Latest Model Examination Questions for LJM Examination

The new LJM examination structure is as follows: - Application [A]: 70% - Evalua
tion [E]: 20% - Synthesis [S]: 10%
Sample Synthesis [S] and Evaluation [E] Type Questions 1. You have provided your
pneumonia patient with health education to prepare him for managing and prevent
ing himself from getting infections. The patients statement that best indicates t
hat he needs further information in understanding your health education is [E] A
. B. C. D. I can resume a normal diet with emphasis on nutritious, healthy foods. I
can stop taking the prescribed antibiotics once the symptoms have completely re
solved. I should continue using the spirometer provided to keep my airways open an
d free of secretions. I am able to continue my daily activities, but I should avoi
d physical exertion and get adequate rest.
Answer: D Rationale: The patient should understand that it is necessary to compl
ete the antibiotics course to ensure the bacteria are fully eradicated and to pr
event them from mutating. Mutated bacteria will produce enzymes that inactivate
the antibiotics, change the antibiotics binding sites, or alter their own cell m
embranes to prevent antibiotics from binding to them when there is a re-infectio
n.
2.
Encik Hamid, a patient with a history of congestive heart failure, arrives at th
e emergency department complaining of dyspnoea. The first action that should be
performed by the nurse in charge is to [S] A. B. C. D. check for blood pressure
send the patient for a chest X-ray ask the patient to lie down on the exam table
draw blood for chemistry panel and arterial blood gases (ABGs)
Answer: A Rationale: Checking the patients blood pressure is the first action tha
t should be taken by the nurse to check for hypertension. If a CHF patient compl
ains of dyspnoea, this can be a sign that the patient is experiencing pulmonary
oedema which is indicated by hypertension. The patient should not be asked to li
e down as this will cause dyspnoea to become worse and reduce venous return. CXR
, ABG and other chemistry tests also need to be done but not as the first action
.
1
3.
Encik Murad has recently been prescribed nitroglycerine for treatment of angina.
He complains of frequent headaches. Which of the following statement by a nurse
to the patient is the correct response? [S] A. B. C. D. Stop taking the nitrogly
cerine and see if the headaches improve. Headaches are a frequent side effect of n
itroglycerine because it causes vasodilation. Go to the emergency department to be
checked because nitroglycerine can cause bleeding in the brain. The headaches are
unlikely to be related to the nitroglycerine, so you should see your doctor for
further investigation.
Answer: B Rationale: The therapeutic effects of nitroglycerine are to decrease m
yocardial oxygen consumption and demand through venous and arterial dilation, wh
ich in turn, reduce preload and afterload. However, the blood supply to the brai
n will be reduced and this may cause headaches.
4.
Puan Maimun, who has diabetes mellitus, is in the second post-operative day foll
owing cholecystectomy. She has complained of nausea and inability to eat solid f
oods. In your assessment, she looked confused and shaky. You conclude that she i
s having [E] A. B. C. D. hypoglycaemia hyperglycaemia anaesthesia reaction diabe
tic ketoacidosis
Answer: A Rationale: A patient who has diabetes mellitus and appears confused an
d shaky is likely to be experiencing hypoglycaemia. This happens when there is e
xcess insulin in the blood and the blood sugar level falls below normal values.
The fact that the patient is unable to eat solid foods following cholecystectomy
may have caused her blood sugar level to become excessively low.
5.
Azim, a 16-year-old boy, is suspected of acute glomerulonephritis. Which of the
following manifestations are consistent with the diagnosis? [S] I. II. III. IV.
A. B. C. D. Proteinuria Periorbital oedema Cola-coloured urine Urine output of 350
ml in 24 hours I, II and III I, II and IV I, III and IV II, III and IV
Answer: A Rationale:
2
Proteinuria is a common manifestation of acute glomerulonephritis due to the swe
lling of glomerular membranes which then become permeable to protein. Oedema, pa
rticularly periorbital oedema, is noted due to salt and water retention that inc
reases extracellular fluid volume. The cola-coloured urine is due to inflammatory
response and proliferation of endothelial cells of the glomerulus.
6.
