MEDICAL SURGICAL NURSING/ ANSWER: Effortless respiration

FUNDAMENTALS OF NURSING 19. When the nurse conducts physical assessment of the abdomen,
1. Purpose of small volume enema auscultation should precede palpation to:
ANSWER: Used to clean the sigmoid and rectum ANSWER: Prevent altering the frequency and character of
bowel sounds
2. How enema function 20. Dimming lights of the room as request by the client, level of
ANSWER: Causes distention of the bowel and stimulates the Maslow’s hierarchy of needs met
defecation reflex ANSWER: Safety and Security
3. During enema administration, direct rectal tip of enema solution 21. Inadequate nutrition
container to ANSWER: Emaciated and weak appearance
ANSWER: Causes distention of the bowel and stimulates the
defecation reflex 22. Desired effect of the bronchodilator in patient with severe
4. Once the client is in position the nurse visualizes the anus and is upper respiratory tract infection
ready to insert the rectal tip. She is doing the procedure ANSWER: effortless respiration
correctly when she directs the rectal tip to the: 23. In abdominal assessment, auscultation should precede
ANSWER: umbilicus palpation to:
5. Principle behind obtaining informed consent before invasive ANSWER: Prevent altering the frequency and character of
procedure bowel sounds
ANSWER: Autonomy 24. During palpation
6. Autonomy ANSWER: use fingertips
ANSWER: respect for an individual’s right to self-determination 25. After giving analgesic, what is the priority
and freedom to choose and implement one’s own decision ANSWER: reassess pain level after 30 minutes to 1 hour of
 be sure that all patients have consented to all treatments giving the drug
and procedure
 explain procedures to patients properly 26. McCaffery’s guideline in pain management
7. A staff nurse reports to the supervisor that a newly hired nurse ANSWER: "whatever the experiencing person says it is, existing
is “falsifying data in the vital signs sheet for the clients assigned whenever and wherever the person say it does" has become the
to her.” What action should the supervisor do FIRST? prevailing conceptualization of pain for clinicians over the past
ANSWER: Take the client’s vital signs and compare with the few decades
data recorded by the new nurse 27. To maintain efficacy of nitroglycerine, store drug where
ANSWER: C ANSWER: Keep sublingual tablets in amber glass bottle
8. Priority management in patient with restraint 28. Appropriate instruction to patient with Patient-Controlled
ANSWER: Release every 2 to 4 hours, Assess every 30 minutes Analgesia
or as needed ANSWER: “Push the button when you feel the pain is starting.”
9. The parents understand safety precautions on children when 29. Possible sign of ruptured appendix
they state that they: ANSWER: Pain subsides
ANSWER: Will keep plastic bags and wraps are away from
reach of children 30. An effective intervention to prevent perforation of the inflamed
ANSWER: C appendix
10. Accidental poisoning is an important concern because poisons ANSWER: Keep patient on N PO
cause serious injuries to children and the elderly. As you 31. Short discrete bubbling sounds over the lower region of lungs
conduct your safety awareness class for parents, you find that ANSWER: crackles
you need to give more detailed instructions when a parent says
“I will: 32. Continuous, high-pitched, squeaky musical sounds adventitious
ANSWER: induce vomiting if my child swallows kerosene.” breath sound
11. Which of the following are required measures observed by ANSWER: wheezing
health care workers when in contact with blood and body fluids? 33. Acromegaly, manifestation
ANSWER: Hand hygiene and gloves ANSWER: Enlarged extremities due to skeletal thickness and
12. When communicating with Theresa, the nurse assumes the face macroglossia (large tongue)
to face position to: 34. Transphenoidal hypophysectomy, incision site
ANSWER: Express availability and desire to communicate ANSWER: under the upper lip
13. Communication zone for communication between nurse and 35. What to wear BEFORE scrubbing of hands in OR
patient ANSWER: head cap, mask, goggles
ANSWER: Personal distance
14. While communicating with Theresa you use attentive listening. 36. Skin preparation in OR, what and how to wear
This requires that the nurse: ANSWER: sterile gloves – open glove technique
ANSWER: Pays attention to both the content and feeling tone 37. Most painful site of the wrist during venipuncture
of the client ANSWER: inner aspect of the WRIST
15. The client complains of pain in the left chest down to the left 38. Cause of hypospadias
shoulder and left jaw. In your documentation for your nurses’ ANSWER: congenital (occurs during 3rd month of fetal
notes, you will record this as: development)
ANSWER: Radiating pain
16. The changes in Mrs. De Vera’s vital signs that you would expect 39. Surgical operation needed to be postponed for a child with
when she complains of pain are the following EXCEPT: hypospadias
ANSWER: Decrease in temperature ANSWER: Circumcision
17. A client with congestive heart failure is taking 40. Radioactive iodine uptake determines what
