid

66. Asin law is on which legal basis:

a. RA 8860

b. RA 2777

c. RI 8172

d. RR 6610

67. Nurse John is aware that the herbal medicine appropriate for urolithiasis is:

a. Akapulco

b. Sambong

c. Tsaang gubat

d. Bayabas

68. Community/Public health bag is defined as:

a. An essential and indispensable equipment of the community health nurse during home visit

b. It contains drugs and equipment used by the community health nurse

c. Is a requirement in the health center and for home visit

d. It is a tool used by the community health nurse in rendering effective procedures during home visit

69. TT4 provides how many percentage of protection against tetanus?

a. 70

b. 80

c. 90

d. 99

70. Third postpartum visit must be done by public health nurse:

a. Within 24 hours after delivery

b. After 2-4 weeks

c. Within 1 week

d. After 2 months

71. Nurse Candy is aware that the family planning method that may give 98% protection to another pregnancy to women

a. Pills

b. Tubal ligation

c. Lactational Amenorrhea method (LAM)

d. IUD

72. Which of the following is not a part of IMCI case management process

a. Counsel the mother

b. Identify the illness

c. Assess the child

d. Treat the child

73. If a young child has pneumonia when should the mother bring him back for follow up?

a. After 2 days

b. In the afternoon

c. After 4 days

d. After 5 days

74. It is the certification recognition program that develop and promotes standard for health facilities:

a. Formula

b. Tutok gamutan

c. Sentrong program movement

d. Sentrong sigla movement

75. Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on:

a. April 1985

b. February 1985

c. March 1985

d. June 1985

76. Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth?

a. 9

b. 7

c. 8

d. 6

77. Which of the following is the primary antidote for Tylenol poisoning?

a. Narcan

b. Digoxin

c. Acetylcysteine

d. Flumazenil

78. A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as:

a. Habit training

b. Sheltered workshop

c. Custodial

d. Educational

79. Nurse Judy is aware that following condition would reflect presence of congenital G.I anomaly?

a. Cord prolapse

b. Polyhydramios

c. Placenta previa

d. Oligohydramios

80. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the child’s diet:

a. Rye toast

b. Oatmeal

c. White bread

d. Rice

81. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by:

a. “Would you like to drink your medicine?”

b. “If you take your medicine now, I’ll give you lollipop”

c. “See the other boy took his medicine? Now it’s your turn.”

d. “Here’s your medicine. Would you like a mango or orange juice?”

82. At what age a child can brush her teeth without help?

a. 6 years

b. 7 years

c. 5 years

d. 8 years

83. Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy prepare this medication via which route?

a. Intra venous

b. Oral

c. Oxygen tent

d. Subcutaneous

84. The present chairman of the Board of Nursing in the Philippines is:

a. Maria Joanna Cervantes

b. Carmencita Abaquin

c. Leonor Rosero

d. Primitiva Paquic

85. The obligation to maintain efficient ethical standards in the practice of nursing belong to this body:

a. BON

b. ANSAP

c. PNA

d. RN

86. A male nurse was found guilty of negligence. His license was revoked. Re-issuance of revoked certificates is after how many years?

a. 1 year

b. 2 years

c. 3 years

d. 4 years

87. Which of the following information cannot be seen in the PRC identification card?

a. Registration Date

b. License Number

c. Date of Application

d. Signature of PRC chairperson

88. Breastfeeding is being enforced by milk code or:

a. EO 51

b. R.A. 7600

c. R.A. 6700

d. P.D. 996

89. Self governance, ability to choose or carry out decision without undue pressure or coercion from anyone:

a. Veracity

b. Autonomy

c. Fidelity

d. Beneficence

90. A male patient complained because his scheduled surgery was cancelled because of earthquake. The hospital personnel may be excused because of:

a. Governance

b. Respondent superior

c. Force majeure

d. Res ipsa loquitor

91. Being on time, meeting deadlines and completing all scheduled duties is what virtue?

a. Fidelity

b. Autonomy

c. Veracity

d. Confidentiality

92. This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient?

a. Responsibility

b. Resourcefulness

c. Autonomy

d. Prudence

93. Which of the following is formal continuing education?

a. Conference

b. Enrollment in graduate school

c. Refresher course

d. Seminar

94. The BSN curriculum prepares the graduates to become?

a. Nurse generalist

b. Nurse specialist

c. Primary health nurse

d. Clinical instructor

95. Disposal of medical records in government hospital/institutions must be done in close coordination with what agency?

a. Department of Health

b. Records Management Archives Office

c. Metro Manila Development Authority

d. Bureau of Internal Revenue

96. Nurse Jolina must see to it that the written consent of mentally ill patients must be taken from:

a. Nurse

b. Priest

c. Family lawyer

d. Parents/legal guardians

97. When Nurse Clarence respects the client’s self-disclosure, this is a gauge for the nurses’

a. Respectfulness

b. Loyalty

c. Trustworthiness

d. Professionalism

98. The Nurse is aware that the following tasks can be safely delegated by the nurse to a non-nurse health worker except:

a. Taking vital signs

b. Change IV infusions

c. Transferring the client from bed to chair

d. Irrigation of NGT

99. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina?

a. Call the attention of the client and encourage to sleep

b. Report the incidence to head nurse

c. Respect the client’s action

d. Document the situation

100. In caring for a dying client, you should perform which of the following activities

a. Do not resuscitate

b. Assist client to perform ADL

c. Encourage to exercise

d. Assist client towards a peaceful death

101. The Nurse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is known:

a. Belongingness

b. Genuineness

c. Empathy

d. Respect

102. The termination phase of the NPR is best described one of the following:

a. Review progress of therapy and attainment of goals

b. Exploring the client’s thoughts, feelings and concerns

c. Identifying and solving patients problem

d. Establishing rapport

103. During the process of cocaine withdrawal, the physician orders which of the following:

a. Haloperidol (Haldol)

b. Imipramine (Tofranil)

c. Benztropine (Cogentin)

d. Diazepam (Valium)

104. The nurse is aware that cocaine is classified as:

a. Hallucinogen

b. Psycho stimulant

c. Anxiolytic

d. Narcotic

105. In community health nursing, it is the most important risk factor in the development of mental illness?

a. Separation of parents

b. Political problems

c. Poverty

d. Sexual abuse

106. All of the following are characteristics of crisis except

a. The client may become resistive and active in stopping the crisis

b. It is self-limiting for 4-6 weeks

c. It is unique in every individual

d. It may also affect the family of the client

107. Freud states that temper tantrums is observed in which of the following:

a. Oral

b. Anal

c. Phallic

d. Latency

108. The nurse is aware that ego development begins during:

a. Toddler period

b. Preschool age

c. School age

d. Infancy

109. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is:

a. Weight loss

b. Weight gain

c. Reduce anxiety

d. Attractive appearance

110. The nurse is aware that the primary nursing diagnosis for the client is:

a. Altered nutrition : less than body requirement

b. Altered nutrition : more than body requirement

c. Impaired tissue integrity

d. Risk for malnutrition

111. After 14 days in the hospital, which finding indicates that her condition in improving?

a. She tells the nurse that she had no idea that she is thin

b. She arrives earlier than scheduled time of group therapy

c. She tells the nurse that she eat 3 times or more in a day

d. She gained 4 lbs in two weeks

112. The nurse is aware that ataractics or psychic energizers are also known as:

a. Anti manic

b. Anti depressants

c. Antipsychotics

d. Anti anxiety

113. Known as mood elevators:

a. Anti depressants

b. Antipsychotics

c. Anti manic

d. Anti anxiety

114. The priority of care for a client with Alzheimer’s disease is

a. Help client develop coping mechanism

b. Encourage to learn new hobbies and interest

c. Provide him stimulating environment

d. Simplify the environment to eliminate the need to make chores

115. Autism is diagnosed at:

a. Infancy

b. 3 years old

c. 5 years old

d. School age

116. The common characteristic of autism child is:

a. Impulsitivity

b. Self destructiveness

c. Hostility

d. Withdrawal

117. The nurse is aware that the most common indication in using ECT is:

a. Schizophrenia

b. Bipolar

c. Anorexia Nervosa

d. Depression

118. A therapy that focuses on here and now principle to promote self-acceptance?

a. Gestalt therapy

b. Cognitive therapy

c. Behavior therapy

d. Personality therapy

119. A client has many irrational thoughts. The goal of therapy is to change her:

a. Personality

b. Communication

c. Behavior

d. Cognition

120. The appropriate nutrition for Bipolar I disorder, in manic phase is:

a. Low fat, low sodium

b. Low calorie, high fat

c. Finger foods, high in calorie

d. Small frequent feedings

121. Which of the following activity would be best for a depressed client?

a. Chess

b. Basketball

c. Swimming

d. Finger painting

122. The nurse is aware that clients with severe depression, possess which defense mechanism:

a. Introjection

b. Suppression

c. Repression

d. Projection

123. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of:

a. Overcoming fear of failure

b. Overcoming feeling of insecurity

c. Relieving depression

d. Relieving anxiety

124. Which of the following may cause an increase in the cystitis symptoms?

a. Water

b. Orange juice

c. Coffee

d. Mango juice

125. In caring for clients with renal calculi, which is the priority nursing intervention?

a. Record vital signs

b. Strain urine

c. Limit fluids

d. Administer analgesics as prescribed

126. In patient with renal failure, the diet should be:

a. Low protein, low sodium, low potassium

b. Low protein, high potassium

c. High carbohydrate, low protein

d. High calcium, high protein

127. Which of the following cannot be corrected by dialysis?

a. Hypernatremia

b. Hyperkalemia

c. Elevated creatinine

d. Decreased hemoglobin

128. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to:

a. 4th CN

b. 8th CN

c. 7th CN

d. 9th CN

129. Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following:

a. Increase intake of tea, coffee and colas

b. Void every 6 hours per day

c. Void immediately after intercourse

d. Take tub bath everyday

130. Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast?