Mr. Lingham is an acute renal failure patient. His arterial blood gases (ABGs) m
easurement was taken at admission. The expected results of his ABGs are [E] A. B
. C. D. pH 7.49, HCO3 24 mEq, PCO2 46 mmHg pH 7.49, HCO3 14 mEg, PCO2 30 mmHg pH
7.26, HCO3 24 mEg, PCO2 46 mmHg pH 7.26, HCO3 14 mEg, PCO2 30 mmHg
Answer: D Rationale: ABGs measurement of acute renal failure patients often show
s metabolic acidosis. The pH falls below 35 mmHg and bicarbonate is less than 22
mEq/L. Metabolic acidosis happens due to the kidneys inability to adequately eli
minate metabolic wastes and hydrogen ions. 7. You are caring for a post-hip repl
acement patient. Which of the following findings should be your biggest concern?
[S] A. B. C. D. Complaints of nausea 0 Temperature of 38.7 C Complaints of pain
during re-positioning Scant bloody discharge on the surgical dressing
Answer: B Rationale: A post-hip replacement patient with a temperature of 38.7 C
may indicate an infection of the surgical wound due to septic operation procedu
re or incompatibility of prosthesis.
0
8.
Encik Ali had a plaster of Paris (POP) cast applied for a fractured right radius
at 10 a.m. on rd th 3 Dec 2010. On 4 Dec 2010 at 10 a.m., he came back to the c
asualty due to a problem related to the POP cast. The nurse should consider that
Encik Ali is having impaired perfusion to his limb when he is having [E] A. B.
C. D. severe itching under the cast increased warmth in the fingers severe pain
in the right shoulder severe pain in the right lower arm
Answer: D Rationale: The severe pain experienced by the patient is due to impair
ed perfusion to the right lower arm as a result of a closed POP cast. This may a
lso cause neurovascular compromise, thus immediate removal of the cast is requir
ed.
3
9.
A child is admitted to the hospital with suspected rheumatic fever. Which of the
following manifestations confirm the diagnosis? [S] I. II. III. IV. A. B. C. D.
An unexplained fever History of sore throat for about two to three weeks Redden
ed rash visible over the trunk and extremities Petechiae on trunk, conjunctiva a
nd mucous membrane I, II and III I, II and IV I, III and IV II, III and IV
Answer: A Rationale: Rheumatic fever is caused by an untreated Group A or B Haem
olytic Streptococcus. The manifestations of rheumatic fever are characterized by
fever, history of sore throat for about 2 to 3 weeks due to streptococcal infec
tion, non-pruritic skin rash over the trunk and extremities as well as fever. Pe
techiae are a manifestation of acute endocarditis.
10.
An infant with congestive heart failure is receiving frusemide as diuretic thera
py at home. The nurse considers the dosage prescribed is inadequate when the ass
essment finding shows [E] A. B. C. D. bradycardia sudden weight gain slow, shall
ow breathing decreased blood pressure
Answer: B Rationale: Diuretics relieve symptoms related to fluid retention and c
ause rapid fluid loss if adequate doses are prescribed. The effects of a diureti
c can be measured by observing the reduction in body weight as compared to body
weight taken before the diuretic is administered. In this case, if the patients b
ody weight is suddenly increased, it may indicate an inadequate dose. . Slow, sh
allow breathing only happens when the patient is experiencing pulmonary oedema.
11.
A patient arrives at the emergency department complaining of mid-sternal chest p
ain. The appropriate action that should be taken by the nurse immediately after
the patient arrived is [S] A. B. C. D. an electrocardiogram chest exam with ausc
ultation careful assessment of vital signs complete history with emphasis on pre
ceding events
Answer: C Rationale: The immediate nursing action for a patient with mid-sternal
chest pain is to assess his/her of vital signs. The vital signs may indicate th
e extent of physical compromise and provides a baseline for further assessment a
nd treatment. An ECG will be done next after the vital signs
4
are taken. General health assessment including chest examination and complete hi
story can be done once the patient is stabilized. 12. A patient arrives and repo
rts of splashing concentrated household cleaner in her eye. The priority nursing
action by the emergency nurse should be [S] A. B. C. D. testing visual acuity i
nstilling fluorescein drops in the eye patching the affected eye with eye shield
irrigating the affected eye repeatedly with normal saline solution
Answer: D Rationale: Irrigation with normal saline to the affected eye to remove
the chemical is of higher priority than assessment of the eye. This should be c
ontinued for at least 10 minutes. Visual acuity will be assessed after irrigatio
n is done. Patching of the eye and fluorescein drops are not part of the initial
care of a chemical splash.
