RNIRC

PREBOARD JULY 2012 NURSING PRACTICE 1 SITUATION 1 - Increased demands for changes in nursing roles due to innovations in health care and expanding health care system have challenged nurses to commit to lifelong learning and career development. 1. The nursing education department of a hospital is offering a program about evidence-based practice to prepare nurses before its implementation in the hospital. Which of the following refers to this type of program? a. Seminar workshop in evidence-based practice. b. Continuing education in evidence-based practice. c. In-service Education Program. d. Scientific forum in evidence-based practice. 2. A newly admitted client is shown how to use the nurse call system. Which of the statements about the nurse call system below is NOT appropriate? a. It should be used whenever the client needs help. b. It should be used during an emergency only. c. It must be pushed or pressed several times to alert the nurse at the station. d. It must be within the reach of the client. 3. Reviews regarding restraints highlight inconsistent and subjective decision making related to its use. As a first step in quality improvement, it is essential for the nurse team to: a. Explore myths and assumptions underlying use of restraints. b. Review patient profiles who have safety and security risks. c. Document current practices on restraint use. d. Develop policies and guidelines for use of restraints. 4. A nurse works in a college of nursing as a faculty and needs further experience to possess clinical skills and theoretical knowledge. Which of the following should this nurse pursue to qualify for teaching current nursing practice? a. Pursue masters degree in other such as business or educational management. b. Possess a graduate degree in nursing and pursue doctorate in advanced degrees innursing, education and administration. c. Participate in continuing education program in national and international conference. d. Keep license valid by updating professional education with organized groups. 5. Nurse Luisa has worked for the past 5 years in the Emergency Care Unit of a tertiary hospital and is fully cognizant of the need for professional enrichment to provide clients with competent care. She has undergone training in advanced cardiac life support and emergency care. Which of the following career roles best describes the path of that nurse Luisa must pursue? a. Clinician b. Clinical nurse specialist c. Advanced practice nurse d. Nurse practitioner 1|

RNIRC
6. You are going to take oral temperature of several clients. Who among these clients is at risk when oral temperature is taken? a. Highly febrile client b. Client with septicemia c. Client who has braces d. Client in a state of confusion 7. You noticed that a clients temperature has widely fluctuated above the normal temperature. You will record this type of fever in the clients chart as: a. Constant b. Relapsing c. Intermittent d. Remittent 8. Another clients temperature readings indicate that he has been having fever but his body temperature would return to normal only to recur the next day. This type of fever is referred to as: a. Relapsing b. Remittent c. Constant d. Intermittent Situation 2 Communication is a unique skill of a nurse and is an essential tool not only in Mental-Health Nursing but also in other fields of nursing. 9. Which of the following communication techniques is considered non-therapeutic? I. Giving information II. False reassurance III. Broad opening IV. Validation V. Clarification VI. Giving Advice A. II only B. II and VI only C. III, IV and V only D. I, III, IV, V only E. All except II

2|

RNIRC

R: B- WERE SEARCHING FOR A NEGATIVE ANSWER... NON-THERA- II AND VI ONLY

10. Listening is an aspect of therapeutic communication that:

A. B. C. D. Encourages patients to guide the interview Allows the nurse to interpret and validate data Is easy for most people to do Reflects what patients say

R: B

11. An elderly client named Sukjong with chronic debilitating disease tells the nurse, ano pa ang silbi ko? Matanda na ko Puro lang ako gastos sa pamilya ko. Siguro dapat tuluyan na akong magpahinga at magpaalam s mundong ito. What is the best therapeutic response of the nurse? A. Mukhang nag-aalala kayo na nagiging pabigat na kayo sa pamilya niyo. B. Tingin ko nga. Tama na magpahinga na kayo ng tuluyan. Matanda na kayo at wala na kayong silbi. C. The nurse will keep silent, nod his head once in a while and maintain eye contact. D. Naiisip niyo ba na magpakamatay? R: D: A AND D ARE CORRECT BUT THE PRIOIRTY IS SAFETY! 12. Dongyi, a home care nurse, is caring for an obese adult client who is at home after receiving treatment for a sprained right ankle. The client is using a cane to ambulate but has not exercised for more than 1 week and has missed the last two rehabilitation appointments. The client says "I'm getting therapy for my ankle and I do my exercises three times a day." The Nurse makes which therapeutic response to the client? A. "Sounds good to me. Have you made all your appointments?" B. "You say you are following your exercise appointments with the physical therapist? C. "Show me how you do your exercises. I want to determine if you're doing them correctly." D. "You must keep your appointments. I already know that you've missed two appointments with the therapist." R: B 13. Lady Jang verbalizes, Pinag-uusapan nila ako. Ayaw nila ako. A therapeutic response is: A. Nalulungkot ba ang pakiramdam mo? B. Hayaan mo sila. Ang mahalaga ay ang palagay mo sa sarili mo. C. Sino ang nila na tinutukoy mo? D. Huwag mong isipin yan. Hindi tama yan. R:C- CLARIFICATION... NDI M PA KC NAIINTINDIHAN ANG IBIG NIA SBIHIN S NILA... SKA ALAM N NILA TO.. ANG DI MKASAGOT NETO MASASAKTAN! Situation 3 - Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas that contain nutrients such assalts, glucose, amino acids, lipids and added vitamins. It is called total parenteral nutrition(TPN) or total nutrient admixture (TNA) when no food is given by other routes.