hydrochlorothiazide once a day. While the client is taking the ANSWER: Absorption of the iodine isotope
medication, the nurse should encourage the client to eat which 41. Diet for hypothyroidism
of the following fruits: ANSWER: low calorie, high fiber
ANSWER: banana
42. Post-thyroidectomy, assessment for possible laryngeal nerve
18. The nurse is administering a bronchodilator to a client with damage
severe upper respiratory tract infection. The client is ANSWER: Talk with the client and note change in voice
manifesting the desired effect of the bronchodilator when the 43. Serum calcium level of 5.0 mg/dl, what to do
nurse assesses which of the following:
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 ANSWER: Assess for signs of tetany
73. Exacerbation of multiple sclerosis
44. Confirmatory diagnosis for hiatal hernia ANSWER: diplopia and nystagmus
ANSWER: barium swallow
74. Patient Marina verbalized to the nurse that she is like her
45. To prevent increase in gastric acid secretion mother
ANSWER: avoid cigarette smoking ANSWER: transference
46. Confirmatory test for cholelithiasis 75. Neurotransmitters that are decrease in depression
ANSWER: UTZ ANSWER: serotonin and norepinephrine
47. Morphine is contraindicated for cholelithaisis because: 76. Therapeutic effect of Sertraline (Zoloft)
ANSWER: Causes spasm of the Sphincter of Oddi ANSWER: increases Serotonin
48. Bilateral tubal ligation, ask for informed consent to whom 77. Crisis
ANSWER: BOTH husband and wife ANSWER: Can no longer cope with usual problem-solving skills
49. Role of nurse in informed consent 78. Crisis, characteristic
ANSWER: witness ANSWER: Opportunity of learning better ways of coping,
Presence of a threatening event, Failure of usual problem-
50. Characteristic (typology) of RBC in iron deficiency anemia solving mechanisms
ANSWER: Microcytic and hypochromic
79. Polyneuropathy, deficiency in vitamin
51. Vitamin B12 deficiency, S/Sx ANSWER: B
ANSWER: Slight jaundice, fatigue, paresthesia, glossitis
80. Prompt treatment of alcoholism, assess for
52. Surgeon came into the OR suite swinging her hands ANSWER: At most eight hours from the time the patient last
ANSWER: Oblige the assistant surgeon to scrub again drank alcohol
53. How to apply dressing after stitching of incisional site 81. “I don’t need help. Leave me alone. I am just fine.”
ANSWER: Put the dressings, remove his gloves to apply the ANSWER: denial
tape
82. A immediate goal of crisis intervention
54. Processes of absorption of nutrients by SMALL intestine ANSWER: Resolve the problem
ANSWER: diffusion and active transport
83. Duration of crisis
55. Psoriasis ANSWER: 4 to 6 weeks
ANSWER: A chronic inflammatory skin disorder, not contagious
84. Research: double blind approach
56. Psoriasis skin lesions ANSWER: Neither the subject of those who administer the
ANSWER: Well demarcated regions of erythematous plaques treatment know how is in the experimental and control group
that shed thick silvery white flakes
85. Right to self-determination is reflected in
57. Herpes Zoster (shingles), precipitating factor ANSWER: Informed consent obtained
ANSWER: decrease immune system
86. Blind patent, nursing diagnosis
58. Shock, position ANSWER: Risk for injury
ANSWER: modified trendelenburg
87. Dementia, nursing diagnosis
59. 2 characteristics of circulating blood volume in septic shock ANSWER: Risk for injury
ANSWER: (1) Vasodilation and (2) Maldistribution of circulating
blood volume 88. Sodium Polystyrene Sulfonate (Kayexalate), effect
ANSWER: Excrete potassium through the intestinal tract
60. Water in the water seal bottle to fluctuate
ANSWER: patent chest tube 89. Before paracentesis
ANSWER: Have patient void
61. Chest tube is dislodged
ANSWER: Cover insertion site with petroleum gauze 90. Increase of 1 kg in body weight is equivalent to
ANSWER: 1 LITER of fluid retention
62. sudden increase drainage in chest tube
ANSWER: Assess for signs of hemorrhage 91. Goal of HIV management
ANSWER: Improve the patient’s immune function
63. Corticosteroids use, nursing diagnosis
ANSWER: Ineffective protection (risk for infection) 92. Juvenile Idiopathic Arthritis, cause
ANSWER: unknown
64. Hypoglycemia, manifestations
ANSWER: Cool, moist skin, Slurred speech, Tremors 93. Plasmapharesis
ANSWER: Remove antibody-antigen complexes from circulation
65. Hyperresonance, determined by
ANSWER: percussion 94. Palliative Care
ANSWER: Provides relief from pain and other distressing
66. Rat bite, what to do first symptoms
ANSWER: Cleanse wound thoroughly
95. Demonstrate respect of client’s autonomy
67. Critical nursing intervention for a patient with status epilepticus ANSWER: Facilitating and supporting client’s choices regarding
ANSWER: protecting airway treatment options
68. Effect of Diazepam in seizure 96. failed to attend to clients needs
ANSWER: Relaxes peripheral muscles AMSWER: negligence
69. Patient with head trauma, seizure happens when 97. “leave me alone, I need rest”, the nurse responds by saying:
ANSWER: Within the first few weeks postrauma ANSWER: “You sound upset.”
