PREBOARD ANGELUS VICTUS TEST 3

Sit. 1: Ambrosia, 50 years old was transported to the Operating Room for Total Abdominal
Hysterectomy after having profuse vaginal bleeding for the past three weeks. She was diagnosed to
have dysfunctional uterine bleeding.

1. The scrub nurse ensures that aseptic technique is maintained throughout the procedure. When she
serves the right gloves to the surgeon, which of the following is correct technique to be followed by the
scrub nurse?
a. Keep thumbs away from the cuff
b. Maintain fingers of gloves facing you
c. Pick up the gloves and place the palm towards you
d. Slide the gloves by holding under glove cuff ,spread to create wide opening

2. The surgeon uses electrosurgical equipment to cauterize blood vessels. Which of the following
nursing activity should have been done by the circulating nurse to ensure safety?
a. Correctly drape electrocautery cable and cord
b. Electrocautery equipment is placed appropriately at the back of surgeon
c. Grounding pad is connected to grounding cable properly place under buttock of patient
d. Electrocautery pencil is made easily available each time the surgeon uses it

3. The surgeon passed the specimen to the scrub nurse. Which of the following is the correct action of
the scrub nurse?
a. Place specimen in basin moistened with saline solution
b. Wipe specimen with sponge
c. Wrap specimen with surgical sponge
d. Pass the specimen to the circulating nurse

4. The surgeon tells the scrub nurse that the procedure done was Total Abdominal Hysterectomy with
bilateral Salphingo-oophorectomy. The scrub nurse understands that the specimen she received would
consist of which of the following organs?
a. Right and left ovaries, uterus and fallopian tube
b. Uterus,fallopian tube, ovary and urinary bladder
c. Uterus, right and left fallopian tubes and ovaries
d. Uterus, urinary bladder, two ovaries, right and left fallopian tube

5. The surgeon asked for a suture to close the peritoneum. Which of the following should have been
done by the scrub nurse before suture is handed to the surgeon?
a. Specimen passed to the circulating nurse
b. Needle holder passed to the surgeon
c. Needle mounted on the needle holder
d. Surgical count completed

Sit. 2: Radiation therapy is another modality of cancer management. With the emphasis on
multidisciplinary management, you have important responsibilities when caring for patent receiving
radiation therapy.

6. All of the following factors except for one are used to determine the cancer patient’s absorbed
radiation dose?
a. Intensity of radiation exposure c. Age of patient
b. Duration of exposure d. Proximity of radiation source to cells

7. Why is the therapeutic dose of radiation fractionated for cancer treatment?

a. To reduce total treatment cost
b.To allow time for chemotherapy to reduce tumor
c. To prevent bone marrow suppression with resulting anemia
d. To ensure higher cancer cells with less damage to normal cells

8. At what point is a patient radioactive when receiving radiation treatment by teletherapy and
therefore potential danger to other people?
a. The patient is never radioactive c. For the first 24-48 hours of treatment
b. When linear accelerator is turned on d. Until radiation source decayed by one half

9. Luisa, a post total hysterectomy, bilateral salphyngo-cephorectomy patient had chemotherapy and
radiation therapy. She is now scheduled for brachytherapy. The nurse oriented her on the rationale
and the measures to be done to prevent movement of the radioactive source which includes the
following, EXCEPT:
a. Complete bed rest while source is implanted
b. Spinal anesthesia while source is implanted
c. Bowel cleansing prior to insertion of source
d. Placement of urinary Foley catheter while source is implanted

10. For a patient undergoing external radiation therapy, what do the nurse’s instructions include?
1. Do not remove the markings 3. Use of soap and water on affected skin
2. Avoid direct sun exposure 4. Do not rub treated areas

a. 1,2, 3 b. 2,3,4 c. 1,2,4 d. 1,2,3,4

Sit. 3: As nurses begin their professional obligations, their legal responsibilities begin as well.
Their license to practice attests that they are qualified under the law to practice their profession.

