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What is the basic requirement of the state for a nurse to practice her profession? A. Willingness to practice the profession B. A BSN degree C. A nursing license D. An NCLEX and CGFNS passer CORRECT ANSWER: C RATIONALE: Based on the definition of a professional nurse, a professional nurse is a person who has completed a basic nursing education program and is licensed in his/her country or state to practice professional nursing. Source: Professional Nursing in the Philippines 10th edition, page 3. 2. The Code of Good Governance for the professions in the Philippines shall be adapted by: A. all registered professionals B. all Filipino professionals C. all professionals D. all registered nurses CORRECT ANSWER: C RATIONALE: Governance is high on the agenda in all sectors – public, private and voluntary. As voluntary and community organisations working for public benefit, we are increasingly expected to demonstrate how well we are governed. Good governance is a vital part of how voluntary and community organisations operate and are held accountable. 3. The standardized guidelines and procedures for the implementation of Continuing Professional Education (CPE) for all professional. Resolution Number 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be: A. 20 credit units per year B. 30 credit units for 3 years C. 60 credit units for 3 years D. 10 Credit units required CORRECT ANSWER: C RATIONALE: Through PRC Resolution No. 2004-179 Series of 2004, Registered professionals are required a total of sixty (60) CPE credit units for Three (3) years. Any excess credit units shall not be carried over to the next three-year period except credits earned for doctoral and masters degrees. Source: Professional Nursing in the Philippines 10th edition, page 206 4. The Board of Nursing is vested with power to issue, suspend, or revoke for cause, the: A. certificate of Good Moral Character B. certificate of Practice C. certificate of Registration D. certificate of Employment CORRECT ANSWER: B RATIONALE: The license to practice nursing is not permanent or vested right since it may be granted upon condition and it may be held subject to conditions. If these conditions are breached or violated, the authority that issues such may revoke this license. A license cannot be revoked arbitrarily, it can only be revoked for special causes. Source: Professional Nursing in the Philippines 10th edition, page 19 5. RA 7193 stipulates the removal examination of the nurse licensure examination shall be taken: A. Within 3 years after the last failed examination B. Anytime the examinee wants to take the examination C. Within 2 years after the last failed examination D. Within the same year after the last failed examination CORRECT ANSWER: C RATIONALE: Renewal examination shall be taken within 2 years after the last failed examination. Source: Professional Nursing in the Philippines 10th edition, page 16 Situation 2 – Mr. Garzon, 35 years old, an accountant of one of the banks in Iloilo went to the clinic complaining of headache and difficulty sleeping at night. 6. Nurse Anne is assessing the blood pressure (BP) of Mr. Garzon. She explains to him that the basis for the diagnosis of hypertension should be established by: A. Five readings one month apart B. At least 3 readings with average blood pressure of 140/90 C. One reading of blood pressure greater than 140/90 D. Three blood pressure readings taken on the same day in different positions Reproduction is strictly prohibited… RN International Review Center 1
CORRECT ANSWER: B RATIONALE: The National Institutes of Health (NIH) Committee has defined hypertension as a systolic pressure of 140 or higher and diastolic of 90 or higher when 2 or more blood pressure measurements are averaged on 2 or more subsequent visits. Options 1, 3, and 4 are incorrect. Source: Page 1491 med-surg Black 7. Mr. Garzon is beginning medication therapy with furosemide (Lasix) once daily. Nurse Anne should instruct him to take the medication at which of the following optimal times? A. 8:00 A.M. B. 12 noon C. 6:00 P.M. D. At bedtime CORRECT ANSWER: A RATIONALE: A client taking a diuretic such as furosemide should self administer the medication in the morning to allow for diuresis throughout the day. This will help to prevent nocturia, which could cause disruption to the client's nightly sleep pattern. The timeframe in option 2 is not as early as option 1, while options 3 and 4 clearly increase the risk of nocturia. 8. During the discharge teaching, Mr. Garzon mentions that he will stop taking her antihypertensive medications as soon as his blood pressure is under control. Which of the following should be included in your instructions? A. "In order to maintain control of your blood pressure, the medication must be continued indefinitely." B. "Only the physician can answer this question." C. "The medication will probably be stopped after your blood pressure is normal D. "The medication will be decreased in time." CORRECT ANSWER: A RATIONALE: Emphasis should be placed on the client's adherence to the plan of treatment to avoid serious consequences of noncompliance. The complications of high blood pressure include stroke, cardiac failure, and chronic renal failure. Situation 3 - Pain is always associated to surgery: 9. As a surgical nurse, which of the following nursing intervention will allay anxiety and pain among surgical patients? A. Assess the client for concerns especially those that can potentially cause pain B. Verify that the operative permit is signed C. Discourage the client from discussing the details of the surgical procedure D. Ensure safety of client while in surgery CORRECT ANSWER: A RATIONALE: All patients undergoing surgery will have fear and anxiety, especially post operatively when they experience pain. As a priority nursing intervention, a nurse should assess further the patient in relation to pain and verbalization of feelings may allay anxiety. Choices B and D are important but do not answer the question, choice C always discourage verbalization 10. Rhizotomy is a condition surgical procedure to manage those that can potentially cause pain. What is the crucial in determining a good candidate for rhizotomy? A. Pain which is resistant to non-pharmacologic protocol for 6 month B. Pain which is resistant to pharmacologic protocol for 12 months C. Local pain with no radiating pain or signs of nervous compression D. Deep pain with obvious signs of peripheral nerve damage CORRECT ANSWER: B RATIONALE: 1. Non pharmacologic management. 2. Pharmacologic management. 3. Surgery including rhizotomy to relieve pain
11. Which of the following would be the nurse's appropriate response to a crying female client scheduled for
emergency surgery who is verbalizing fear of pain but afraid to go to sleep? A. Let her cry and tell significant other to stand by B. Squeeze her hand and assure her that there will be no pain at ail because she will be given anesthesia C. Stand by her side and quietly ask her to describe her feelings D. Check her name tag and request anesthesiologist to sedate client CORRECT ANSWER: C Reproduction is strictly prohibited… RN International Review Center 2
