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NP4 - test

BS in Nursing (Central Mindanao University)

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REFRESHER COURSE: PREBOARD EXAMINATION

Nursing Practice IV: Care of Clients with Physiologic and
Psychosocial Alterations (Part B)
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE IV” on the box provided.

Situation: Burns are caused by transfer of heat source B. Hemorrhage

to the body. It can be thermal, electrical, radiation, or C. Shock
chemical. D. Laryngeal spasms and swelling

1. A burn characterized by pale, white appearance, charred or 9. When a client is running towards you and he has burning
with fat exposed, and painless is: clothes on, it is your priority to do which of the following first?
A. Superficial partial thickness burn A. Instruct him to log roll on the ground SAFEST
B. Deep partial thickness burn B. Instruct him to slap flames with his hands
C. Full thickness burn C. Remove the burning clothes
D. Deep full thickness burn D. Splash the client with one bucket of cool water

2. Which of the following describes superficial partial thickness 10. Once the flames are extinguished, it is most important to:
or first degree burn? A. Cover client with a warm blanket
A. Structures beneath the skin are damaged B. Give him sips of water
B. Dermis is partially damaged C. Calculate the extent of burns
C. Epidermis and dermis are both damaged D. Assess his breathing
D. Epidermis is damaged
MOIST 11. During the first 24 hours after the thermal injury, you
3. A burn that is said to be “weeping” is classified as: should assess the client for:
A. Superficial partial thickness burn A. Hypokalemia and hypernatremia
B. Deep partial thickness burn B. Hypokalemia and hyponatremia
C. Full thickness burn C. Hyperkalemia and hyponatremia
D. Deep full thickness burn D. Hyperkalemia and hypernatremia

4. During the acute phase of burn injury, which of the 12. A client, who sustained deep partial thickness and full
following is a priority? thickness burns of the face, whole anterior chest and both
A. Wound healing upper extremities two days ago, begins to exhibit extreme
B. Reconstructive surgery restlessness. You recognize that this most likely indicate that
C. Emotional support the client is developing:
D. Fluid resuscitation A. Cerebral hypoxia C. Metabolic acidosis
B. Hypervolemia D. Renal failure
5. While in the emergent phase, the nurse knows that the Text
priority is to: 13. A 165-lbs trauma client was rushed to the emergency room
A. Prevent infection with full thickness burns on the whole face, right and left arm
B. Control pain and at the anterior upper chest sparing the abdominal area. He
C. Prevent deformities and contractures also has superficial partial thickness burn at the posterior trunk
D. Return the hemodynamic stability via fluid resuscitation and at the upper half portion of the left leg. He was in the
EMERGENT PHASE emergent phase of the burn. Using the Parkland’s formula, you
6. The most effective method of delivering pain medication know that during the first 8 hours of burns, the amount of fluid
during the emergent phase is: to be given is: RIGHT AND LEFT ARM = 18%
A. Intramuscularly C. Orally A. 5,400 mL C. 9,450 mL ANTERIOR CHEST = 9%
B. Subcutaneously D. Intravenously B. 10, 500 mL D. 6,750 mL TBSA = 36%
Text 165 lbs = divided by 2.2 = 75kg WHOLE FACE = 95
7. When a client accidentally splashes chemicals to his eyes, 14. The doctor incorporated insulin on the client’s fluid during
the initial priority care following the chemical burn is to: the emergent phase. The nurse knows that insulin is given:
A. Irrigate with normal saline for 1 to 15 minutes A. Because clients with burns also develop metabolic acidosis
B. Transport to a physician immediately B. Because clients with burn also develop hyperglycemia
C. Irrigate with water for 15 minutes or longer C. Because insulin is needed for additional energy and glucose
D. Cover the eyes with a sterile gauze burning after stressful incidence, to hasten wound healing,
regain consciousness, and rapid return of hemodynamic
8. Which of the following can be a fatal complication of upper stability
airway burns? D. For hyperkalemia
A. Stress ulcers