a. Blanching or cyanosis of legs

b. Complaints of pressure or tightness

c. Inability to move toes

d. Numbness of toes

131. During acute gout attack, the nurse administer which of the following drug:

a. Prednisone (Deltasone)

b. Colchicines

c. Aspirin

d. Allopurinol (Zyloprim)

132. Information in the patients chart is inadmissible in court as evidence when:

a. The client objects to its use

b. Handwriting is not legible

c. It has too many unofficial abbreviations

d. The clients parents refuses to use it

133. Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place?

a. Planning

b. Implementation

c. Diagnosing

d. Evaluation

134. When examining a client with abdominal pain, Nurse Hazel should assess:

a. Symptomatic quadrant either second or first

b. The symptomatic quadrant last

c. The symptomatic quadrant first

d. Any quadrant

135. How long will nurse John obtain an accurate reading of temperature via oral route?

a. 3 minutes

b. 1 minute

c. 8 minutes

d. 15 minutes

136. The one filing the criminal care against an accused party is said to be the?

a. Guilty

b. Accused

c. Plaintiff

d. Witness

137. A male client has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

a. Call the physician

b. Stay with the client and do nothing

c. Call another nurse

d. Call the family

138. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year?

a. 1994

b. 1992

c. 2000

d. 2001

139. When is the first certification of nursing informatics given?

a. 1990-1993

b. 2001-2002

c. 1994-1996

d. 2005-2008

140. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is:

a. Obesity

b. Race

c. Job

d. Age

141. A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear?

a. Tymphanic membranes

b. Inner ear

c. Auricle

d. External ear

142. When performing Weber’s test, Nurse Rosean expects that this client will hear

a. On unaffected side

b. Longer through bone than air conduction

c. On affected side by bone conduction

d. By neither bone or air conduction

143. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:

a. Kernigs sign

b. Brudzinski’s sign

c. A positive sweat chloride test

d. A positive edrophonium (Tensilon) test

144. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant?

a. Even, unlabored respirations

b. Soft, non distended abdomen

c. Urine output of 50 ml/hr

d. Warm skin

145. For a female client with suspected intracranial pressure (ICP), a most appropriate respiratory goal is:

a. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg

b. Promote elimination of carbon dioxide

c. Lower the PH

d. Prevent respiratory alkalosis

146. Which nursing assessment would identify the earliest sign of ICP?

a. Change in level of consciousness

b. Temperature of over 103°F

c. Widening pulse pressure

d. Unequal pupils

147. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following:

a. Pulmonary embolism

b. Cardiac arrest

c. Thrombus formation

d. Myocardial infarction

148. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed:

a. 7 days after menstruation

b. At the same day each month

c. During menstruation

d. Before menstruation

149. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be?

a. 60 gtts/min.

b. 21 gtts/min

c. 30 gtts/min

d. 15 gtts/min

150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated?

a. 13-14 drops

b. 17-18 drops

c. 10-12 drops

d. 15-16 drops

The post NLE Comprehensive Exam 3 (150 Items) appeared first on Nurseslabs.

As a nurse, we have an extensive knowledge about different drugs. But how really extensive your knowledge about Pharmacology? This is an examination about the concepts of Pharmacology.

Guidelines:

• Read each question carefully.
• Choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationales are given below. Be sure to read them!

1. The nursery nurse is putting erythromycin ointment in the newborn’s eyes to prevent infection. She places it in the following area of the eye:

A. under the eyelid
B. on the cornea.
C. in the lower conjunctival sac
D. by the optic disc.

2. The physician orders penicillin for a patient with streptococcal pharyngitis. The nurse administers the drug as ordered, and the patient has an allergic reaction. The nurse checks the medication order sheet and finds that the patient is allergic to penicillin. Legal responsibility for the error is:

A. only the nurse’s—she should have checked the allergies before administering the medication.
B. only the physician’s—she gave the order, the nurse is obligated to follow it.
C. only the pharmacist’s—he should alert the floor to possible allergic reactions.
D. the pharmacist, physician, and nurse are all liable for the mistake

3. James Perez, a nurse on a geriatric floor, is administering a dose of digoxin to one of his patients. The woman asks why she takes a different pill than her niece, who also has heart trouble. James replies that as people get older, liver and kidney function decline, and if the dose is as high as her niece’s, the drug will tend to:

A. have a shorter half-life.
B. accumulate.
C. have decreased distribution.
D. have increased absorption.

4. The nurse is administering Augmentin to her patient with a sinus infection. Which is the best way for her to insure that she is giving it to the right patient?

A. Call the patient by name
B. Read the name of the patient on the patient’s door
C. Check the patient’s wristband
D. Check the patient’s room number on the unit census list

5. The most important instructions a nurse can give a patient regarding the use of the antibiotic Ampicillin prescribed for her are to

A. call the physician if she has any breathing difficulties.
B. take it with meals so it doesn’t cause an upset stomach.
C. take all of the medication prescribed even if the symptoms stop sooner.
D. not share the pills with anyone else.

6. Mr. Jessie Ray, a newly admitted patient, has a seizure disorder which is being treated with medication. Which of the following drugs would the nurse question if ordered for him?

A. Phenobarbitol, 150 mg hs
B. Amitriptylene (Elavil), 10 mg QID.
C. Valproic acid (Depakote), 150 mg BID
D. Phenytoin (Dilantin), 100 mg TID

7. Mrs. Jane Gately has been dealing with uterine cancer for several months. Pain management is the primary focus of her current admission to your oncology unit. Her vital signs on admission are BP 110/64, pulse 78, respirations 18, and temperature 99.2 F. Morphine sulfate 6mg IV, q 4 hours, prn has been ordered. During your assessment after lunch, your findings are: BP 92/60, pulse 66, respirations 10, and temperature 98.8. Mrs. Gately is crying and tells you she is still experiencing severe pain. Your action should be to

A. give her the next ordered dose of MS.
B. give her a back rub, put on some light music, and dim the lights in the room.
C. report your findings to the MD, requesting an alternate medication order
D. be obtained from the physician.
E. call her daughter to come and sit with her.

8. When counseling a patient who is starting to take MAO (monoamine oxidase) inhibitors such as Nardil for depression, it is essential that they be warned not to eat foods containing tyramine, such as:

A. Roquefort, cheddar, or Camembert cheese.
B. grape juice, orange juice, or raisins.
C. onions, garlic, or scallions.
D. ground beef, turkey, or pork.

9. The physician orders an intramuscular injection of Demerol for the postoperativepatient’s pain. When preparing to draw up the medication, the nurse is careful to remove the correct vial from the narcotics cabinet. It is labeled

A. simethicone.
B. albuterol.
C. meperidine.
D. ibuprofen.

10. The nurse is administering an antibiotic to her pediatric patient. She checks the patient’s armband and verifies the correct medication by checking the physician’s order, medication kardex, and vial. Which of the following is not considered one of the five “rights” of drug administration?

A. Right dose
B. Right route
C. Right frequency
D. Right time

11. A nurse is preparing the client’s morning NPH insulin dose and notices a clumpy precipitate inside the insulin vial. The nurse should:

A. draw up and administer the dose
B. shake the vial in an attempt to disperse the clumps
C. draw the dose from a new vial
D. warm the bottle under running water to dissolve the clump

12. A client with histoplasmosis has an order for ketoconazole (Nizoral). The nurse teaches the client to do which of the following while taking this medication?

A. take the medication on an empty stomach
B. take the medication with an antacid
C. avoid exposure to sunlight
D. limit alcohol to 2 ounces per day

13. A nurse has taught a client taking a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which of the following beverages from the dietary menu?

A. chocolate milk
B. cranberry juice
C. coffee
D. cola

14. A client is taking famotidine (Pepcid) asks the home care nurse what would be the best medication to take for a headache. The nurse tells the client that it would be best to take:

A. aspirin (acetylsalicylic acid, ASA)
B. ibuprofen (Motrin)
C. acetaminophen (Tylenol)
D. naproxen (Naprosyn)

15. A nurse is planning dietary counseling for the client taking triamterene (Dyrenium). The nurse plans to include which of the following in a list of foods that are acceptable?

A. baked potato
B. bananas
C. oranges
D. pears canned in water

16. A client with advanced cirrhosis of the liver is not tolerating protein well, as eveidenced by abnormal laboratory values. The nurse anticipates that which of the following medications will be prescribed for the client?

A. lactulose (Chronulac)
B. ethacrynic acid (Edecrin)
C. folic acid (Folvite)
D. thiamine (Vitamin B1)

17. A female client tells the clinic nurse that her skin is very dry and irritated. Which product would the nurse suggest that the client apply to the dry skin?

A. glycerin emollient
B. aspercreame
C. myoflex
D. acetic acid solution

18. A nurse is providing instructions to a client regarding quinapril hydrochloride (Accupril). The nurse tells the client:

A. to take the medication with food only
B. to rise slowly from a lying to a sitting position
C. to discontinue the medication if nausea occurs
D. that a therapeutic effect will be noted immediately

19. Auranofin (Ridaura) is prescribed for a client with rheumatoid arthritis, and the nurse monitors the client for signs of an adverse effect related to the medication. Which of the following indicates an adverse effect?

A. nausea
B. diarrhea
C. anorexia
D. proteinuria

20. A client has been taking benzonatate (Tessalon) as ordered. The nurse tells the client that this medication should do which of the following?