RATIONALE: Choice B is false reassurance, choice D is not therapeutic, choice C is offering self, and encouraging verbalization of clients 12. Which of the following client's statement indicates that he understands the nurse's instruction about postoperative wound pain? A. "I shall call the nurse when my wound itches and smells". B. "I shall expect slight pain and discomfort from the surgical incision". C. "I should call my doctor if my wound has no drainage, and intact". D. "I should not touch my surgical wound". CORRECT ANSWER: B RATIONALE: this is an expected finding during the post-op period OPTION A – The dressing over the surgical incision must be checked frequently. If it is soiled, note the color, type and amount of drainage. Reinforce the dressing but do not change it or open it without a physician’s order. Although correct, it is not related to post-op wound pain but rather it is related to post-op infection risk Source: page 303 MS Black 13. What do you think is an important responsibility related to pain that is subjective in nature? A. Divert attention of client in pain B. Leave the patient alone while in pain C. Believe what the patient says about the pain D. Assume responsibility to eliminate pain as described by the client CORRECT ANSWER: D RATIONALE: Pain is an expected outcome postoperatively and yet one of the most frequent postoperative problems is inadequate analgesic administration. You must carefully and regularly assess the client’s level of pain. Pain may be caused by a factor unrelated to the surgical procedure such as positioning that occurred during surgery. Source: page 304 MS Black Situation 4 – Nurse Bryan is taking care of the client who was diagnosed with osteomyelitis. 14. Nurse Bryan is knowledgeable that the primary organism responsible for osteomyelitis is: A. Staphylococcus aureus B. Escherichia coli C. Streptococcus D. Pseudomonas CORRECT ANSWER: A RATIONALE: The most common causative agent in clients with osteomyelitis is Staphylococcus aureus. The other organisms could contribute but are not usually the primary organism; look for key words. Source: page 610 MS Black 15. Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis? A. Apply heat compresses to the affected area B. Immobilize the affected area C. Administer narcotic analgesics for pain D. Administer OTC analgesics for pain CORRECT ANSWER: A RATIONALE: Options 2, 3, and 4 are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilatation. Source: page 610 MS Black Situation 5 - Nurses' attitudes toward pain influence the way they perceive and interact with clients in pain. 16. Nurses should be aware 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 labeled a "bad” patient CORRECT ANSWER: A RATIONALE: Elderly: May consider it unacceptable to admit or show pain, May withhold complaining of pain because of fear of the treatment, of any lifestyle changes that may be involved or of becoming dependent Source: page 1138-1139 Funda Kozier 17. Nurses should understand that when a client responds favorably to a placebo, it is known as the placebo effect. Placebos do not indicate whether or not a client has: Reproduction is strictly prohibited… RN International Review Center 3
A. B. C. D.
conscience real pain disease drug tolerance
CORRECT ANSWER: B RATIONALE: A positive response to a placebo dose is not indicative of a lack of real pan but only of the reality of the placebo effect, which can be expected in 30% or more of any population. Because placebos fail to relieve pain for many people it is recommended that the deceptive use of placebos be considered unacceptable in the management of pain Source: page 1154 Funda Kozier 18. You are the nurse in the pain clinic where you have a client who has difficulty specifying the location of pain. How can you assist such client? A. The pain is vague B. By charting-it hurts all over C. Identify the absence and presence of pain D. Ask the client to point to the painful area by just one finger CORRECT ANSWER: D RATIONALE: To ascertain the specific location of the pain, ask the individual to point to the site of the discomfort. A chart consisting of drawings of the body can assist in identifying pain location. The client marks the location on the chart. This tool can be especially effective with clients who have more than one source of pain Source: page 1142 Funda Kozier 19. 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 CORRECT ANSWER: C RATIONALE: Opiods relieve pain and euphoria largely by binding to opiate receptors and activating endogenous pain suppression in the CNS. Opiods cause a CNS depressant effect like drowsiness, nausea, vomiting, constipation and respiratory depression Source: page 1152 Funda Kozier 20. Physical dependence occurs in anyone who takes opioids 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 CORRECT ANSWER: A RATIONALE: Tolerant patients can still be given additional opioids on top of their withdrawal-preventing maintenance levels to achieve adequate postsurgical pain control. This can be accomplished by using opioids different from those in the patient's maintenance regimen, to which he or she may have less cross-tolerance, or by combining opiates with other pain-control modalities. In addition, tolerance to the side effects of opioids, particularly respiratory depression, is usually greater than any tolerance to their pain-relieving effects; dosages can be titrated carefully to prevent adverse events. Slowing the withdrawal of the patient taking an opioid will prevent withdrawal manifestation of the client. Situation 6 - As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. 21. Items that enter sterile tissue or vascular system are categorized as critical items and should be: A. Clean B. Decontaminated C. Sterilized D. Disinfected CORRECT ANSWER: C RATIONALE: since the tissue or vascular system is sterile, it should only have contact with a sterile item or articles which makes option C the correct answer (following principles of surgical asepsis) 22. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection? A. Material compatibility and efficiency B. Odor and availability Reproduction is strictly prohibited… RN International Review Center 4
C. Cost and duration of disinfection process D. Duration of disinfection and efficiency CORRECT ANSWER: D RATIONALE: 23. Before you use a disinfected instrument, it is essential that you: A. Rinse with tap water followed by alcohol B. Wrap the instrument with sterile towel C. Dry the instrument thoroughly D. Rinse with sterile water CORRECT ANSWER: D RATIONALE: Rinsing is the most important part of the cleaning process. Rinsing removes the debris loosened with manual and/or ultrasonic cleaning and residual cleaning agent. Sterile deionized/distilled water is preferred for the final rinse to prevent mineral deposits and reduce the potential for pyrogens. The water should not be reused/ 24. You have a critical heat labile instrument to sterilize and you are considering to use a high level disinfectant. What should you do? A. Cover the soaking vessel to contain the vapor B. Double the amount of high level disinfectant C. test the potency of the high level disinfectant D. Prolong the exposure time according to manufacturer's direction CORRECT ANSWER: D RATIONALE: 25. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin should be: A. Disinfected B. Sterile C. Clean D. Alcoholized CORRECT ANSWER: B RATIONALE: Situation 7 - The OR is divided into three zones to control traffic flow and contamination. 26. 