Nursing Practice III b.
Output
Situation: Leo lives in the squatter area. He goes to nearby
school. He helps his mother gather molasses after school.
One day, he was absent because of fever, malaise, anorexia,
and abdominal discomfort.
1. Upon assessment, Leo was diagnosed to have
hepatitis a. Which mode of transmission has the
infection agent taken?
a. Fecal-oral
b. Droplet
c. Airborne
d. Sexual contact
2. Which of the following is concurrent disinfection in
the case of Leo?
a. Investigation of contact
b. Sanitary disposal of feces, urine and blood
c. Quarantine of the sick individual
d. Removing all detachable objects in the room,
cleaning lighting and air duct surfaces in the
ceiling, and cleaning everything downward
to the floor.
3. Which of the following must be emphasized during
mother’s class to Leo’s mother?
a. Administration of immunoglobulin to
families
b. Thorough hand washing before and after
Situation: Mrs. Pichay is admitted to your ward. The MD
eating and toileting
ordered “prepare for thoracentesis this pm to remove excess
c. Use of attenuated vaccines
air from the pleural cavity.
d. Boiling of food especially meat
4. Disaster control should be undertaken when there
are 3 or more hepatitis A cases. Which of these
measures is a priority?
a. Eliminate fecal contamination from foods
b. Mass vaccination of uninfected individuals
c. Health promotion and education to families
and communities about the disease it’s
cause and transmission
d. Mass administration of immunoglobulin
5. What is the average incubation period of Hepatitis
A?
a. 30 days
b. 60 days
c. 50 days
d. 14 days
Situation: as a nurse researcher you must have a very good
understanding of the common terms of concept used in
research.
6. The information that an investigator collects from
the subjects or participants in a research study is
usually called;
a. Hypothesis
b. Variable
c. Data
d. Concept
7. Which of the following usually refers to the
independent variables in doing research?
a. Result
c. Cause
d. Effect
8. The recipients of experimental treatment are an
experimental design or the individuals to be
observed in a non-experimental design are called;
a. Setting
b. Treatment
c. Subjects
d. Sample
9. The device or techniques an investigator employs to
collect data is called;
a. Sample
b. Hypothesis
c. Instrument
d. Concept
10. The use of another person’s ideas or wrong doings
without giving appropriate credit result from
inaccurate or incomplete attribution of materials to
its sources. Which of the following is referred to
when another person’s idea is inappropriate credited
as one’s own;
a. Plagiarism
b. Assumption
c. Quotation
d. Paraphrase
11. Which of the following nursing responsibilities is
essential in Mrs. Pichay who will undergo
thoracentesis?
a. Support and reassure client during the
procedure
b. Ensure that informed consent has been
signed
c. Determine if client has allergic reaction to
local anesthesia
d. Ascertain if chest x-rays and other tests
have been prescribed and completed
12. Mrs. Pichay who is for thoracentesis is assigned by
the nurse to which of the following position?
a. Trendelenburg position
b. Supine position
c. Dorsal recumbent position
d. Orthopneic position
13. During thoracentesis, which of the following nursing
intervention will be most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advise patient to sit perfectly still during
needle insertion until it has been
withdrawn from the chest
d. Apply pressure over the puncture site as
soon as the needle is withdrawn
14. To prevent leakage of fluid in the thoracic cavity,
how will you position the client after thoracentesis?
a. Place flat in the bed
 b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
15. Chest X-ray was ordered after thoracentesis. When
your client asks what is the reason for another chest
x-ray, you will explain:
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body
Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was
brought to the hospital for diagnostic workup after he had
experienced seizure in his office.
16. Just as the nurse was entering the room, the patient
who was sitting on his chair begins to have a seizure.
Which of the following must the nurse do first?
a. Ease the patient to the floor to rule out
pneumothorax
b. Lift the patient and put him on the bed
c. Insert a padded tongue depressor between
his jaws
d. Restraint patient’s body movement
17. Mr. Santos is scheduled for CT SCAN for the next day,
noon time. Which of the following is the correct
preparation as instructed by the nurse?
a. Shampoo hair thoroughly to remove oil and
dirt
b. No special preparation is needed. Instruct
Situation: You are assigned at the surgical ward and Clients
the patient to keep his head still and stead
have been complaining of post pain at varying Degrees. Pain
c. Give a cleansing enema and give fluids until 8
as you know, is very subjective.