70. Chlorpromazine (Thorazine), adverse effect 98. A client suddenly shouts “Why is this taking so long? I have
ANSWER: Agranulocytosis and jaundice been waiting for several hours and nobody attends to us?”
What should be the initial response of the nurse?
71. “Ants are crawling all over my body.” (Akathisia), problem in ANSWER: Talk to the client and determine her immediate needs
ANSWER: sensorium or orientation
99. Client says to the nurse, “I’m nervous. Is the doctor competent
72. Patient with multiple sclerosis with fluctuating physical in this kind of surgery? Are there clients with similar surgery
condition and generalized weakness, management who survived the procedure?” How should the nurse best
ANSWER: Space activities throughout the day respond?
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 ANSWER: “You seem concerned about the surgery.”
100. An order to discontinue catheterization of the client was
implemented. She has complaints of difficulty in her first
attempt to urinate. The nurse explains that this is due to:
ANSWER: Attempt of the body to adjust to normal reflex
mechanism.
101. removal of the inner cannula when he/she:
ANSWER: Unlocks inner cannula by turning counter-clockwise
and gently withdrawing in line with its curvature
102. clear liquid diet for a post-surgery client
ANSWER: Tea, cola drinks, gelatin
103. assists the client to identify and cope with stressful emotional
problems
ANSWER: Counselor
104. hospital director gives the nurse a position of authority within a
formal organization, she assumes the role of:
ANSWER: Manager
105. The nurse who uses his interpersonal skills to guide the client in
making decisions about his health care is acting the role of:
ANSWER: Leader
106. Part of your teaching plan that helps address nutrition
problems in the community include all
ANSWER:
 Aiming for ideal body weight in all age brackets
 Building health nutrition related practices
 Choosing food wisely focusing on food pyramid guide
107. The nurse observes that childhood obesity is more common
now. The frequent cause of this is the Filipino parents’ belief
that:
ANSWER: A fat child is healthy, a thin child is sickly
108. plan to do first for a client who is experiencing depression?
ANSWER: Assist the patient to express feelings, beliefs, and
values
109. While the nurse is assisting the client in her care, the client
starts to cry and strikes her. The behavior that the client is
manifesting best describes which of the following stages of
death and dying?
ANSWER: Anger
110. A client with injured left leg is sitting on the bed preparing to
transfer to a wheel chair. The nurse is assisting the client and
positions the wheelchair on the:
ANSWER: Client’s right side
111. A client has difficulty walking and needs a wheel chair to
facilitate performance of daily activities. Anticipating the needs
of the client, the nurse should have the wheel chair ready by
placing it at:
ANSWER: 45-degree angle to the bed
112. You noticed that a client’s temperature has widely fluctuated
above the normal temperature. You will record this type of
fever in the client’s chart as:
ANSWER: Remittent
113. temperature readings indicate that he has been having fever
but his body temperature would return to normal only to recur
the next day
ANSWER: Relapsing
114. While conducting rounds, the nurse notices a fire in a client’s
room. Which of the following should be the appropriate action
of the nurse?
ANSWER: Evacuate the client from the room
115. To confirm pregnancy, the doctor will most likely:
ANSWER: Order an ultrasound examination
116. Madelaine complains that her early morning nausea and
vomiting really bothers her and prevents her from completing
her work. To decrease the discomfort and keep her nourished,
you advise her to:
ANSWER: Eat dry crackers or toast before getting up in the
morning
117. Last menstrual period (LMP) was March 15, 2010. Using Nagel’s
rule, her expected date of delivery (EDD) is:
ANSWER: December 22, 2010
118. A pregnant she was diagnosed with gestational diabetes. She
asks, ‘what are my chances of becoming a real diabetic later in
life?” The best reply by the nurse would be:
ANSWER: “Women diagnosed with gestational diabetes have
an increased risk of developing diabetes later in life.”
119. A 17 weeks gestation a type 1 diabetic undergoes an
ultrasound examination. What information about the fetus at
this time in pregnancy will the results of this examination
provide?