13.
An evening shift emergency nurse is presented with four patients at the same tim
e. Which of the following patients should be triaged as highest priority? [E] A.
B. C. D. A patient with abdominal and chest pain following a large, spicy meal
A patient with low-grade fever, headache, and myalgias for the past 72 hours A c
hild with a one-inch bleeding laceration on the chin but otherwise well after fa
lling while jumping on his bed A patient who is unable to bear weight on the lef
t foot, with swelling and bruising following a running accident
Answer: A Rationale: The patient with chest pain following a large, spicy meal n
eed to be triaged as highest priority because he may be having an acute myocardi
al infarction, although the symptom may indicate heartburn. 14. Your patient is
lethargic, nauseated and has a pulse of 52. You see that he is taking digoxin (L
anoxin) 0.25mg daily, and also has hydrochlorothiazide (HydroDiuril) 50mg twice
daily. Therefore, you should check his [E] A. B. C. D. sodium levels digoxin lev
els calcium levels potassium levels
Answer: D Rationale: The patient may be having hypokalaemia as a result of takin
g hydrochlorothiazide (the potassium-wasting diuretic). Hypokalaemia can precipi
tate digitalis toxicity even when the serum digitalis level is in the normal ran
ge.
5
15.
A child weighing 30 kg who is having diffuse itching after an insect bite is pre
scribed with an antihistamine, Diphenhydramine 25 mg 3 times a day. If the corre
ct paediatric dose for the drug is 5mg/kg/day, which of the following is true ab
out the prescribed drug dose? [E] A. B. C. D. The dose is too low The dose is to
o high It is the correct dose The dose should be increased or decreased, dependi
ng on the symptoms
Answer: A Rationale: This child weighs 30 kg, and the paediatric dose of Diphenh
ydramine is 5 mg/kg/day. Therefore, the correct dose is 150 mg/day (5 mg/kg/day
X 30 kg = 150 mg/day). Divided into 3 doses per day, the child should receive 50
mg 3 times a day rather than 25 mg 3 times a day which is lower than the recomm
ended dose.
16.
The team leader on the coronary care unit is planning assignments for her shift.
Which of the following is the most appropriate assignment for the float staff n
urse who specialized in maternity nursing? [S] A. B. C. D. A patient with unstab
le angina being closely monitored for pain and medication titration A post-opera
tive valve replacement patient who was recently admitted to the unit because all
surgical beds were filled A one-week post-operative coronary bypass patient, wh
o is being evaluated for placement of a pacemaker prior to discharge A suspected
myocardial infarction patient on telemetry, just admitted from the Emergency De
partment and scheduled for an angiogram
Answer: C Rationale: When planning the assignment, the team leader should consid
er the skills of the staff and the needs of the patients. The maternity-trained
staff nurse who is not experienced with cardiac patients should be assigned to t
hose with the least acute needs. Therefore, assigning the float staff to the one
-week post-operative patient who is nearing discharge and likely to require rout
ine care is appropriate.
17.
Which of the following is the most important nursing action of a nurse who cares
for a neutropenic patient in the oncology ward? [S] A. B. C. D. Minimize patien
t contact Change gloves immediately after use Minimize conversation with the pat
ient Change the disposable mask immediately after use
Answer: B Rationale: The neutropenic patient is at risk of infection due to impa
ired immunity and inflammatory response. Changing gloves immediately after use p
rotects the patient from opportunistic microorganisms that may infect the patien
t (by cross infection).
6
18.
Madam Kong is now in remission after undergoing surgery and chemotherapy for col
on cancer and completing therapy in the last 3 months. She complains of fatigue
following evening walks and difficulty with concentrating at work. Which of the
following problems is best to explain her symptoms? [E] A. B. C. D. She may be d
epressed She may be dehydrated She may be immune-suppressed She may be having an
aemia caused by chemotherapy
Answer: D Rationale: The chemotherapy drugs will affect the bone marrow tissues
and depress most blood cells including erythrocytes, causing severe anaemia. Fat
igue following activities and lack of concentration are some of the manifestatio
ns of anaemia.