14. A client has been discharged to home on total parenteral nutrition (TPN). With each visit, home care nurses assess which of the following parameters most closely in monitoring this therapy?
A. B. C. D. Temperature and weight Temperature and blood pressure Pulse and weight Pulse and blood pressure

Rationale: The client receiving TPN at home should have the temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection could also result in sepsis, since the catheter

3|

RNIRC
15. A nurse is caring for a group of adult clients on an acute care medical- surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for total parenteral nutrition (TPN) solution via the central line of an assigned client. The nurse plans to obtain which of the following most essential pieces of equipment before hanging the solution? A. Electronic infusion pump B. Blood glucose meter C. Urine test strips D. Noninvasive blood pressure monitor Rationale: The nurse obtains an electronic infusion pump before hanging TPN solution. Because of high glucose content, it is necessary to use an infusion pump to ensure that the solution does not infuse too rapidly or fall to far behind. Because the clients blood glucose is monitored every 4 to 6 hours during administration of TPN, a blood glucose meter will also be needed; this is not the most essential itemneeded prior to hanging the solution. Urine test strips (to measure glucose) are rarely used since the advent of blood glucose monitoring. A non invasive blood pressure monitor is unnecessary for this procedure.

16. A client is receiving nutrition by means of total parenteral nutrition (TPN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia? A. Nausea, vomiting, and oliguria B. Sweating, chills, and abdominal pain C. Fever, weak pulse, and thirst D. Weakness, thirst, and increased urine output Rationale: The high glucose concentration in TPN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmauls respirations, dieresis and coma, when hyperglycem ia is severe. If the client presents with these symptoms, the blood glucose level should be checked immediately.

17. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? A. Tightness of tubing connections B. Clients temperature C. Expiration date on the bag D. Time of last dressing change Rationale: Redness at the catheter insertion site s a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is next item to be assessed. The tightness of tubing connections should be assessed each time the TPN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable alternative, but that also should be checked at the time the solution is hung, with each shift change. The time of the last dressing change should be checked with each shift change.

18. A nurse is making initial rounds at the beginning of the shift. The total parenteral nutrition (TPN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered to the nursing unit? A. 5% dextrose in water B. 5% dextrose in 0.9% sodium chloride C. 5% dextrose in Ringers lactate D. 10% dextrose in water Rationale: The solution containing the highest amount of glucose should be hung until the new TPN becomes available. Since TPN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. Situation 3- When positioning a patient it is helpful to be able to focus on key parts. The key parts are the skin, head and neck, arms and shoulders, hips, buttocks, knees and extremities. Nurses must be knowledgeable in different patient positions especially during 4|

RNIRC
diagnostic, therapeutic and physical exam. 19. A nurse is administering a cleansing enema to a client with fecal impaction. Before administering the enema, the nurse places the client in which of the following positions? A. On the left side of the body, with the head of the bed elevated 45 degrees B. On the right side of the body, with the head of the bed elevated 45 degrees C. Left sims position D. Right sims position Rationale: For administering an enema, the client is placed in a left sims position so that the enema solution can flow by g ravity in the natural direction of the colon. The head of bed is not elevated in the Sims position. 20. A client is being prepared for a thoracentesis. A nurse assists the client to which of the following positions for the procedure? A. lying in bed on the affected side, with the head of the bed elevated 45 degrees B. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees C. Prone with the head turned to the side and supported by pillow. D. Sims position with the head of the bed flat. Rationale: To facilitate removal of fluid from the chest wall. The client is positioned sitting at the edge of the bed leaning over the bedside table with feet supported on a stool, or lying in bed on the unaffected side with the head of the bed elevated to 35-35 degrees. The prone and Sims positions are in appropriate positions for this procedure.

21. A nurse assists a physician with the insertion of a harris tube in a client with a bowel obstruction. Following insertion of the tube, the nurse assists the client to which of the following positions initially? A. Prone B. Supine with the head flat C. Right side D. Sims Rationale: The harris tube is a single lumen, mercury weighted tube. The weight of the mercury tube carries the tube by gravity. After insertion, to facilitate movement of the tube the client is positioned 2 hours on the right side, 2 hours in the back with the head elevated, and two hours on the left. 22. A client is diagnosed with deep vein thrombophlebitis. A nurse develops a plan of care for the client position/ activity in the plan? A. Bed rest with the affected extremity in a dependent position B. Out-of -bed activities as desired C. Bed rest with an affected extremity kept flat D. Bed rest with elevation of the affected extremity Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

23. A nurse is preparing to care for a client who has had a supratentorial craniotomy. The nurse plans to place the client in which position? A. Prone B. Supine C. Semi fowlers D. Dorsal recumbent Rationale: After supratentorial surgery, the clients head s usually elevated 30 degrees to prevent venous outflow through the jugular 5|

RNIRC
veins.
Situation 4 A safe environment must be maintained for the safety of the client and the health team as well. 24. While conducting rounds, the nurse notices a fire in a clients room. Which of the following should be the appropriate action of the nurse? a. Evacuate the client from the room b. Set the fire alarm c. Ask for help d. Get the fire extinguisher 25. The nurse must ensure that safe patient handling is carried out in transferring the client from sitting to standing position. Which of the following must be considered when transferring the client? a. Ability to follow directions b. Height of client c. Weight-bearing status d. Type of equipment used in the past 26. The nurse is aware that falls are common among elderly clients. Which of the following measures should the nurse consider to be most effective in preventing falls? a. Allowing a relative to be with the client all the time b. Locking beds and wheelchairs during transfers c. Placing a bedside table at the midpart of the bed d. Placing the bed at its lowest level 27. The nurse is assisting the client to ambulate in the hallway. All of a sudden the client complained of shortness of breath. The patients bed is 60 feet away. Which of the following will the nurse do first? a. Assist the client to assume a sitting position on the floor b. Get help c. Leave the client and get a chair d. Bring the client back to bed