AM
d. Shave scalp and securely attach electrodes to
it
18. Mr. Santos is placed on seizure precaution. Which of
the following would be contraindicated?
a. Obtain his oral temperature
b. Encourage to perform his own personal
hygiene
c. Allow him to wear his own clothing
d. Encourage him to be out of bed
19. Usually, how does the patient behave after his
seizure has subsided?
a. Most comfortable walking and moving
about.
b. Becomes restless and agitated
c. Sleeps for a period of time
d. Say he is thirsty and hungry
20. Before, during and after seizure. The nurse knows
that the patient is ALWAYS placed in what position?
a. Low fowler’s
b. Side lying
c. Modified Trendelenburg
d. Supine
Situation: Mrs. Damian an immediate post op
cholecystectomy and choledocholithotomy patient,
complained of severe pain at the wound site.
21. Choledocholithotomy is:
a. The removal of the gallbladder
b. The removal of the stones in the gallbladder
c. The removal of the stones in the common
bile duct
d. The removal of the stones in the kidney
22. The simplest pain-relieving technique is:
a. Distraction
b. Deep breathing exercise
c. Taking aspirin
d. Positioning
23. Which of the following statement on pain is TRUE?
a. Culture and pain are not associated
b. Pain accompanies acute illness
c. Patient’s reaction to pain Varies
d. Pain produces the same reaction such as
groaning and moaning
24. In pain assessment, which of the following condition
is a more reliable indicator?
a. Pain rating scale of 1 to 10
b. Facial expression and gestures
c. Physiological responses
d. Patient’s description of the pain sensation
25. When a client complains pain, your initial response
is:
a. Record the description of pain
b. Verbally acknowledge the pain
c. Refer the complaint to the doctor
d. Change to a more comfortable position
26. A one-day postoperative abdominal surgery client
has been complaining of severe throbbing abdominal
pain described as 9 in a 1-10 pain rating. Your
assessment reveals bowel sounds on all quadrants
and the dressing is dry and intact. What nursing
intervention would you take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
27. Pentoxidone 5 mg IV every 8 hours was Prescribed
for post abdominal pain. Which will be your priority
nursing action?
a. Check abdominal dressing for possible
swelling
b. Explain the proper use of PCA to alleviate
anxiety
c. Avoid overdosing to prevent
dependence/tolerance
d. Monitor VS, more importantly RR
28. The client complained of abdominal distention and
pain. Your nursing intervention that can alleviate
pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and avoid
deep breathing and talking
c. Offer hot and clear soup
 d. Turn to sides frequently and avoid too much
talking
29. Surgical pain might be minimized by which nursing
action in the O.R.
a. Skill of surgical team and lesser manipulation
b. Appropriate preparation for the scheduled
procedure
c. Use of modern technology in closing the
Situation: The nurse is performing health education activities
wound
for Janevi Segovia, a 30-year-old Dentist with insulin
d. Proper positioning and draping of clients
dependent Diabetes Miletus.
30. Inadequate anesthesia is said to be one of the
common causes of pain both in intra and post op
patients. If general anesthesia is desired, it will
involve loss of consciousness. Which of the following
are the 2 general types of GA?
a. Epidural and Spinal
b. Subarachnoid block and intravenous
c. Inhalation and regional
d. Intravenous and inhalation
Situation: Nurse’s attitude toward the pain influence the way
they perceive and interact with clients in pain.
31. 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 patient seldom tends to report pain
than the younger once
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 label
ed a ‘bad’ patient
32. Nurse should understand that when a client
responds favorable to a place, it is known as the
‘placebo effect’. Placebos do not indicate Whether or
not a client has:
a. Conscience
b. Disease
c. Real pain
d. Drug tolerance
33. You are the nurse in the pain clinic where you have
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. As the client to point to the painful are by
just one finger
34. What symptom, more distressing than pain, should
the nurse monitor when giving opioids, especially
among elderly clients who are in pain?
a. Forgetfulness
b. Drowsiness
c. Constipation
d. Allergic reactions like pruritis
35. 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
36. Janevi is preparing a mixed dose of insulin. The nurse
is satisfied with her performance when she:
a. Draw insulin from the vial of clear insulin
first
b. Draw insulin from the vial of the
intermediate acting insulin first
c. Fill both syringe with the prescribed insulin
dosage then shake the bottle vigorously
d. Withdraw the intermediate acting insulin
first before withdrawing the short Acting
insulin first
37. Janevi complains of nausea, vomiting, diaphoresis
and headache. Which of the following nursing
intervention are you going to carry out first?