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 CORRECT ANSWER: B RATIONALE: The surgical area is divided into three zones: Unrestricted zone – where street clothes are allowed Semi-restricted zone – where attire consists of scrub clothes, caps & shoe cover Restricted zone – where scrub clothes, shoe covers, caps and mask are worn Source: MS Brunner, page 420 27. Which of the following nursing interventions should be given the highest priority when receiving a client in the OR? A. Check for presence of dentures, jewelry, nail polish, and other accessories B. Receive the client at the semi-restricted area and change his gown C. Assess level of consciousness D. Verify the identification and informed consent CORRECT ANSWER: D RATIONALE: Although all options are correct, verifying for the correct patient and checking for the signed consent will be the priority. (How can you do options A, B & C if it was a wrong patient and/or a consent form has not been signed yet?) 28. Conversation while in the operation is ongoing is minimized because: A. full concentration is demanded during the entire procedure B. it annoys the surgeon C. it is unethical to talk about the client D. it enhances the spread of microorganism to the incision site Reproduction is strictly prohibited… RN International Review Center 5
CORRECT ANSWER: D RATIONALE: The number of personnel and unnecessary physical movements and talking may be restricted to minimize bacteria in the air in the OR. Source: MS Brunner, page 422 29. Spaulding categorized instruments according to use. Where do you classify endoscopic instrument? A. Decontaminated instruments B. High level disinfected instruments C. High technology instruments D. Sterile instruments CORRECT ANSWER: B RATIONALE: 30. In the OR. "Surgical Conscience" means. A. Observance of Operating Room Protocol at all times B. Use of prescribed OR attire in all areas of the OR C. Honest adherence to surgical aseptic techniques all the time D. Strict implementation of "Standard Precaution" CORRECT ANSWER: C RATIONALE: Surgical Conscience: All patients have the right to expect and receive exceptional and ethical care. It is the patient that we, in health care, work for. Operating room personnel are keenly aware of the potential for harm to the patient. While in the operating room, the patient is generally unable to provide self-protection. The patient may be partially or completely impaired due to anesthetic needs. It is personal moral values and professional ethics that guide health care professionals to carefully and vigilantly protect their patients. When there is a breach in aseptic technique or when it is noticed that instruments are contaminated, this must be reported so corrective action can take place immediately, regardless of personal consequences or embarrassment. A delay in reporting such incidents unnecessarily places the patient at great risk. Placing of the patient's well being above personal/professional embarrassment demonstrates good surgical conscience. www.geocities.com/alamedacounty/repspolicy.html Situation 8 - Nurses have the responsibility to assist diabetic clients with insulin administration it is essential that both nurse and client learns how to measure insulin dosage accurately. 31. Insulin concentration is labeled and measured in: A. units/ml B. gm/ml C. grain D. mg/ml CORRECT ANSWER: A RATIONALE: Insulin is commercially available in concentrations of 100 or 500 units/ml (designated U-100 and U500, respectively; 1 unit equals 36 µg of insulin). U-500 is only used in rare cases of insulin resistance when the patient requires extremely large doses 32. Each unit of insulin provides the client with the same effect regardless of its concentration per 1 ml of solution. Is insulin of 500 "u" per ml more potent that insulin of 100 "u" per ml? A. Moderate potency B. Less potent C. More potent D. Same potency CORRECT ANSWER: C RATIONALE: Insulin is commercially available in concentrations of 100 or 500 units/ml (designated U-100 and U500, respectively; 1 unit equals 36 µg of insulin). U-500 is only used in rare cases of insulin resistance when the patient requires extremely large doses 33. 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 CORRECT ANSWER: C RATIONALE: A nurse in Insulin IV administration should monitor vital signs and for signs of fluid overload, monitor potassium levels, glucose levels and urinary output and signs for increased intracranial pressure. Reproduction is strictly prohibited… RN International Review Center 6
Source: page 642 Saunders 34. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going IV. The strength is 500 u/ml. How much should you incorporate into the IV solution? A. 10 ml B. 2 ml C. 0.5 ml D. 5 ml CORRECT ANSWER: B RATIONALE: 1000u / 500u /ml = 2 ml 35. Multiple vial-dose-insulin when in use should be: A. kept at room temperature B. kept in the refrigerator C. kept in the narcotic cabinet D. stored in the freezer CORRECT ANSWER: A RATIONALE: Vials of insulin not in use should be refrigerated. Extreme temperatures (<36 or >86°F, <2 or >30°C) and excess agitation should be avoided to prevent loss of potency, clumping, frosting, or precipitation. Specific storage guidelines provided by the manufacturer should be followed. Insulin in use may be kept at room temperature to limit local irritation at the injection site, which may occur when cold insulin is used. Situation 9 - Collaborative planning is essential if nursing and health care are to be made available to all people. 36. Perioperative examples of collaboration are the following EXCEPT: A. Communicate with other members of the health profession to improve the integrity B. Communicate with health officials the incidence of Hepatitis B among OR personnel C. Collaboration with other OR personnel regarding the practices of surgeons collecting exorbitant professional fees D. Collaborate with DOM regarding disposal or specimens CORRECT ANSWER: C RATIONALE: collaboration means a collegial working relationship with another health care provider in the provision of patient care. Collaborative practice requires the discussion of patient diagnosis and cooperation in the management and delivery of care. Source: page 111 funda kozier 37. The nurses collaborate with other members of the health profession to improve the integrity of the hospital working environment through the following ways EXCEPT: A. Joining barangay health club projects B. Joining the Mayo Uno Labor Union C. Joining labor day rally to increase wages of healthcare workers and improve dilapidated health centers D. Affiliating with The All Healthcare Alliance CORRECT ANSWER: C RATIONALE: Collaboration means a collegial working relationship with another health care provider in the provision of patient care, but it does not entail joining a rally to increase wages 38. An example of a collaborating effort on public service particularly during summer is: A. Boto Mo. Ipatrol Mo B. Operation Linis C. Clean and Green D. Operation Tuli CORRECT ANSWER: D RATIONALE: Usually during summer season, children are on vacation leading to a program in the government to conduct an operation tuli
39. When does a nurse accept the interdependence of providers and patients in achieving access to health care?
A. B. C. D. "Our hospital does not honor visiting doctors " When the nurse replies to a client's relative "You have the best doctor in town". When the nurse communicates to the attending physician the desire of the patient to be seen by a urologist “The doctor is not on duty today."
