Aug 2, 2010

1. Which of the following is a major theorist on nursing as caring?

A. Roy C. Leininger
B. Orem D. Rogers

Rationale: C. Madeleine Leininger, a transcultural nursing expert, has provided a starting

place for many researchers on the study of caring concepts in nursing. She has developed a
list of “ethnocaring” constructs: traits or behaviors that she believes are elements of caring.

2. Providing information to the public regarding sexually transmitted disease is an example

of:
A. primary prevention C. tertiary prevention
B. secondary prevention D. health promotion

Rationale: A. Primary prevention efforts are aimed at improving general health and at
protection from specific diseases.

3. The nurse observes Ms. Cruz’s overall appearance and any signs of distress. This method
of examination is
A. palpation C. auscultation
B. inspection D. percussion

Rationale: B. Inspection uses the sense of sight, or looking at a client, to make specific
observations. It is the natural beginning to the physical examination.

4. Continuous rumbles or gurgles that should not be heard in John’s lungs are
A. rhonchi C. crackles
B. rales D. wheezes

Rationale: A. Continuous rumbles or gurgles are called ronchi.

5. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also
known as the transition phase from wellness to illness.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

* A favorite board question are Stages of Illness. When a person starts to believe something is
wrong, that person is experiencing signs and symptoms of an illness. The patient will then ASSUME
that he is sick. This is called assumption of the sick role where the patient accepts he is Ill and try to
give up some activities. Since the client only ASSUMES his illness, he will try to ask someone to
validate if what he is experiencing is a disease, This is now called as MEDICAL CARE CONTACT. The
client seeks professional advice for validation, reassurance, clarification and explanation of the
symptoms he is experiencing. client will then start his dependent patient role of receiving care from
the health care providers. The last stage of Illness is the RECOVERY stage where the patient gives up
the sick role and assumes the previous normal gunctions.
6. How many ml of liquid soap is recommended for handwashing procedure?

A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml

* If a liquid soap is to be used, 1 tsp [ 5ml ] of liquid soap is recommended for handwashing procedure.

7. This is considered as the most important aspect of handwashing

A. Time
B. Friction
C. Water
D. Soap

* The most important aspect of handwashing is FRICTION. The rest, will just enhance friction. The use
of soap lowers the surface tension thereby increasing the effectiveness of friction. Water helps remove
transient bacteria by working with soap to create the lather that reduces surface tension. Time is of
essence but friction is the most essential aspect of handwashing.

8. Which gloves should you remove first?

A. The glove of the non dominant hand
B. The glove of the dominant hand
C. The glove of the left hand
D. Order in removing the gloves Is unnecessary

* Gloves are worn in the non dominant hand first, and is removed also from the non dominant hand
first. Rationale is simply because in 10 people removing gloves, 8 of them will use the dominant hand
first and remove the gloves of the non dominant hand.

9. A woman undergoing radiation therapy developed redness and burning of the skin around the best.
This is best classified as what type of disease?

A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic

* Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, A
child frequently exposed to the X-RAY Machine develops redness and partial thickness burns over the
chest area. Neoplastic are malignant diseases cause by proliferation of abnormally growing cells.
Traumatic are brought about by injuries like Motor vehicular accidents. Nosocomial are infections that
acquired INSIDE the hospital. Example is UTI Because of catheterization, This is commonly caused by
E.Coli.

10. Which of the following is true about masks?

A. Mask should only cover the nose

B. Mask functions better if they are wet with alcohol
C. Masks can provide durable protection even when worn for a long time and after each and every
patient care
D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimeter

* only D is correct. Mask should cover both nose and mouth. Masks will not function optimally when
wet. Masks should be worn not greater than 4 hours, as it will lose effectiveness after 4 hours. N95
mask or particulate mask can filter organism as small as 1 micromillimeter.

Aug. 10, 2010

1. A client with the diagnosis of acute cholecystitis continues to experience nausea, vomiting, and severe right
upper quadrant pain. The nurse should question the physician's order that states:

Insert gastric tube to low suction

This is reasonable therapy; insertion of a gastric tube to suction helps eliminate the stimulus for bile flow,
which intensifies pain.