a. Withhold the client’s next insulin injection
b. Test the client’s blood glucose level
c. Administer Tylenol as ordered
d. Offer fruit juice, gelatin and chicken bouillon
38. Janevi administered regular insulin at 7 am and the
nurse should instruct Jane to avoid exercising at
around:
a. 9 to 11 A.M
b. Between 8 A.M to 9 A.M
c. After 8 hours
d. In the afternoon, after taking lunch
39. Janevi was brought at the emergency room after
four months because she fainted in her clinic. The
nurse should monitor which of the following test to
evaluate the overall therapeutic compliance of a
diabetic patient?
a. Glycosylated hemoglobin
b. Ketone levels
c. Fasting blood glucose
d. Urine glucose level
40. Upon the assessment of Hba1c of Mrs. Segovia, the
nurse has been informed of a 9% Hba1c result. In this
case, she will teach the patient to:
a. Avoid infection
b. Prevent and recognize hyperglycemia
c. Take adequate food and nutrition
d. Prevent and recognize hypoglycemia
41. The nurse is teaching plan of care for Jane with
regards to proper foot care. Which of the following
should be included in the plan?
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet but
not between the toes
 d. Always have a podiatrist to cut your toe
nails; never cut them yourself
42. Another patient was brought to the emergency room
in an unresponsive state and a diagnosis of
hyperglycemia hyperosmolar nonketotic syndrome is
made. The nurse immediately prepares to initiate
which of the following anticipated physician’s order?
a. Endotracheal intubation
b. 100 unites of NPH insulin
c. Intravenous infusion of normal saline
d. Intravenous infusion of sodium bicarbonate
43. Jane eventually developed DKA and is being treated
in the emergency room. Which finding would the
nurse expect to note as confirming this diagnosis?
a. Comatose state
b. Decreased urine output
c. Increased respiration and an increase in pH
d. Elevated blood glucose level and low
plasma bicarbonate level
44. The nurse teaches Jane to know the difference
between hypoglycemia and ketoacidosis. Jane
demonstrates understanding of the teaching by
stating the glucose will be taken if which of the
Situation: In the OR, there are safety protocols that should
following symptoms develops?
be followed. The OR nurse should be well versed with all
a. Polyuria
these to safeguard the safety and quality of patient delivery
b. Shakiness
outcome.
c. Blurred Vision
d. Fruity breath odor
45. Jane has been scheduled to have FBS taken in the
morning. The nurse tells Jane not to eat or drink
after midnight. Prior to taking the blood specimen
the nurse noticed that Jane is holding a bottle of
distilled water. The nurse asked Jane if she drink any,
and she said “yes.” Which of the following is the best
nursing action?
a. Administer syrup of ipecac to remove the
distilled water from the stomach
b. Suction the stomach content using NGT prior
to specimen collection
c. Advice a physician to reschedule to
diagnostic examination next day
d. Continue as usual and have the FBS analysis
performed and specimen be taken
Situation: Elderly clients usually produce unusual signs When
it comes to different diseases. The ageing process is a
complicated process and the nurse understand that it is an
inevitable fact and she must be prepared to care for the
growing elderly population.
46. Hypoxia may occur in the older patient because of
which of the following physiologic changes
associated with aging.
a. Ineffective airway clearance
b. Decreased alveolar surfaced area
c. Decreased anterior-posterior chest
diameter
d. Hyperventilation
47. The older patient is at higher risk for incontinence
because of:
a. Dilated urethra
b. increased glomerular filtration rate
c. Diuretic use
d. Decreased bladder capacity
48. Merle, age 86, is complaining of dizziness when she
stands up. This may indicate:
a. Dementia
b. Functional decline
c. A visual problem
d. Drug Toxicity
49. Cardiac ischemia in an older patient usually
produces:
a. ST-T wave changes
b. Chest pain radiating to the left arm
c. Very high creatinine kinase level
d. Acute confusion
50. The most dependable sign of infection in the older
patient is:
a. Change in mental status
b. Fever
c. Pain
d. Decreased breath sounds with crackles
51. Which of the following should be given highest
priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed
consent
c. Asses vital signs
d. Check for jewelry, gown, manicure, and
dentures.