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15. The IV fluid of choice for burn as well as dehydration is: A. Gender
A. 0.45% NaCl C. Sterile water B. Medications
B. NSS D. D5LRS C. Educational level
TO COUNTER METABOLIC ACIDOSIS D. Previous knowledge of illness
Situation: Enterostomal therapy is now considered a
specialty in nursing. You are participating in the 24. Which of the following statements does not apply to
ostomy care class. critically ill patients?
A. Majority need extensive rehabilitation
16. You plan to teach Phineas how to irrigate the colostomy B. All have been hospitalized previously
when: TO STIMULATE BOWEL MOVEMENT C. All physically unstable
A. The perineal wound heals and Phineas can sit comfortably D. Most have chronic illness
on the commode ALL, NEVER, NOT - absolute words
SAFEST WORDS; AMOST, MOST
B. Phineas can lie on the side comfortably about the 3 rd 25. Which of the following should be met first by the nurse for
postoperative day the families of critically ill patients?
C. The abdominal incision is closed and contamination is no A. Provision of comfortable space
longer a danger B. Emotional support
D. The stool start to become formed, around the 3 rd C. Updated information of client’s status
postoperative day D. Spiritual counseling

17. When preparing to teach Phineas how to irrigate the Situation: Julian sought consultation to the hospital
colostomy, when should you plan to do the procedure? because of irritability. He is jittery, and has been
A. When Phineas would have a normal bowel movement experiencing these signs and symptoms for about a
B. At least 2 hours before visiting hours week.
C. Prior to breakfast and morning care
D. After Phineas accepts the alteration in body image 26. His diagnosis was hyperthyroidism. The following are
expected symptoms, except: (-)
18. When observing a return demonstration of a colostomy A. Anorexia
irrigation, you know that further teaching is required when B. Palpitation
Phineas: C. Fine tremors of the hands
A. Lubricate the tip of the catheter prior to inserting into the D. Hyper alertness
stoma
B. Hangs the irrigating bag on the bathroom door cloth hook 27. He has to take drugs to treat his hyperthyroidism. Which of
during fluid insertion the following will the nurse expect to be prescribed by the
C. Discontinue the insertion of fluid after 500 mL of fluid has doctor?
been instilled A. Colace (Docusate) STOOL SOFTNER
D. Clamps off the flow of fluid if discomfort occurs B. Cytomel (Liothyronine) SYNTHETIHIC ( T3) hypothyrpodidism
hang in irrigating bag (45 - 50cm) 18 - 20 inches C. Tapazole METHIMAZOLE
19. You are aware that teaching about colostomy care is D. Levothyroxine SYnthethic T4 ( hypothyrodism)
understood when Phineas states, “I will contact my physician
and report:” 28. The nurse knows that Tapazole has which of the following
A. If I have any difficulty inserting the irrigating tube into the side effects that will warrant immediate withholding of the
stoma medication? METHIMAZOLE = Once a day, potent drug
B. If I notice a loss of sensation upon touch in the stoma tissue A. Death PROPYTHIOURACIL =( 3 - 4 doses /day)
MORE SIDE EFFECT. most common sore
C. The expulsion of flatus while the irrigating fluid is running B. Sore throat AGRANULUCYTOSIS throat, for pregnant women
out C. Hyperthermia
D. When mucus is passed from the stoma between the D. Thrombocytosis
irrigation
29. You asked questions as soon as she regained
20. You would know that dietary instructions for Phineas is consciousness from thyroidectomy primarily to assess:
effective when he states, “It is important that I eat:” A. Level of consciousness
A. Soft food that is easily digested and absorbed by my large B. Thyroid storm
intestines C. Damage to the laryngeal nerve
B. Bland food so that my intestines do not become irritated D. Hypocalcemia, tetany
C. Food low in fiber so that there are fewer stools
D. Everything that I ate before the operation, while avoiding 30. To check for hemorrhage, you will:
food that cause gas A. Slip your hand under the nape of her neck
B. Check for hypotension
C. Apply neck collar to prevent hemorrhage
Situation: Based on studies of nurses working in D. Observe the dressing if it is soaked with blood
special units like the intensive care unit and coronary
care unit, it is important for nurses to gather as much 31. Basal metabolic rate is assessed on Julian to determine his
information to be able to address their needs for metabolic rate. In assessing the BMR using the standard
nursing care. procedure, you need to tell Julian that the procedure requires:
A. Weighing the patient
21. Critically ill patients frequently complain about which of the B. Restraining his upper and lower extremities
following when hospitalized? C. Obstructing his hearing with ear plugs
A. Hospital hood D. Obstructing his nostrils with a clamp
B. Lack of blankets Text
C. Lack of privacy 32. The BMR is based on the measurement that:
D. Inadequate nursing staff A. Rate of respiration under different conditions of activity and
rest
22. Who of the following is at greatest risk of developing B. Amount of oxygen consumption under resting condition over
sensory problem? a measured period of time
A. Female patients C. Transplant patient C. Amount of oxygen consumption under stressed condition
B. Adolescent D. Unresponsive patient over a measured period of time
D. Ration of respiration to pulse rate over a measured period
23. Which of the following factors may inhibit learning in of time
critically ill patients?