Test next 3 stools for occult blood

Obstruction of bile flow affects prothrombin production and leads to risk of bleeding.

Morphine sulfate 10 mg IM q4h as necessary

Morphine is contraindicated because it causes spasm of the sphincter of Oddi, blocking bile flow and
intensifying symptoms.

IV of D5/0.45 NaCl with 20 mEq KCl at 100 ml/hr

The client has nausea and vomiting, so fluid and electrolyte replacement would be expected.

2. An abdominal cholecystectomy is performed on a client with gangrene of the gallbladder. During the first 24
hours postoperatively, analgesics should be administered:

As ordered by the physician

Relief of pain helps the client cooperate with coughing, deep breathing, turning, and ambulation;
this in turn prevents pneumonia, a frequent complication because the proximity of the incision to the
diaphragm limits lung expansion.

If repositioning is ineffective
Repositioning will not relieve pain associated with deep breathing and coughing, although it may relieve
incisional pain; analgesics should be given as ordered to enable the client to successfully take part in
postsurgical activity.

When the pain becomes severe

Analgesics are less effective if given when pain has intensified; they should be given before pain is
unbearable for best results.

In gradually increasing dosages

Pain is most intense in first 24 hours, and analgesics should be administered as ordered; pain and hence
dosages may gradually decrease as the postoperative period progresses.

3. On admission to the intensive care unit, a client exhibits symptoms of compensated metabolic acidosis. The
symptom that would most likely be present would be:

Muscle twitching
Muscle twitching results from low serum calcium (hypocalcemia).

Mental instability
Mental confusion would not occur in compensated acidosis; confusion could occur in uncompensated
metabolic acidosis.

Abdominal cramping
An elevated potassium level (hyperkalemia) produces abdominal cramping.

Deep, rapid respirations

 The deep, rapid respiratory pattern is an adaptation to a decreased serum pH; carbonic acid dissociates in
the lungs to hydrogen ions and carbon dioxide; this helps to raise the serum pH.

4. A client with a recent colostomy expresses concern about the inability to control the passage of gas. The
nurse should suggest that the client plan to:

Eliminate foods high in cellulose

Foods high in fiber are not necessarily related to formation of flatus; reducing foods high in fiber could result
in constipation; a regular diet is encouraged.

Decrease fluid intake at meal times

This is not a factor in the formation of flatus.

Avoid foods that in the past caused flatus

In general, foods that bothered a person preoperatively will continue to do so after a colostomy.

Adhere to a bland diet prior to social events

A bland diet may be used initially after the colostomy, but then the client should progress to a regular diet; to
control the formation of flatus the client should eliminate foods that have this effect.

5. A client is receiving combination chemotherapy for treatment of metastatic carcinoma. The nurse should
monitor the client for the systemic side effect of:

Ascites
Ascites is not a side effect of chemotherapy.

Nystagmus
Chemotherapy does not affect the eyes; nystagmus is involuntary, rapid rhythmic movement of the eyeballs;
this is a local, not a systemic, adaptation.

Leukopenia
Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

Polycythemia
The RBCs will be decreased, not increased; polycythemia is an elevation of RBCs.

AUG 13,2010
MEDICAL SURGICAL NURSING
1. Which is the most relevant knowledge about oxygen administration to a
client with COPD?

A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for

breathing.

B. Hypoxia stimulates the central chemoreceptors in the medulla that

makes the client breath.

C. Oxygen is administered best using a non-rebreathing mask

D. Blood gases are monitored using a pulse oximeter.

 Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing.
COPD causes a chronic CO2 retention that renders the medulla insensitive to
the CO2 stimulation for breathing. The hypoxic state of the client then
becomes the stimulus for breathing. Giving the clientoxygen in low
concentrations will maintain the client’s hypoxic drive.

2. A client, who is suspected of having Pheochromocytoma, complains of

sweating, palpitation and headache. Which assessment is essential for the
nurse to make first?

A. Pupil reaction

B. Hand grips

C. Blood pressure

D. Blood glucose

Answer: (C) Blood pressure

Pheochromocytoma is a tumor of the adrenal medulla that causes an
increase secretion of catecholamines that can elevate the blood pressure.