28. You noticed another nurse taking the clients pulse rate using her thumb. The senior nurse cal ls her attention and tells her that the thumb should not be used when taking the pulse rate because the: a. Thumb is least sensitive to touch b. Other fingers are more sensitive and more accurate when used c. Thumb may apply too much pressure making reading inaccurate d. Nurse might feel her own pulse 29. The nursing student reports to you that a clients blood pressure reading is really high. Your appropriate nursing action should be to: a. Wait 5 minutes and retake the blood pressure b. Use the diaphragm of the stethoscope and sphygmomanometer c. Wait 2 minutes before taking the clients blood pressure again d. Change your stethoscope and cuff to ensure a more accurate reading

6|

RNIRC

SITUATION 5 You started to chart of the shift when you discovered that there was an error in medication. The following question applies. 30. You have just administered a per orem medication which should be taken sublingually. Which of the following actions should you do FIRST? a. Induce the client to vomit. b. Monitor the client closely. c. Notify the attending physician of the incident. d. Chart the medication. 31. Fortunately your client did not manifest any untoward reaction. Even so you still have to accomplish an: a. Justification letter. b. Explanation that the client did not react. c. Incident report. d. Affidavit that you gave a medication by a wrong route. 32. In the patients chart the following should be documented EXCEPT: a. The fact that you wrote an incident report. b. Time the incident happened. c. The physician who examined the client. d. The clients response. 33. The incident report should not be viewed as an acceptance of negligence because it offers the following advantages. Identify all the benefits derived from an incident report. 1. For potential liability claims. 2. Identify risks areas. 3. Find ways to prevent similar incident in the future. 4. Rich source for research. a. 1, 2, and 3 b. 1, 3, and 4 c. 2, 3, and 4 d. all the above 34. An incident report is best written when all facts are still fresh in the mind of the nurse. It should include all of the following EXCEPT: a. How the patient responded. b. Draw your conclusion. c. What you saw. d. How you intervened. SITUATION 6 The practice of Nursing should be directed by the existing laws and Code of Ethics.The following questions apply.

7|

RNIRC
35. A newly hired nurse started a prescribe blood transfusion to her assigned client without a consent form signed. This can lead to which of the following liabilities? a. Harassment b. Assault and Battery c. Break of confidentiality d. Fraud 36. When the above incident happens, the head nurse expects which of the following formal communication from the newly hired nurse? a. Incident report b. Excuse letter c. Oral report d. Explanatory note 37. The nurse should be mindful that there are two legal documents that specify the wishes of a client before hospitalization. Which documents are these? a. Informed consent and advanced directive. b. Living will and a durable power of attorney. c. Power of attorney and informed consent. d. Advanced directive and living will. 38. A 32 year old married client who is for elective cesarean section (CS) expresses her wish to have a bilateral tubal ligation performed after the CS. The nurse should make sure that the consent is legally binding. Who should sign the consent for surgery? a. Client and witnessed by the husband. b. Client and husband. c. Either the client or the husband. d. Husband witnessed by the client. 39. In case an informed consent is signed by a client who is scheduled for vaginal hysterectomy, the nurse acts as: a. Interpreter b. Facilitator c. Witness d. Advocate SITUATION 7 Nina, a staff nurse in the Oncology unit was asked to participate as a member of the team in the Phase III clinical trial of the effect of a new drug treatment for cancer patients. The study has been approved by the Institutional Review Board of the hospital where Nina is employed. 40. Nina reviewed the written informed consent. Which of the following observations noted in the written informed consent should Nina question? a. Foreseeable risks and treatments for possible injuries are described. b. Participant may withdraw from the study anytime he wish. c. Participants are expected to participate until the study is completed. d. Participation is strickly voluntary and failure to continue will cause no penalty.

8|

RNIRC
41. Nina was informed that a double blind approach will be utilized. Which of the following is the CORRECT description of this approach? a. Subjects who are randomly assigned to different treatments are different to people. b. Neither the subject or those who administer the treatment know who is in the experimental and control group. c. Pairing of subjects in one group with those in another group based on similarities. d. Control group receives the full treatment and deferred temporarily. 42. Nina recognized that the participants right to self determination is reflected in which of the following? a. Researchers describe to participants full nature of the study. b. Provision of equitable treatment before, during and after the study. c. Informed consent obtained. d. Protection from physical harm. 43. A participant questioned Nina, How will study maintain my privacy? Which of the following is the MOST appropriate response? a. As the study evolves, we will continually ask you if you wish to continue. b. Throughout the study, identify if the researcher will not be disclosed. c. Each participant will be assigned an identification number. d. Be assured that you will have access to a research personnel at any point in the study. 44. During course of the study, a participant approached Nina and told her that she will withdraw. Which of the following will Nina do FIRST? a. Discontinue the treatment. b. Inform attending physician. c. Encourage to continue because of loss of benefits. d. Remind her of the content of the informed consent.

Situation 8 Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies between a maximum (systolic) and a minimum (diastolic) pressure. 45. According to the National Institutes of Health stepped-care approach to treating secondary hypertension, the FIRST step involves: A. Correcting the underlying cause B. Modifying lifestyle C. Using drug monotherapy D. Using combination drug therapy 2 TYPES OF HPN ACCORDING TO CAUSE: 1. Primary cause is unknown MGT: 1st modify lifestyle 2nd drug mono therapy 3rd drug combination 2. Secondary cause is known Secondary to a disease process. MGT: TREAT THE CAUSE 46. If the BP of the patient is 160/70, what is Pulse pressure and MAP? A. PP=90, MAP=110 B. PP=90, MAP=100 C. PP=90, MAP=120 9|