A. take away nausea and vomiting
B. calm the persistent cough
C. decrease anxiety level
D. increase comfort level

The post Pharmacology Exam Questions 2 (20 Items) appeared first on Nurseslabs.

New set of examination questions about Medical-Surgical Nursing. This is a more general examination about Medical-Surgical Nursing which contains 80 questions.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

Situation: Intrapartal Nursing Care

1. In the delivery room, Mrs. Oro Is 10 cm. Dilated- and the head is fast emerging. Her attending physician has not yet arrived. The initial action the nurse must take after the head emerges is:

a. Support the head while the rest of the body is spontaneously delivered.
b. Push down on the fundus to help expel the infant.
c. Call the doctor STAT
d. Deliver the shoulder by turning the presenting part to internal rotation.

2. As labor progresses satisfactorily, it would be appropriate to administer pain medication with cervical dilatation of:

a. 4 cm.
b. 3 cm.
c. 5 cm.
d. 7 cm.

3. Mrs. Oro is kept informed of the, progress of her delivery, the nurse anticipates the placenta to be delivered within what period of time following delivery

a. 10-15 minutes
b. 3-10 minutes
c. 15-20 minutes
d. 1-3 minutes

4. Several minutes after the delivery, the placenta is still intact. The nurse will do which of these actions?

a. Push gently, but firmly on the fundus
b. Call the nursing supervisor for help
c. Allow the infant to suck on the breast
b. Initiate separation by gently pulling on the cord.

5. The placenta has been delivered and the nurse now adds the medication ordered to the i.V. solution which is:

a. Methergin
b. Oxytocin
c. Penicellin
d. Atropine

6. The nurse is giving health education to Felicity about discomfort of pregnancy. Which of the following conditions is brought about by increased absorption of phosphorus?

a. Back pain
b. Leg cramps
c. Constipation
d. Heartburn

7. The nurse was Instructed to watch out for the occurrence of norma! physiologic changes of pregnancy. Which of the following is usually observed during pregnancy?

a. Increased BP
b. Palpitation
c. Anemia
d. Blurred vision

8. Which of the following is TRUE about latent stage of labor?

a. self-focused
b. effacement 100%
c. dilatation for 2 hours
d. 3 cm cervical dilatation

9. What is the term that refers to menopausal stage of women?

a. cessation of menstruation
b. onset of’menstruation
c. excessive menstruation
d. intermittent menstruation

10 What structure of the body is responsible for the production of follicle-stimutattng hormone (FSH)?

a. hypothalamus
b. thymus
c. kidney
d. anterior pituitary gland

11. A primigravida asks the nurse, “When will I fee! the baby move?” The correct response of the nurse is:

a. 3 mos
b. 5 mos.
c. 4 mos
d. 6rnos.

Situation: Rico. 1 month deliverd via NSVD

12. Mrs. Cadacia observed on Rico’s buttocks, a gray color, What do you call this pigmentation in the skin?

a. milia
b. telangiectatic nevi
c. erythema toxicum
d. mongolian spots

13. How would you define a word, “acrocyanosis?

a. cyanosis of hands and feet.
b. transient mottling when infant is exposed to the temperature.
c. fine, downy hair
d. thin, white mucus

14. How can you assess a child who is mentally retarded?

a. let .the child make story
b. observe for the developmental milestone
c. ask the mother what food the child is eating
d. ask the child to sing

15. What serves as sperm producers?

a. epididymis
b. Vas deferens
c. prostate gland
d. testes

Situation: Pediatric nursing.

16. In what psychosexuai development according to Freud is temper tantrum observed?

a. phallic
b. oral
c. anal
d. latency

17. The baby cries and the mother notices tiny, shiny and white specks on the mouth and hard palate- The mother understood If she states:

a. “it is caused by milk curd
b. I’ll use sterile gauzed in removing the crusts.”
c. “I’ll notify the dentist
d. “prevent infection”

18. The nurse is giving Instruction about neonatal care. Which of the following instruction is most critical?

a. proper feeding
b. provide bathing
c. provide warm clothing
d. prevent infection

19. The mother notices a cheese-like substances in a neonate forehead. She asked the nurse if it can be removed. The appropriate response is:

a. a soft towel and a baby oil can be used to remove the subslance
b. an alcohol and gauzed can removed it
c. it is a protected substance, leave It alone there
d. baby lotion can be used to remove it .

20. A 12-month old boy weighs 9 kgs. His birth weight was 3 kgms. “The mother asks if her baby’s weight Is appropriate to his age. The nurse’s therapeutic response is:

a. He needs to take more milk for supplement
b. Weight must be doubled during this time
c. Weight is right because weight is tripled at this age
d. He is underweight for this age.

21. At the age of 2 years, which of the following teeth have not been erupted?
a. canine
b. pre-molar
c. molar
d. incisor

22. The mother asks the nurse when will the soft bone at the head be closed? The nurse response would be:

a. 12-18wks
b. 2-3 mos.
c. 12-18 mos.
d. 14-18 wks

23. What is the most appropriate factor in toilet training?

a. age of child
b. developmental readiness of the child
c. available time
d. maternal flexibility

Situation: Medical – Surgical Nursing

24. In what area of the body will be affected by bed sore if the patient maintains supine position?

a. heels
b. ilium
c. sacrum
d. malleolus

25. Which of the following can you visualize in intravenous pyelogram (IVP )?

a. bladder
b. bladder and kidney
c. bladder, kidney , ureter
d. bladder and ureter

26. An anesthetic agent which has side effects of confusion and suicidal tendencies;

a. ether
b. ketalar
c. halothane
d. sodium pentothal

27. What instrument is not included in Mayo table?

a. retractor
b. tissue forcep
c. smooth forcep
d. towel forcep

Situation: The adolescent years have the potential to be very exciting as well as a different time for both the child and his parents.

28. As stated by Erikson, the major concern of the adolescent years is the:

a. formation of romantic association
b. attainment of independence ‘
c. gratification of his needs
d. resolution of the crisis of personal identity

29. Parental actions which can help achieve the goal of adolescent years are all of the following, EXCEPT;

a. permits increasing independence
b. discusses future plans with the adolescent
c. intolerance of .adolescent’s need to be liked by peers
d. permits and encourages peer relationships

30. Here are teenagers today who engage In sex without realizing the repercussions of their actions. Witch of the parental response would be appropriate for this problem?

a. Providing regular and open communication
b. Limiting the number of teenager’s social activities
c. Inforcing stricter rules and punishment
d. Screening the teenager’s company of friends

31. Some of the task of adolescent years include the following, except:

a. developing a personal Identity
b. advicing independence from patients
c. developing relationship with peers
d. unlimited expression of sexual drives

32. Which of the following statements best describe the nutritional profiie of the adolescent?

a. Rapid growth, desires company with meals
b. Rapid growth, eat meals alone
c. Slow but steady growth, poor eating habits
d. Stunted growth, voracious appetite

Situation: You are assigned a Rural Health Unit which is a training area for student nurse, in a conference with the students, questions on the DOH programs such as:

33. The most effective measure of controlling schistosomlasis is;

a. casefinding and prompt treatment of cases
b. provision of sanitary toilets
c. environmental sanitation and environmental control
d. practice of hygiene

34. Rabies virus can be transmitted through:

a. Penetration of broken skin
b. contact with a pre-existing wound or scratch
c. penetration of intact mucosa
d. any of these modes of transmission

35. Which of the followimg statements about- diphtheria is false?

a. Immunity is often acquired through a complete immunization series of Diphtheria
b. infants born to immune mothers maybe protected up to 5 months
c. Diphtheria transmission Is Increased in hospital households, schools and other crowded areas.
d. Recovery from clinical attack is always followed by a lasting Immunity to the disease

Situation: The following questions pertain to concepts on Community Health Nursing:

36. A logical approach used by the nurse in providing community health and communicable nursing is:

a. problem solving
b. nursing process
c. logical nursing intervention
d. nursing assessment

37. Which of the following statement is wrong:

a. A nursing diagnosis is stated in terms of a problem and not a need
b. A nursing diagnosis describes a patient’s health problem
c. A nursing process to the method of data gathering and diagnosing diseases
d. A component of the nursing process that pertains to the organization of data and describes the nursing problem is the assessment

38. Debbie is experiencing dystocia, a painful, difficult and prolonged delivery. The nurse is aware that the primary cause related to problems with all of these Except the.

a. Power
b. Prognosis
c. Passenger
d. Passageway

39. In dystocia, the nurse assessess:

1. contractions dropping intensity and frequency
2. progress of labor
3. vagina! exam
4. abdominal palpation and fetal position

a. 1,2 and 3
b. 1,2,3 and 4
c. 2,3 and 4
d. 1,3, and 4

40. The nursing intervention that Is most important in a patient on IV Morphine?

a. Monitor for hypertension
b. Monitor for decreased respiratlons
c. Monitor for cardiac rates
d. Monitor for hyperglycemia

Situation: A clinical instructor, Mrs. Romero is giving a pre-test on Psychiatric Nursing to third year nursing students.

41. The fundamental concepts in Psychiatric nursing is seeing the patient as a whole organism with distinct personality. The nurse should:

a. Respect the patient’s moral values
b. Avoid labeling the patient as psychiatric entity
c. Understand the patient’s family background
d. Uphold the patients right to make decisions

42. On crisis intervention, one of the important personal qualities . that can enhance the nurse’s effectiveness is:

a. Friendliness
b. Flexibility
c. Patience
d. Consistency

43. A technique In crisis intervention which ‘involves using the clients emotion and values to his own benefit in the therapeutic regmen Is known as:

a. clarification
b. reinforcement of behavior
c manipulation
d. Support defense

44. Family therapy is the treatment of choice in one of the following situatlons:

a. There is a need to uncover repressed feelings and concerns of the clients
b. There is a need to promote an environment adaptive to the individual client’s needs
c. The primary problem Is related to marital conflict or sibling rivalry
d. The client requested for this type of therapy

Situation – This pertains to Intrapartum Care.