11. Which of the following BEST deserves the responsibility of the nurse as a witness in a case in court?
a. Protect the patient c. State the truth
b. Collaborate with the primary physician d. Relate a dramatic experience

12. When a nurse who is under oath gave false informations on the case, he may be held for which of
the following?
a. Lying c. Contempt of the court
b. Motto propio d. Perjury

13. Over all what can a nurse do to reduce the risk of malpractice litigation?
a. Do not discuss medication errors with patient and family
b. Give value judgment when appropriate
c. Be expert and competent in practice
d. Secure an incident report on file

14. Which of the following may serve as the best guide for nurses to utilize as it defines the scope of
nursing practice in the philippines?
a. RA 9173 c. RA 7160
b. RA 2382 d. RA 6713

15. Nurse Inie was summoned to appear and testify in court. In the witness stand Inie mentioned only
on what he knows based on the circumstances of the events. This is known as
.a. Testimony of opinion c. Testimony of truth
b. Testimony of facts d. Privilege spech against self-incrimination

Sit. 4: Angelo sought admission for acute gouty attack of the right foot. Nurse Krispy was in
charge of the patient.

16. Angelo is in acute phase of gouty attack. Which of the following should the nurse identify as the
lowest priority in the plan of care?
a. Relieving pain c. Preserving joint function
b. Prevent joint deformity d. Maintain usual ways of activity

17. Nurse Krispy perform initial assessment. Which of the following types of joint pains supports the
doctor’s diagnosis?
a. Bilateral c. Polyarticular
b. Symmetrical d. Monoarticular

18. Which of the following examinations would the nurse expect to be ordered?
a. Bone marrow aspiration c. Synovial fluid analysis
b. Knee jerk examination d. Bone density

19. Colchicine is prescribed for Angelo. Nurse Krispy is aware that the action of the drug is to
a. Provide fast symptomatic relief c. Lowers serum uric acid level
b. Block conduction of pain d. Interfere with inflammation response

20. During the acute attack, the pain on the affected foot can be so intense that even the weight of the
linen can be unbearable. The most appropriate nursing intervention is to
a. Apply splint on the affected foot c. Elevate the affected foot
b. Place foot cradle on bed d. Apply bandage around the affected foot
 Sit. 5: Catherine a corporate secretary was admitted to the hospital complaining of extreme
nervousness, irritability and fatigue. Her skin was warm and moist with staring expression with diffuse
enlargement of the thyroid. She was diagnosed with hyperthyroidism.

21. In addition to exophthalmos, Catherine is apt to display all but one of the following eye signs?
a. Tortuous retinal vessel c. Lid lag on down ward gaze
b. Inability to converge d. Infrequent blinking

22. Which of the following complication would Catherine be most apt to develop if she were untreated
or failed to respond satisfactorily to treatment for hyperthyroidism?
a. Cerebrovascular accident c. Heart failure
b. Pulmonary embolism d. Heatstroke

23. Catherine should be given a complete bath and several partial baths daily in order to
a. Provide a relaxing effect to promote sleep and rest
b. Remove irritating salts eliminated in perspiration
c. Stimulate arterial circulation to the periphery
d. Reduce elevated temperature by skin evaporation

24. The nurse is aware that Catherine will be placed on a euthyroid stage to lessen her symptoms. The
doctor prescribed Methimazole for her. Which of the following if seen from the patient warrant
immediate attention?
a. Nausea and vomiting c. Poor attention span
b. Weakness and chills d. Metallic taste on the mouth

25. Catherine was treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the
nurse instructs the patient to
a. Monitor for loss of appetite and weight gain
b. Symptom of hyperthyroidism will disappear after one week
c. Stop all antithyroid drugs days before the procedure
d. Precaution with stool, urine and perspiration

Sit. 6: Considering the ethical and moral responsibilities inherent in nursing practice, nurses
need to examine their own value system to determine the BEST approach in managing the care of
clients whose values differ.

26. A 40 year old male client has been confined in a semi-private room for 2 days until another client
came. He asks the nurse what the condition of the client is. Which of the following should be the nurse’s
response?
a. Advise him that all client’s condition are held in confidence
b. Tell him to ask the new client himself
c. Explain in layman’s term the condition of the new client
d. Ask the client what her wants to know

27. A nurse who functions from an ethic of care is best illustrated when she/he:
a. Uses touch to provide comfort
b. Provides a person-to-person encounter
c. Listens to clients
d. Show sensitivity to unequal relationship

28. A 16 year old female client got pregnant and was abandoned by her boy friend. She visited a
doctor’s clinic and asked the nurse if she could have an abortion. What should be the initial response of
the nurse?
a. “Why not think it over and ten decide after careful assessment of the situation.”
b. “You should not feel that way.”
c. “What are your feelings about abortion?”
d. “You seek advise from your parents.”