19.
A severe anaemic patient is ordered to have packed cell infusion as a treatment.
Which of the following nursing intervention is the best action in handling pack
ed cell infusion? [S] A. B. C. D. Packed cells should be flushed with a 5% dextr
ose solution Packed cells are best infused slowly through a non-filter chamber I
V giving set Transfusion reaction is most likely to manifest immediately after t
he infusion is completed Close observation by a nurse on the patient should be e
nsured during the first 15 minutes of infusion
Answer: D Rationale: Blood transfusion reaction and febrile reaction (fever and
chills) typically begin during the first 15 minutes of the transfusion. Besides
that, hypersensitivity and haemolytic reaction may also occur. The nurse should
observe the patient closely for transfusion reaction by monitoring and recording
vital signs and comparing results with the baseline data.
20.
A patient who received 2 packs of blood for the last 4 hours is found sitting up
in bed and appears dyspnoeic and uncomfortable. By chest auscultation, crackles
are heard in the bases of both lungs. The most likely blood transfusion complic
ation experienced by this patient is [S] A. B. C. D. fluid overload acute haemol
ytic reaction allergic transfusion reaction febrile non-haemolytic reaction
17. Answer: A Fluid overload is another risk of blood infusion. Most patients ca
n tolerate an infusion of a unit of blood (ranging from 250 to 500ml) in 2 hours
. However, when a high volume of fluid is infused over a short period of time, i
t can affect the patients vascular system by causing the fluid to leak into the l
ungs. Dyspnoea, rapid respirations, lung sounds that sound like crackles and dis
comfort are symptoms of fluid overload.
7
21.
A dengue patient with a platelet count of 20,000/millilitre of blood and body te
mperature of 0 39 C is complaining of headaches. Which of the following is the m
ost important intervention by the nurse? [E] A. B. C. D. Limit visitors to famil
y only Impose immune precautions Give aspirin in case of headaches Observe for e
vidence of spontaneous bleeding
Answer: D Rationale: A platelet count of less than 100,000 per millilitre of blo
od can lead to abnormal bleeding. If the platelet count is less than 20,000 per
millilitre, it can lead to spontaneous bleeding and haemorrhage from minor traum
a. Therefore, the patient should be observed for petechiae, epitaxis, gum bleedi
ng, hematuria, and spontaneous bleeding from the GI tract and vagina.
22.
Encik Ahmad, a 70-year-old, asks a nurse to recommend strategies to prevent cons
tipation. Which of the following suggestions are appropriate for Encik Ahmad? [S
] I. II. III. IV. A. B. C. D. Take laxatives to ensure daily bowel movement Take
more high-fibre diet such as vegetables and fruits Do moderate exercises such a
s walking to the mosque Drink 2 to 3 litres of water each day if there is no con
traindication I, II and III I, II and IV I, III and IV II, III, and IV
Answer: D Rationale: High fibre foods are recommended because they are indigesti
ble and help increase stool bulk. Fibre also helps draw water into the faecal ma
ss, softening the stool and making defecation easier. The nurse should also enco
urage the patient to engage in some form of exercise such as walking to stimulat
e the bowel movement and promote faecal transit in the large intestine. Drinking
plenty of water helps to soften the stool and makes defecation easier.
23.
A schizophrenic patient is taking haloperidol for treatment since the last five
years. She complains of abnormal movements of her face and tongue. Which of the
following indicates that the patient is experiencing a side effect of haloperido
l? A. B. C. D. Tardive dyskinesia Co-morbid depression Psychotic hallucinations
Negative symptoms of schizophrenia
Answer: A
8
Rationale: Tardive dyskinesia is a side effect of long-term or high-dose use of
antipsychotic drugs such as haloperidol. Tardive dyskinesia is characterized by
repetitive, involuntary, purposeless movements, such as grimacing, tongue protru
sion, lip smacking, puckering and pursing of the lips, and rapid eye blinking. T
he abnormal facial movements and tongue protrusion experienced by this patient i
s most likely due to tardive dyskinesia.
24.
A nurse is counselling the mother of a newborn infant with hyperbilirubinaemia.
Which of the following instructions by the nurse is correct? [E] I. II. III. IV.