RNIRC
D. PP=90, MAP=90 PP = SBP DBP MAP = SBP + 2DBP 3 47. The following are correct methods in assessment of the blood pressure of the patient except: A. When assessing the BP, the patient can assume supine, sitting and even standing position provided that the arm should be at the level of the heart of the patient B. The proper way of deflation in BP taking should be done slowly at a rate of 2-3mmHg/sec C. The left arm is usually used for subsequent examination because it is the arm that has lower BP ------ (higher dapat) D. In BP taking, infection control measure must always be observed 48. If a nurse finds it necessary to reassess the BP of the patient, what is the acceptable waiting time for reinflating the BP cuff? A. 30 seconds B. 30 minutes C. 45 seconds D. 60 seconds REASSESSMENT = 1-2mins RESTING = 30mins 49. When taking blood pressure reading the cuff should be: A. deflated fully then immediately start second reading for same client B. deflated quickly after inflating up to 180 mmHg C. large enough to wrap around upper arm of the adult client 1 cm above brachial artery ------ (antecubital space) D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery Situation 9 Vital signs are signs of life that a nurse must always be able to assess accurately and efficiently. 50. Which of the following best describes a relapsing type of fever? A. body temperature that alternates at regular intervals between periods of fever and periods of normal and subnormal temperature ------ (intermittent) B. wide range of temperature fluctuations (>2C or 3.6F) that occurs over a 24 hour period all of which are above normal ------ (remittent) C. short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature D. body temperature that fluctuates minimally (<2C or 3.6F) but always remains above normal ------ (constant) 51. Which methods of physical examination are necessary when assessing the temperature of a patient? SATA. i. ii. iii. iv. A. B. C. D. Inspection Palpation Percussion Auscultation

i and ii only i only ii only All of them

52. A post-stroke patient who has an increased ICP is starting to manifest hyperventilation, followed by hypoventilation and then 15 seconds of apnea. Based on the manifestation of the patient, a competent nurse knows that this is called: A. Biots breathing B. Cheyne-stokes breathing C. Kussmauls breathing D. Post-stoke breathing

10 |

RNIRC
53. The nurse is about to administer digoxin to a client suffering from heart failure. Because of its (+) inotropic and (-) chronotropic effect, the nurse knows that it will improve a patients heart contractility but will also decrease the heart rate. Therefore, the nurse must assess the patients pulsefirst using which site? A. Carotid B. Apical C. Radial D. Femoral 54. A nurse must be knowledgeable about all the matters that pertain to vital signs. And one of the most integral parts of it is conversion of temperature. A competent nurse knows that 41OC is equal to ___OF and 101OF is equal to ___OC. A. 106 OF and 38 OC B. 105.8 OF and 38.3 OC C. 105 OF and 38.3 OC D. 105.8 OF and 38 OC

C to F (C x 1.8) +32 F to C = F 32
1.8 Situation 10 Urinary catheters are used to drain the bladder. Your health care provider may recommend a catheter for short-term or long-term use.

55. A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complaints of a discomfort. The appropriate nursing action is to:
A. B. C. D. Aspirate the fluid, remove the catheter and insert a new catheter Aspirate the fluid, advance the catheter further and reinflate the balloon Remove the syringe from the balloon; discomfort is normal and temporary Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon

If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little further into the bladder to provide sufficient space to inflate the balloon. The balloon of the catheter is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter and insert a new one. Pain when the balloon is inflated is not normal. 56. A nurse instructs a female client to obtain a clean catch urine specimen for C and S testing. Which statement by the client indicates that she understands the procedure for collecting specimen? A. I should empty my bladder into a container so that the full amount of the urine can be determined. B. A urine specimen will be obtained from a catheter. C. I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container. D. I need to clean the labia with toilet paper and then void into the sterile specimen container. Urine specimens for culture and sensitivity need to be obtained using proper cleansing and voiding techniques to avoid contamination from external sources. The use of toilet paper will contaminate the specimen. The procedure described in option 1 would not provide a clean specimen. It is not necessary to obtain the specimen via a catheter. 57. Ryan Jayson, a 62-year old police officer, is admitted to the hospital with benign prostatic hyperplasia (BPH.) The doctor inserts an indwelling urinary catheter to relieve Mr. RJs urine retention. Which nursing action would help maintain the urinary drainage systems patency? A. Restricting fluids to 500ml per day B. Taping the catheter to the inner aspect of the thigh C. Positioning the tubing with dependent loops D. Keeping the drainage bag below the bladder level RATIO: A Forcing (not restricting) fluids maintains urine volume, causing steady movement of urine through the drainage system preventing clots.(mali kc restrict dw po..) B it is done to prevent tension on the urinary meatus 11 |

RNIRC
C- dependent loops should be avoided to help prevent drainage stagnation and possible clogging D correct answer. Keeping the drainage bag below bladder level allows steady drainage from gravity. Ndi xa maiipon sow continuous an flow,,,kpg continuous an flow,ndi xa mgclot and maintained an patency 58. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by: A. Emptying the drainage bag frequently B. Collecting a weekly urine specimen C. Maintaining the ordered hydration D. Assessing the specific gravity RATIO: accdng to kozier, the most common nosocomial infection is UTI secondary to urinary catheterization. Sow super laki concern po sa my indwelling cath an UTI. Question is about how to prevent UTI sa my indwelling cath. Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection. Other method includes Avoiding soaking the perianal area in water. Keep the urine bag below the level of the bladder. Acidify urine. Use sterile technique when handling the cath. Perform perineal cleaning in a regular interval. 59. Which of the following statements regarding indwelling urinary catheterization is accurate? SATA. i. ii. iii. iv. v. vi. vii. viii. A. B. C. D. When inserting catheter, position of choice for both male and female patient is dorsal recumbent Location of urethral meatus in female patients is between the clitoris and vaginal orifice while in male clients, it is located at the tip of the glans penis Length of catheter insertion for male clients is 6-9 inches while 3-4inches for female patients To prevent penoscrotal pressure in male clients, secure the catheter tubing upward to the lower abdomen of the patient To prevent tension to the urinary meatus and to maintain traction of urinary catheter in male and female clients, the catheter must be secured in the upper thigh and inner thigh respectively Strict aseptic technique is utilized Urine bag should always be maintained below the level of the bladder to prevent formation of calcium stones Plastic catheter can be used for maximum of 2 -3 weeks while rubber or silastic tube can be used for less than 1 week

ii, iii, iv, v, vi ii, iii, iv, v, vi, vii ii, iii, iv, v, vi, viii ii, iii, iv, v, vi, vii, viii