29. The nurse has a responsibility to perform nursing care activities based upon standards of practice.
This means that:
a. Minimum level of performance is accepted to ensure high quality care
b. Nursing action performed by the nurse is based on scientific knowledge
c. Nursing activities performed by the nurse to an acceptable level
d. Practices observed by nurses ensure quality care
30. A 45 year old female client is admitted to a semi-private room for elective surgery. She tells the
nurse that her prayer group will be coming to pray for her. The group arrived, starting chanting inside
the room. What should be the appropriate action of the nurse?
a. Arrange for the group to go to the prayer room or chapel if available
b. Ask the client’s roommate for their understanding and respect the other client wish
c. Ignore the prayer group and allow their chanting
d. Call the attention of the group and pray quietly

Sit. 7: Nora had been complaining of easy fatigue lately after recovering from a flu like
symptoms. She observes beginning loss of appetite with marked pallor. Her history seems
unremarkable with no history of chronic illness, travel and other significant event that may give clue to
her present problems.

31. Significant information obtained from the patient’s health history that relates to the hematologic
system includes
a. Jaundice c. Early menopause
b. Bladder surgery d. Multiple pregnancies

32. The nurse suspects of anemia and this is confirmed by which of the following symptoms?
a. Dyspnea and tachycardia c. Cardiomegaly and pulmonary fibrosis
b. Cyanosis and pulmonary edema d. Dysrythmias and wheezing

33. The doctor orders bone marrow biopsy. Immediately following the procedure, the nurse should
instruct the patient to
a. Expect to receive blood transfusion
b. Lie still with sterile pressure dressing intact
c. Lie with knees slightly bent and head elevated
d. Cleanse the site immediately with povidone iodine

34. The doctor ordered blood transfusion for Nora. Which of the following might indicate acute
hemolytic reaction from the transfusion?
a. Low back pain c. Itching
b. Hypertension d. Distended neck veins

35. Nora had multiple bags of blood transfused in an effort to reduced her symptoms. Which of the
following electrolyte disturbances may be affected from the therapeutic intervention?
a. Potassium c. Calcium
b. Sodium d. Magnesium

Sit. 8: Phillip is a heavy smoker have been complaining of repeated respiratory infections and
dyspnea on moderate exertion for the past two years. He was at the emergency room again for labored
expiration and the nurse notes increased anteroposterior diameter of the chest as well as clubbing of
fingers. The nurse suspects of emphysema with cor pulmonale.

36. The doctor has prescribed Flovent inhaler for Willie. What is the purpose of this drug for the
patient?
a. Relaxes smooth muscle of the airway
b. Acts as bronchodilator in severe episodes
c. Reduces obstruction of airways by reducing swelling
d. Reduces the histamine effect of the triggering agent

37. While at the emergency room, the nurse provides Phillip with nebulization. What is the advantage
of using aerosol route for the administration of short acting beta agonist like Salbutamol?
a. Achieves a rapid and effective anti-inflammatory action
b. Reduces the risk for fungus infections
c. Increases patient compliance because it is easy to use
d. Provides rapid therapy with fewer systemic side effects

38. Which of the following results of emphysema is primarily responsible for Phillip’s cardiomegaly?
a. Hypertrophy of muscles encircling the bronchi
b. Increased pressure in the pulmonary circulation
c. Decreased number of circulating red blood cells
d. Secretion of excessive amounts of pericardial fluid

39. In cor pulmonale, which of the following symptoms or sign may be seen first?
a. Pedal edema c. Watery sputum
 b. Shortness of breath d. Substernal pain

40. Which of the following is a priority goal for Phillip with chronic obstructive pulmonary disease
(COPD)?
a. Minimizing chest pain c. Increased CO2 in the blood
b. Maintain functional ability d. Treating infectious agent

Sit. 9: Consumers of health care require improvement in health care. Nurses must deliver
activities and behaviors and do the right things well and continue to strive to do better to meet and
satisfy the diverse needs of clients.