ANSWER: Placental Maturity
120. a toddler loves to play at the park, and the nurse encourages
the mother to continue physical activities for what reason
ANSWER: allowing the toddler to walk, run and hop enhances
the child’s kinaesthesia
121. how to prevent early-childhood dental cavities
ANSWER: “Make sure your child’s diet is nutritious, and limit
snacks high in sugar.”
122. In caring for a 3-year-old Nurse Sarah knows that she needs to
obtain the height of the child as part of routine health
screening. To obtain an accurate measurement, the child must:
ANSWER: Remove his shoes and stand upright, with head level
123. The 12 month old child with birth weight 8 lbs. Upon
assessment the child now weighs 18 lbs. in documenting this
result, the nurse knows that this weight is:
ANSWER: Below the expected weight
124. radiation safety
ANSWER: Shielding, distance, time
125. LEAST protection from radiation
ANSWER: Rubber gloves
126. On auscultation, Mitral Stenosis?
ANSWER: Low pitched, rumbling murmur occurring during
diastole
127. On auscultation, Aortic Stenosis?
ANSWER: Cresendo-decresendo systolic murmur
128. On auscultation, Mitral regurgitation?
ANSWER: Blowing high pitched systolic murmur
129. Which of the following chemotherapeutic agent’s effects will be
interfered by vitamin folic acid?
ANSWER: methotrexate
130. Chronic Hepatitis B can transmitted by
ANSWER: Contaminated needle
131. therapeutic range of lithium
ANSWER: 0.5 to 1.5 mEq/L
132. When the body responds to stress, epinephrine is released
producing which physiological response?
ANSWER: A more forceful heart beat
133. terminate SVT through stimulation of which of the following
cranial nerves?
ANSWER: Cranial nerve X
134. Stevens-Johnson Syndrome?
ANSWER: Hypersensitivity reaction
135. Which of the following symbols are used to document arterial
oxygen saturation as measured by pulse oximeter?
ANSWER: SpO2 (SaO2)
136. The ICU nurse orientee observed the following arterial blood
gases results in one of the patient’s record: ph-7.46; paO2-
97mmHg; paCO2-40mmHg and HCO3-30meq/L. Which of the
following is the interpretation of these results?
ANSWER: Metabolic alkalosis
137. Epinephrine
ANSWER: Bronchodilating effects
138. Based on the suspected diagnosis, the nurse would expect that
the gnawing epigastric pain will DECREASE with which of the
following activities of the client?
ANSWER: Eating a bland diet
139. The stool examination result of clients with peptic ulcer is
POSITIVE for:
ANSWER: blood
140. Intussusception, manifestation
ANSWER: Crampy and intermittent severe abdominal pain
141. intussusception
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 ANSWER: Telescoping of bowel into the adjacent segment 161. The nurse’s focus of care on clients with hearing and balance
problems is:
142. primary indication of the NGT in intussusception ANSWER: safety and promotion of independence
ANSWER: decompresssion
162. The onset of crisis is triggered by a:
143. Which of the following food enhance absorption of iron? ANSWER: sudden precipitating event
ANSWER: Citrus fruits
163. A client is in a skeletal traction, the nurse understands that this
144. The client was prescribed ferrous Sulfate as iron supplement. procedure involves pulling force:
For better absorption, the nurse would instruct the client to ANSWER: Directly through pins inserted into the bone
take this supplement.
ANSWER: 1 hour before 164. High in purine
ANSWER: Organ meats, wine and mussels
145. The scrub nurse aids the assistant surgeon apply the sterile
drape. The scrub nurse understands that once the drapes are 165. Shooting in ER, first to do by the nurse
positioned over the prepped incision site, the drapes must not ANSWER: hide
be:
ANSWER: Moved 166. Hypotension, compensatory mechanism of the body
ANSWER: Activation of Renin-Angiotensin
146. During the interview, nurse found out that the client takes
Prophythiouracil (Prophyl-Thracil) daily. Which of the following 167. Scrub nurse, role played for patient under anesthesia
is the specific action of this drug? ANSWER: Client advocate (the nurse fights for the rights of the
ANSWER: Blocks thyroid hormone production patient)
147. Along with other treatments. Metformin HCL (Glucophage) was 168. Scrub nurse
prescribed. The nurse should monitor for which potential ANSWER: “Guardian of asepsis”
serious side effect of the drug?
ANSWER: Lactic acidosis 169. Surgeon
ANSWER: Captain of the ship (makes major decision)
148. Colchicine is prescribed during the acute attack phase. Nurse
Karmela is aware that the action of the drug is to: 170. Circulating nurse, function
ANSWER: Interfere with the inflammation response of uric acid ANSWER: Validates informed consent
crystals in the joints.