RATIO: i incorrect because dorsal recumbent is for female patient while for male pts, supine pxn with knee slightly abducted dpt Ii correct accdg to kozier Iii correct accdg to kozier Iv correct accdg to kozier V correct accdg to kozier upper thigh for males while inner thigh for females po tlga..CBQ ito last july 2011 Vi very yes accdg tokozier Vii incorrect kc po dpt UTI Viii incorrect..accdg to kozier. Plastic cath <1week; rubber or silastic tube 2-3 weeks; silicone catheter is 2-3months; PVC is 4-6weeks

Situation 11 Bladder irrigation is used to prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery. 12 |

RNIRC

60. The following is/are true regarding bladder irrigation. SATA. i. ii. iii. iv. v. vi. vii. A. B. C. D. CBI involves instilling sterile irrigation solution into the bladder, then allowing the fluid to drain out A triple lumen catheter rather than the typical 2 double lumen (foley catheter) is used in CBI The closed method is the preferred technique for bladder irrigation because it is associated with a lower risk of UTI The purpose of continuous bladder irrigation is to maintain patency of urinary catheter and tubing The purpose of the intermittent bladder irrigation is to prevent spasm of the bladder Continuous bladder irrigation (CBI) is also known as CYSTOCLYSIS CBI can help prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery

All except v All except iv and vi All except v and iv All of the above

RATIO: (pure kozier po ito) i correct. Irrigation means flushing or washing out with a solution, then iddrain un solution Ii correct. 1st lumen is for instilling solution, 2nd is for draining the solution, 3rd is for balloon anchoring Iii we have 2 methods po. Closed and open. Sa closed pra po xang typical indwelling foley cath. Connected sa urine bag ung urine input port ng cath then kpg naginstill ka ng solution, sa urine bag poi to maddrain. Kpg open, wala urine bag po...manual po iddrain ung solution na naintroduce. Kpg closed system,mas less an risk for uti po kc ndi xa exposed sa external environment. Iv yes accdg to kozier v incorrect. kpg intermittent po,purpose is to free the blockage of catheter tubings..bale ganito po,kpg PREVENT blockage,dpt continuous... ngaun if ndi continuous an bladder irrigation and nagkaron clot and u want to remove that blockage po,intermittent po ggmitn. Vi yes Vii yes po 61. When preparing the equipments for a continuous bladder irrigation, which of the following is the rationale for flushing the irrigating tubes first? A. Flushing the tubing removes air and prevents it from being instilled into the bladder and prevents bladder distention B. Flushing the tubing is necessary because presence of air in the bladder may cause spasm C. Flushing the tubing is important because presence of excess air may traumatize the bladder wall leading to hematuria D. Flushing the tubing is necessary to prevent infection RATIO: verbatim po kay kozier. A lng ang sagot. Kpg mdme air, madidistend ang bladder,mas konting solution lng mainstill. BCDspasm, hematuria and infection eh imbento ko lng po...hehehe 62. When doing the actual continuous bladder irrigation, which of the following is incorrect? A. Open the flow clamp of the urinary drainage tubing to allow the solution to flow out of the bladder continuously. B. If not specifically prescribed by the MD, the flow rate of solution should be 20 30 drops per minute C. Assess the urine for amount, color and clarity. D. The amount of drainage should equal the amount of irrigant entering the bladder plus expected urine output RATIO: kozier po lhat ito sa procedure nia po I yes.bale an setup po eh nkahng like IVF un solution po sa iv pole.. nkaclamp po un initially den kpg start na,ttnggalin na un clamp and it wud be regulated din. My picture po ako na niprovide

13 |

RNIRC
Ii no. Normally dw po my bbgay na flow rate c MD, but kpg wla niprescribe or most common dw po is 40 60 drops accdg to kozier Iii yes Iv yes 63. Two hours after the start of irrigation, the nurse has instilled 120 ml of irrigating solution. To ensure that the desired flow rate is being achieved, the nurse must acquire how many ml of urine output? A. 100 200ml B. 220 270ml C. 180 240ml D. 300 500ml RATIO: here is the rule po during irrigation to know how much ang expected return fluid po ntin. Amount of returning fluid = fluid introduced plus expected urine output per hour (30 60cc/hr) Fluid introduced = 120ml Expected urine output = 30-60 cc/hr x 2 (kc 2hours ung given) 60 120cc Amount of returning fluid = 120 + 60 = 180; 120 + 120 = 240ml NOTE: if output is less than expected, NOTIFY MD because it may cause bladder injury

64. After the bladder irrigation procedure, which of the following must be not reported to the MD stat except all but one? A. Presence of blood clots, pus and mucous constituents in the urine B. Less than expected amount of urine output C. Pink tinged urine 24 hours after irrigation 14 |

RNIRC
D. Obstruction of the irrigating tube RATIO: pink-tinged urine dw po is just normal 24-hours post-op... if bright red urine, it is indicative of bleeding... notify MD! ***********************gnito kopo yan raratio over-all kng ako.... CYSTOCLYSIS -Also called continuous bladder irrigation or CBI -Can help prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery -It may also be used to treat an irritated, inflamed, or infected bladder lining - CBI can be either open or closed: In an open system, the bladder is drained using a 60 ml syringe Also called manual irrigation Performed by the nurse In closed system, the bladder drains directly into a Foley bag