41. Which of the following safety precaution should the nurse employ in caring for Lola Karing during
the first few hours following her cataract surgery?
a. Elevation of the side rails c. Head immobilization with sand bags
b. Application of wrist restraints d. Closing the window shades tightly

42. While Lola Karing’s eye is shielded, the nurse’s greatest contribution toward helping her
compensate for impaired reality testing ability would be to
a. Relieve the patient on all the responsibility for self care
b. Foster a reliable trusting relationship between patient and nurse
c. Make and explain all decisions relative to patient care
d. Describe in detail everything and everyone in the unit

43. In the administration of Lola Karing’s eyedrops, the nurse should

1. Wash hands before instillation
2. Pull down on the skin overlying cheek
3. Steady hand holding the dropper by placing on forehead
4. Drop medication on the inverted lower eyelid

a. 1,2 and 4 b. 1 and 3 c. 1,2 and 3 d. 1,2,3, and 4

44. The members of the nursing team were discussing about the activity of the patient treated with
detached retina during the nursing rounds. Which of the following statements serves as guide for the
client during the rehabilitation phase?
a. Resume his activity with moderation the day after the treatment
b. Indulge in normal activities after the treatment
c. The patient must be restricted in bed for one week
d. Resume gradually her usual activities within 5 to 6 weeks

45. A patient with detachment of the retina asks the nurse why it is necessary to patch both of her eyes.
The nurse reply should be based on the knowledge that eye patches serve to
a. Reduce rapid eye movement
b. Decrease the irritation caused by light entering the damaged eye
c. Protect the injured eye from infection
d. Rest the eye to promote healing

Sit. 10: Nursing practice is governed by laws and ethical principles As a beginner nurse,
knowledge of these laws and principles helps in the prevention of lawsuits arising from malpractice.

46. Which of the following questions represents an ethical issue in nursing practice that cannot be
resolved through research?
a. Incidence of medication errors on the pediatric unit compare with errors on the neonatal unit?
b. Does the use of local anesthesia during circumcision make a difference in infants?
c. Is the ER nurse obligated to report suspicion of child abuse if signs are noted on assessment?
d. Which method of irrigating central venous line results in less line infection?

47. Shortly before a child’s surgery, the parents tells the nurse, “I am having second thoughts about my
child undergoing this surgery” The nurse respects the concern of the parent and calls the surgeon.
What ethical principle is represented by the situation?
a. Autonomy c. Fidelity
b. Justice d. Equality

48. Staff members working with school age children believe it is important for each child to understand
and agree to medical treatment especially when treatment is part of research protocols. The term for
this process is
a. Assent c. Confidentiality
b. Informed consent d. Emancipation
49. After the parent leaves the side rail down, a hospitalized toddler falls from the crib and suffers a
skull fracture. Earlier that day the nurse has discussed the importance of side rails with that parent and
recorded the discussion on the nursing notes. Which element of malpractice is missing in this case?
a. Relationship with the patient c. Injury
b. Breach of duty of care d. Damage

50. The nurse makes an error by giving the wrong medication to a patient. An incident report is
completed per hospital policy. What information should the nurse chart in the medical record?
a. Date, time and name of person completing the incident report
b. Completion of the incident report
c. Description of specific occurrence and treatment given
d. Nothing it should be keep secret

Sit. 11: Mariano, a PACU nurse, receives simultaneously several patients in the unit as he is about to
start his afternoon shift in the area. He ahad been working for almost three years and is quite adept in
managing post-operative patients.

51. When receiving a post ex-lap patient, Mariano was told that the patient lost 2 units of blood during
surgery. For which of the following patient’s adaptation which are significant to the situation should
Mariano assess?
a. Rapid deep breathing and decreased blood pressure
b. Rapid deep breathing and increased blood pressure
c. Slow, shallow breathing and increased blood pressure
d. Slow, shallow breathing and decreased blood pressure

52. Sterile technique is maintained when Mariano

a. Cleans the edges of the wound before the center of the wound
b. Wipe the wound in a circular motion from the outside inward
c. Always hold a wet gauze upward until ready for use
d. Changes the gloves if positioned below the waist