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IODINE + POTASSIUM Hypocalcemia lead to tetany

33. Her physician orders Lugol’s solution in order to: B. Dyspnea D. Tetany
A. Decrease the vascularity and size of the thyroid gland
B. Decrease the size of the thyroid gland 45. After surgery, Johnny develops peripheral numbness,
C. Increase the vascularity and size of the thyroid gland tingling, muscle twitching and spasm. What would you
D. Increase the size of the thyroid gland anticipate to administer?
A. Magnesium Sulfate C. Potassium Iodide
34. Which of the following is a side effect of Lugol’s solution? B. Calcium Gluconate D. Potassium Chloride
A. Hypokalemia
B. Nystagmus Situation: Budgeting is an important part of a nurse
C. Enlargement of the thyroid gland managerial activity. The correct allocation and
D. Excessive salivation distribution of resources is vital in the harmonious
operation of the financial balance of the agency.
35. In administering Lugol’s solution, the precautionary
measure should include: 46. Which of the following best define Budget?
A. Administer with glass only A. Plan for the allocation of resources for future use
B. Dilute with juice and administer with a straw B. The process of allocating resource for future use
C. Administer it with milk and drink it C. Estimate goods and resources
D. Follow it with milk of magnesia D. Continuous process in seeing that the goals and objective of
the agency is met
Situation: Pharmacologic treatment was not effective
for Julian’s hyperthyroidism, now, he is scheduled for 47. Which of the following best define Capital budget?
thyroidectomy. A. Budget to estimate the cost of direct labor, number of staff
to be hired and necessary number of workers to meet the
36. Instruments in the surgical suite for surgery are classified general patient needs
as critical, semi-critical, or non-critical. If the instruments are B. Include the monthly and daily expenses and expected
introduced directly into the blood stream or into any normally revenue and expenses LONG TERM
PLANNING
sterile cavity or area of the body, it is classified as: C. These are related to long term planning and includes major
A. Critical C. Non-critical BP APP , PULSE OX replacement or expansion of the plant, major equipments and
B. Semi-critical D. Ultra critical inventories
MUCUS MEMBARNES
D. These are expenses that are not dependent on the level of
37. Instruments that do not touch the patient or have contact production or sales. They tend to be time-related, such as
only to intact skin are classified as: salaries or rents being paid per month
A. Sterilized C. Disinfected
B. Decontaminated D. Clean 48. Which of the following best described Operational Budget?
A. Budget to estimate the cost of direct labor, number of staff
38. If an instrument is classified as Semi-Critical, an acceptable to be hired and necessary number of workers to meet the
method of making the instrument ready for surgery is through: general patient needs
A. Sterilization C. Disinfection B. Include the monthly and daily expenses and expected
B. Decontamination D. Cleaning revenue and expenses BATTERIES,
C. These are related to long term planning and includes major
39. While critical items and should be: replacement or expansion of the plant, major equipments and
A. Clean C. Sterilized inventories
B. Decontaminated D. Disinfected D. These are expenses that are not dependent on the level of
production or sales. They tend to be time-related, such as
40. As a nurse, you know that intact skin acts as an effective salaries or rents being paid per month
barrier to most microorganisms. Therefore, items that come in
contact with the intact skin or mucus membranes should be: 49. Which of the following accurately describes a fixed cost in
A. Disinfected C. Clean budgeting?
B. Sterile D. Alcoholized A. These are usually the raw materials and labor salaries that
depend on the production or sales
41. You are caring for Julian who is scheduled to undergo total B. These are expenses that change in proportion to the activity
thyroidectomy because of a diagnosis of thyroid cancer. Prior of a business ELECTRICITY , WATER , RENT ,
to total thyroidectomy, you should instruct Johnny to: C. These are expenses that are not dependent on the level of
A. Perform range and motion exercise on the head and neck production or sales. They tend to be time-related, such as rent
B. Apply gentle pressure against the mouth while swallowing D. This is the summation of Variable Cost and the cost in
C. Cough and take a deep breath every 2 hours Budgeting
D. Support head with the hands in side-lying position
50. Which of the following accurately describes variable cost in
42. As Julian’s nurse, you plan to set up an emergency budgeting?
equipment at his bedside following thyroidectomy. You should A. These are related to long term planning and includes major
include: ANTICPATE: AIRWAY OBSTRUCTION replacement or expansion of the plant, major equipments and
A. An airway and rebreathing tube ANTICPATE COMPLICATIONS inventories
B. A tracheostomy set and oxygen DIGOXIN = DIGIBIND B. These are expenses that change in proportion to the activity
C. A crash cart with bed board of a business DELIVERY AND PACKAGING
D. Two ampules of sodium bicarbonate C. These are expenses that are not dependent on the level of
TRACHEOSTOMY = OBTURATOR; HEMOSTAT
production or sale. They tend to be time-related, such as rent
43. Which of the following nursing interventions is appropriate D. This is the summation of the Variable Cost and the Fixed
after a total thyroidectomy? cost VARIABLE COST VS FIX COST
CAPITAL VS OPERATIONAL
A. Place pillows under your patient’s shoulders
B. Raise the knee-gatch to 30 degrees Situation: Rizza is admitted to the ER following an
C. Keep you patient in high – fowler’s position assault where she was hit in the face and head. She
D. Support the patient’s head and neck with pillows and was brought to the ER by a police woman. Emergency
sandbags measures were started.
TACHYPNEA AND EPISODE OF APNEA
44. If there is an accidental injury to the parathyroid gland 51. Rizza’s respiration is described as waxing and waning. You
during a thyroidectomy, which of the following might lead to know that this rhythm of respiration is defined as:
develop post-operatively? ( REGULAR BREATHING THEN ANEA) A. Biot’s C. Cheyne Stokes( WAXING AND WANNING)
A. Cardiac arrest C. Respiratory failure B. Kussmaul’s D. Eupnea
( RAPID DEEEP BREATHING)