Note: CBI should not go beyond in weeks

CBI involves instilling sterile irrigation solution into the bladder, then allowing that fluid to drain out Failure to recognize that the fluid isnt draining can result in severe bladder injury, as large volumes of irrigation solution are typically instilled Ex. If 100 cc is irrigated + 30 cc urine output/min = >130 cc is expected If output is less than, notify the physician

Typically, triple lumen catheter are used -One port, is to fill the balloon so the catheter stays in place -One is used to infused fluid -Another is to drain fluid If bleeding occur, infuse more that, put a plaster on the thigh 30 cc water to apply pressure on the lining & stretch the catheter &

Procedure: 1. Handwashing 2. Assemble irrigation solution and tubing and clamp it closed. (RATIO: to prevent air from entering the bladder which in turn might cause bladder distention) 3. Insert the 3-way catheter to the patient. (same po ito ng paginsert ng typical na indwelling foley cath. Nature po nmin ito sa funda compre phase.) *** one lumen controls balloon inflation, one allows irrigant inflow and the other lumen controls the outflow *** solution used: sterile water *** 30ml is needed to anchor the cath 4. Connect the outflow lumen tubing to a urine bag and tape/tie it in the bedframe. Keep it below the leve of the bladder. 5. Connect tubing from the irrigation solution to inflow lumen of the 3-way catheter. 15 |

RNIRC
*** use macro set ***irrigation bag first then fill the baloon Situation 12 Nurses must be knowledgeable in the transfer of patients from bed to chair. ******pure kozier po an basis ko ditto po 65. A client may need to be transferred between the bed and a wheelchair or chair, and/or between the bed and the commode. There are numerous variations in the technique. When transferring a patient from bed to chair, how should the nurse position the wheel chair in reference to the bed? A. Parallel B. Perpendicular C. Normal D. Beside RATIO: BARBARA KOZIER PO ITO... nkadrawing po tlga ito sa step by step procedure nia bout sa transfer of pt from bed to chair. 66. In accordance with the answer to the previous number, what should be the angle of the wheelchair in reference to the bed? A. 45 B. 90 C. 180 D. 360 RATIO: bale ang dilemma po ditto is dpt alm ntin kung anu ba ang angle kpg cnbe ntin na PARALLEL sila...ang niconsult ko po ditto eh mga bath books and internet..and sbe nila, kpg parallel lines, 180 degrees poi to...my aattach po ako na journal d2..un po un pliwanag po panu naging 180 an parallel lines ... 67. A transfer belt is a device used when transferring the patient from bed to chair. It permits the nurse to transfer a patient without holding the clients axilla. Remember to avoid placing your hands on the clients axilla especially to a patient who have upper extremity paralysis or paresis because it might aggravate the problem. If a transfer belt is not available and the client needs to be transferred from bed to chair, what should the nurse do to promote a safe transfer? A. Reach through the clients axilla and place the hands on the clients scapula during the transfer B. Reach through the clients axilla and place the hands on the clients costovertebral angle during the transfer C. Reach through the clients axilla and place the hands on the clients 5th ICS during the transfer D. Reach through the clients axilla and place the hands on the clients gluteal muscle during the transfer RATIO: verbatim poi to kay kozier...umm, kng wla transfer belt, hand should be at the clients scapula...costovertebral angle yan po ung location ng kidneys ntn. Diagnostic plng,na discus na po ito ng team rationale sow my foundation na po tlga sila..pero during dat tym,with transfer belt un discussion. Dis tym without po..sa hahawakan lng an pngkaiba po nila..if my transbelt,sa belt..if wla transbelt, sa scapular area po or at the back. 68. The clients right leg is injured and the client is sitting on the edge of the bed. When preparing the client to be transferred to a wheelchair, which side of the client and the nurse should the wheelchair be placed? A. Right side of the nurse, right side of the client B. Right side of the nurse, left side of the client C. Left side of the nurse, right side of the client D. Left side of the nurse, left side of the client RATIO: accdg to kozier po,kpg tpos kna mgprepare ng wheelchair and bed including locking of wheels and assisting the pt on d edge of the bed...dpt mg mirror position or FACE TO FACE position po..kpg nka mirror or face to face pxn kau, ung ryt side mu eh left side ng khrap mu... ung left side mu eh ryt side ng khrap mu (d students shud realize dat po)... eh ang rule, dpt ang wheelchair ay nasa stronger or unaffected side ni patient so he can use it effectively and safely..ang affected kay patient ay ryt..sow dpt nsa left ni patient..eh face to face cla ni nurse sow dpt po ryt nmn ni nurse ung wheelchair... 69. Which of the following demonstrates proper technique in moving a client from sitting on the side of the bed to the wheelchair? SATA. 16 |

RNIRC
i. ii. iii. iv. v. vi. vii. viii. A. B. C. D. Placing the bed in the lowest possible position (knee level) and locking the wheels of the bed is needed The wheelchair is placed 90 degrees or parallel to the bed The wheelchair must be placed in the stronger side of the nurse and lock the wheels of the wheelchair The client must be placed in the middle of the bed to prevent falls Walking belt is placed around the clients waist The nurse and the patient must be in a mirror position before the actual transfer The nurse rocks from the rear foot to the front foot while standing the client. Have the client grasp the nurse around the neck for stability while standing