53 Mariano assesses the post operative incision as part of his care. After surgery when should the nurse be
alert for signs of clinical signs of wound infection?
a. Between day 1 and 2 after surgery c. Within 24 hours after surgery
b. Between day 3 and 5 after surgery d. One week after surgery

54. While monitoring post op patients, which among the following interventions best prevents atelectasis
after surgery?
a. Oxygen via cannula c. Progressive activity
b. Diaphragmatic breathing d. Postural drainage

55. Nursing care that is unique to a portable wound drainage such as Jackson Pratt, which is different from
tubes like T-tube or an indwelling urinary catheter, is the need to
a. Maintain patency of the drainage tube c. Ensure negative pressure
b. Assess characteristic of drainage d. Measure output

Sit. 12: Brian, had been admitted in the hospital because of a hacked wound sustained at the chest
area and right upper extremities after sustaining it from a fraternity war in the University belt.

56. The doctor ordered Povidone –iodine for wound care. When pouring the solution to the gauze
bandages, the nurse should
a. Hold the bottle with the label facing the sterile field
b. Pour while holding the bottle high over the sterile field
c. Pour 1-2 ml into another container before pouring on sterile field
d. Pour some into a cap and then over the sterile bandages

57. The edges of Brian’s incision have separated and purulent drainage is seeping from the wound. The
nurse classifies this as
a. Intentional,incisional, infected
b. Unintentional, open,infected
c. Intentional,close,clean contaminated
d. Unintentional,incisional,contaminated
58. Local physical injury produces a systemic response as well. Identify the systemic reaction to a hacked
wound?
a. Decreased body temperature c. Slowed respiration
b. Increased heart rate d. Skeletal muscle relaxation

59. Which data would be most supportive of the nursing diagnosis Alteration in skin integrity related to
purulent wound drainage?
a. Pulse rate is 72 c. Temperature of 37.8 C
b. Ambulates in the hall twice d. Dressing is dry and intact

60. The nurse is changing the dressing covering of Brian. The gauze is saturated with foul smelling yellow
exudates. The nurse removes the dressing by
a. With bare hands c. After donning nonsterile gloves
b. After sterile gloves d. After double gloving

Sit. 13: Because of multiple barriers to adequate pain management, the nurse is aware that all
patients are at risk for under- treatment of pain. Since pain is identified and reported primarily
through patient self- reporting, difficulty in communicating increases the patient’s risk for under-
treatment hence careful assessment is essential.

61. Korina is 45-year-old patient has breast cancer that has spread to the liver and spine. The patient
has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has
constant severe pain and is hospitalized for pain control and development of a pain-management
program. When doing the initial assessment, which question will be most appropriate to ask first?
a. How would you describe your pain?
b.How much medication do you take for the pain?
c. How long have you had this pain?
d. How many times a day do you medicate for pain?

62. Chuck is with chronic abdominal pain has learned to control the pain with the use of imagery and
hypnosis. A family member asks the nurse how these techniques work. The nurse’s reply will be based
on the information that these strategies
a. Prevent transmission of nociceptive stimuli to the cortex
b. Increase the modulating effect of the efferent pathways
c. Impact the cognitive and affective components of pain
d. Slow the release of transmitter chemicals in the dorsal horn.

63. Mrs. Ferraren is with extensive second-degree burns on the legs and trunk is using patient-
controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the
pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour
to regain pain relief. The most appropriate action by the nurse is to
a. Request that the doctor order a bolus dose of morphine to be given when the patient
awakens with pain
b. Consult with the patient’s doctor about adding a continuous morphine infusion to the
PCA regimen at night.
c. Teach the patient to push the button every 10 minutes for an hour before going to sleep even
if the pain is minimal
d. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is
sleeping

64. Sam is receiving prn intermittent IV administration of opiates following gastric surgery watches a
favorite television program every morning. The patient does not request pain medication during this
time and when questioned denies the need for medication. The nurse’s evaluation of this situation is
that
a. Lying quietly in bed is the best method of controlling incisional pain
b. Encouraging to watch other television programs will decrease the pain
c. Dose of opiates needs to be decreased because her pain is well controlled
d. Distraction of the television enables to decrease the perception of pain