171. Circulating nurse, first thing to be done upon entrance of
149. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once daily patient in OR
has been prescribed for the client. The specific action of this ANSWER: Greet the patient and CHECK the IDENTITY
thiazide diuretic is to:
ANSWER: Promote excretion of sodium and chloride be 172. Surgery done without consent
decreasing absorption in the distal tubule. ANSWER: Battery
150. From the results of the laboratory test prescribed by the 173. Role of nurse in obtaining informed consent
physician, which of the following will the nurse consider as an ANSWER: Witness
indication of impaired renal function? Elevated levels of:
ANSWER: Creatinine 174. Role of head nurse in OR
ANSWER: Scheduling of patients for surgery
151. Which of the following examination would the nurse expect to
be ordered? 175. Anterior Pituitary Gland, hormones
ANSWER: Synovial fluid analysis ANSWER:
Prolactin/ Lactotropic
152. The client is 24-hour urine collection for uric acid determination. TSH
To have a reliable result, the nurse anticipates which diet Growth Hormone (Somatostatin)
prescribed prior to the examination? GnRH: FSH and LH
ANSWER: Low-purine diet MSH
ACTH
153. Which activity indicates that a client is fully aware of his/her
impending surgery? 176. Posterior Pituitary Gland
ANSWER: Voluntarily signs the consent for surgery ANSWER: Oxytocin
ADH
154. For client who cannot totally give up smoking, nurses should
instruct client to cease smoking at least how many weeks 177. Hypophysectomy, post-op position
before surgery? ANSWER: Fowlers
ANSWER: 1
178. Transphenoidal Hypophysectomy, watch out for bleeding
155. Health instructions like encourage the client to move after ANSWER: Nose
surgery should also be understood and reinforced to the
significant others. The goal of the instruction includes the 179. Potassium, acceptable rate
following EXCEPT: ANSWER: 10 to 15 mEq/ hr
ANSWER: Comply with Institutional policy Give with NSS
156. The purpose of pre-anesthetic medication is one vital 180. Maximum drug given subcutaneously
information given by the nurse prior to any surgery. Clients ANSWER:
should be made to understand that this medication will: 1 ml – pedia
ANSWER: Facilitate induction of anesthesia 2 ml – adult
157. Virgilio has been taking Atenolol (Tenormin) 50 mg orally once 181. Maximum drug given intramuscularly
daily. The nurse understands thatr the specific action is to block: ANSWER: 3 ml
ANSWER: Beta receptor stimulation of the heart
182. SQ, drug administration, obese
158. Stools of breastfed babies ANSWER: 90 degrees and taut the skin
ANSWER: Breastfed infants usually have soft stools the bottle-
fed infants. 183. SQ, drug administration, skinny
ANSWER: 45 degrees and pinch the skin
159. The nurse is inserting a nasogastric tube on a toddler. Which of
the following restraints would be most appropriate for the 184. ID, drug administration
nurse to use with this child during the procedure? ANSWER:
ANSWER: elbow Parallel to skin, 10 to 15 degree
Bevel up
160. When assessing a client with Meniere’s disease, the nurse
expects the client to experience: 185. 1L NSS to be given in 24 hours, rate per hour
ANSWER: ringing of the ears ANSWER: 41 ml/ hr

4
186. D5W, classification 211. Death certificate, signing
ANSWER: Isotonic fluid but hypotonic in function ANSWER: physician/ municipal health officer
187. Heparin lock 212. Suctioning, oropharyngeal/ nasopharyngeal
ANSWER: ANSWER: Interval: 20 to 30 seconds
S.A.S.H. method (Saline, Antibiotic, Saline, Heparin)
213. Suctioning, tracheal
188. Infiltration ANSWER: Interval: 2 to 3 minutes
ANSWER: Stop and warm compress
214. Suctioning, entire procedure
189. Dehiscence ANSWER: 5 minutes
ANSWER: Stop and cold compress
215. Suctioning, per attempt
190. Billroth 1 ANSWER: 5 to 10 seconds
ANSWER: Gastroduodenostomy
216. Withdrawal of NGT
191. Billroth 2 ANSWER: Inhale  hold breath  pinch the catheter 
ANSWER: Gastrojejunostomy withdraw
192. Complication of Billroth 1 and 2 217. During liver biopsy, instruction
ANSWER: dumping syndrome and pernicious anemia ANSWER: Inhale  exhale  hold breath
193. Confirmatory test for cancer 218. Sleep disturbance
ANSWER: Biopsy ANSWER: Quality of sleep > Quantity of sleep
194. Preferred treatment of cancer for pedia 219. Kidney transplant patient taking immunosuppressant may still
ANSWER: Chemotherapy experience rejection, what is the possible sign