45. True labor contraction Is best described by this discomfort that:

a. starts over the fundus, radiating downward to the cervix
b. radiates upward and downward from the umbilicus
c. Is localized over the fundus of the uterus
d. begins In the lower back and the abdomen radiating over entire abdomen

46. The nurse performs vaginal exams on a laboring woman and records this data is correctiy Interpreted as:

a. fetal presenting part is 1 cm. above the ischlal spines
b. cervical dilatation is 25% completed
c. progress of effacement is 5 cm. completed
d. fetal presenting part is 1 cm below the ischial spines

47.Monitoring the progress of labor in’the delivery room is a standard activity. The. nurse prioritizes her work load by recognizing that a nulliparous mother in the first stage of labor would expect these;

a. Latent phase is completed less than 20 hours
b. Maximum slope averages 4 to 5 hrs
c. Acceleration phase is 6 to 8 hours
d. Transition phase lasting no longer than 4 hours.

Situation – Growth and development is a human cycle with milestone to achieve.

48- Based on Erikson’s theory, the primary developmental task of the middle years is:

a. to attain independence
b. to achieve generativity
c. to establish heterosexual relationship
d. to develop a sense of personal identity

49. Early adult age Is partlcular!y focused on achieving

a. independence from parental control
b. greater stability and life style
c. greater stability and life style
d. self-direction and self-appraisal

50. These are characteristics of a mature person, except;

a. practical and ambitious
b. accountable and responsible for his actions
c. feels comfortable with himself
d. acknowledges strengths and weaknesses .

51. The group at greatest risk for unmet needs is:

a. the very young and the very old
b. all age groups
c. the poor and the very rich
d. the adult and the aged

Situation -At the health center, the nurse conducts a, nutrition class, very lively question and answer prevailed in this group meeting-

52.Amy, a pregnant mother from a sectarian group strictly adheres to a. vegetarian diet. The vitamin supplement the nurse recommend Is

a. Vit.C
b. Vit B12
c. Vit D
d. Vit. A

53. For point of clarification a patient asks for the importance of Folic Acid in pregnancy. The nurse explains that vitamin is especially needed during pregnancy as it:

a. assists in growth of heart and lungs
b. helps in coagulation of red blood cells
c. is essential for cell and RBC formation
d. helps in maternal circulation

54. In this mother’s class, the nurse discusses about: specific needs during pregnancy and lactation, She states that the daily servings required for the carbohydrates group are:

a. 4 servings
b. 6 servings
c. 2 servings
d. 3 servings

Situation – Charito de Lapaz, a PHN, is discussing with the mothers the different herbal medicines used In the community.

55. It is effective for asthma, cough, and dysentery:

a. Yerba Buena
b. Lagundi
c. Sambong
d. Tsaang-gubat

56. lt is an anti-edema, diuretic and anti-urolithiasis.

a. Sambong
b. Tsaang-gubat
c. Niyug-niyogan
d. Akapulko

57. Its seeds are taken 2 hours after supper to expel round worms, which can cause ascariasis;

a. Akapulko
b. Bayabas
c. Niyug-niyogan
d. Bawang

58. It is effectively used for mild non-insulin dependent diabetes mellitus.

a. bawang
b. Bayabas
c. Ulasimang Bato
d. ampalaya

59. The following are true in the preparation of herbal medicines, EXCEPT:

a. Avoid the use of Insecticides as may poison on plants
b. Stop giving the medication in case reaction such as allergy occurs
c. Use only the part of the plant being advocated
d. Use a day pot and cover while boiling at low heat.

Situation – Leo Leon, a carpenter has been complaining of headache for 2 days. his wife, a trained BHW used the acupressure technique on Leo to relieve Mm of his discomfort.

60. Acupressure was started same 5.000 years ago by:

a. Germans
b. Filipinos
c. Chinese
d. Americans

Situation – In a mother class, several topics are discussed. Questions 15 to 20 pertain to these

61. According to the goals of Reproductive health, all are true, EXCEPT:

a. Every pregnancy should be Intended
b. Every birth be healthy
c. Every woman should be g|ven a condom to protect herself from pregnancy and other STDs
d. Every sex should be free or coercion and infection

62. It is record used when rendering prenatal care in the community,

a. Prenatal record
b. Home Based mother’s record
c. Pink Card
d. Mother’s book

63. Which of the following is given to the pregnant woman?

a. Chloroquine
b. Iron
c. iodized oil capsule
d. All of the above

64 All of the following should be observed in home deliveries, EXCEPT:

a. Clean hands
b. Clean sheets
c. Clean cord
d. Clean surface

65. What is the major cause of maternal death?

a. Infection
b. Hemorrhage
c. Prolonged labor
d. Retained placenta

66. The first postparturn should be done when:

a. After 48 hours
b. After 24 hours
c. After 3 days
d. Within 24 hours .

Situation: The following questions are Included In the review of EPI

67. It provides for compulsory basic immunization for infants and children below 8 years of age;

a. Presidential proclamation N.773
b. Republic Act 7846
c Presidertial Decree No, 996
d. Presidential Proclamation No.147

68. The vaccine should be given on:

a. 1 month
b. 6 months
c. 3 months
d. 9 months

69. How much Vit A should be given to 6-11 months old Infants who is experiencing Vit. A deficiency?

a. 200,000 IU
b. 400.000 IU
c. 100,000 IU
d. 50,000 IU

70. Micronutrient supplementation is included In what program of the DOH?

a. Expanded program on Immunization
b. Reproductive Health
c. Araw ng Sangkap Pinoy
d. Sentrong sigla

Situation – Communicabie Diseases are most prevalent in Brgy, Problemado, a group of PHN went to the area to disseminate necessary information regarding early detection, control and cure of the different communicable diseases.

71. It is the name for a comprehensive strategy which primary health services around the world is using to detect and cure TB patients.

a. National TB program
b. Direct Observe Treatment Short Course (DOTS)
c. center for Communicable diseases
d. international TB control Organization

72. All but one is the early sign of leprosy:

a. Madarosis
b. Nasal obstruction or bleeding
c. Change In skin color
d. Ulcers that do not heal

73. Leprosy can be transmitted through

a. Blood
b. Sex
c. Semen
d. Prolonged skin to skin contact

74. The best method of prevention of TB and leprosy esp. among children is:

a. Taking INH for prophylaxis
b. Healthy environment
c. Good nutrition
d. BCG immunization

75. What is the host of schistosoma japonlcum?

a. Mosquitoes
b. Rats
c. Snails
d. Dogs

76.The drug cf choice for schistosomiasis:

a. Metrifonate
b. Praziquante
c. Hetrazan
d. Quinidine Suifale

Situation – Ella Caidic Is pregnant with her first baby. She went to the clinic for check-up

77. According to Mrs. Caidic, her LMP is November 15, 2002. Using the Naegele’s rule what is her EDC

a. August 22, 2003
b. July 22, 2003
c. August 18, 2003
d. February 22, 2003

78. She Is so concerd about the development of varicose veins, which of the statement below indicates a need for further education?

a. “I should wear support hose”
b. ‘”I should be wearing flat, non-slip shoes that have an arch support
c. “I should wear a pantyhose”
d. I can wear knee-high as long as I don’t leave them on longer than 8 hours

79. She complained of leg cramps, winch usually occurs at night. To provide relief, the nurse must telI Mrs. Caidic to:

a. dorsiftex the foot white extending the knee when the cramps occur
b. dorsiflex the foot whiie flexing the knee when the cramps occur.
c. Plantar flex the foot while flexing the knee when cramps occur
d. plantar flex the foot while extending the knee when the cramps occur.

80. A nurse has just been told by a physician that an order has been written to administer an iron injection to an adult client. The nurse plans to administer the medication In which of the following locations?

a. In the gluteal muscle using Z-track technique
b. In the deltoid muscle using an air lock
c. In the subcutaneous fesue of the abdomen
d. in the anterior lateral thigh using a 5/8 inch needle ‘

The post Medical-Surgical Nursing Exam 22: NLE Style (80 Items) appeared first on Nurseslabs.

Preboard Exam D — Test 1: Fundamentals of Nursing - This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Fundamentals of Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today.

1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and population. This is the most accepted definition of nursing as defined by the:

A. PNA
B. ANA
C. Nightingale
D. Henderson

2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT expanded career role for nurse?

A. Nurse practitioner
B. Clinical Nurse Specialist
C. Nurse Researcher
D. Nurse anaesthesiologist

3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following EXCEPT:

A. Issue, suspend revoke certificates of registration
B. Issue subpoena duces tecum, ad testificandum
C. Open and close colleges of nursing
D. Supervise and regulate the practice

4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make judgments about them is in what stage of Nursing Expertise?

A. Novice
B. Newbie
C. Advanced Beginner
D. Competent

5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:

A. The ability to organize and plan activities
B. Having attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations

Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer this.

6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is to be administered to the client. Which of the following site will you choose?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection?
A. Deltoid
B. Rectus Femoris
C. Ventrogluteal
D. Vastus lateralis

8. In order to decrease discomfort in Z track administration, which of the following should be done? 

A. Pierce the skin quickly and smoothly at 90 degree angle
B. Inject the medication at around 10 minutes per millilitre
C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel
D. Pierce the skin slowly and carefully at a 90 degree angle

9. After injection using the Z track technique, the nurse should know that she needs to wait for few second before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle?