CORRECT ANSWER: C RATIONALE: As a nurse she can become a client advocate when he/she can provide what is best for the patient not for the doctor or the hospital, it’s for the client’s best interest Reproduction is strictly prohibited… RN International Review Center 7
40. Individual patients and society as a whole benefit from nursing participation in decisions made about health care. This is exemplified in: A. Supporting, political candidates that advance nursing health care issues B. Bringing the NCLEX in the Philippines C. Supporting the proliferation of colleges of nursing in the country D. Following the decision of CGFNS to retake test III and V to validate the visa screen for the U.S. CORRECT ANSWER: A RATIONALE: The patient and society can benefit from the nurse’s participation in supporting country’s political advances towards the health care development system and issues. Situation 10 - Pain management is not limited to pharmacological means. 41. Ronald, one of your clients who is being worked out for AIDS, tells you that he has been using acupuncture to help with his pain. You questioned his treatment because: A. acupuncture uses needles to stimulate certain points on the body to treat pain B. acupuncture uses a variety of herbs and oils from wild plants C. acupuncture uses manipulation of the skeletal muscles to relieve stress and pain D. acupuncture uses pressure from the fingers and hands to stimulate body responses CORRECT ANSWER: A RATIONALE: Acupuncture is to restore balance and free flow of body’s vital energy in order to help the body to heal itself. This is achieved by the insertion of fine, sterile needles into specific points along meridians, in various areas of the body. 42. Your younger brother came home with a right black eye. He asked you for an eye ointment to relive the pain and swelling. You should offer: A. ice pack over the right eye B. tetracycline ophthalmic ointment C. hot compress over the right eye D. ice cold drinks CORRECT ANSWER: A RATIONALE:Cold lowers the temperature of the skin and underlying tissues and causes vasoconstriction. Vasoconstriction reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes and produces skin pallor and coolness. Cold compresses usually indicated for the first 24H in sport injuries ( e.g. sprains, strains, fractures) Source: page 884 funda kozier 43. Menstrual pain and discomfort account for absences in schools and offices. A non-pharmacological remedy for menstrual pain is: A. regular bowel movement B. knee-chest exercises before menstruation and hot water bag application over lower abdomen during onset C. warm shower during onset of menstrual period D. diet restriction on fatty foods and liberal fluid intake CORRECT ANSWER: C RATIONALE: Dysmenorrhea or painful menstruation is usually caused by prostaglandin synthesis that causes spasm during menstruation. Usual management is knee-chest position, regular exercise, hot compress or analgesics for pain. 44. Among burn clients, especially 1st and 2nd degree, one of the primary nursing functions is to alleviate pain. The following are appropriate nursing interventions, EXCEPT : A. using cold water for hydrotherapy B. avoiding exposure to draft C. administering morphine S04 as proscribed D. using of bed cradle to relive pain CORRECT ANSWER: A RATIONALE: flame and scald burns should be cooled by submerging small burns in cool water NOT COLD until the sensation of burning stops. Major burn victims should have an initial “wet down” at the scene to stop the burning process, but not submerged in water. Source: 1446 med-surg Black
45. Nurses taking care of post skin graft patients know that the post-op pain is at the:
A. B. C. D. Buttocks Donor site Recipient site Injection site Reproduction is strictly prohibited… RN International Review Center 8
CORRECT ANSWER: B RATIONALE: Case specific to debrided wounds includes assessment of bleeding and pain control. Many patients report more pain in donor sites (owing to exposed nerve endings) than the recipient sites. Page 1460 funda kozier Situation 11 - One learns by doing especially when you practice the best methods 46. Which action by a new nurse signifies a need for further teaching in infection control? A. The nurse places the side rails the time to an unconscious patient B. The nurse elevates the head of the bed to check the BP C. The nurse uses her bare hands to change the dressing D. The nurse applies oxygen mask to the mouth CORRECT ANSWER: C RATIONALE: Infection control in changing dressing to patient is always considered to be sterile technique to prevent infection 47. You are on PM shift and about 5 patients are for discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue? A. Call the attention of the orderly in private B. Ignore the situation because you are busy C. Report this behavior to the nurse in charge D. Monitor the situation and note whether any other items are reported missing CORRECT ANSWER: A RATIONALE: the nurse should 1st confront the person concerned before reporting to the immediate head. 48. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? A. Try to explore the interaction with the nursing attendant concerned B. Change the attendant's assignment C. Initiate a group discussion with all other nursing attendants D. Discuss the matter with the patient's family CORRECT ANSWER: A RATIONALE: Ensuring a therapeutic communication, a nurse overhearing the nursing attendant should first confront the nursing attendant for reasons of his/her actions
49. You have been in the surgical ward for almost a year and have cared for a number of clients with CVP. Which
observation from a colleague would indicate a need for further teaching, EXCEPT? A. The colleague turns the stop-cock to the off position from the IV fluid to the patient B. The nurse colleague notes the level at the top of the meniscus C. The colleague instructs the client to perform the valsalva maneuver during the CVP reading D. The nurse colleague charting medication administration that she has not yet given CORRECT ANSWER: A RATIONALE: Pt is relaxed, activities that increase intrathoracic pressure such as coughing or straining will cause false increase in the reading, although charting if the drug is not given yet is wrong, but it does not answer to the question regarding CVP. Source: page 784 Saunders
50. You saw one colleague charting medication administration that she has not yet administered. After talking to her,
you also report the incident to the charge nurse. The charge nurse should: A. require the staff to submit an incident report B. terminate the nurse C. charge the erring nurse with dishonest D. report to the Board of Nursing CORRECT ANSWER: A RATIONALE: Error that is usually committed should be required to submit an incident report Situation 12 – You are assigned at the PACU at 9:30 AM, post-op clients started to be wheeled in from the OR. 51. Which nursing diagnosis has priority among client in the PACU? A. Acute pain related to discomfort of wound and immobility B. Body image disturbance because of wound dressing and drains C. Ineffective airway clearance related to general anesthesia D. Knowledge deficit related to lack of information because patients are all sedated CORRECT ANSWER: C Reproduction is strictly prohibited… RN International Review Center 9