ANSWER: Increase serum creatinine
195. Preferred treatment of cancer for adult
ANSWER: Surgery 220. Dialysis, not affected by the treatment
ANSWER: Hemoglobin
196. Cruciferous vegetables (anti-cancer)
ANSWER: 221. Iron deficiency anemia
Cabbage, broccoli, cauliflower, Brussels sprouts, Kohlrabi ANSWER: Spoon shaped fingernail (koilonychia)
197. Prostate cancer, risk factors 222. Post-pneumonectomy, position
ANSWER: Age above 40 ANSWER: Supine or to the affected side
198. Bladder cancer, risk factors 223. Post-mastectomy, position
ANSWER: Smoking, hair dye ANSWER: Elevate arms (liberty position)
199. Lung cancer, risk factors 224. Post-laminectomy, position
ANSWER: Smoking, asbestosis, radon gas ANSWER: Supine position
200. Cervical cancer, risk factors 225. Post-laryngectomy, expect
ANSWER: ANSWER: Absence of voice
Multiple sex partners, early sexual experience, HPV
226. Rich in iron
201. Breast cancer, risk factors ANSWER: Clams, leafy greens, enriched cereals, and liver
ANSWER:
Nulliparity, high fat diet/obesity, 227. Rich in calcium
early menarche, late menopause ANSWER: Orange, yogurt, spinach
202. Breast cancer, S/Sx 228. Hepatitis A and E
ANSWER: ANSWER: Fecal-oral
Dimple or mass at RUQ o the breast (tail of Spence)
229. Hepatitis B, C and D
203. Stage III Breast Cancer ANSWER: Blood, sexual intercourse, needle prick
ANSWER: Surgery and Chemotherapy
230. Hepatic encephalopathy, diet
204. Korotkoff sounds ANSWER: Low protein diet (protein increases ammonia)
ANSWER:
1- loud tapping 231. Hepatic encephalopathy, laboratory findings:
2- whoosing sound ANSWER:
3- crisp tapping a. Increase serum ammonia
4- muffled sound b. Increase bilirubin level in blood
5- silence
232. Non absorbable suture (silk, nylon, vicryl, cotton, daron)
205. BP of 104/100/90 ANSWER: Commonly used in SKIN
ANSWER: Korotkoff sound phases I/IV/V
(systolic/ muffling/ disappearance) 233. Absorbable sutures (chromic gut, plain gut)
ANSWER: Commonly used in internal organs
206. Auscultate pulse, use
ANSWER: Bell of stethoscope 234. 1st successful heart transplant
(diaphragm for obese patients) ANSWER: Cape Town, South Africa
207. Inflate cuff more after palpable systolic BP around 235. 1st successful bone marrow and kidney transplant
ANSWER: 30 mmHg ANSWER: USA
208. Deflate cuff, rate 236. Coumadin (Warfarin), foods to avoid
ANSWER: 2 to 3 mmHg/ beat ANSWER: Green leafy vegetables (contains Vitamin K)
209. Correct about VS taking 237. Anticoagulants (Coumadin, Heparin), how does it work
ANSWER: wait at last 30 minutes after exercise, eating or ANSWER: It inhibit synthesis of Vitamin K dependent clotting
smoking factors
210. Sequence of chest physiotherapy (CPT) 238. Heparin-induced side effect
ANSWER: ANSWER: Thrombocytopenia
1 – postural drainage
2 – percuss 239. Burn in chest, arms, face
3 – vibrate ANSWER: Priority patient because it may cause inhalation burn
4 – let the patient cough and airway edema
5
240. Electrical burn, immediate management 265. pH – 7.30
ANSWER: Turn off the electrical source CO2 – 28
HCO3 – 12
241. Patient is burning, priority management ANSWER: Metabolic acidosis, Partially compensated
ANSWER: “STOP, DROP and ROLL”
266. Long bone fracture, check
242. Burns, 2 parameters to measure ANSWER: RR (possible fat embolism)
ANSWER:
1 – extent  percentage 267. Rheumatoid arthritis and Osteoarthritis
2 – severity  degree ANSWER: RA pain occurs during immobility whereas OA pain
happens because of mobility
243. Fire in hospital, management (in sequence)
ANSWER: 268. Patient prone to chocking or aspiration, priority management
1 – protect client ANSWER: Position the patient in upright
2 – activate the alarm
3 – confine the fire 269. Otic medication administration
4 – extinguish the fire ANSWER:
Up and back (out) – adults
244. Burns, 2nd degree (superficial partial thickness burn) Down and back (out) – pedia
ANSWER: Blisters (vesicles), painful
270. Patient prone to infection
245. Burns, 3rd degree (deep partial thickness burn) ANSWER:
ANSWER: Red to gray, local edema, wet, painless Removal of spleen
ICU patients
246. Burns, 4th degree (full thickness burn) Steroids (Kidney transplant patient, Cushing’s disease)
ANSWER: Charred, dry, leathery, painless HIV
247. MRI, avoid 271. Phytochemicals, examples
ANSWER: Pacemaker, jewelry, metallic objects ANSWER: lycopene in tomatoes, isoflavones in soy and
flavanoids in fruits.