3. Included in the plan of care for the immediate post-gastroscopy period will
be:

A. Maintain NGT to intermittent suction

B. Assess gag reflex prior to administration of fluids

C. Assess for pain and medicate as ordered

D. Measure abdominal girth every 4 hours

Answer: (B) Assess gag reflex prior to administration of fluids

The client, after gastroscopy, has temporary impairment of the gag reflex
due to the anesthetic that has been sprayed into his throat prior to the
procedure. Giving fluids and food at this time can lead to aspiration.
4. Which description of pain would be most characteristic of a duodenal ulcer?

A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is

relieved by food intake

B. RUQ pain that increases after meal

C. Sharp pain in the epigastric area that radiates to the right shoulder

D. A sensation of painful pressure in the midsternal area

Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric

area that is relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl. This can be
buffered by food intake thus the relief of the pain that is brought about by
food intake.

5. What instructions should the client be given before undergoing a

paracentesis?

A. NPO 12 hours before procedure

B. Empty bladder before procedure

C. Strict bed rest following procedure

D. Empty bowel before procedure

Answer: (B) Empty bladder before procedure

Paracentesis involves the removal of ascitic fluid from the peritoneal cavity
through a puncture made below the umbilicus. The client needs to void
before the procedure to prevent accidental puncture of a distended bladder
during the procedure.

Answer:
acbab

6. Immediately after cholecystectomy, the nursing action that should assume

the highest priority is:
 A. encouraging the client to take adequate deep breaths by mouth

B. encouraging the client to cough and deep breathe

C. changing the dressing at least BID

D. irrigate the T-tube frequently

Answer: (B) encouraging the client to cough and deep breathe

Cholecystectomy requires a subcostal incision. To minimize pain, clients have
a tendency to take shallow breaths which can lead to respiratory
complications like pneumonia and atelectasis. Deep breathing and coughing
exercises can help prevent such complications.

7. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding

esophageal varices in a patient with complicated liver cirrhosis. Upon
insertion of the tube, the client complains of difficulty of breathing. The first
action of the nurse is to:

A. Deflate the esophageal balloon

B. Monitor VS

C. Encourage him to take deep breaths

D. Notify the MD

Answer: (A) Deflate the esophageal balloon

When a client with a Sengstaken-Blakemore tube develops difficulty of
breathing, it means the tube is displaced and the inflated balloon is in the
oropharynx causing airway obstruction

8. The client presents with severe rectal bleeding, 16 diarrheal stools a day,
severe abdominal pain, tenesmus and dehydration. Because of these
symptoms the nurse should be alert for other problems associated with what
disease?
 A. Chrons disease

B. Ulcerative colitis

C. Diverticulitis

D. Peritonitis

Answer: (B) Ulcerative colitis

Ulcerative colitis is a chronic inflammatory condition producing edema and
ulceration affecting the entire colon. Ulcerations lead to sloughing that
causes stools as many as 10-20 times a day that is filled with blood, pus and
mucus. The other symptoms mentioned accompany the problem.

9. A client is being evaluated for cancer of the colon. In preparing the client for
barium enema, the nurse should:

A. Give laxative the night before and a cleansing enema in the morning
before the test

B. Render an oil retention enema and give laxative the night before

C. Instruct the client to swallow 6 radiopaque tablets the evening before

the study

D. Place the client on CBR a day before the study

Answer: (A) Give laxative the night before and a cleansing enema in
the morning before the test
Barium enema is the radiologic visualization of the colon using a die. To
obtain accurate results in this procedure, the bowels must be emptied of
fecal material thus the need for laxative and enema.

10.The client has a good understanding of the means to reduce the chances of
colon cancer when
he states:
 A. “I will exercise daily.”

B. “I will include more red meat in my diet.”

C. “I will have an annual chest x-ray.”

D. “I will include more fresh fruits and vegetables in my diet.”

Answer: (D) “I will include more fresh fruits and vegetables in my

diet.”
Numerous aspects of diet and nutrition may contribute to the development of
cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal
or lacking in the diet, slows transport of materials through the gut which has
been linked to colorectal cancer.