RATIONALE: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation to prevent hypoxemia and hypercarpnia because both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). That is why in all the options the nursing diagnosis ineffective airway clearance has the priority. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 349 52. Which of the following clients at the PACU will demonstrate the effectiveness of preoperative teaching? A. The client demonstrates deep breathing, coughing, splinting chest and leg exercises B. The client manifests normal temperature C. The client sleeps well D. The client has good balance I and O CORRECT ANSWER: A RATIONALE: Important preoperative patient education includes: i. Teaching deep breathing and coughing exercises (prevention of pneumonia and atelectasis) and splinting wound when coughing (reduce pain and prevent wound dehiscence) ii. Encouraging mobility and active body movement (prevention of thrombosis/DVT, promotes circulation and respiratory function) iii. Explaining pain management and cognitive coping strategies (pain relief) Source: MS Nursing by Brunner 9th ed., vol. 1, p. 324 53. Which of the following remark indicates that the client's relative understood the discharge instruction for wound care? A. "If the wound is painful, I will say it is normal." B. "It is alright to use adhesive tape over the wound to keep it intact." C. "It is ok for his pet to remain at his bedside to keep him company." D. "I will report any redness or swelling of the wound.” CORRECT ANSWER: D RATIONALE: Reporting of redness and swelling is important to monitor infection risk Option A – Painful wound is not always normal Option B – Sterile dressings are used to cover wounds not adhesive tape Option C – Animal saliva might come in contact with the wound (risk for infection) 54. You just transferred out a post-op client to her room. What would your instruction to the family include to prevent accidents? A. Report when the IV infusion is almost finished B. Test the call system if functioning C. Keep the room lights on for 24 hours D. Make sure the side rails are up CORRECT ANSWER: D RATIONALE: Side rails up ensures safety of patient while he/she is on the bed. Option A – It is the nurse’s responsibility to monitor IV. The nurse in charge of the patient should know when the IV fluid will be consumed. Option B – Does not answer safety Option C – There is no assurance that when lights are turned on, patient will be free from falling from the bed. 55. One of your post-op patients has a temperature of 37.9°C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9°C. The nursing student asked you to explain the absence of shivering even if the temperature was higher. A. The patient is no longer febrile thus he is no longer chilling B. Shivering normally disappears as temperature becomes higher C. The body has reached its new set point thus the absence of shivering D. The patient is feeling better CORRECT ANSWER: C RATIONALE: Option A & D - 37.9°C to 38.9°C is still febrile The body maintains stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment. The "thermostat" that controls this process is located in the hypothalamus, a small structure located deep within the brain. The nervous system constantly relays information about the body's temperature to the thermostat, which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances. These responses include: decreasing or increasing the flow of blood from the body's core, where it is warmed, to the surface, where it is cooled; slowing down or speeding up the rate at which the body turns food into energy (metabolic rate); inducing shivering, which generates heat through muscle contraction; and inducing sweating, which cools the body through evaporation. A fever occurs when the thermostat resets at a higher temperature, primarily in response to an infection. To reach the higher temperature, the body moves blood to the warmer interior, increases the metabolic rate, and induces shivering. The "chills" that often accompany a fever are caused by the movement of blood to the body's core, leaving the surface and extremities cold. Once the higher temperature is achieved, the shivering and chills stop. Reproduction is strictly prohibited… RN International Review Center 10
Source: http://www.answers.com/topic/fever?cat=health Situation 13 - Patients with chest tubes can be very challenging to new nurses. 56. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. Which of the following condition is the possible cause of the malfunctioning sealed drainage? A. A suction being too high B. An air leak C. A tube being too small D. A tension pneumothorax CORRECT ANSWER: B RATIONALE: Bubbling in the water-seal compartment is caused by the air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal and indicates that the system is accomplishing one of its purposes, that is, removing air from the pleural space. Continuous bubbling during both inspiration and expiration, however, indicates that air is leaking in the drainage system or pleural cavity. Source: MS Nursing by Black and Hawks 7th ed., vol. 2, p. 1864 57. While you were making your endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action? A. Assist the client back to his bed and place him on the affected side B. Cover the end of the chest tube with sterile gauze C. Reconnect the tube to the chest tube system D. Put the end of the chest tube into a cup of sterile normal saline CORRECT ANSWER: D RATIONALE: If the tube becomes disconnected, it is best to reattach it to the drainage system or to submerge it the end in a bottle of sterile water or saline to reestablish a water seal. Source: MS Nursing by Black and Hawks 7th ed., vol. 2, p. 1865 58. Dr. Reyes asked you to assist him with the removal of Tirso's chest tube. You would instruct the client to : A. continuously breathe normally during the normal of the chest tube B. take a deep breath, exhale, and bear down C. exhale upon actual removal of the tube D. hold breath until the chest tube is pulled out CORRECT ANSWER: B RATIONALE: When removing the chest tube, instruct the patient to perform valsalva maneuver by exhaling fully and bearing down. Valsalva maneuver effectively increases intrathoracic pressure thus preventing entry of air in the incision site in the lungs. Source: Lippincott’s Nurse’s Quick Check: Skills. P. 115 59. Chest tube diameter is measured or expressed in : A. french B. gauge C. millilitres D. inches CORRECT ANSWER: A RATIONALE: French catheter scale (most commonly abbreviated with Fr., FR or F) is commonly used to measure the outer diameter of cylindrical medical instruments including catheters. Source: Wikipedia.com Option B – gauge are used to measure needle sizes 60. When transporting clients with chest tube, the system should be: A. disconnected B. closed C. placed lower than the patient's chest D. placed between the legs of the client to prevent breakage CORRECT ANSWER: C RATIONALE: to promote drainage Situation 14 - The perioperative nurse collaborates with the client, significant others, and healthcare providers 61. Patient outcome reflect the collaborative interdisciplinary effort and independent nursing activities. Who is the primary partner of the nurse in health care? A. The family B. The doctor C. The client Reproduction is strictly prohibited… RN International Review Center 11