i, ii, iii, iv, v, vi, vi i, ii, iii, v, vi i, ii, iv, v i, v, vi

RATIO: i correct po. D feet shud be touching the floor sow dat mas madali xa mkakalipat...kpg nkaelevate ang bed and nagdangle feet,mas mhrap po umalis ng kama Ii wrong. tama po un parallel but mali ung 90 deg..it shud be 180 Iii wrong. stronger side of the patient po,...not the nurse Iv wrong. edge of the bed pod pt rather than middle v correct. hehehe palagay q po mdme ndi pipili nito kc ang turo ng team rationale nun dx eh transfer belt dpt..but transfer belt and walking belt po eh pareho lng po... =) vi - correct. yes...mirror position or face to face po vii wrong. eh iaassist mu po c patient eh...sow dpt bale an force shifting po eh front to rear foot then ska mu xa assist sa wheelchair viii wrong.grasping the neck may cause the nurse to lose balance and neck injury po.. kpg nasa bed pa,side of the bed hhwak..kpg nsa wheelchair na,sa armrest po ng wheelchair hhwak...not to the nurse Situation 13 Many patients or residents (especially nursing home residents) are totally dependent on staff members to provide activities of daily living, such as dressing, bathing, feeding, and toileting. Each of these activities involves multiple interactions with handling or transferring of patients or residents and could result in employee injuries. Employee injuries lead to increased injury costs, higher turnover rates, increased sick or injured days, and staffing shortages. 70. When turning the patient to a lateral position, where should you place the client before turning? A. Middle of the bed B. Side of the bed opposite the side the client will face when turned C. Side of the bed on the same side the client will face when turned D. Same side where in the nurse will position himself B- is the correct answer. Ratio: Turning the patient to a Lateral position in Bed. 1. Move the patient closer to the side of bed opposite the side the client will face when turned. 2. Place the near arm of the patient across the chest. Abduct the patients far shoulder slightly from the side of the body (to facilitate movement and prevent one arm from being caught beneath the patients body during the roll) 3. Place the patients near ankle and foot across the far ankle and foot (to facilitate turning motion) 4. Pull or roll the patient to a lateral position Y placing one hand on the clients far hip and the other hand on the patients far shoulder (for greater control in movement during the roll) 71. After putting the client on the side of the bed, the nurse must stand nearest to the client and correctly place the upper extremities of the client to facilitate proper turning. How should it be done? (in reference to the nurse) A. Place the clients far arm across the chest. Then abduct the clients near shoulder slightly from the side of the body and externally rotate the shoulder. B. Place the clients near arm across the shoulder. Then abduct the clients far chest slightly from the side of the body and externally rotate the shoulder. 17 |

RNIRC
C. Place the clients far arm across the shoulder. Then abduct the clients near chest slightly from the side of the body and externally rotate the shoulder. D. Place the clients near arm across the chest. Then abduct the clients far shoulder slightly from the side of the body and externally rotate the shoulder. For ratio please refer on # 41 72. How about the clients feet? A. Near ankle and foot across the far ankle and foot B. Far ankle and foot across the near ankle and foot C. Near knee, ankle and foot across the far ankle D. Far knee, ankle and foot across the near ankle For ratio, please refer to # 4 73. After putting the clients extremities in its correct placement, the nurse can now start turning the client. Where should the nurse put his/her hands when turning the client to a lateral or prone position? A. One hand on the clients neck and the other hand on the clients far hip B. One hand on the clients neck and the other hand on the clients popliteal area (behind the knee) C. One hand on the clients far hip and the other hand on the clients shoulder D. One hand on the clients popliteal area (behind the knee) and the other hand on the clients shoulder For ratio please refer to # 41 74. Which of the following is correct when turning the patient to the side or prone position? SATA. Tighten the gluteal, abdominal leg and arm muscle when turning the patient Rock backward, shifting your weight from the forward to the backward foot Roll the client onto the side of the body to face you When the patient is in prone position, it is ok to pull the client towards the center of the bed to promote safety and prevent falls All except i All except ii All except iii All except iv All of the above i. ii. iii. iv.

A. B. C. D. E.

RATIO for no. 41-45 (kng ako po, gnito ko xa raratio po) Steps when turning the patient to the side 1. Move the client closer to the side of the bed opposite the side the client will face when turned. (to ensure that the client will be positioned safely in the center of the bed after turning.) 2. Stand on the side of the bed nearest to the client (e2 muna po...) 3. Place the clients near arm across the chest. Abduct the clients far shoulder slightly from the side of the body and externally rotate the shoulder. (pulling the one arm forward facilitates the turning motion. Pulling the other arm away from the body and externally rotating the shoulder prevents that arm from being caught beneath the clients body during the roll) 4. Place the clients near ankle and foot across the far ankle and foot. (this facilitates turning motion. Making these preparations on the side of the bed closest to the client helps prevent unnecessary reaching.) 5. Position yourself on the side of the bed toward which the client will turn, directly inline with the clients waistline and as close to the bed as possible. 6. Pull or roll the client towards you to the lateral position. Place one hand on the clients far hip and the other hand on the clients far shoulder. (this position of the hands supports the client at the two heaviest part of the body, providing greater control in movement during the roll. 7. Tighten your gluteal, abdominal, leg, and arm muscles; rock backward, shifting your weight from the forward to the backward foot, and roll the client onto the side of the body to face you. Turning the client toward you promotes the clients sense of security. 8. Position the client on his or her side with arms and legs positioned and supported properly. 18 |

RNIRC
Situation 14 Ethical and Legal Issues in Nursing.

75. A registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action?
A. B. C. D. Refuse to float to the ICU Call the hospital lawyer Call the nursing supervisor Report to the ICU and identify tasks that can be safely performed

Rationale: Floating is an acceptable, legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contarct guarantees that nurses can work only in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When encountering this situation, nurses should set priorities and identify potential areas of harm to the client.