248. CT scan, before
ANSWER: check for allergy to iodine 272. Antioxidants and phytochemicals, benefits
ANSWER: Anti-cancer
249. Cardiac catheterization, after
ANSWER: Check for distal pulses and possible bleeding 273. Total Parenteral Nutrition (TPN), most appropriate
ANSWER: Sterile technique
250. Ventricular tachycardia, characteristic
ANSWER: Bizarre QRS complex, regular rhythm 274. Total Parenteral Nutrition (TPN), type of dressing to be use
ANSWER: Air occlusive and transparent dressing
251. Ventricular fibrillation, characteristic
ANSWER: Chaotic pattern, no rhythm, no P wave, no QRS 275. TPN solution is emptied but no follow up doctors order, what
complex will you give
ANSWER: hypertonic solution
252. Parkinson disease, S/Sx: D10 W– pedia
ANSWER: D50W – adult
Tremors (resting and pill rolling)
Rigidity (cogwheel) 276. Liver cirrhosis, health teaching
Akinesia or Bradykinesia ANSWER: Good nutrition, avoid infection and abstain from
Mask like appearance alcohol
253. Meniere’s disease, S/Sx: 277. Bronchoconstriction, appropriate nursing diagnosis
ANSWER: Vertigo, Hearing loss (sensorineural), Tinnitus ANSWER: Ineffective airway clearance
254. Meniere’s disease, priority 278. Crackles, appropriate nursing diagnosis
ANSWER: Safety (Nursing Diagnosis: Risk for Injury) ANSWER: Impaired breathing pattern
255. Meniere’s disease, diet 279. Respiratory acidosis, appropriate nursing diagnosis
ANSWER: Low sodium, restrict fluid ANSWER: Impaired gas exchange
256. Legal Blind, visual acuity 280. Infusion pump, alarm on when
ANSWER: 20/ 200 ANSWER:
Empty/ near empty IV fluid
257. DM patient, before extraneous activity, AVOID Sudden twisting or movement
ANSWER: Insulin injection Tension on the tubing/ occlusion
Sudden change on the solution
258. Insulin, when to decrease dose
ANSWER: During breastfeeding 281. Pulse oximeter, purpose
ANSWER: measures oxygen saturation and pulse
259. 100ml of NSS to be given at 10ml/ hour starting at 10 am, when
will it end 282. To reduce tenacity of secretions
ANSWER: 8pm ANSWER: Increase fluid intake
260. Cholecystitis, pain location 283. Stimulant of breathing
ANSWER: RUQ radiating to midsternal, shoulders and back ANSWER: Carbon dioxide
261. Cholecystitis, laboratory data 284. Metered dose inhaler, correct teaching
ANSWER: ANSWER:
Increase bilirubin Disperse drug with inhalation
Increase alkaline phosphatase Do not place inside the mouth the tip of the inhaler, provide 1
Increase WBC to 2 inches apart from the lips
Provide mouthwash after drug administration
262. Obstructed bile flow
ANSWER: increase bilirubin 285. Evaluation of Tissue perfusion
ANSWER: Monitor hourly urine output
263. Pericarditis, characteristic of breathing
ANSWER: Rapid and shallow 286. Foods that retain fluids in the body
ANSWER: Salty foods (dried fish), cola, pickles
264. Pericarditis, pain location
ANSWER: Substernal 287. Foods that causes diuresis
ANSWER: Tea, coffee

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288. To prevent atelectasis: 315. Increased ICP (Cushing’s response)
ANSWER: Ambulate as soon as possible ANSWER:
Increased BP, Increased MAP
289. Fifth vital sign: Decreased RR, Decreased PR
ANSWER: Pain Widening pulse pressure
290. SEVERE pain medication: 316. Reason for elevating patient with increase ICP
ANSWER: Morphine ANSWER:
To promote venous drainage
291. Pain assessment used in pediatric clients
ANSWER: Faces scale 317. Shock
ANSWER:
292. Colonic Cancer Decreased BP, Decreased MAP
ANSWER: CEA- Carcino Embryonic Antigen Increased RR, Increased PR
Narrowing pulse pressure
293. Ascites, measure
ANSWER: abdominal girth 318. Digoxin (Lanoxin), effects
ANSWER:
294. Eye pain after cataract surgery Increased force of contraction,
ANSWER: Call the MD increased cardiac output, increased tissue perfusion
increased urine output