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Text

61. A client has an indwelling urinary catheter and she is

52. What do you call the triad of sign and symptoms seen in a suspected of having urinary infection. How should you collect a
client with increasing ICP? urine specimen for culture and sensitivity?
A. Virchow’s Triad VENOUS STASIS , VESS WALL DAMAGE A. Clamp tubing for 60 minutes and insert a sterile needle into
B. The Chinese Triad the tubing above the clamp to aspirate urine
C. Cushing’s Triad ( WIDENED PULSE PRESSURE , BRADYPNEA and B. Drain urine from the drainage bag into the sterile container
BRADYCARDIA
D. Charcot’s Triad C. Disconnect the tubing from the urinary catheter and let
(MULTIPLE SCLEROSIS:SCANNING/ or NYSTAGMUS , TREMORS
ACUTE CHOLANGITIS ( INFLAMMATION OF BILE DUCTS, JAUNDICE , ABDOMINAL PAIN urine flow into a sterile container
53. Which of the following is true with the triad seen in head D. Wipe the self-sealing aspiration port with antiseptic solution
injuries? and insert sterile needle into the self-sealing port
A. Narrowing of pulse pressure, Cheyne Stokes respiration,
tachycardia 62. To obtain specimen for sputum culture and sensitivity,
B. Widening pulse pressure, irregular respiration, bradycardia which of the following instruction is best?
C. Hypertension, Kussmaul’s Respiration, tachycardia A. Upon waking up, cough deeply and expectorate into the
D. Hypotension, irregular respiration, bradycardia container
B. Cough after pursed lip breathing
54. In a client with a Cheyne stokes respiration, which of the C. Save sputum for two days in covered container
following is the most appropriate nursing diagnosis? D. After respiratory treatment, expectorate into a container
A. Ineffective airway clearance
B. Ineffective breathing pattern 63. What is the best time for collecting the sputum specimen
C. Impaired gas exchange for culture?
D. Activity intolerance A. Before retiring at night
B. Upon waking up in the morning
55. You know that apnea is seen in clients with Cheyne stokes C. Anytime of the day
respiration. Apnea is defined as: d. Before meals
A. Inability to breath in a supine position so the patient sits up
in bed to breath 64. When suctioning the endotracheal tube, the nurse should:
B. The patient is dead, the breathing stops A. Explain procedure to patient, insert catheter gently while
C. There is an absence of breathing for a period of time, applying suction, withdraw using twisting motion
usually 15 seconds or more B. Insert catheter until resistance is met, then withdraw
D. A period of hypercapnea and hypoxia due to the cessation slightly, apply suction intermittently as catheter is withdrawn
of respiration effort inspite of normal respiratory functioning C. Hyperoxygenate patient, insert catheter using back and
Situation: After an abdominal surgery, the circulating forth motion ( SWIRLING MOTION )
and scrub nurse have critical responsibilities. D. Insert suction catheter four inches into the tube, suction 30
seconds using twirling motion as catheter is withdrawn
56. Counting is performed thrice: during the pre-incision
phase, the operative phase and closing phase. Who counts the 65. The purpose of NGT immediately after an operation is:
sponges, needles, and instruments? A. For feeding or gavage FLATUS - INCREASED PAIn (DISCOMFORT)
A. The scrub nurse only B. For gastric decompression
B. The circulating nurse only C. For lavage, or the cleansing of stomach content
C. The surgeon and assistant surgeon D. For the rapid return of peristalsis
D. The scrub nurse and circulating nurse
Situation: Mr. Delos Reyes, 48, is to undergo
57. The layer of the abdomen is divided into five. Arrange the cystoscopy due to multiple problems like scanty
following from the first layer going to the deepest layer. urination, heamturia, and dysuria.
1.Fascia 3rd
2. Muscle 4th 66. You are the nurse in charge to Mr. Delos Reyes. When
3. Peritoneum (5th) asked what are the organs to be examined during cystoscopy,
4. Subcutaneous tissue (2nd) you will enumerate as follows:
5. Skin ( 1st) A. Ureters, kidney, bladder, urethra
A. 5,4,3,2,1 C. 5,4,1,3,2 B. Urethra, bladder wall, trigone, ureteral opening
B. 5,4,2,1,3 D. 5,4,1,2,3 C. Bladder wall, uterine wall, and urethral opening
D. Urethral opening, ureteral opening, bladder
Text
58. When is the first sponge and instrument count reported?
A. Before closing the subcutaneous layer 67. In the OR, you will position Mr. Delos Reyes, who is for
B. Before the peritoneum is closed cystoscopy, in:
C. Before closing the skin A. Supine C. Semi-fowler’s
D. Before the fascia is sutured B. Lithotomy D. Trendelenburg