A. 2 second
B. 5 seconds
C. 10 seconds
D. 15 seconds

10. The rationale in using the Z track technique in an intramuscular injection is:

A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissue.
B. It will allow a faster absorption of the medication
C. The Z track technique prevent irritation of the muscle
D. It is much more convenient for the nurse

Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment:

11. All of the following are correct methods in assessment of the blood pressure EXCEPT:

A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff sound
C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control

12. You attached a pulse oximeter to the client. You know that the purpose id to:

A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertension medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be

14. Through the client’s health history, you gather that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes

15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximiter is. Your action will be to:

A. Set and turn on the alarm of the oximeter
B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours

16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of:

A. 15 seconds
B. 1 to 2 minutes
C. 30 minutes
D. 15 minutes

17. If the arm is said to be elevated when taking the blood pressure. It will create a:

A. False high reading
B. False low reading
C. True False reading
D. Indeterminate

18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature?

A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 15 minutes

19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down to 80 mmHg and then silence. What is the client’s pressure?

A. 130/80
B. 150/100
C. 100/80
D. 150/100

20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading?

A. 10 – 20 seconds
B. 30 – 45 seconds
C. 1 – 1.5 minutes
D. 3 – 3.5 minutes

Situation 4 – Oral care is an important part of hygienic practices and promoting client comfort.

21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?

A. lemon glycerine
B. hydrogen peroxide
C. Mineral oil
D. Normal saline solution

22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?

A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

23. The advantages of oral care for a client include all of the following, EXCEPT:

A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food

24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by:

A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums
D. suctioning as needed while cleaning the buccal cavity

25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:

A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment

Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.

26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure:

A. Clenching his fist every 2 minutes
B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds

27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication:

A. Nausea and vomiting
B. Shortness of breath and laryngeal stridor
C. Blood tinged sputum and coughing
D. Sore throat and hoarseness

28. Immediately after bronchoscopy, you instructed Fernan to:

A. Exercise the neck muscles
B. Breathe deeply
C. Refrain from coughing and talking
D. Clear his throat

29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to:

A. Keep the sterile equipment from contamination
B. Assist the physician
C. Open and close the three-way stopcock
D. Observe the patient’s vital signs

30. Right after thoracentesis, which of the following is most appropriate intervention?

A. Instruct the patient not to cough or deep breathe for two hours
B. Observe for symptoms of tightness of chest or bleeding
C. Place an ice pack to the puncture site
D. Remove the dressing to check for bleeding

Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions.

31. A client with diabetes mellitus has glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the involvement at which type of acid base imbalance?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimen are drawn?

A. Guthing test
B. Allen’s test
C. Romberg’s test
D. Weber’s test

34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

35. Allen’s test checks the patency of the:

A. Ulnar artery
B. Radial artery
C. Carotid artery
D. Brachial artery

37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.

38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?

A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’s buttocks
D. to the patient lower abdomen

39. Which of the following menu is appropriate for one with low sodium diet?

A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda

40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?

A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area

Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary.

41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland:

A. Hypothalamus
B. Anterior pituitary gland
C. Posterior pituitary gland
D. Thyroid gland

42. All of the following are secreted by the anterior pituitary gland except:

A. Somatotropin/Growth hormone
B. Follicle stimulating hormone
C. Thyroid stimulating hormone
D. Gonadotropin hormone releasing hormone

43. All of the following hormones are hormones secreted by the Posterior pituitary gland except:

A. Vasopressin
B. Oxytocin
C. Anti-diuretic hormone
D. Growth hormone

44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:

A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the:

A. Thyroid gland
B. Hypothalamus
C. Parathyroid gland
D. Anterior pituitary gland

Situation 8 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.

46. The plan of the nurse supervisor is an example of

A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention

47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra

A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated

48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse supervisor should

A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life

49. Process of formal negotiations of working conditions between a group of registered
nurses and employer is

A. grievance
B. arbitration
C. collective bargaining
D. strike

50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is

A. professional course towards credits
B. inservice education
C. advance training
D. continuing education

Situation 9: As a nurse, you are aware that proper documentation in the patient chart is your responsibility.

51. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting?

A. Bill of rights as provided in the Philippine Constitution
B. Scope of nursing practice as defined in R.A. 9173
C. Board of Nursing resolution adopting the Code of Ethics
D. Patient’s Bill of Rights

52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication?

A. Incident Report
B. Oral report
C. Nursing kardex
D. Complain report

53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges?

A. Fraud
B. Assault and Battery
C. Harassment
D. Breach of confidentiality

54. Which of the following is the essence of informed consent?

A. It should have a durable power of attorney
B. It should have coverage from an insurance company
C. It should respect the client’s freedom from coercion
D. It should discloses previous diagnosis, prognosis and alternative treatments available for the client.

55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation?

A. The RN must supervise all delegated tasks
B. After a task has been delegated. It is no longer a responsibility of the RN.
C. The RN is responsible and accountable for the delegated task in a adjunct with the delegate.
D. Follow up with a delegated task necessary only if the assistive personnel is not trustworthy.

Situation 10 – When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke.

56. The most important risk factor is:

A. Cigarette smoking
B. Hypertension
C. binge drinking
D. heredity

57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT:

A. Embolic stroke
B. Hemorrhagic stroke
C. diabetic stroke
D. thrombotic stroke

58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT:

A. phlebitis
B. trauma
C. damage to blood vessel
D. aneurysm

59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this?

A. Amphetamines
B. Cocaine
C. shabu
D. Demerol

60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:

A. “More red blood cells thicken blood and make clots more possible.”
B. “Increased RBC count is linked to high cholesterol.”
C. “More red blood cell increases hemoglobin content.”
D. “High RBC count increases blood pressure.”

Situation 11: Recognition of normal values is vital in assessment of clients with various disorders.

61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following?

A. 60%
B. 47%
C. 45%
D. 32%

62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?

A. ST depression
B. Inverted t wave
C. Prominent U wave
D. Tall peaked T waves

63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value?

A. U waves
B. Absent P waves
C. Elevated T waves
D. Elevated ST segment

64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding?

A. Neutrophils 60%
B. White blood cells (WBC) 9000/mm
C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr
D. Iron 75 mg/100 ml

65. Which of the following laboratory test result indicate presence of an infectious process?

A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18,000/mm3
C. Iron 90 g/100ml
D. Neutrophils 67%

Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Question to 66 to 70 refer to this?

66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion?

A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachypnea and shortness of breath.
B. Hypoxemia
C. Noisy respiration, crackles, stridor and wheezing
D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds

67. Thoracentesis is performed to the client with effusion. The nurse knows that he removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause:

A. Pneumothorax
B. Pleurisy or Pleuritis
C. Cardiovascular collapse
D. Hypertension

68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that the pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to:

A. Restore positive intrathoracic pressure
B. Restore negative intrathoracic pressure
C. To visualize the intrathoracic content
D. As a method of air administration

69. The chest tube is functioning properly if:

A. There is an oscillation
B. There is no bubbling in the drainage bottle
C. There is a continuous bubbling in the water seal.
D. The suction control bottle has a continuous bubbling

70. In a client with pleural effusion, the nurse is instructing a appropriate breathing technique. Which of the following is included in the teaching?

A. Breath normally
B. Hold the breath after each inspiration for 1 full minute
C. Practice abdominal breathing
D. Inhale slowly and hold the breath for 3-5 seconds after each inhalation.

Situation 13: Health care delivery system affects the health status of every Filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life.

71. When should rehabilitation commence?

A. The day before discharge
B. When the patient desires
C. Upon admission
D. 24hours after discharge

72. What exemplified the preventive and promotive programs in the hospital?

A. Hospitals as a center to prevent and control infection
B. Program for smokers
C. Program for alcoholics and drug addicts
D. Wellness Center

73. Which makes nursing dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being
B. The patient participate in the over all nursing care plan
C. Nursing practice is expanding in the light of modern development that takes place
D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes.

74. Prevention is an important responsibility of the nurse in:

A. Hospitals
B. Community
C. Workplace
D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a periodic payment.

A. Health Maintenance Organization
B. Medicare
C. Philippine Health Insurance Act
D. Hospital Maintenance Organization

91. Health care reports have different purposes. The availability of patients record to all health ream members demonstrates which of the following purposes:

A. Legal documentation
B. Education
C. Research
D. Vehicle for communication

92. When a nurse commits medication error she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes:

A. Research
B. Nursing Audit
C. Legal documentation
D. Vehicle for communication

93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should include:

A. Prescription of the doctor to the patient’s illness
B. Plan of care for patient
C. Patient’s perception of one’s illness
D. Nursing Problem and Nursing Diagnosis

94. The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording?

A. POMR
B. SOAPIE
C. Modified POMR
D. SOMR

95. Which of the following is the advantage of SOMR or Traditional Recording?

A. Increase efficiency of Data gathering
B. Reinforces the use of the nursing process
C. The caregiver can easily locate proper section for making charting entries
D. Enhances effective communication among health care team members

Situation 17: June is 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest X-ray revealed pleural effusion. The physician will perform thoracentesis

96. Thoracentesis is useful in treating which of the following pulmonary disorders except:

A. Hemothorax
B. Tuberculosis
C. Hydrothorax
D. Empyema

97. Which of the following psychological preparation is not relevant for him?

A. Telling him that the gauge of the needle and anesthesia to be used
B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place.
C. Allow June to express his feeling and concerns
D. Physician’s explanation on the purpose of the procedure and how it will be done.