52. Surgeries like I and D (incision and drainage and
debridement are relatively short procedures but
considered ‘dirty cases’ when are these procedures
best scheduled?
a. Last case
b. In between cases
c. According to availability of anesthesiologist
d. According to the surgeon’s preference
53. Or nurses should be aware that maintaining the
client’s safety is the overall goal of nursing care
during the intraoperative phase. As the circulating
nurse, you make certain that throughout the
procedure…
a. The surgeon greets his client before
induction of anesthesia
b. The surgeon and anesthesiologist are in
tandem
c. Strap made of strong non-abrasive
materials are fastened securely around the
joints of the knees and ankles and around
the 2 hands around an arm board.
d. Client is monitored throughout the surgery
by the assistant anesthesiologist.
 54. Another nursing check that should not be missed Situation: Nurses hold a variety of roles when providing care
before the induction of general anesthesia is: to a perioperative patient.
a. Check for presence underwear
61. Which of the following role would be the
b. Check for presence dentures
responsibility of the scrub nurse?
c. Check patient’s ID
a. Assess the readiness of the client prior to
d. Check baseline vital signs
surgery
55. Some lifetime habits and hobbies affect
b. Ensure that the airway is adequate
postoperative respiratory function. If your client
c. Account for the number of sponges,
smokes 3 packs of cigarettes a day for the past 10
needles, supplies, used during the surgical
years, you will anticipate increased risk for:
procedure
a. Perioperative anxiety and stress
d. Evaluate the type of anesthesia appropriate
b. Delayed coagulation time
for the surgical client
c. Delayed wound healing
62. As a perioperative nurse, how can you best meet the
d. Postoperative respiratory infection
safety need of the client after administering
Situation: Sterilization is the process of removing ALL living preoperative narcotic?
microorganism. To be free of ALL living microorganism is a. Put side rails up and ask the client not to
sterility. get out of bed
b. Send the client to OR with the family
56. There are 3 general types of sterilization use in the
c. Allow client to get up to go to the comfort
hospital, which one is not included?
room
a. Steam sterilization
d. Obtain consent form
b. Physical sterilization
63. It is the responsibility of the pre-op nurse to do skin
c. Chemical sterilization
prep for patients undergoing surgery. If hair at the
d. Sterilization by boiling
operative site is not shaved, what should be done to
57. Autoclave or steam under pressure is the most
make suturing easy and lessen chance of incision
common method of sterilization in the hospital. The
infection?
nurse knows that the temperature and time is set to
a. Draped
the optimum level to destroy not only the
b. Pulled
microorganism, but also the pores. Which of the
c. Clipped
following is the ideal setting of the autoclave
d. Shampooed
machine?
64. It is also the nurse’s function to determine when
a. 10,000°C for 1-hour
infection is developing in the surgical incision. The
b. 5,000°C for 30 minutes
perioperative nurse should observe for what signs of
c. 37°C for 15 minutes
impending infection?
d. 121°C for 15 minutes.
a. Localized heat and redness
58. It is important that before a nurse prepare the
b. Serosanguinous exudates and skin blanching
material to be sterilized, a chemical indicator strip
c. Separation of the incision
should be placed above the package, preferably,
d. Blood clots and scar tissue are visible
Muslim sheet. What is the color of the striped
65. Which of the following nursing interventions is done
produced after autoclaving?
when examining the incision wound and changing
a. Black
the dressing?
b. Blue
a. Observe the dressing and type and odor of
c. Gray
drainage if any
d. Purple
b. Get patient’s consent
59. Chemical indicators communicate that:
c. Wash hands
a. The items are sterile
d. Request the client to expose the incision
b. That the items had undergone sterilization
wound
process but not necessarily sterile
c. The items are disinfected Situation: The preoperative nurse collaborates with the
d. That the items had undergone disinfection Client significant others, and healthcare providers.
process but not necessarily disinfected
66. To control environmental hazards in the Or, the
60. If a nurse will sterilize a heat and moisture labile
nurse collaborates with the following departments
instruments, it is according to AORN
EXCEPT:
recommendation to use which of the following
a. Biomedical division
method of sterilization?
b. Infection control committee
a. Ethylene oxide gas
c. Chaplaincy services
b. Autoclaving
d. Pathology department
c. Flash sterilizer
67. An air crash occurred near the hospital leading to a
d. Alcohol immersion
surge of trauma patient. One of the last patients will
 need surgical amputation but there no sterile
surgical equipment. In this case, which of the
following will the nurse expect?