59. Like any nursing interventions, counts should be 68. After cystoscopy, Mr. Delos Reyes asked you to explain
documented. To whom does the scrub nurse report any why there is no incision of any kind. What do you tell him?
discrepancy of counts so that immediate and appropriate A. Cystoscopy is a direct visualization and examination by the
action is instituted? urologist
A. Anesthesiologist C. OR nurse supervisor B. Cystoscopy is done by x-ray visualization of the urinary tract
B. Surgeon D. Circulating nurse C. Cystoscopy is done by using lasers on the urinary tract
D. Cystoscopy is an endoscopic procedure of the urinary tract
60. Which of the following are two interventions of the surgical
team when an instrument was confirmed missing? 69. Within 24-48 hours post cystoscopy, it I normal to observe
A. MRI and incidence report which of the following?
B. CT Scan, MRI, incidence report A. Pink-tinged urine
C. X-ray and incidence report B. Distended bladder
D. CT Scan and incidence report C. Signs of infection
D. Prolonged hematuria
Situation: An entry level nurse should be able to apply (-)
theoretical knowledge in the performance of the basic 70. Leg cramps are not uncommon post cystoscopy. Nursing
nursing skills. intervention includes:
A. Bed rest C. Early ambulation
B. Warm moist towel D. Hot sitz bath