Breastfeed infant 8 to 12 times a day Keep the baby quiet and swaddled, and pla
ce the bassinet in a dimly lit area Watch for signs of dehydration, including de
creased urinary output and changes in skin turgor Follow up with the infant s ph
ysician within 72 hours of discharge for a re-check of the serum bilirubin and e
xam I, II and III I, II and IV I, III and IV II, III and IV
A. B. C. D.
Answer: C Rationale: Increasing the frequency of breastfeeding decreases the lik
elihood of subsequent significant hyperbilirubinemia. Poor caloric intake and/or
dehydration associated with inadequate breastfeeding may contribute to the deve
lopment of hyperbilirubinemia. All infants should be examined by a qualified hea
lth care professional in the first few days after discharge to assess infant wel
l-being and the presence or absence of jaundice.
25.
A bowel obstruction patient has a nasogatric tube connected to the low suction a
pparatus. The gastric content and juice was collected. Which of the following ar
terial blood gasses results indicate that he is having acid base imbalance relat
ed to his condition? [E] A. B. C. D. pH 7.52, HCO3 27mEq/L pH 7.42, HCO3 26mEq/L
pH 7.25, HCO3 25mEq/L pH 7.38, HCO3 23mEq/L
Answer: A Rationale: Metabolic alkalosis occurs when there is an excess of bicar
bonate in relation to the amount of hydrogen ion. The ABGs pH is above 7.45 and
the bicarbonate concentration is greater than 26 mEq/L. The common cause of meta
bolic alkalosis is acid loss during gastric suction.
26.
Madam Nana is scheduled for an elective surgery. Upon admission, the nurse is in
formed that she is currently on warfarin (Coumadin) at a high dose. If the nurse
is concerned about the possible effects of warfarin, particularly in a patient
scheduled for surgery, which of the following actions should the nurse take? [S]
9
A. B. C. D.
Inform doctor and administer vitamin K as prescribed Draw a blood sample for typ
e, cross-match and request blood from the blood bank Draw a blood sample for pro
thrombin (PT) and international normalized ratio (INR) level Cancel the surgery
after the patient reports stopping the Coumadin one week previously
Answer: A Rationale: Warfarin is an anticoagulant drug. The nurse needs to infor
m the doctor and administer vitamin K as prescribed as vitamin K is an antidote
to warfarin to prevent excessive bleeding or haemorrhage during and after surger
y.
27.
Mr Kamal is at 24 hours post-abdominal surgery. The nurse conducts a dressing as
sessment and found a moderate amount of serous drainage on the dressing. Which o
f the following is the appropriate decision taken by the nurse? [E] A. B. C. D.
Remove the dressing and leave the wound site open to air Notify the surgeon abou
t evidence of infection immediately Leave the dressing intact to avoid disturbin
g the wound site Change the dressing and document the clean appearance of the wo
und site
Answer: D Rationale: A moderate amount of bleeding from the wound 24 hours after
surgery is expected. The nurse can change the dressing to prevent infection by
pathogenic microorganisms since blood or even serum is a good medium for microor
ganism growth.
28.
Puan Nor, who has fibromyalgia syndrome, is experiencing stress in response to c
hronic pain and stiffness. Which of the following activities should be suggested
by the nurse as a mind-body therapy for Puan Nor?[S] A. B. C. D. Tai Chi Colour
therapy Aromatherapy Magnetic therapy
Answer: A Rationale: Tai Chi is an exercise which involves movement of the gener
al muscles and mind concentration to help divert the feeling of pain. Colour the
rapy and aromatherapy are suggested for the stimulation of senses. Magnetic ther
apy is a localized therapy.
29.
Mr Ramoo, a 60-year-old businessman, has been a heavy drinker for the past 30 ye
ars. He came to the clinic to seek treatment for acute gastritis. The nurse iden
tifies that the patient is in the contemplation stage of change when he says [E]
A. B. C. D. Alcohol has never bothered my stomach. I may just have the flu. Im olde
r and wiser now, and I know I can change my drinking habit. I think my drinking is
affecting my stomach, but maybe some drugs will help calm it down. My wife keeps
telling me that I am killing myself with alcohol, but I really feel pretty good
except for my stomach.