11.Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest

tubes are inserted, and one-bottle water-seal drainage is instituted in the
operating room. In the
postanesthesia care unit Mario is placed in Fowler's position on either his
right
side or on his back to

A. Reduce incisional pain.

B. Facilitate ventilation of the left lung.

C. Equalize pressure in the pleural space.

D. Increase venous return

Answer: (B) Facilitate ventilation of the left lung.

Since only a partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the opposite
unoperated side.

12.Which statement by the client indicates understanding of the possible side

effects of Prednisone therapy?
 A. “I should limit my potassium intake because hyperkalemia is a side-
effect of this drug.”

B. “I must take this medicine exactly as my doctor ordered it. I shouldn’t

skip doses.”

C. “This medicine will protect me from getting any colds or infection.”

D. “My incision will heal much faster because of this drug.”

Answer: (B) “I must take this medicine exactly as my doctor ordered

it. I shouldn’t skip doses.”
The possible side effects of steroid administration are hypokalemia, increase
tendency to infection and poor wound healing. Clients on the drug must
follow strictly the doctor’s order since skipping the drug can lower the drug
level in the blood that can trigger acute adrenal insufficiency or Addisonian
Crisis

13.The nurse is attending a bridal shower for a friend when another guest, who
happens to be a diabetic, starts to tremble and complains of dizziness. The
next best action for the nurse to take is to:

A. Encourage the guest to eat some baked macaroni

B. Call the guest’s personal physician

C. Offer the guest a cup of coffee

D. Give the guest a glass of orange juice

Answer: (D) Give the guest a glass of orange juice

In diabetic patients, the nurse should watch out for signs of hypoglycemia
manifested by dizziness, tremors, weakness, pallor diaphoresis and
tachycardia. When this occurs in a conscious client, he should be given
immediately carbohydrates in the form of fruit juice, hard candy, honey or, if
unconscious, glucagons or dextrose per IV.

14.During the first 24 hours after thyroid surgery, the nurse should include in her
care:
 A. Checking the back and sides of the operative dressing

B. Supporting the head during mild range of motion exercise

C. Encouraging the client to ventilate her feelings about the surgery

D. Advising the client that she can resume her normal activities
immediately

Answer: (A) Checking the back and sides of the operative dressing
Following surgery of the thyroid gland, bleeding is a potential complication.
This can best be assessed by checking the back and the sides of the
operative dressing as the blood may flow towards the side and back leaving
the front dry and clear of drainage.

15.On discharge, the nurse teaches the patient to observe for signs of surgically
induced hypothyroidism. The nurse would know that the patient understands
the teaching when she states she should notify the MD if she develops:

A. Intolerance to heat

B. Dry skin and fatigue

C. Progressive weight gain

D. Insomnia and excitability

Answer: (C) Progressive weight gain

Hypothyroidism, a decrease in thyroid hormone production, is characterized
by hypometabolism that manifests itself with weight gain.

16.The client underwent Billroth surgery for gastric ulcer. Post-operatively, the
drainage from his NGT is thick and the volume of secretions has dramatically
reduced in the last 2 hours and the client feels like vomiting. The most
appropriate nursing action is to:

A. Reposition the NGT by advancing it gently NSS

 B. Notify the MD of your findings

C. Irrigate the NGT with 50 cc of sterile

D. Discontinue the low-intermittent suction

Answer: (B) Notify the MD of your findings

The client’s feeling of vomiting and the reduction in the volume of NGT
drainage that is thick are signs of possible abdominal distention caused by
obstruction of the NGT. This should be reported immediately to the MD to
prevent tension and rupture on the site of anastomosis caused by gastric
distention.

17.After Billroth II Surgery, the client developed dumping syndrome. Which of

the following should
the nurse exclude in the plan of care?

A. Sit upright for at least 30 minutes after meals

B. Take only sips of H2O between bites of solid food

C. Eat small meals every 2-3 hours

D. Reduce the amount of simple carbohydrate in the diet

Answer: (A) Sit upright for at least 30 minutes after meals

The dumping syndrome occurs within 30 mins after a meal due to rapid
gastric emptying, causing distention of the duodenum or jejunum produced
by a bolus of food. To delay the emptying, the client has to lie down after
meals. Sitting up after meals will promote the dumping syndrome.