98. Before thoracentesis, the legal consideration you must check is:

A. Consent is signed by the client
B. Medicine preparation is correct
C. Position of the client is correct
D. Consent is signed by relative and physician

99. As a nurse, you know that the position for June before thoracentesis is:

A. Orthopneic
B. Knee-chest
C. Low fowlers
D. Sidelying position on the affected side

100. Which of the following anesthetic drug is used for thoracentecis?
A. Procaine 2 %
B. Valium 250 mg
C. Demerol 75 mg
D. Phenobarbital

The post Preboard Exam D — Test 1: Fundamentals of Nursing appeared first on Nurseslabs.

Preboard Exam D — Test 3: Medical Surgical Nursing Exam - This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Medical-Surgical Nursing. This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

Situation 1: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort.

1. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken?
A. Fecal oral
B. Droplet
C. Airborne
D. Sexual contact

2. Which of the following is concurrent disinfection in the case of Leo?
A. In
B. Sanitary disposal of feces, urine and blood
C. Quarantine of the sick individual
D.

3. Which of the following must be emphasized during mother’s class to Leo’s mother?
A. Administration of immunoglobulin to families
B. Thorough hand washing before and after eating and toileting
C. Use of attenuated vaccines
D. Boiling of food especially meat

4. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority?
A. Eliminate fecal contamination from foods
B. Mass vaccination of uninfected individuals
C. Health promotion and education to families and communities about the disease it’s cause and transmission.
D. Mass administration of immunoglobulin

5. What is the average incubation period of Hepatitis A?
A. 30 days
B. 60 days
C. 50 days
D. 14 days

Situation 2: As a nurse researcher you must have a very good understanding of the common terms of concept used in research.

6. The information that an investigator collects from the subjects or participants in a research study is usually called:
A. Hypothesis
B. Data
C. Variable
D. Concept

7. Which of the following usually refers to the independent variables in doing research?
A. Result
B. Cause
C. Output
D. Effect

8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called;
A. Setting
B. Subjects
C. Treatment
D. Sample

9. The device or techniques an investigator employs to collect data is called?
A. Sample
B. Instrument
C. Hypothesis
D. Concept

10. The use of another persons ideas or wordings giving appropriate credit results from inaccurate attribution of materials to its sources. Which of the following is referred to when another persons idea is inappropriate credited as one’s own?
A. Plagiarism
B. Quotation
C. Assumption
D. Paraphrase

Situation 3: Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”

11. Which of the following nursing responsibilities 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 anesthesia
D. Ascertain if chest x-rays and other tests have been prescribed and completed

12. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions?
A. Trendelenburg position
B. Supine position
C. Dorsal Recumbent position
D. Orthopneic position

13. 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 as soon as the needle is withdrawn

14. 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 side
D. On bed rest

15. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:
A. to rule out pneumothorax
B. to rule out any possible perforation
C. to decongest
D. to rule out any foreign body

Situation 4: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.

16.Just as nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
A. Ease the patient to the floor
B. Lift the patient and put him on the bed
C. Insert a padded tongue depressor between his jaws
D. Restrain patient’s body movement

17. Mr. Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
A. Shampoo hair thoroughly to remove oil and dirt
B. No special preparation is needed. Instruct the patient to keep his head still and stead.
C. Give a cleansing enema and give until 8 AM
D. Shave scalp and securely attach electrodes to it

18. Mr. Santos is placed on seizure precaution. Which of the following would be contraindicated?
A. Obtain his oral temperature
B. Encourage to perform his own personal hygiene
C. Allow him to wear his own clothing
D. Encourage him to be out of bed.

19. Usually, how does the patient behave after his seizure has subsided?
A. Most comfortable walking and moving about.
B. Becomes restless and agitated.
C. Sleeps for a period of time
D. Say he is thirsty and hungry.

20. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
A. Low fowler’s
B. Modified trendelenburg
C. Side Lying
D. Supine

Situation 5: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site.

21. Choledocholithotomy is:
A. The removal of the gallbladder
B. The removal of the stones in the gallbladder
C. The removal of the stones in the common bile duct
D. The removal of the stones in the kidney

22. The simplest pain relieving technique is:
A. Distraction
B. Taking aspirin
C. Deep breathing exercise
D. Positioning

23. Which of the following statement on pain is true?
A. Culture and pain are not associated
B. Pain accomplished acute illness
C. Patient’s reaction to pain varies
D. Pain produces the same reaction such as groaning and moaning

24. In a pain assessment, which of the following condition is a more reliable indicator?
A. Pain rating scale of 1 – 10
B. Facial expression and gestures
C. Physiological responses
D. Patients description of the pain sensation

25. When a client complains of pain, your initial response is:
A. Record the description of pain
B. Verbally acknowledge the pain
C. Refer the complaint to the doctor
D. Change to a more comfortable position

Situation 6: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective.

26. A one-day post operative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in 1 – 10 pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take?
A. Medicate client as prescribed
B. Encourage client to do-imagery
C. Encourage deep breathing exercise
D. Call surgeon stat

27. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain, which will be your priority nursing action?
A. Check abdominal dressing for possible swelling
B. Explain the proper use of PCA to alleviate anxiety
C. Avoid overdosing to prevent dependence/tolerance
D. Monitor VS, more importantly RR

28. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is:
A. Instruct client to go to sleep and relax
B. Advice the client to close the lips and avoid deep breathing and talking
C. Offer hot and clear soup
D. Turn to sides frequently and avoid too much talking

29. Surgical pain might be minimized b which nursing action in the O.R.
A. Skill of surgical team and lesser manipulation
B. Appropriate preparation for the scheduled procedure
C. Use of modern technology in closing the wound
D. Proper positioning and draping of client.

30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post-op patients. If general anesthesia is desired, it will involve loss of consciousness. Which of the following are the 2 general types of GA?
A. Epidural and Spinal
B. Subarachnoid block and intravenous
C. Inhalation and Regional
D. Intravenous and inhalation

Situation 7: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain.

31. Nurses should be aware of that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following beliefs EXCEPT:
A. Older patients seldom tend to report pain than the younger ones
B. Pain is a sign of weakness
C. Older patients do not believe in analgesics, they are tolerant.
D. Complaining of pain will lead to being labelled a bad patient

32. Nurses should understand that when a client responds favourably to a placebo, it is known as the placebo effect. Placebos do not indicate whether or not a client has:
A. Conscience
B. Real pain
C. Disease
D. Drug tolerance

33. You are the nurse in the pain clinic where you have client who has difficulty specify the location of pain. How can you assist such client?
A. The pain is vague
B. By charting-it hurts all over
C. Identifying the absence and presence of pain
D. Ask the client to point to the painful are by just one finger.

34. What symptom more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain?
A. Forgetfulness
B. Constipation
C. Drowsiness
D. Allergic reactions like pruritus

35. Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice?
A. Start another drug and slowly lessen the opioid dosage
B. Indulge in recreational outdoor activities
C. Isolate opioid dependent to a restful resort
D. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms.

Situation 8: The nurse is performing health education activities for Janevi Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus.

36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she:
A. Draw insulin from the vial of clear insulin first
B. Draw insulin from the vial of the intermediate acting insulin first
C. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously
D. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first.

37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry first?
A. Withhold the client’s next insulin injection
B. Test the client’s blood glucose level
C. Administer Tylenol as ordered
D. Offer fruit juice, gelatine and chicken bouillon

38. Janevi administered regular insulin at 7 A.M. and the nurse should instruct Jane to avoid exercising at around:
A. 9 to 11 A.M.
B. After 8 hours
C. Between 8 A.M. to 9 A.M.
D. In the afternoon, after taking lunch.

39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient?
A. Glycosylated Hemoglobin
B. Fasting blood glucose
C. Ketone levels
D. Uirne glucose level

40. Upon the assessment of HbA1C of Mrs. Segovia. The nurse has been informed of a 9 % HbA1C result. In this case, she will teach the patient to:
A. Avoid infection
B. Take adequate food and nutrition
C. Prevent and recognize hypoglycaemia
D. Prevent and recognize hypoglycaemia

41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan?
A. Soak feet in hot water
B. Avoid using mild soap on the feet
C. Apply a moisturizing lotion to dry feet but not between the toes
D. Always have a podiatrist to cut your toe nails; never cut them yourself

42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately prepare to initiate which of the following anticipated physician’s order?
A. Endotracheal intubation
B. 100 units of insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate

43. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis?
A. Comatose state
B. Decreased urine output
C. Increased respiration and increase in pH
D. Elevated blood glucose level and plasma bicarbonate level

44. The nurse teaches Jane to know the difference between hypoglycaemia and ketoacidosis. Jane demonstrates understanding of the teaching by stating that glucose will be taken of which of the following symptoms develops?
A.
B. Shakiness
C. Blurred vision
D. Foul breath odor

45. Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane to eat or drink after midnight. Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said yes. Which of the following is the best nursing action?
A. Administer syrup of ipecac to remove the distilled water from the stomach.
B. Suction the stomach content using NGT prior to specimen collection
C. Advice to physician to reschedule to diagnostic examination next day
D. Continue as usual and have the FBS analysis performed and specimen be taken.

Situation 9: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population.

46. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation

47. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity

48. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity

49. Cardiac ischemia in an older patient usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion

50. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles

Situation 10 – In the OR, there are safety protocols that should be followed. The OR nurseshould be well versed with all these to safeguard the safety and quality of patient delivery outcome.