a. Equipment’s needed for surgery need not be
sterilized if this is an emergency
necessitating life saving measures
b. Forwarding the trauma client to the nearest
hospital that has available sterile equipment
is appropriate
c. The nurse will need to sterilize the item
before using it to the client using the regular
sterilization setting at 121 degree Celsius in
15 minutes
d. In such cases, Flash sterilizer will be use at
132°C in 3 minutes
68. Tess, the PACU nurse, discovered that Malou, who
weighs 110lbs 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. Nurse supervisor
b. Surgeon
c. Anesthesiologist
d. Intern on duty
69. Rosie, 57 who is diabetic is for debridement if
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
at ending MD
b. Communicate with the ward nurse to verify
if insulin was incorporated or not
c. Communicate with the client to verify if
Situation: Basic knowledge on Intravenous solution is
insulin was incorporated
necessary for care of clients with problems with fluids and
d. Incorporate insulin as ordered
electrolytes.
70. The 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 prosthetic devices such as
dentures, artificial limbs hearing aid, etc.
b. Baseline physical, emotional, and
psychosocial data
c. Arguments between nurses and residents
regarding treatments
d. Observed untoward signs and symptoms and
interventions including contaminant
intervening factors
Situation: Team efforts is best demonstrated in the OR.
71. If you are the nurse in charge for scheduling surgical
cases, what important information do you need to
ask the surgeon?
a. Who is your internist
b. Who is your assistant and anesthesiologist,
what is your preferred time and type of
surgery?
c. Who is your anesthesiologist, internist, and
assistant?
d. Who is your anesthesiologist
72. In the OR, the nursing tandem for every surgery is:
a. Instrument technician and circulating nurse
b. Nurse anesthetist, nurse assistant, and
instrument technician
c. Scrub nurse, nurse anesthetist
d. Scrub and circulating nurse
73. While team effort is needed in the OR for efficient
and quality patient care delivery, we should limit the
number of people in the room for infection control.
Who comprises this team?
a. Surgeon, anesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse, circulating
nurse, anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist,
scrub nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist,
intern, scrub nurse
74. Who usually act as an important part of the OR
personnel by getting the wheelchair or stretcher, and
pushing/pulling them towards the operating room?
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anesthesiologist
75. The breakdown in teamwork is often times a failure
in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
76. A client involved in a motor vehicle crash presents to
the emergency department with severe internal
bleeding. The client is severely hypotensive and
unresponsive. The nurse anticipates which of the
following intravenous solutions will most likely be
prescribed to increase intravascular volume, replace
immediately blood loss and increase blood pressure?
a. 0.45% sodium chloride
b. 0.33% sodium chloride
c. Normal saline solution
d. Lactated ringer’s solution
77. The physician orders the nurse to prepare an isotonic
solution. Which of the following IV solution would
the nurse expect the intern to prescribe?
a. 5% dextrose in water
b. 0.45% sodium chloride
c. 10% dextrose in water
d. 5% dextrose in 0.9% sodium chloride
78. The nurse is making initial rounds on the nursing unit
to assess the condition of assigned clients. The nurse
notes that the client’s IV site is cool, pale and swollen
 and the solution is not infusing. The nurse concludes Situation: as a perioperative nurse, you are aware of the
that which of the following complications has been correct processing methods for preparing instruments and
experienced by the client? other devices for patient use to prevent infection.
a. Infection
86. As an OR nurse, what are your foremost
b. Phlebitis
considerations for selecting chemical agents for
c. Infiltration
disinfection?
d. Thrombophlebitis
a. Material compatibility and efficiency
79. A nurse reviews the clients electrolyte laboratory
b. Odor and availability
report and notes that the potassium level is 3.2
c. Cost and duration of disinfection process
mEq/L. Which of the following complications has
d. Duration of disinfection and efficiency
been experienced by the client?
87. Before you use a disinfected instrument, it is
a. U waves
essential that you:
b. Absent P waves
a. Rinse with tap water followed by alcohol
c. Elevated T waves
b. Wrap the instrument with sterile water
d. Elevated ST segment
c. Dry the instrument thoroughly
80. One patient had a “runaway’ IV of 50% dextrose. To
d. Rinse with sterile water
prevent temporary excess of insulin or transient
88. You have a critical heat labile instrument to sterilize
hyper insulin reaction what solution you prepare in
and are considering to use high level disinfectant.
anticipation of doctor’s Order?
