Situation I -- Nurse a is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.
1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall movesin during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:
a. Hemothorax b.
Flail chest
c. Atelectasisd. Pleural effusion
2
. A young man is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on amechanical ventilator (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratoryfunction?
a. Dullness to percussion in the third to 5th intercostals space, midclavicular line b. Decreased paradoxical motionc.
Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases
3
. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system (Pleur-evac). To ensure that thesystem functions effectively the nurse should:
a.
Observe for intermittent bubbling in the water seal chamber
b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hoursc. Maintain the client in an extreme lateral positiond. Strip the chest tubes in the direction of the client
4
. The nurse enter the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube isdislodge from the chest. The most appropriate nursing intervention is to:
a. Notify the physician b. Insert a new chest tubec.
C
over the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives
5
. A 71-year old is admitted to the hospital with congestive heart failure. She has shortness of breath and a +
3
-
4
peripheral edema. Thecare plan to reduce the client's edema should include nursing strategies for:
a. Establishing limits on activity b. Fostering a relaxed environmentc. Identifying goals for self cared.
R
estricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.
6
. Mr. Sison,
65
years old has been smoking since he was 11 years old. He has long history of emphysema. Mr. Sison is admitted to thehospital because of a respiratory infection, which has not improved with outpatient therapy. Which finding would the nurse expect toobserve during Mr. Sison's nursing assessment?
a. Electrocardiogram changes b.
Increased anterior-posterior chest diameter
c. Slow labored respiratory patternd. Weight-Height relationship indicating obesity
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the oxygen via the low-flow system recognizes that this methodof delivery:
a.
M
ixes room air with oxygen
b. Delivers a precise concentration of oxygenc. Requires humidity during deliveryd. Is less traumatic to the respirator tract
8
. Which statement by Mr. Sison indicates that client teaching regarding oxygen therapy has been effective?
a. "I was feeling fine so I removed my nasal prongs." b. "I've increased my fluids to six glasses of water daily."c. "Don¶t forget to come back quickly when you get me out of the bed; I don't want to be without my oxygen for too long."d.
"M
y family was angry when I told them they could not smoke in my room.
"
9
. Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential for the nurse to initiate?
a. Anticipate the need for humidification b. Notify the physician that this order is contraindicatedc. Place client in high Fowler's positiond.
S
chedule nursing care to allow frequent observations of the client
Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse for the past 15 years. His wife brings him to theemergency department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. He has ascitesand esophageal varices.
10. Assessment of Mr. Silverio would reveal all of the following, except:
a. Bulging flanks b. Protruding umbilicusc. Abdominal distensiond.
B
luish discoloration of the umbilicus
11. Which laboratory value would the nurse expect to find in a client as a result of liver failure?
a. Decreased serum creatinine b. Decreased sodiumc.
Increased ammonia
d. Restricted sodium
1
2
. The major dietary treatment for ascites calls for:
a. High protein b. Increased potassiumc. Restricted fluidsd.
R
estricted sodium
1
3
. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding. Base on this information, the first action the nurse shouldtake is to:
a. Deflate the esophageal balloon b. Encourage him to take the deep breathc.
M
onitor his vital signs
d. Notify the physician
1
4
. Because the detoxification of alcohol damages tissues a high-calorie diet, fortified with vitamins should be encouraged to protect Mr.Silverio's:
a.
Liver
b. Kidneysc. Adrenalsd. PancreasSituation 4 - Rape is one of the most tragic things that could happen to anyone especially with young girls. Incidence such as these could developinto a crisis situation involving not only the rape victims but also their families.
1
5
. This type of crisis could be an example of which of the following?
a. Combination of developmental and situational b.
S
ituational
c. Emotionald. Developmental
1
6
. Noemi, a staff nurse in the emergency room, realizes that she has an important role to play as a patient advocate to rape victims. Todemonstrate this role, she takes note of one of the responsibilities?
a. Since this is a legal case, call the press about the incidence of rape b.
P
erform thorough physical assessment and documenting objectively all the evidences of rape
c. Ask the patient to stay in one isolated room first to provide privacy while attending to other patientsd. Provide emotional support first and postponed physical assessment when patient is already calm
17. Which of the following is a form of active, focused, emotional environmental first aid for patients in crisis?
a. Attitude therapy b. Psychotherapyc.
C
risis intervention
d. Re-motivation technique
1
8
. Which of the following is true with regards to crisis?
a.
C
risis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or conditionc. Crisis always result in adaptive behavior d. The person in crisis is not susceptible for any help
1
9
. If help is not provided in a crisis situation, an individual may spontaneously resolve in negatively or positively by returning to pre-crisis state, usually within which of the following duration?
a. 2-3 weeks b. 3-4 weeksc. 1-2 weeksd.
4
-6 weeks
Situation 6 - One Important fact that will guide the nurse in the practice of the profession is her knowledge of the nursing law.
2
0. The nurse practice Act of 1
99
1 regulates the practice of nursing in the Philippines. Which of the following statements about this Act istrue?
a. This Act delineates the practice of nursing and midwifery b. It was enacted in November 1991c. The primary purpose is to protect the publicd. The Act defines the practice of nursing in the Philippines
2
1. When a nurse starts working In a hospital but without a written contract, which of the following is expected of her?
a. She's not bound to perform according to the standards of nursing practice b.
P
rovides nursing care within the acceptable standards of nursing practice
c. She's not obligated to provide professional serviced. The employer does not hold the nurse responsible for her action
22
. A patient, G
8
P
5
, refused to be injected with the
3
rd dose of Depoprovera. Thenurse insisted inspite of the patients refusal and forcibly injected the contraceptive. She can be sued for which of the following?
a. Misrepresentation b.
A
ssault and
B
attery
c. Malpracticed. Negligence
23
.A patient has been in the ICU for
2
weeks. The relatives have consented to a "Do not resuscitate order," When the patient develops acardiac arrest, the nurse will carry out which of the following actions?
a. Only medication will be given b. All ordinary measure will be stoppedc.
B
asic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped
24
. When a patient falls from bed, which of the following is your immediate action?
a. Report to the head nurse and calls someone to help b.
D
etermine any injury or harm
c. Refer to the resident on dutyd. Put back patient to bedSituation 7 - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her tothe hospital.
25
. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
a. Headache b. Vomitingc.
Vertigo
d. Changes on the level of consciousness
26
. Which of the following drug may be given to reduce increase intracranial pressure?
a. Scopalamine
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FOUNDATION OF PROFESSIONAL NURSING PRACTICE for nle 2007
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