51. Which of the following should be given highest priority when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
D. Check for jewelry, gown, manicure, and dentures

52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference

53. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure…
A. the surgeon greets his client before induction of anesthesia
B. the surgeon and anesthesiologist are in tandem
C. strap made of strong non-abrasive materials are fastened securely
around the joints of the knees and ankles and around the 2 hands around
an arm board.
D. Client is monitored throughout the surgery by the assistant anaesthesiologist

54. Another nursing check that should not be missed before the induction of general
anesthesia is:
A. check for presence underwear
B. check for presence dentures
C. check patient’s ID
D. check baseline vital signs

55. Some lifetime habits and hobbies affect postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk
for:
A. perioperative anxiety and stress
B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory function

Situation 11: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility.

56. There are 3 general types of sterilization use in the hospital which one is not included?
A. Steam sterilization
B. Chemical sterilization
C.
D. Sterilization by boiling

57. Autoclave or steam steam under pressure is the most common method of sterilization in the hospital. The nurse knows that the temperature and time is set to the optimum level to destroy not only the microorganism, but also the spores. Which of the following is the ideal setting of the autoclave machine?
A. 10,000 degree Celsius for 1 hour
B. 5,000 degree Celsius for 30 minutes
C. 37 degree Celsius for 15 minutes
D. 121 degree Celsius for 15 minutes

58. It is important that before a nurse prepares the material to be sterilized, A chemical indicator strip should be placed above the package, preferably, Muslin sheet. What is the color of the striped produced after autoclaving?
A. Black
B. Blue
C. Gray
D. Purple

59. Chemical indicators communicate that:
A. The items are sterile
B. That the items had undergone sterilization process but not necessarily sterile
C. The items are disinfected
D. That the items had undergone disinfection process but not necessarily disinfected

60. If a nurse will sterilize a heat and moisture labile instruments, it is according to AORN recommendation to use which of the following method of sterilization?
A. Ethylene oxide gas
B. Autoclaving
C. Flash sterilizer
D. Alcohol immersion

Situation 12 – Nurses hold a variety of roles when providing care to a perioperative patient.
61. Which of the following role would be the responsibility of the scrub nurse?
A. Assess the readiness of the client prior to surgery
B. Ensure that the airway is adequate
C. Account for the number of sponges, needles, supplies, used during the surgical procedure.
D. Evaluate the type of anesthesia appropriate for the surgical client

62. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic?
A. Put side rails up and ask the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form

63. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing\ surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?
A. Draped
B. Pulled
C. Clipped
D. Shampooed

64. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection?
A. Localized heat and redness
B. Serosanguinous exudates and skin blanching
C. Separation of the incision
D. Blood clots and scar tissue are visible

65. Which of the following nursing interventions is done when examining the incision wound and changing the dressing?
A. Observe the dressing and type and odor of drainage if any
B. Get patient’s consent
C. Wash hands
D. Request the client to expose the incision wound

Situation 13: The preoperative nurse collaborates with the client significant others, and healthcare providers.

66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:
A. Biomedical division
B. Chaplancy services
C. Infection control committee
D. Pathology department

67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last patients will need surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the nurse expect?
A. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures
B. Forwarding the trauma client to the nearest hospital that has available sterile equipment is appropriate
C. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes.
D. In such cases, flash sterilizer will be use at 132 degree Celsius in 3 minutes.

68. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 8 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with:
A. Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty

69. Rosie, 57, who is diabetic is for debridement if 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 doctor’s order and call the attending MD
B. Communicate with the ward nurse to verify if insulin was incorporated or not
C. Communicate with the client to verify if insulin was incorporated
D. Incorporate insulin as ordered

70. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
B. Baseline physical, emotional, and psychosocial data
C. Arguments between nurses and residents regarding treatment
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.

Situation 14 – Team efforts is best demonstrated in the OR.

71. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
A. Who is your internist
B. 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

72. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses

73. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for 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

74. Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating room?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist

75. The breakdown in teamwork is often times a failure in:
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication

Situation 15: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes.

76. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure?
A. 0.45 % sodium chloride
B. Normal saline solution
C. o.33% sodium chloride
D. Lactated ringer’s solution

77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe?
A. 5 % dextrose in water
B. 10 % dextrose in water
C. 0.45 % sodium chloride
D. 0.5 % dextrose in 0.9% sodium chloride

78. The nurse is making initial rounds on the nursing unit to assess the condition or assigned clients. The nurse notes that the client’s IV site is cool, pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombophlebitis

79. A nurse reviews the client’s electrolytes laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the lectrocardiogram as a result of the laboratory value?
A. U waves
B.
C. Elevated T waves
D. Elevated ST segment

80. One patient has a runaway IV of 50 % dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order?
A. Any IV solution available to KVO
B. Isotonic solution
C. Hypertonic solution
D. Hypotonic solution

81. An informed consent is required for:
A. Closed reduction of a fracture
B. Insertion of intravenous catheter
C. Irrigation of the external ear canal
D. Urethral catheterization

82. Which of the following is not true with regards to the informed consent?
A. It should describe different treatment alternatives
B. It should contain a thorough and detailed explanation of the procedure to be done
C. It should describe the client’s diagnosis
D. It should given an explanation of the client’s prognosis

83. You know that the hallmark of nursing accountability is the:
A. Accurate documentation and reporting
B. Admitting your mistakes
C. Filing an incidence report
D. Reporting a medication error

84. A nurse is assigned to care for a group of clients. On review of the client’s medical records the nurse determines that which client is at risk for excess fluid volume?
A. The client taking diuretics
B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning

85. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for deficient fluid volume?
A. A client with colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigation

Situation 16: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.

86. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?
A. Material compatibility and efficiency
B. Odor and availability/
C. Cost and duration of disinfection process
D. Duration of disinfection and efficiency

87. Before you used disinfected instrument it is essential that you:
A. Rinse with tap water followed by alcohol
B. Wipe the instrument with sterile water
C. Dry the instrument thoroughly
D. Rinse with sterile water

88. You have a critical heat labile instrument to sterilize and are considering to use high level of disinfectant. What should you do?
A. Cover the soaking vessel to contain the vapour
B. Double the amount of high level of disinfectant
C. Test the potency of the high level of disinfectant
D. Prolong the exposure time according to manufacturer’s direction

89. To achieve sterilization using disinfectants, which of the following is used?
A. Low level disinfectants immersion in 24 hours
B. Intermediate level disinfectants immersion in 12 hours
C. High level disinfectants immersion in 1 hour
D. High level disinfectants immersion in 10 hours

90. Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the following?
A. Autoclaving at 121 degree Celsius in 15 minutes
B. Flash sterilizer at 132 degree Celsius in 3 minutes
C. Ethylene Oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 10 hours

Situation 17: The OR is divided in three zones to control traffic flow and contamination.

91. What OR attires are worn in the restricted area?
A. Scrub suit, OR shoes, head cap
B. Head cap scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, Mask, gloves, shoes

92. Nursing intervention for a patient on low dose IV insulin therapy includes the following EXCEPT:
A. Elevation of serum ketones to monitor ketosis
B. Vital signs including BP
C. Estimate serum potassium
D. Elevation of blood glucose levels

93. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going IV. The strength is 500/ml. How much should you incorporate into the IV solution?
A. 10 ml
B. 2 ml
C. 0.5 ml
D. 5 ml

94. Multiple vial-dose-insulin when in use should be:
A. Kept at room temperature
B. Kept in the refrigerator
C. Kept in narcotic cabinet
D. Store in the freezer

95. Insulin using insulin syringe are given using how many degrees of needle insertion?
A. 45
B. 180
C. 90
D. 15

Situation 18: Maintenance of sterility is an important function a nurse should perform in any OR setting.

96. Which of the following is true with regards to sterility?
A. Sterility is time related items are not considered sterile after a period of 30 days of being not in use.
B. for 9 months sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers.
C. Sterility is event related, not time related.
D. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization process

97. 2 organizations endorsed that sterility are affected by factors other that the time itself, these are:
A. The PNA and the PRC
B. AORN and JCAHO
C. ORNAP and MCNAP
D. MMDA and DILG

98. All of these factors affect the sterility of the OR equipments, these are the following except:
A. The material used for packaging
B. The handling of the materials as well as its transport
C. Storage
D. The chemical or process used in sterilizing the material

99. When you say sterile, it means:
A. The material is clean.
B. The material as well as the equipments are sterilized and had undergone a rigorous sterilization process
C. There is a black stripe on the paper indicator
D. The material has no microorganism nor spores present that might cause an infection

100. In using liquid sterilizer versus autoclave machine, which of the following is true?
A. Autoclave is better in sterilizing OR supplies verus liquid sterilizer
B. They are both capable of sterilizing the equipments, however, it is necessary to soak supplies in the liquid sterilizer for a longer period of time.
C. Sharps are sterilized using autoclave and not cidex.
D. If liquid sterilizer sterilization process is used, rinsing it before using is not necessary.

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‘Judge not, lest ye be judged’.

Yes, these are fine words to live by and when I became an R.N. back in the late ‘80’s, I strove to not only adhere to this notion of fairness, but live it in my professional life as well. However, it is sometimes harder to put into practice despite what you know is true. Very early in my traveling nursing career, I was working as a TB Clinic nurse, testing Mississippi inmates for TB when one of them become irrationally incensed at my presence, grabbed the needle I was using to administer the test and ended up stabbing me with it instead. Needless to say, after that incident I swore off any nursing duties for prisoners and I spent a good year completely fearful of another needlestick. Fortunately, there was no exposure or transmissions of anything like HIV or Hepatitis B or C, though for an entire year I fretted every time I got my blood drawn to check for it. I tested negative, but it did little to alleviate some preconceived notions that I began to build, namely that prisoners were unworthy and ungrateful of my good deeds. Fast forward twenty-five years, and I found myself tested by my preconceived prejudices, once more.