65. The doctor plans to titrate a patient-controlled opioid infusion (PCA) to provide pain relief for a
patient with acute surgical pain who has never received opioids in the past. Which of the following
nursing actions regarding opioid administration are appropriate at this time
1. Monitoring for therapeutic and adverse effects of opioid administration
2. Teaching about the need to decrease opioid doses by the second post-op day
3. Assessing for signs that the patient is becoming addicted to the opioid
4. Educating the patient about how analgesics improve postoperative activity level
 5. Emphasizing that the risk of opioid side effects increases over time

a. 1 and 4 b. 1,2 and 3 c. 2,4 and 5 d. 1,3 and 5

Sit. 14: Clinical excellence in nursing remains to be the goal of every nurses to keep them
motivated and ensure quality nursing care in all aspects of their works. In here nurse promote
evidence-based practice by effectively connecting theory and research with clinical applications as well
as demonstrate and encourage clinical expertise and collaborative practice.

66. Mang Benito is unable to expectorate sputum and the nurse is preparing to obtain the
sample via saline inhalation. The nurse instruct Mang Benito to inhale the warm saline vapor
via nebulizer by
a. Alternating one vapor breath with one breath of room air
b. Keeping lips closely tightly over the mouthpiece
c. Keeping the lips closed lightly over the mouthpiece
d. Holding the nebulizer under the nose

67. A nurse evaluates the patency of a peripheral intravenous site and suspects an infiltration.
Which does the nurse implement to determine if the IV has infiltrated?
a. Gently palpates regional tissue for edema and coolness
b. Strips the tubing and assesses for a blood return
c. Checks the regional tissue for redness and warmth
d. Increases the infusion rate and observes for swelling

68. Nurse May is caring for a patient who develops compartment syndrome from a severely
fractured arm. The patient asks the nurse how this can happen. The nurse’s best response is
based on the understanding that
a. Fascia expand with injury causing pressure on underlying nerves and muscles
b. Bleeding and swelling causes increased pressure on area that cant expand
c. Injured artery causes impaired arterial perfusion through the compartment
d. Bone fragment has injured the nerve supply in the area

69. The patient has undergone fasciotomy to treat compartment syndrome of the leg. The
nurse prepares to provide which type of wound care to the fasciotomy site?
a. Dry sterile dressings c. Wet sterile saline dressings
b. Hydrocolloid dressing d. One half strength Betadine dressings

70. The nurse provides dietary measures to a patient with diverticulosis. The nurse
encourages the patient to eat foods that are
a. High in fat c. Low in fiber
b. Low roughage d. High in fiber

Sit. 15: Pierre Roxas is a 55 year old patient who was in the OPD area of Southern Mindanao
Medical Center. She was evaluated by a nurse for a possible health problems.

71. Pierre denies any serious chronic health problems. Which sudden onset sign or symptoms suggests
possible kidney disease in this patient?
a. Hypertension c. Confusion
b. Weakness d. Arrythmias

72. Pierre becomes uncomfortable with the nurse’s questions about urinary functions and patterns.
What is the best technique for the nurse to elicit relevant information and decrease the patient’s
discomfort?
a. Defer the question until a later time
b. Use anatomic or medical terminology
c. Use the patient’s own terminology
d. Direct the questions toward the family member

73. Looking at Pierre’s medical and personal history, which circumstances creates the greatest risk for
recurrent urolithiasis?
 a. Giving him milk with every meal tray
b. Giving him an opiod analgesics for pain
c. Keeping him NPO for longer periods
d. Inserting indwelling catheter

74. Pierre was required to provide a 24 hour urine specimen. What does the nurse expect to see with
the specimen if he suspects him to have acute glomerulonephritis?
a. Clear and very diluted urine c. Smoky or cola colored urine
b. Urine with pus and very thick d. Bright orange colored urine

75. Which nursing intervention is applicable to Pierre who was diagnosed with acute
glumerulonephritis?
a. Restricting visitors to adults only
b. Inspecting the vascular access on his hand
c. Using alift sheet to turn the patient
d. Measuring abdominal girth daily