D. The significant other CORRECT ANSWER: B RATIONALE: Test taking strategies: Option A, C & D all refer to our clientele 62. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT: A. biomedical division B. chaplaincy services C. infection control committee D. pathology department CORRECT ANSWER: B RATIONALE: Chaplaincy services provide objective crisis intervention and competent spiritual support. All other options are concerned with the control of OR environmental hazards. 63. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated limbs) disposal should be coordinated with the following agencies EXCEPT: A. Crematorium B. DOH C. MMDA D. DILG CORRECT ANSWER: A RATIONALE: Crematorium is not a government agency in the 1st place. The rest of the options render service that is concerned with solid waste disposal and management. 64. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs prior to surgery, is in severe pain 3 hrs 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. A Nurse supervisor B. Anesthesiologist C. Surgeon D. Intern on duty CORRECT ANSWER: C RATIONALE: It is the Surgeon who is responsible for giving medication orders for the patient so verifications should be addressed to the person in charge of the medication order. 65. Rosie, 57 who is a diabetic is for debridement of incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do? A. Double check the 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. CORRECT ANSWER: A RATIONALE: Verify to the person who made the order – the doctor. Situation 15 – Technology and patient’s education has dramatically improved the management of the diabetic client. 66. The current insulin pumps available in the market have the following capability. EXCEPT ; A. prevent unexpected saving in blood glucose measurements B. detect signs and symptoms of hypoglycemia and hyperglycemia C. deliver a pre-meal bolus dose of insulin before each meal D. deliver a continuous basal rate of insulin at 0.5 units to 2.0 units per hour CORRECT ANSWER: B RATIONALE: Insulin pumps commonly improve blood glucose control by means of continuous subcutaneous insulin infusion. However they do not have a built-in feedback mechanism for monitoring blood glucose levels. Therefore hypoglycemia and hyperglycemia are not detected. Option A – Option C & D– insulin is normally infused at a low basal rate (a rate that matches the client’s basal metabolic needs) with additional infusion of larger amounts (boluses) before meals. Source: MS Nursing by Black 7th Ed, Vol. 1, p. 1255 67. Discharge plan of diabetic clients include injection-site-rotation. You should emphasize that the space between sites should be : A. 6 cm B. 5 cm C. 2.5 cm Reproduction is strictly prohibited… RN International Review Center 12
D. 4 cm CORRECT ANSWER: C RATIONALE: Systemic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy). It is recommended to administer injection 0.5 – 1 inch (approximately 2.5 cm) away from the previous injection. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 1001 68. It is critical also that a diabetic client should be educated in the possible sites of regular insulin injection. The fastest absorption rate happens at the tissue areas of: A. gluteal area B. deltoid area C. anterior thigh D. abdominal area CORRECT ANSWER: D RATIONALE: The four main areas for injection are the abdomen, arms (posterior surface), thighs (anterior surface) and hips. Insulin is absorbed faster when injected in certain areas. The speed of absorption is greatest in the abdomen and decreases progressively in the arm, thigh and hips. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 1001
69. Sell-monitoring of blood glucose (SMBG) is recommended for patient's use. You will recommend this technology
in the following diabetic patients, EXCEPT : A. client with proliferative retinopathy B. unstable diabetes C. hypoglycemia without warning D. Abnormal renal glucose threshold CORRECT ANSWER: A RATIONALE: Proliferative retinopathy will eventually lead to blindness. A blind person needs assistance when monitoring blood glucose level that is why SMDG is not recommended for these individuals. Blood glucose monitoring is a useful procedure for all people with diabetes. It is a cornerstone of treatment for any intensive insulin therapy regimen and for managing diabetes in a pregnant woman. It is highly recommended for patients with: i. Unstable diabetes ii. A tendency for severe ketosis or hypoglycemia iii. Hypoglycemia without warning symptoms iv. Abnormal renal glucose threshold Source: MS Nursing by Brunner 9th ed., vol. 1, p. 986 70. It is necessary for a diabetic client to exercise regularly. What is the effect of regular exercise to a diabetic client? A. It burns excess glucose B. It improves insulin utilization and lowers blood glucose C. It lowers glucose, improves insulin utilization, decrease total triglyceride levels D. It will make you fit and energized CORRECT ANSWER: C RATIONALE: Exercise lowers blood glucose by increasing the uptake of glucose by the body muscles and by improving insulin utilization. Exercise also alters blood lipids, increasing high density lipoproteins and decreasing total clolesterol and triglyceride levels. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 984 Situation 16 - RN's should always be conscious that the contents in charting are admissible in court as evidence. 71. If there is any deviation from normal practice or procedure e.g. streptomycin was given by IV not IM, this should documented in the: A. progress notes B. incident report C. nurse's note D. patient's chart CORRECT ANSWER: B RATIONALE: An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Source: Funda by Kozier p. 63 72. Documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patient's chart? A. Presence of prosthetics, devices such as dentures, artificial limbs, hearing aid. etc. B. Baseline physical, emotional, and psychosocial data Reproduction is strictly prohibited… RN International Review Center 13
C. Arguments between nurses and residents regarding treatments D. Observed untoward signs and symptoms and interventions including concomitant intervening factors CORRECT ANSWER: C RATIONALE: Information related to patient care should be included in the patient’s chart. By virtue of professionalism, arguments between health care providers should not be reflected in the chart. 73. During your morning rounds. Mr. Tipol, 60 year old widower, tried to sit up and instead of holding to the side rail held the IV stand causing the IV bottle to fall and break. You wrote an incident report to show: A. document the incident B. be a part of the patient's chart C. present confidential report D. evidence of the quality of care CORRECT ANSWER: A RATIONALE: An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are use to make all the facts available to agency personnel, to contribute to statistical data about the accidents or incidents, and to help health personnel prevent future incidents or accidents. The purpose of this is to document the event. Source: Funda by Kozier p. 63 74. Erasures, alterations, and additions in medical records and the nurse's notes can be avoided. The following are some tips on how to do corrections EXCEPT: A. Cross out blank spaces B. Cross out wrong word or phrase with one or two lines making the crossed out word discernible C. Insert additions or corrections D. State the reason for any deviation from normal procedure/practice CORRECT ANSWER: D RATIONALE: Deviation from normal procedure/practice is a negligent act and should be recorded in the incident report. It is not about tips on doing charting corrections. All other options are correct 75. Kathy is one of your patient's: Her uncle, who is a doctor, wants to read her chart. Your appropriate action would be to: A. Instruct Kathy's uncle to present a written authorization signed by the patient B. Refer to the hospital director C. Instruct Kathy’s uncle to present a written request to the Medical Records Section of the hospital D. Refer to the attending physician CORRECT ANSWER: RATIONALE: Situation 17 - During the month of July, you noticed that there is an incidence of upper respiratory disorders. 76. One of your cases is with acute pharyngitis. Your nursing management includes the following EXCEPT? A. Suggest a soft or liquid diet during acute stage B. Encourage liberal amount of color fruit juices C. Encourage bed rest during febrile stage D. Apply ice collar for symptomatic relief of severe sore throat CORRECT ANSWER: B RATIONALE: Option A – a liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree if discomfort with swallowing. Option C – nurse instructs the patient to stay in bed during the febrile stage of illness Option D – Severe sore throat can be relieved using ice collars. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 407 77. For a nurse to assess an upper respiratory tract infection, you should palpate the following: A. The ears. eyes, nose, and throat B. Adenoids, tonsils and nose C. Nose and throat only D. The tracheal and nasal mucosa including the frontal sinuses CORRECT ANSWER: D RATIONALE: When assessing patient with upper respiratory tract infection, the nurse palpates the frontal and maxillary sinuses for tenderness. Also the nurse palpates the trachea to determine its midline position in the neck and to identify any masses or deformities. The neck lymph nodes are palpated to detect enlargement and tenderness. Option B – adenoids are palpated but tonsils and throat are assessed through inspection Reproduction is strictly prohibited… RN International Review Center 14