Being a traveling nurse has been one of the greatest joys of my life, it has afforded me many unique experiences to live in exciting places and to meet many wonderful people. I am completely self-sufficient and satisfied with my career, something many of my close friends will never experience themselves. They constantly worry about job security and retirement whereas I am happy and fancy-free, living a life most people just dream of. However, after my little prison stint there were jobs I refused to take on and planned for the rest of my career to keep convicts and myself, mutually exclusive. As much as I hate to admit, the thought of being around prisoners terrified me so that I refused to work with anything that had to do with criminals or prisons and so it went until I ended up in Sandy, Utah working as an emergency room nurse. It was there that one of my worst fears came true; a man had just been brought in, shot and injured during the commission of a crime. Yes, a criminal, under my care.

I never discussed my personal beliefs with anyone I worked with but my supervisor could tell something was wrong by the look on my face. Here, I had spent my career intentionally avoiding criminals at all cost and yet, it seemed unavoidable that I would find myself facing a prisoner again. As I swallowed my fears, I walked into the room. My patient was exceedingly calm and quiet, which surprised me. I was picturing someone up in arms, blaming the system, a cold and indignant felon who had been once more unfairly treated by a trigger-happy and overzealous police officer, but that was not what I found. He had his head turned towards the wall and all I saw was a disheveled mop of sandy-blond hair, limp and a bit sweaty, no doubt as a result from his run-in with the law.

Sensing my presence, the man turned his head my direction and I was greeted with a pair of blue eyes which to my shock were filled with tears. I say man, but he was more boy than man, no facial hair and of very small build. After seeing me, he wiped his tears away and quickly returned his gaze back to the wall. I continued with my assessments, when he spoke aloud. “I messed up…big this time.” I didn’t answer, I proceeded to read his chart and check his vitals, but I felt as though he needed to talk. “My dad already hates me, now I don’t know what he’ll do. Probably blame my mom again. Last time I got arrested, he beat her, not me.” He looked like he carried the weight of the world upon his thin shoulders. “Stealing is wrong, I know it is, I was just trying to help my mom. She’s sick and can’t pay for her medicines. She’ll probably die while I’m in prison, I’ll bet they won’t let me go to her funeral.” This statement brought another round of tears and I left him huddled under a sheet, watching his body shudder while he cried.

A couple hours later, a very thin lady walked in to the ER with the assistance of a young lady, who I assumed was her daughter. The lady must have been going through rounds of chemo since as her head was covered in a downy fuzz, her skull was veiny and her face was drawn and yellowed, in her nose was an oxygen tube. I didn’t need to ask who she was here to see. A police officer was stationed outside the young man’s door and visitors were not permitted, no exceptions. I asked her what message I could relay to him and though she struggled to speak, finally her voice came out in a breathy whisper, “Just tell him no matter what happens, I forgive him and will always love him.” The two of them left the ER and as I wrote down the message, my own eyes blurred. The young man was right; he never would see his mother again. Why would this one experience change my lifelong bias against criminals? Because only six months previously my brother and I buried our own mother and I cannot begin to imagine not having those last moments to say our final farewells. My heart ached for that young man and his loss. He would carry that grief in his heart forever. And no matter how much time would pass, it would be forever marked by this day. When I walked back into the room I passed on the note and held his hand while he cried.

This is why I became a nurse.

The post How being a Traveling Nurse helped me overcome my own Prejudices appeared first on Nurseslabs.

Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse.

Purposes

1. Communication
2. Planning Client Care
3. Auditing Health Agencies
4. Research
5. Education
6. Reimbursement
7. Legal Documentation
8. Health Care Analysis

Documentation Systems

1. Source – Oriented Record

1. The traditional client record
2. Each person or department makes notations in a separate section or sections of the client’s chart
3. It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information
   • Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes
4. NARRATIVE CHARTING is a traditional part of the source-oriented record

2. Problem – Oriented Medical Record (POMR)

1. Established by Lawrence Weed
2. The data are arranged according to the problems the client has rather than the source of the information.

The four (4) basic components:

1. Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data
2. Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified &    the list is continually updated as new problems are identified & others resolved
3. Plan of Care – care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans
4. Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data

Example: SOAP Format or SOAPIE and SOAPIER

S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R- Revision

Advantages of POMR:

• It encourages collaboration
• Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.

Disadvantages of POMR:

• Caregivers differ in their ability to use the required charting format
• Takes constant vigilance to maintain an up-to-date problem list
• Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.

3. PIE (Problems, Interventions, and Evaluation)

• Groups information in to three (3) categories
• This system consists of a client care assessment floe sheet & progress notes
• FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns
• Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes

4. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns for recording are usually used: date & time, focus & progress notes

5. Charting by Exception

• Documentation system in which only abnormal or significant findings or exceptions to norms are recorded
• Incorporates three (3) key elements:
  • Flow sheets
  • Standards of nursing care
  • Bedside access to chart forms

6. Computerized Documentation

• Developed as a way to manage the huge volume of information required in contemporary health care
• Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.

7. Case Management

• Emphasizes quality, cost-effective care delivered within an established length of stay
• Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

Nursing Care Plan (NCP)

Two Types:

1. Traditional Care Plan – written for each client; it has 3 columns: nursing diagnoses, expected outcomes &  nursing interventions.
2. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high quality of nursing care

KARDEX

• Widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms.

Information may be organized into sections:

1. Pertinent information about the client
2. List of medications
3. List of IVF
4. List of daily treatments & procedures
5. List of Diagnostic procedures
6. Allergies
7. Specific data on how the client’s physical need is to be met
8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge & Referral Summaries

These are completed when the client is being discharged or transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it includes some or all of the following:

1. Description of client’s physical, mental & emotional state
2. Resolved health problems
3. Unresolved continuing health problems
4. Treatments that can be continued (e.g. wound care, oxygen therapy)
5. Current medications
6. Restrictions that relate to activity, diet & bathing
7. Functional/self-care abilities
8. Comfort level
9. Support networks
10. Client education provided in relation to disease process
11. Discharge destination
12. Referral Services (e.g. social worker, home health nurse)

Guidelines for Good Documentation and Reporting

1. Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells
2. Accuracy – information must be accurate so that health team members have confidence in it
3. Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand
4. Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:
   • a. Vital signs
   • b. Administration of medications and treatments
   • c. Preparation of diagnostic tests or surgery
   • d. Change in status
   • e. Admission, transfer, discharge or death of a client
   • f. Treatment for a sudden change in status
5. Organization – the nurse communicate in a logical format or order
6. Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed

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Definition

A burn is damage to your body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

Types of Burns

• First-degree burns damage only the outer layer of skin
• Second-degree burns damage the outer layer and the layer underneath
• Third-degree burns damage or destroy the deepest layer of skin and tissues underneath

Nursing Priorities

1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other (SO).
6. Provide information about condition, prognosis, and treatment.

Discharge Goals

1. Homeostasis achieved.
2. Pain controlled/reduced.
3. Complications prevented/minimized.
4. Dealing with current situation realistically.
5. Condition/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

Nursing Care Plans

Here are 11 Burn Injury Nursing Care Plans

Impaired Physical Mobility

May be related to

• Neuromuscular impairment, pain/discomfort, decreased strength and endurance
• Restrictive therapies, limb immobilization; contractures

Possibly evidenced by

• Reluctance to move/inability to purposefully move
• Limited ROM, decreased muscle strength control and/or mass

Desired Outcomes

• Maintain position of function as evidenced by absence of contractures.
• Maintain or increase strength and function of affected and/or compensatory body part.
• Verbalize and demonstrate willingness to participate in activities.
• Demonstrate techniques/behaviors that enable resumption of activities.

Knowledge Deficit

May be related to

• Lack of exposure/recall
• Information misinterpretation; unfamiliarity with resources

Possibly evidenced by

• Questions/request for information, statement of misconception
• Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

• Verbalize understanding of condition, prognosis, and potential complications.
• Verbalize understanding of therapeutic needs.
• Correctly perform necessary procedures and explain reasons for actions.
• Initiate necessary lifestyle changes and participate in treatment regimen.

Disturbed Body Image

May be related to

• Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

• Negative feelings about body/self, fear of rejection/reaction by others
• Focus on past appearance, abilities; preoccupation with change/loss
• Change in physical capacity to resume role; change in social involvement

Desired Outcomes

• Incorporate changes into self-concept without negating self-esteem.
• Verbalize acceptance of self in situation.
• Talk with family/SO about situation, changes that have occurred.
• Develop realistic goals/plans for the future.

Fear/Anxiety

May be related to

• Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Possibly evidenced by

• Expressed concern regarding changes in life, fear of unspecific consequences
• Apprehension; increased tension
• Feelings of helplessness, uncertainty, decreased self-assurance
• Sympathetic stimulation, extraneous movements, restlessness, insomnia

Desired Outcomes

• Verbalize awareness of feelings and healthy ways to deal with them.
• Report anxiety/fear reduced to manageable level.
• Demonstrate problem-solving skills, effective use of resources.

Impaired Skin Integrity

May be related to

• Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Possibly evidenced by

• Absence of viable tissue

Desired Outcomes

• Wound Healing: Secondary Intention (NOC)
• Demonstrate tissue regeneration.
• Achieve timely healing of burned areas.

Imbalanced Nutrition

May be related to

• Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
• Protein catabolism
• Anorexia, restricted oral intake