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Situation: Mang Nardo, 75, was brought to the surgical
unit from PACU after a transurethral resection. You are
assigned to receive him. You noted that he has a 3-way
indwelling urinary catheter for continuous fast drip
bladder irrigation which is connected to a straight
drainage.
71. Immediately after surgery, you expect the urine to be:
A. Light yellow C. Bright
B. Amber D. Pinkish to red
72. The purpose of the continuous bladder irrigation is to:
A. Allow continuous monitoring of the fluid output status
B. Provide continuous flushing of clots and debris from the
bladder
C. Allow for proper exchange of electrolytes and fluids
D. Ensure accurate monitoring of intake and output
73. Mang Nardo informs you that he feels some discomfort on
the hypogastric area and he has to void. What will be your
most appropriate action?
A. Remove his catheter then allow him to void on his own
B. Irrigate his catheter
C. Tell him to go ahead and void, anyway, he has an
indwelling catheter
D. Note if there is a change in color and rate of outflow then
refer to the urologist for possible irrigation
74. You decided to check on Mang Nardo’s IV fluid infusion.
You noted a change in flow rate, pallor and coldness around
the insertion site. Your assessment findings suggest:
A. Phlebitis WARMTH , REDNESS
B. Infiltration to subcutaneous tissues ( PALLOR, COLDNESS)
C. Pyrogenic reaction ( CHILLS , FEVER, some symptoms of infection)
D. Air embolism
75. Knowing that proper documentation of assessment findings
and interventions are important responsibilities of the nurse
during the first post-operative day. Which of the following is
the least relevant to document in the case of Mang Nardo?
A. Chest pain and vital signs
B. Intravenous infusion rate
C. Amount, color, and consistency of bladder irrigation
drainage
D. Activities of daily living started
Situation: Many hospitals form bioethical review
committees to ensure the quality of life. You are invited
by the nursing service department to participate in
their bioethical review committee. You are expected to
know the purpose and apply bioethical principles.
76. Which of the following is the purpose of the bioethical
review committee?
A. Promote implementation of general standards
B. Enhance health care providers’ liability
C. Increase individual’s responsibility for decision making
D. Decrease public scrutiny of health care provider’s action
77. Badz, who is admitted to the hospital with autoimmune
thrombocytopenia and a platelet count of 20,000, develops
epistaxis and melena. Treatment with corticosteroids and
immunoglobulin has not been successful. Her physician
recommended splenectomy. Badz states “I do not need
surgery. This will go away on its own.” In considering your
response to Badz, you must depend on the ethical principle of:
A. Beneficence DOING GOOD
B. Justice RESOURCES; TIME ;
C. Autonomy ( DECISION MAKING )
D. Advocacy
78. Janelle is terminally ill and is experiencing severe pain. She
has bone and liver metastasis. She has been on morphine for
several months now. Janelle is aware that they are having
financial problems. She decides to sign a DNR form. What
ethical principle did Janelle and her family utilize as basis for
their decision to sign a DNR.
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A. Justice C. Beneficence
B. Autonomy D. Advocacy
79. Cindy, a staff nurse working in a cancer unit, is considered
a role model not only by her colleagues but also by her
patients. She goes out of her way to help others. She is very
active in their professional organization and she practices what
she teaches. What ethical principle is she practicing?
A. Beneficence C. Advocacy
B. Autonomy D. Justice
80. You are commuting to work riding the LRT. An older
person collapsed and nobody seems to notice her. The security
guard tried to make her sit down but she remained
unconscious. You saw what happened and you decided to
help. With help, you brought the patient to the nearest
hospital. You learned later that the woman was diabetic. She
was on her way to the diabetes clinic to have her fasting blood
sugar tested. She developed hypoglycemia. You were able to
save a life. You felt good. What principle was applied?
A. Advocacy C. Justice
B. Beneficence D. Autonomy
MALEFICENCE= AVOIDING HARM, DO ANY PROCEDURES
Situation: Bryan G., 65 years old, was admitted due to
end-stage renal failure
81. During the assessment of Bryan’s scheduled hemodialysis,
the nurse hears bruit over the site of the AV graft. The nurse
should:
A. Notify the physician immediately
B. Recognize that the graft is patent
C. Reposition the client and listen agin
D. Delay dialysis until an x-ray is obtained
Kapag hindi patent . irefer agad sa physician
82. Mr. G has an order for a diet containing protein with high
biologic value. An example of a protein source with high
biologic value is:
A. Gelatin
B. Nuts
C. Eggs
D. Legumes
83. The chart of Mr. G lists his dry weight as 61.36 kg. The
term dry weight refers to:
A. The client’s weight before dialysis
B. The client’s morning weight
C. The client’s evening weight
D. The client’s weight after dialysis
84. A client’s family member asks the nurse why the client on
hemodialysis developed disequilibrium syndrome. The nurses’
response should be based on the understanding that dialysis
disequilibrium syndrome occurs as a result of:
A. A contaminated connection site between the catheter and
the machine
B. A Rapid change in the sodium and water levels
C. The presence of residual blood left in the dialysis machine
D. Too rapid decrease in the blood urea nitrogen levels
( EARLY SYMPTOMS NEUROLOGIC SYMPTOMS - HEADCAHE, VOMITING )
85. The nurse is assessing a client following hemodialysis.
Which of the following findings indicates the treatment was
effective?
A. Hypertension
B. Hyperkalemia
C. Fluid volume decrease
D. Cardiac dysrhythmias
Situation: Breast cancer is the 2nd most common type
of cancer after lung cancer. 99% of which occurs in
women. The survival rate is at 98% if this is detected
early and treated promptly. Marian is a 55-year-old
patient in the high risk group for breast cancer, and
was recently diagnosed.
86. All of the following are factors that are said to contribute to
the development of breast cancer, except:
A. Prolonged exposure to estrogen
B. Genetics
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C. Increasing age Situation: Radiation therapy is another modality of