Option C – nose is assessed through inspection and palpation while throat is assesses through inspection Source: MS Nursing by Brunner 9th ed., vol. 1, p. 409 78. Among patients with upper airway infection, airway clearance can be facilitated by the following, EXCEPT: A. regularly administering prescribed vasoconstrictive medications B. decreasing systemic hydration C. positional drainage D. humidifying inspired room air CORRECT ANSWER: B RATIONALE: Option B – decreasing systemic hydration will not facilitate airway clearance but rather increasing fluid intake helps thin mucus Option A – Vasoconstrictive medications like decongestants work by reducing swelling of the mucous membranes in the nasal passages thus relieving nasal congestion Option C – Allow drainage of nasal secretions by gravity Option D – Humidifying the environment with room vaporizers or inhaling steam also loosens secretions and reduces inflammation of the mucous membrane. 79. A friend asked you some nursing measures of uncomplicated common colds. You will include the following measures. EXCEPT: A. instruct client about symptoms of secondary infections B. administer prescribed antibiotics C. teach that the causative virus is contagious even before symptoms appear D. suggest adequate of fluids and rest CORRECT ANSWER: B RATIONALE: This is not nursing measure. It is a dependent nursing action. All other options are nursing interventions. 80. The following are your nursing suggestions for a patient with acute or chronic sinusitis EXCEPT: A. Local heat application to promote drainage B. Consult an ENT surgeon C. Increase humidity D. Advice adequate fluid intake CORRECT ANSWER: B RATIONALE: The nurse should teach the patient to promote sinus drainage by increasing the environment humidity (steam bath, how shower, facial sauna), increasing fluid intake, and applying a local heat (hot wet packs). The nurse also instructs the patient about ways to prevent a sinus infection and how to recognize early signs and symptoms. Source: MS Nursing by Brunner 9th ed., vol. 1, p. 405 Situation 18 -A specimen is a piece of tissue or body fluid taken from the disease body organ or tissue to aid the health care team in diagnosis and effective treatment. Necessarily, the nurse assumes responsibility in the care of the specimen. 81. Carmen is suspected to have left breast CA. She is scheduled in your room for frozen section. How will you prepare the specimen for laboratory? A. Refrigerate and send it along with the day's specimens B. Send to pathology immediately without soaking solution C. Soak it in NSS D. Soak it in formalin CORRECT ANSWER: B RATIONALE: The frozen section procedure is a pathological laboratory procedure to perform rapid microscopic analysis of a specimen. It is used most often in oncological surgery. The technical name for this procedure is cryosection. The report given by the pathologist is usually limited to a "benign" or "malignant" diagnosis, traditionally shouted into an intercom Special Instructions: Notify Pathology 48 hours in advance. Request must state operative diagnosis and source of specimen. Specimen: Fresh tissue Container: Sterile towel, sterile Petri dish, or sterile jar (no added fixative or fluid) Collection: Container must be labeled with patient's full name, date, operating room, and surgeon requesting the frozen section. Causes for Rejection: Reproduction is strictly prohibited… RN International Review Center 15
Specimen submitted in fixative, water, or saline; improper labeling; incomplete or improperly filled out request form Sources: http://en.wikipedia.org/wiki/Frozen_section http://www.labcorp.com/datasets/labcorp/html/chapter/mono/ap002500.htm 82. How will you label this specimen? What information is essential in the label? A. Name of client, age, sex. hospital number B. Name of client, age, sex C. Name, age, site, type of specimen, hospital number, doctor D. Name, doctor, type of specimen, hospital number CORRECT ANSWER: C RATIONALE: Option C is the most complete information about specimen collection 83. Foreign body extracted from the body like pins, needles, seeds or bullets are also considered as specimen. You assisted in the multiple gun-shot wound exploration. During the surgery 3 bullets were recovered. You should send the specimen to: A. the department of pathology B. the National Bureau of Investigation C. the OR head nurse D. client's family CORRECT ANSWER: B RATIONALE: 84. A post dilation and curettage (D and C) client is for discharge. Follow-up of lab result should be part of the discharge plan. You will instruct the client to follow up result at the: A. Medical record B. Laboratory C. Doctor's clinic D. Nurse's station CORRECT ANSWER: B RATIONALE: 85. You are the circulating nurse in OR 2. You have 4 thyroidectomy cases for the day. How do you prevent switching of specimens? A. Send specimens to laboratory right away after the operation with the proper labels B. Collect all specimens and send to laboratory at the end of the day C. Label specimen at once D. Prepare 4 specimen vials first thing in the morning CORRECT ANSWER: A RATIONALE: Specimens must be handled quickly so that they are placed into the collection transport media as soon as possible after extraction. since this is the right thing to do, option B will then be wrong. Option C – Labelling of specimen is right but it should be sent right away to the laboratory after the surgical procedure Option D – Specimen vials are prepared during the surgical procedure. The sterile field should be prepared as close as possible to the time of use. The sterility of supplies used during a surgical procedure can be affected by the events taking place within the operating room, and the length of time the items have been exposed to the environment. Source: http://www.precisiontherapeutics.com/healthcare/idealSpecimenCollection.htm Situation 19 – Nurse Paul is providing care for clients with rheumatoid arthritis admitted in the unit. 86. A health history and physical assessment on a client with rheumatoid arthritis (RA) may reveal which of the following assessment data? A. Heberden's nodes B. Morning stiffness no longer than 30 minutes C. Asymmetric joint swelling D. Swan neck deformities CORRECT ANSWER: D RATIONALE: Swan neck deformities of the hand are classic deformities associated with rheumatoid arthritis secondary to the presence of fibrous connective tissue within the joint space. Clients with RA do experience morning stiffness, but it can last from 30 minutes up to several hours. RA is characterized by symmetrical joint involvement, and Heberden's nodes are characteristic of osteoarthritis.