76. A nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid., into the antecubital area. The most appropriate initial action by the nurse is which of the following? A. Call the police B. Call security C. Lock the coworker in the medication room until help is obtained D. Call the nursing supervisor Rationale: nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. 77. A nurse has made an error in documenting an assessment finding on a client and obtains the clients record to correct the error. The nurse corrects the error by: A. Trying to erase the error to provide space to write in the correct data B. Using whiteout to delete the error and writing in the correct data C. Drawing one line through the error, initialing and dating the line, and then documenting the correct information. D. Documenting a late entry into the clients record Rationale: If the nurse makes an error in documenting in the clients record, the nurse should follow agency policies to correct the error. 78. A nursing instructor provides a lecture to nursing students regarding the issue of clients rights. The instructor asks a nur sing student to identify a situation that represents an example of invasion of clients privacy. Which of the following is identified by the student indicates an understanding of a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she cannot leave the hospital C. Threatening to give a client a medication D. Observing care provided to the client without the clients permission. Rationale: Invasion of privacy takes place when an individuals private affairs are unreasonably intruded into. Telling a cli ent that he or she cannot leave the hospital constitutes false imprisonment. Threatening to give a client a medication constitutes assault. Performing a procedure without consent is an example of battery.

79. A nurse hears a client calling out for help. The nurse hurries down the hallway to the clients room and finds a client lying on the floor. The nurse performing a thorough assessment and assists the client back to bed. The nurse notifies the physician of the incident and completes an incident report? A. The client was found lying on the floor B. The client climbed over the side rails C. The client fell out of bed 19 |

RNIRC
D. The client became restless and tried to get out of bed. Rationale: Defamation takes place when something untrue is said (slander) or written (libel) about a person, resulting in injury to that persons good name and reputation. An assault occurs when a person when a person puts another person in fear of harmful or offensive contact. Negligence involves the action of professionals that fall below the standard of care for a specific professional group. Situation 15 Intravenous fluids are a critical component of modern medical therapy. Nurses must be able to know correct IVF calculations.

80. A physician orders 1000 ml of NS to infuse over 12 hours. The drop factor is 15 drops per 1 ml. A nurse prepares to set the flow rate at how many drops per minute?
A. B. C. D. 15 drops per minute 17 drops per minute 21 drops per minute 23 drops per minute

ANSWER IS C: Use the IV flow rate formula

81. A physician orders 3000ml of D5w to infuse over a 24-hr period. The drop factor is 10 drops per 1 ml. A nurse sets the flow rate at how many drops per minute? A. 15 drops per minute C. 21 drops per minute B. 17 drops per minute D. 24 drops per minute ANSWER IS C: Use the IV flow rate formula

82. Gentamicin sulfate (Garamycin), 80 mg in 100 ml NS, is to be administered over 30 minutes. The drop factor is 10 drops per ml. A nurse sets the flow rate at how many drops per minute? A. 18 drops B. 23 drops C. 33 drops D. 43 drops ANSWER IS C:Use the IV flow rate formula

83.

A physicians order reads morphine sulfate, gr 1/8 IM stat. The medication ampule reads morphine sulfate, 10 mg per ml. A nurse prepares how many milliliters to administer the correct dose? A. 0.5 ml B. 0.75 ml C. 0.85 ml D. 1.5 ml

ANSWER IS B : Use the IV flow rate formula

84. physician orders Regular insulin, 8 units per hour by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled 100 units of Regular insulin in 100 ml NS . An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units per hour? A. 1 ml B. 4 ml C. 8 ml D. 10 ml 20 |

RNIRC
ANSWER IS B : Use the IV flow rate formula Situation 16 Blood transfusion is the process of receiving blood products into one's circulationintravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, clotting factors, and platelets. 85. Which one of the following nursing actions must be taken immediately if a transfusion reaction occurs? A. Notify the physician. B. Check the vital signs, and take a urine sample. C. Stop the blood transfusion, and infuse normal saline. D. Slow down the rate of blood flow and continue the assessment. - mas madami incompatible blood na pumasok, mas severe ang reaction. 86. A nurse has just obtained a unit of blood from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, the nurse next looks for which of the following members of the health care team to assist in the checking the unit of blood? A. Student nurse C. Nursing attendant B. Staff nurse D. Licensed practical nurse - RN DAPAT.. LICENSED 87. A nurse has just received an order to transfuse a unit of PRBC for an assigned client. In planning coverage for the client assignment, the nurse asks if another nurse will be available to check on the other assigned clients for how long when the unit of blood is hung? A. 5 mins C. 30 mins B. 15 mins D. 45 mins - if post 15mins and wala, walang reaction. Immediate kasi ang BT reaction 88. A client has an order to receive of PRBC. A nurse would obtain which of the following IV solutions from the IV storage area to hang with the blood product at the clients bedside? A. NSS C. D5NSS B. Lactated Ringers D. 5% Dextrose in 0.45% Saline 89. A nurse is assigned to care for a client who was just admitted to the hospital for treatment of iron overload. The nurse reviews the MDs admission orders and anticipates the MD will prescribe which medications to treat the iron overload? A. Granisetron (Kytril) C. Ketoconazole (Nizoral) B. Deferoxamine (Desferal) D. Terbinafine (Lamisil)

90. A nurse hears an attending physician asking intern to prescribe a hypotonic I solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe?
A. 0.45% saline (1/2 NS) B. 5% dextrose in water (5% D/W) C. 10% dextrose in water (10% D/W) D. 5% dextrose in 0.9 saline (5% D/NS)

Rationale: Hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution. 0.45% saline (1/2 NS) is hypotonic and is probably the only hypotonic solution used in clinical situations. 5% dextrose in water (5% D/W) is an isotonic solution. 10% dextrose in water (10 %D/W) and %% dextrose in 0.9% saline (5% D/NS)are hypertonic solutions. Distilled water is another example of a hypotonic solution.

21 |

RNIRC

22 |