D. Prolonged intake of Tamoxifen (Nolvadex) cancer management. With emphasis on
multidisciplinary management, you have important
87. Protective factors for the development of breast cancer are responsibilities as a nurse.
the following except: (-)
A. Exercise 96. Jhon is receiving external radiation therapy and he
B. Prophylactic Tamoxifen complains of fatigue and malaise. Which of the following
C. Breastfeeding nursing interventions would be most helpful for Jhon?
D. Alcohol intake A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
88. A patient diagnosed with breast cancer has been offered C. Reassure him that these feelings are normal
the treatment choices of breast conservation surgery with D. Help him plan his activities
radiation or a modified radical mastectomy. When questioned
by the patient about these options, the nurse informs the 97. Immediately following the radiation teletherapy. Jhon is:
patient that the lumpectomy with radiation: A. Considered radioactive for 24 hours
A. Reduce the fear and anxiety that accompany the diagnosis B. Given a complete bath
and treatment of cancer C. Placed on isolation for 6 hours
B. Has about the same 10 year survival rate as the modified D. Free from radiation
radical mastectomy
C. Provide a shorter treatment period with a fewer long term 98. Jhon is admitted with radiation-induced thrombocytopenia.
complications As a nurse, you should observe which of the following
D. Preserve the normal appearance and sensitivity of the symptoms?
breast A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor
89. Carmen asked the most appropriate time of the month to C. Headache, dizziness, blurred vision
do her self-examination of the breast. The most appropriate D. Severe sore throat, bacteremia, splenomegaly
reply by the nurse would be:
A. The 26th day of the menstrual cycle 99. Which nursing diagnosis should be of highest priority?
B. 7 to 8 days after conclusion of the menstrual period A. Knowledge deficit regarding thrombocytopenia precautions
C. During her menstruation B. Activity intolerance
D. The same day each month C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral,
90. Marian is being treated with radiation therapy. What cardiovascular, gastrointestinal, renal
should be included in the plan of care to minimize skin damage
from the radiation therapy? 100. What intervention should you include in your care plan?
A. Cover the areas with thick clothing materials A. Inspect his skin for petechiae, bruising, GR bleeding
B. Apply a heating pad to the site regularly
C. Wash skin with water after the therapy B. Place Jhon on strict isolation precautions
D. Avoid applying cream and powder to the area C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 0C
91. Based on the DOH and World Health Organization (WHO)
guidelines, the mainstay for early detection method for breast
cancer that is recommended by developing countries is:
A. A monthly breast self-examination (BSE) and annual health
worker breast examination (HWBE)
B. An annual hormone receptor assay
C. An annual mammogram
D. A physician conducts a breast examination every 2 years

92. The purpose of performing the breast self-examination

regularly is to discover:
A. Fibrocystic masses
B. Cancerous lumps
C. Areas of thickness or fullness
D. Changes from previous BSE

93. If you are to instruct a post-menopausal woman about

BSE, when should you tell her to do BSE?
A. On the same day each month
B. Right after the menstrual period
C. On the first day of her menstruation
D. On the last day of her menstruation

94. During breast self-examination, the purpose of standing in

front of the mirror is to observe the breast for:
A. Thickening of the tissue
B. Axillary lymph nodes
C. Lumps in the breast tissue
D. Changes in size and contour

95. When preparing to examine the left breast in a reclining

position, the purpose of placing a small folded towel under the
client’s left shoulder is to:
A. Bring the breast closer to the examiner’s right hand
B. Tense the pectoral muscle
C. Balance the breast tissue more evenly on the chest wall
D. Facilitate lateral positioning of the breast

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