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87. Which of the following is a priority when providing health teaching to a client with rheumatoid arthritis (RA)? Instruct the client: A. On weight reduction. B. To decrease activity to avoid joint pain. C. To pace activities to decrease joint stress. D. To contact the Arthritis Foundation for support services. CORRECT ANSWER: C RATIONALE: Although options 1, 2, and 4 are all important interventions in the health teaching of clients with rheumatoid arthritis, instructing the client on energy conservation techniques and pacing activities early in the teaching plan will help to provide immediate symptom control. Decreasing activity (option 2) may further limit range-of-motion. Notice the stem asks for the priority intervention. Situation 20 - During the surgical procedure, contamination should be confined and contained within the immediate vicinity of the surgical field to prevent the spread of pathogenic microorganisms. 88. The following technique illustrates the concept "confine and contain", EXCEPT: A. contaminated items like sponges are handled using gloves B. all blood, tissue, and body fluid specimens should be placed in leak-proof C. surgeons conduct their patient's rounds in scrub suit D. prompt cleanup of accidental spills of contaminated debris e.g. Blood, body fluids CORRECT ANSWER: C RATIONALE: OR attire should be worn within the OR room. If a doctor goes on rounds, he/she should change his/her attire to reduce spread of microorganisms. All other options are correct. 89. The OR is a 'restricted area' where OR attire is worn. Temperature and humidity are set for patient and personnel safety and reduce bacterial contamination. During surgery, movement of personnel including the circulating nurse is : A. kept to a minimum B. eliminated when possible C. restricted D. monitored CORRECT ANSWER: A RATIONALE: Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons. Source: OR Technique Instructional Manual by Barela et al, p. 8 90. Sterility is the condition of almost all items, devices or supplies used in the OR are ready for any surgical procedure. Shelf-life of packaged sterile item is event related and depends on the following. EXCEPT: A. type of sterilizer used to "sterilize” items B. amount of handling C. the quality of packaging material used D. storage conditions CORRECT ANSWER: A RATIONALE: Shelf life refers to the period of time a sterilized or disinfected item is safe to use. How long an item remains suitable for use is more event-related than time-related. Actual sterility of a packaged item may be indefinite depending on the package materials (Option C), the item itself and the handling (Option B) and storage (Option D). Source: http://www.unimaxsupply.com/sitepgs/1shelflife.htm 91. Precaution recommends that the use of standard personal protective equipment (PPE) to prevent cross contamination. Which is NOT considered a piece of PPE? A. Cover gown B. Eyewear C. Gloves D. Sterile gauze CORRECT ANSWER: D RATIONALE: Personal Protective equipment: All health care providers must apply clean or sterile gloves, gowns masks and protective eyewear according to risk of exposure to potentially infective materials. Sterile gauze is not part of PPE Source: Funda by Kozier p. 650 92. Traffic patterns in the OR suite should: A. prevent unauthorized personnel from entering the OR B. prevent transmission of pathogenic microorganisms C. assure that personnel walk in the same direction D. allow personnel to move freely between restricted and unrestricted areas Reproduction is strictly prohibited… RN International Review Center 17
CORRECT ANSWER: B RATIONALE: Traffic Patterns Movement in and around the surgical suite should be limited to that which is absolutely necessary only. Air turbulence is created with movement that in turn increases the likelihood of bacterial fallout from the skin and lint from draping materials to contaminate the sterile field and wound. When it is necessary to move around a functioning operating room, you should face the sterile field at all times. This may require some unusual pathways. However, one should never take a pathway between two sterile fields. Sterile fields consist of any two objects that have draped with sterile materials and have sterile supplies and or instruments/ equipment on them. Some possibilities are personnel, patients, furniture, equipment, or instrument tables. It is the responsibility of the entire surgical team to monitor and protect the sterile field and the integrity of the room. Entry into and exit from a surgical room should be done only when absolutely necessary. Source: http://www.geocities.com/alamedacounty/repspolicy.html Option D - Movement in and around the surgical suite should be limited to that which is absolutely necessary only. Option A & C – are correct options but generally these are performed to reduce if not prevent transmission of microorganisms. (Umbrella effect) Situation 21 - Nokia is so powerful to "connect people" from continent to continent, all through communication via the cellphone. Other ways of communication to relay information or instructions exist even in the healthcare setting. 93. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb. 30 year old athlete. She requests the circulating nurse to prepare a pink spinal set with another blue set as stand by. What gauge spinal sets will you make available in the OR suite? A. Gauge 16 and 22 B. Gauge 18 and 23 C. Gauge 16 and 20 D. Gauge 25 and 22 CORRECT ANSWER: B RATIONALE: Option A – White & Black Option B – Pink & Blue Option C – White & Yellow Option D – Orange & Black Spinal Needle Hub Color Codes: 16G - White 17G - Violet 18G - Pink 19G - Cream 20G - Yellow 21G - Green 22G – Black 23G - Blue 24G - Purple 25G - Orange 26G - Brown 27G - Gray 29G - Red Source: http://www.mycomedical.com/spinepid.html 94. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains 'laughing gas'? A. Yellow B. Green C. Black D. Blue CORRECT ANSWER: D RATIONALE: Laughing gas medically known to be as nitrous oxide is a blue colored tank. Option B – Green tank – oxygen tank 95. On a traffic light, yellow means "proceed with caution". In the field of healthcare, where do you discard your used tissue papers? A. Yellow bin infectious B. Orange bin radioactive waste C. Green bin biodegradable D. Black bin chemical waste Reproduction is strictly prohibited… RN International Review Center 18
CORRECT ANSWER: A RATIONALE: Used tissue papers may contain secretions thus classified as infectious Trash bin color codes: Black non-biodegradable Green biodegradable Yellow infectious Orange radioactive waste Red sharps Yellow with black band chemical waste 96. An instrument tray with black striped autoclave/steam chemical indicator tape communicates that the instrument tray: A. Is clean B. is ready for use in surgery C. Is sterile D. Has undergone the sterilization process CORRECT ANSWER: D RATIONALE: Option A – autoclaving completely destroys microorganisms therefore not considered clean. Option B – not all the time true (ex. Presence of black strips on the tape but was autoclaved months ago will reduce the sterility of the item therefore not ready fro use in surgery) Option C – not true all the time (ex. Presence of black strips on the tape but presence of a puncture on the package is noted therefore it can’t be considered sterile anymore) Option D - Regardless if it has a puncture or stored for a long months already, you are certain that it has undergone sterilization process as evidenced by black strips in the autoclave indicator tape. It is safe to say that it has undergone sterilization process than by saying it is sterile or is ready for surgery. 97. In health care, when lead apron is required in any procedure like orthosurgery, there is danger of exposure to: A. Water and blood splashes B. pseudomona C. radiation D. bone fragments CORRECT ANSWER: C RATIONALE: wearing of lead shield reduces transmission of radiation Source: Saunders NCLEX-RN 3rd ed, p. 583 Situation 22 - Nurse Ervin is a newly registered nurse who works as a volunteer in the burn unit. 98. A client is admitted to the burn unit with 50 percent burns to the chest and arms. The skin is white, dry, and there is no pain. Nurse Ervin assesses the type of burn the client has as which of the following? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness CORRECT ANSWER: D RATIONALE: There is no sensation of pain to light touch in full thickness burns because the pain and touch receptors have been destroyed. There may not be pain with some partial thickness degree burns, but the appearance described is characteristic of full thickness. 99. A young boy is brought to the unit with a chemical burn to the face. Priority assessment would include which of the following? A. Skin integrity B. Blood pressure and pulse C. Patency of airway D. Amount of pain CORRECT ANSWER: C RATIONALE: A burn involving the face, neck, or chest may cause airway closure because of the edema that occurs within hours. Remember the ABCs: airway, breathing, and circulation. Airway always comes first, even before pain. The nurse will also assess skin integrity (option 1), blood pressure and pulse (option 2), and pain (option 4), but these are not the highest priority assessments. 100. A client who presents with a burn to the anterior chest and both arms anterior and posterior is said to have burned what percentage of the body using the Rule of Nines? A. 27 percent Reproduction is strictly prohibited… RN International Review Center 19
B. 45 percent C. 37 percent D. 36 percent CORRECT ANSWER: D RATIONALE: Remember that according to the Rule of Nines, the anterior chest is 18 percent and both arms are 9 percent each, totaling 36 percent.
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