What should you do?
a. Any IV solution available to KVO
a. Cover the soaking vessel to contain the
b. Isotonic solution
vapor
c. Hypertonic solution
b. Double the amount of high-level disinfectant
d. Hypotonic solution
c. Test the potency of a high-level disinfectant
81. An informed consent is required for:
d. Prolong the exposure time according to
a. Closed reduction of a fracture
manufacturer’s direction
b. Irrigation of the external ear canal
89. To achieve sterilization using disinfectants, which of
c. Insertion of intravenous catheter
the following is used?
d. Urethral catheterization
a. Low level disinfectants immersion in 24
82. Which of the following is not true with regards to be
hours
informed consent?
b. Intermediate level disinfectants immersion
a. It should describe different treatment
in 12 hours
alternatives
c. High level disinfectants immersion in 1 hour
b. It should contain a thorough and detailed
d. High level disinfectant immersion in 10
explanation to the procedure to be done
hours
c. It should describe the client’s diagnosis
90. Bronchoscope, thermometer, Endoscope, ET tube,
d. It should explain the client’s prognosis
Cystoscope are all BEST sterilized using which of the
83. You know that the hallmark of nursing accountability
following?
is the:
a. Autoclaving at 121 degree Celsius in 125
a. Accurate documentation and reporting
minutes
b. Admitting your mistakes
b. Flash sterilizer at 132 degree Celsius in 3
c. Filling an incident report
minutes
d. Reporting a medication error
c. Ethylene oxide gas aeration for 20 hours
84. A nurse is assigned to care for a group of clients. On
d. 2% Glutaraldehyde immersion for 10 hours
review of the client’s medical records, the nurse
determines that which client is at risk for excess fluid Situation: The OR is divided into three zones to control traffic
volume? flow and contamination.
a. The client taking diuretics
b. The client with renal failure 91. What OR attires are worn in the restricted area?
c. The client with an ileostomy a. Scrub suites, OR shoes, head cap
d. The client who requires gastrointestinal b. Head cap, scrub suit, mask, OR shoes
suctioning c. Mask, OR shoes, scrub suit
85. A nurse is assigned to care for a group of clients. On d. Cap, mask, gloves, shoes
review of the client’s medical records, the nurse 92. Nursing intervention for a patient on low dose IV
determines that which client is at risk for deficient insulin therapy includes the following EXCEPT:
fluid volume? a. Elevation of serum ketones to monitor
a. A client with colostomy ketosis
b. A client with congestive heart failure b. Vital signs including BP
c. A client with decreased kidney function c. Estimate serum potassium
d. A direct receiving frequent wound irrigation d. Elevation of blood glucose levels
 93. The doctor ordered to incorporate 1000” u” insulin 100. In using liquid sterilizer versus autoclave machine,
to the remaining on –going IV. The strength is which of the following is true?
500/ml. how much should you incorporate into the a. Autoclave is better in sterilizing OR supplies
IV solution? versus liquid sterilizer
a. 10ml b. They are both capable of sterilizing the
b. 0.5ml equipment, however, it is necessary to soak
c. 2 ml supplies in the liquid sterilizer for a longer
d. 5ml period of time
94. Multiple vial-dose-insulin when in use should be c. Sharps are sterilizes using autoclave and not
a. Kept at room temperature cidex
b. Kept in narcotic cabinet d. If liquid sterilizer is used rinsing it before
c. Kept in the refrigerator using is not
d. Store in the freezer
95. Insulins using insulin syringe are given using how
many degrees off needle insertion?
a. 45
b. 180
c. 90
d. 15

Situation: Maintenance of sterility is an important function a

nurse should perform in any OR setting.

96. Which of the following is true with regards to

sterility?
a. Sterility is time related, items are hot
considered sterile after a period of 30 days
of being not use.
b. For 9 months, sterile items are considered
sterile as long as they are covered with
sterile muslin cover and stored in a dust
proof cover.
c. Sterility is event related, not time related
d. For 3 weeks, items double covered with
muslin are considered sterile as long as they
have undergone the sterilization process
97. 2 organizations endorsed that sterility are affected
by factors other than the time itself, these are:
a. The PNA, and the PRC
b. AORN and JCAHO
c. ORNAP and MCNAP
d. MMDA and DILG
98. All of these factors affect the sterility of the OR
equipment, these are the following except:
a. The material used for packaging
b. The handling of the materials as well as its
transport
c. Storage
d. The chemical or process used in sterilizing
the material
99. When you say sterile, it means:
a. The material is clean
b. The material as well as the equipment are
sterilized and had undergone a rigorous
sterilization process
c. There is black stripe on the paper indicator
d. The material has no microorganism nor
spores present that might cause an
infection