10
Answer: C Rationale: The patient is aware that his drinking behaviour is affecti
ng his condition. He is still motivated to change his behaviour and hopes there
is a medication to treat his drinking complication. This indicates that the pati
ent is considering the possibility of changing his habits and is open to receivi
ng information and suggestions to improve his health.
30.
A patient, who is a drug addict, was found unconscious by the roadside and broug
ht in to the emergency unit by a passerby. Upon examination, you found that he i
s unresponsive with pinpoint pupils. Based on your assessment, you anticipate th
e treatment by preparing him for [S] A. B. C. D. caffeine naloxone diazepam meth
adone
Answer: B Rationale: Unconsciousness and pinpoint pupils indicate that the patie
nt was under opium effect. Naloxone is an antidote for opium.
31.
A nurse has established the nursing diagnosis for a patient who has undergone a
bowel surgery due to bacterial peritonitis as hyperthermia related to infection
with a body 0 temperature of 38.5 C and diaphoresis. The intervention by the nur
se should include [S] A. B. C. D. reducing the patients caloric intake to slow th
e bodys metabolic rate changing linens frequently to prevent rapid heat loss and
subsequent chilling administering anti-pyretic drugs immediately to prevent feve
r-induced cell damage covering the patient with additional blankets to promote h
eat loss through sweating
Answer: B Rationale: The wet linens due to diaphoresis need to be changed to ens
ure the patients comfort and prevent rapid heat loss through evaporation. The pat
ients caloric intake is under control since the patient is required to fast until
bowel sounds are heard. The patient should not be covered by blankets as this w
ill increase the body temperature. Anti-pyretics should not be administered sinc
e nurses are not allowed to prescribe medications.
32.
A paraplegic patient is admitted for intensive management of an open, infected p
ressure ulcer on the left buttock at the prominence of the ischial tuberosity. T
he initial assessment of the patients pressure ulcer indicates that it is 5cm lon
g, 25cm wide and involves subcutaneous tissue. The nurse classifies the pressure
ulcer as [E] A. B. C. D. Stage I Stage II Stage III Stage IV
Answer: C
11
Rationale: Pressure ulcer staging is done by assessing the anatomic depth of sof
t tissue damage. Intact skin with redness over a bony prominence is considered a
s Stage I pressure ulcer. Stage II pressure ulcer is recognized by shiny or dry,
shallow open ulcer without slough or bruising while Stage III pressure ulcer is
when the full thickness of tissue is lost revealing subcutaneous fat. Stage IV
ulcer is when the full thickness of tissue is lost to reveal muscle, tendon or b
one. Since the pressure ulcer of the paraplegic patient involves subcutaneous ti
ssue, it can be classified as in Stage III.
33.
Mr Heng is admitted for renal failure. His ABG results are: pH 7.32, PO2 88mmHg,
PCO2 34 mmHg and HCO3 16mEq/L. His ECG pattern is as shown below.
The nurse interprets these results as [E] A. B. C. D. Metabolic alkalosis with h
ypokalaemia Metabolic acidosis with hyperkalaemia Respiratory alkolosis with hyp
okalaemia Respiratory acidosis with hyperkalaemia
Answer: B Rationale: The pH is < 35mmHg, HCO3 < 22mEq/L and PCO2 < 35mmHg, which
indicate metabolic acidosis. The ECG indicates he is having hyperkalaemia when
the ECG shows prolonged QRS and tall T wave
34.
A preoperative patients CBC results include: RBC 4.6x10 /l; WBC, 10.2 x 10 /l; Hb 3
15g/dl; Hct 45%; platelet 150x10 /l. Based on these results, the nurse concludes
that the patient [E] A. B. C. D. is at risk for intraoperative bleeding needs p
acked red blood cells intraoperative infusion has impaired oxygen-carrying capac
ity of the blood has no obvious risk for intraoperative or post-operative bleedi
ng
6
3
Answer: D Rationale: The CBC results indicate normal values.
12
35.