Sit.16: A group of intensive care unit nurses decided to conduct a research study to describe the
relationship between the frequency of endotracheal suctioning and the incidence of infection among
ventilator assisted patients. The team selected the non-experimental design specifically the
prospective approach.
76. If you are a member of the research team, which of the following will you consider as the research
study’s independent variable when you formulate the research problem?
a. Incidence of infection
b. Relationship of endotracheal suctioning and incidence of infection
c. Dependence of clients on mechanical ventilation
d. Frequency of endotracheal suctioning

77. Data regarding the study’s dependent variable will be collected by the research team through
which of the following:
a. Self report techniques c. Projective Techniques
b. In vitro measures d. Available data in the patient’s chart

78. The research team is fully aware that measurement of variables is a very important consideration
in obtaining quality data in the study. Which of the following statements will you accept as true?
a. Reliability quality of an instrument is independent of its validity
b. An instrument can be valid without being reliable
c. A measuring device which is unreliable can be valid
d. High reliability of an instrument provides no evidence of its validity

79. Taking into consideration the content of the written informed consent, which of the following
reflects the research team’s recognition of the participant’s right to privacy?
a. Right to withdraw and withhold information c. Voluntary consent
b. Confidentiality pledge d. Potential benefits and risk

80. The research team decided to conduct the study for 3 months. Utilizing the perspective approach,
which of the following will the researcher appropriately do?
a. Participants will be assigned to the experimental and control group and incidence of
infection in the two groups will be compared.
b. During the period of 3 months, those ventilator assisted patients who developed infection
will be included in the study.
c. On the last day of the 3rd month, charts of participants will be reviewed and data collected
regarding frequency of endotracheal suction and incidence of infection
d. From day 1 to the last day of the 3rd month, data regarding frequency of endotracheal
suctioning and incidence of infection will be collected.

Sit. 17: Noy Noy is with a history of chronic heart failure is admitted to the emergency
department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both
ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28.

81. Noy Noy has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of
heart failure. The patient data that will require the most immediate action by the nurse is if the
patient’s
a. Weight increases from 120 pounds to 122 pounds over 3 day
b. Liver is palpable 2 cm below the ribs on the right side
c. Serum potassium level is 3.0 mEq/L after 1 week of therapy
 d. Has 1 to 2+ edema in the feet and ankles in the morning

82. Noy Noy while in the ICU, is receiving dobutamine (Dobutrex) for the treatment of heart failure has
all of the following nursing actions included in the plan of care. Which action will be best for the nurse
to delegate to a nursing student?
a. Teach the patient the reasons for remaining on bed rest
b. Monitor the patient’s BP every hour
c. Adjust the drip rate to keep the systolic BP >90 mm Hg.
d. Call the health care provider about a decrease in urine output

83. While completing all the data from the patient, the most important assessment for the nurse to
accomplish next is to
a. Auscultate the lung sounds c. Assess the orientation
b. Check the capillary refill d. Palpate the abdomen

84. During assessment of Noy Noy, the nurse notes jugular venous distention (JVD) with the head of the
patient’s bed elevated 45 degrees. The nurse knows this finding indicate
a. Decreased fluid volume c. Incompetent jugular vein valves
b. Elevated right atrial pressure d. Jugular vein atherosclerosis

85. When the nurse is developing a teaching plan for Noy Noy to prevent the development of heart
failure who also noted to be hypertensive, the information that is most likely to improve compliance
with antihypertensive therapy is that
a. Hypertensive crisis may lead to development of heart failure in some patients
b. High BP increases risk for rheumatic heart disease
c. High systemic pressure precipitates papillary muscle rupture
d. Hypertension will lead to heart failure by overworking the heart muscle

Sit. 18: The basis for all infection free surgery is founded on the principle of basic aseptic
technique. Every attempt must be made to prevent the invasion of microorganisms into the surgical
wound during the perioperative period

86. The physical environment and traffic control measures of the operating room are designed
primarily to
a. Protect the privacy of the patient
b. Prevent transmission of infection
c. Ensure efficient completion of surgical procedures
d. Allow smooth functioning of the operating room team

87. For which of these actions by an inexperienced staff member would the charge nurse be required to
intervene?
a. Wearing a surgical mask into the holding room
b. Putting on a surgical mask, cap, and scrubs before entering the operating room
c. Wearing street clothes into the nursing station
d. Walking into the hallway outside an operating room without the hair covered