Puan Minah is placed in PACU to recover from anaesthesia. For the past hour, her
vital signs show the following: blood pressure 110/80114/82 mmHg, pulse rate 7680
bpm, respiration rate 226, her SpO2 is 90%. She is sleepy but awakens easily and
is oriented when spoken to. Her surgical dressing is dry and intact. The most a
ppropriate action by the nurse is to [S] A. B. C. D. position the patient in a l
ateral position encourage the patient to take deep breaths check the patients tem
perature and apply warm blankets notify the anaesthesia care provider that the p
atient is ready for discharge from the PACU
Answer: D Rationale: Puan Minahs vital signs and consciousness level indicate she
is recovering from anaesthesia. She is able to protect her airway and ready to
be transferred to general surgical ward.
36.
Miss Ina, a 24-year-old, spilled hot oil from a deep fryer on her anterior and p
osterior right lower leg and foot. Her leg and foot are red and swollen, covered
with large blisters and she states that they are very painful. The nurse should
classify the burn as [E] A. B. C. D. major; full-thickness skin destruction maj
or; deep partial-thickness skin destruction minor; superficial partial-thickness
skin destruction moderate uncomplicated; deep partial-thickness skin destructio
n
Answer: B Rationale: Hot liquid will cause a deep partial-thickness burn. The de
rmis changes to red and becomes swollen and large blisters that form may easily
rupture.
37.
Referring to the scenario in Question 36, if the nurse follows the rule of nine to
estimate the total body surface area (TBSA) percentage of Miss Inas burn, what i
s the percentage of the area involved? [E] A. B. C. D. 4% 9% 18% 36%
Answer: B Rationale: According to the rule of nine, Miss Inas burn on the right ant
erior and posterior lower limb contributes to 9% TBSA.
38.
While administering IV nitroglycerine to a patient with myocardial infarction, t
he patient asks the nurse about the medication. The nurse decides to explain the
expected outcome of the drug. Which of the following statement is correct? [S]
A. It will relieve the chest pain.
13
B. It will increase your cardiac output. C. It will control your cardiac arrhythmia
s. D. It will decrease myocardium contractility. Answer: A Rationale: The best stat
ement is A since the other statements require further explanation by the nurse.
39.
After evaluating the CK-MB level (6%) of a patient with chest pain who was admit
ted 12 hours ago by comparing it with the normal value (03%), the nurse found the
CK-MB level is markedly elevated. The nurse immediately informs the cardiologis
t because she predicts this is as evidence of [S] A. B. C. D. lactic acidosis a
need for thrombolytic therapy deterioration of cardiac function cellular necrosi
s of myocardial tissue
Answer: D Rationale: Elevated CK-MB greater than 5% is considered the most sensi
tive indicator of myocardial infarction, the necrosis of myocardial tissues. The
treatment will be decided after the patient is reviewed by the cardiologist.
40.
Total parenteral nutrition (TPN) is initiated for a patient who has multiple fra
ctures with burns after a motor vehicle accident. The capillary blood sugar leve
l is 8.9 mmol/L after 6 hours of administration. The most appropriate action by
the nurse is to [S] A. B. C. D. notify the doctor the capillary blood glucose le
vel re-check the capillary blood glucose in 4 hours time check the catheter inse
rtion site for signs of inflammation slow the rate of the TPN solution to preven
t hyperglycaemia
Answer: B Rationale: Capillary blood sugar level of 8.9 mmol/L is not only due t
o TPN but it also maybe due to the stress experienced by the patient. Therefore,
it is not necessary to inform the doctor immediately. The inflammation of the i
nsertion site does not cause the increase in blood glucose level. Slowing the ra
te of TPN will cause inadequate calorie and volume intake.
14
Summary of Question Type:
No.
Level
No.
Level
No.
Level
No.
Level
1
Evaluation
11
Synthesis
21
Evaluation
31
Synthesis
2
Synthesis
12
Synthesis
22
Synthesis
32
Evaluation
3
Synthesis
13
Evaluation
23
Evaluation
33
Evaluation
4
Evaluation
14
Evaluation
24
Evaluation
34
Evaluation
5
Synthesis
15
Evaluation
25
Evaluation
35
Synthesis
6
Evaluation
16
Synthesis
26
Synthesis
36
Evaluation
7
Synthesis
17
Synthesis
27
Evaluation
37
Evaluation
8
Evaluation
18
Evaluation
28
Synthesis
38
Synthesis
9
Synthesis
19
Synthesis
29
Evaluation
39
Synthesis
10
Evaluation
10
Synthesis
30
Synthesis
40
Synthesis
15