88. Contamination from the surgical team is a potential source of infection during the intraoperative
period and usually relates to
a. Direct contact from hands or from shedding skin or mucus membrane
b. Improper sterilization of surgical instrument or supplies
c. Contamination of air inside the operating room
d. Improper aseptic preparation of skin before surgical scrub

89. Among the guidelines for maintaining and monitoring a sterile field are all of the following except
a. Sterile field should be created as close to the time of the procedure as possible
b. Under no circumstances should a sterile field be covered for use at later time
c. If possible, the sterile team should sit when not directly involved in procedure
d. Field should be in constant view

90. The primary supply needed to create a sterile field is the

a. Sterile drape c. Covered mayo stand
b. Sterile pack d. Covered ring stand

Sit. 19: Diabetes mellitus remains to be on top of the list as one of the leading chronic
debilitating disease worldwide. The nurse caring for patients has significant role in the
treatment and prevention of morbidity
91. One patient is scheduled for routine glycosylated hemoglobin test (HbA1). What is important for
the nurse to tell the patient prior to the test?
a. Drink only water after midnight and come to the clinic early in the morning
b. Eat a normal breakfast and come to the clinic 2 hours after
c. Expect to be at the clinic for several hours because of multiple blood draws
d. Come to the clinic at convenient time to have blood drawn

92. In her teachings the nurse is aware that Humulin (human insulin) is not directly harvested from
human organs but is derived from which of the following agent by recombinant DNA technology?
a. Eschirichia coli c. Lactobacillus acidophilus
b. Streptococcal pyogenes d. Staphylococcus strain

93. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient
about mealtime coverage using which of the following insulin?
a. NPH c. Glargine
b. Lispro d. Detemir

94. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular
disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient
that
a. Feet should be soaked in warm water on a daily basis
b. Flat-soled leather shoes are the best choice to protect the feet from injury
c. Heating pads should always be set at a very low temperature
d. Over-the-counter (OTC) callus remover may be used to remove callus

95. A nurse evaluates a patient who is being treated for diabetic ketoacidosis. Which finding indicates
that the patient is responding to the treatment plan?
a. Skin flushed with eyes sunken
b. Serum potassium level is 3.3 mEq/L
c. Skin moist with rapid elastic recoil
d. Able to sleep deeply without interruption

Sit. 20: Critical thinking among nurses involves use of sound judgment and assessment
skill. Setting priorities when caring for patients involves the use of multidisciplinary discipline
and experience in handling patients at various clinical settings.

96. The nurse is caring for patients on a medical unit. Which intervention should the nurse implement
first?
a. Place a call on another hospital to give the report of a transferred patient
b. Check on a male patient who called the station he has just vomited
c. Discuss the correct method of getting blood sugar with a nursing student
d. Change the leg wound dressing for a patient who has ambulated in hall

97. Jessica is preparing a patient diagnosed with peptic ulcer for a barium study. Which intervention is
a priority for this patient?
a. Obtain informed consent c. Explain he will drink white chalky fluid
b. Tell her not to eat anything d. Discuss increase fluids after the test

98. Greg is administering drugs on the medical ward. Which medication should he given first?
a. An antacid to a patient with pyrosis who has called several times in station
b. An anticholinesterase medication to a patient with myasthenia gravis
c. A loop diuretic to a patient with heart failure and +3 pitting edema
d. Narcotic pain medication to patient complaining of pain as “8”

99. The nurse is preparing to give drug after receiving the morning endorsement. Which medication
should the nurse administer first?
a. Loop diuretic of patient with serum potassium level of 3.2mEq/l
b. Rapid acting insulin to a diabetic patient who has breakfast tray in room
c. Stimulant laxative to a patient who has not had bowel movement in 3 days
d. Proton pump inhibitor of a patient on NPO to be given IV

100. The nurse has just received the endorsement report from the out-going nurse in the surgical unit.
Which of the following patient should be assessed first?
a. George, 2 days post-op appendectomy complaining of pain on scale of 8
b. Emilio, one day post-op for abdominal surgery has rigid, hard abdomen
c. Jay with open reduction on the right ulna and has +1 pitting edema
d. Melfred with left fractured hip who is crying and frightened about surgery