295. Myasthenia Gravis, initial manifestation decreased electrical impulse
ANSWER: Ptosis (drooping, sinking or falling down of an organ decreased heart rate, decreased workload
or part, particularly the drooping of the upper eyelid) increased myocardial oxygenation
296. AV fistula how long does it mature? 319. Decreased tissue perfusion in kidney, effect
ANSWER: 3-4 weeks ANSWER: Stimulates erythropoietin causing bone marrow
stimulation leading to polycythemia
297. AV fistula with no bruit/thrill
ANSWER: Obstruction/clot 320. Most common nosocomial infection:
ANSWER: UTI
298. Purpose of neomycin in peri-ops
ANSWER: To kill bacteria in the gut 321. Best management for UTI
ANSWER: increased water intake
299. Heparin/Insulin is measured as
ANSWER: Units/ml 322. Stridor and wheezing, first drug to be given
ANSWER: bronchodilator
300. 1 grain is equal to
ANSWER: 60 mg 323. Pruritus
ANSWER: oatmeal bath – colloidal bath
301. 1 tsp is equal to
ANSWER: 5 ml 324. Tinea Capitis hair loss is:
ANSWER: temporary
302. Appendicitis report ASAP
ANSWER: Rigid abdomen, indicates peritonitis 325. Pediculosis Capitis:
ANSWER:
303. Colorectal cancer, screening: Treat all household members
ANSWER: Lindane is not given in children (can cause seizure in children)
a. Rectal exam (DRE)  correct answer
b. Biopsy  confirmatory test 326. Gastric Cancer s/sx:
ANSWER: Weight Loss
304. Best way to measure fluid retention
ANSWER: Weight 327. Lung Cancer s/sx:
ANSWER: dry hacking cough
305. Best way to measure body fat
ANSWER: Skin fold thickness 328. Herpes zoster:
ANSWER: give antiviral
306. Nursing audit
ANSWER: Review of records 329. Patient with Luccid (clear thoughts) then unarousable:
ANSWER: hematoma cerebral
307. Quality assurance
ANSWER: ensuring and evaluating that the nursing care 330. Most reliable sign of cardiac arrest:
rendered is within the minimum standards of care (REACTIVE) ANSWER: absence of pulse
308. Structure evaluation 331. High Risk for bleeding:
ANSWER: physical setting ANSWER: Patient with thrombocytopenia
309. Process evaluation 332. Non-plaster cast a.k.a. synthetic cast gets wet:
ANSWER: how the nursing care is given ANSWER: Hair blower on a cool setting for itchiness
310. Outcome evaluation 333. Assessing brachial plexus injury in Newborn
ANSWER: output of nursing care given (demonstrable changes) ANSWER: Assess moro reflex
311. Total quality management 334. Collecting urine specimen for C&S sterile procedure
ANSWER: focus on identifying real and potential problem ANSWER: 5 to 10ml
(PROACTIVE)
335. Routine urinalysis
312. Hyperparathyroidism, main problem ANSWER: 30 to 50 ml
ANSWER:
Increased serum calcium 336. Abdominal: post-op: sleeping intestines:
Decreased serum phosphate ANSWER: paralytic ileus
313. Hypoparathyroidism, main problem 337. Residual volume of urine
ANSWER: ANSWER: 50-100 ml
Decreased serum calcium
Increased serum phosphate 338. Spina Bifida lack of:
ANSWER: folic acid
314. Increased ICP, position
ANSWER: Fowler’s position 339. Arthralgia is
ANSWER: with pain and no swelling

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340. Arthritis is 369. Theophylline toxicity
ANSWER: with pain and swelling ANSWER: Tachycardia and nausea and vomiting
341. PRESBYOPIA 370. In OR, who validates/verifies consent:
ANSWER: Decrease accommodative ability of the lens that ANSWER: Ciculator
occurs with aging
371. Sellick maneuver
342. HYPEROPIA ANSWER: application of pressure in the cricoid cartilage
ANSWER: Farsightedness
372. Discharges
343. MYOPIA Serous Clear
ANSWER: Nearsightedness Sanguineous Red (open wounds)
Seroanguineous Pinkish (surgical incision)
344. SIADH s/s: Purulent Pus
ANSWER: (dilutional) hyponatremia Purosanguineous Pus and blood (new infected wound)
345. Meningeal irritation s/s:
ANSWER: nuchal rigidity, photophobia, 373. OSTEOMYELITIS
kerning’s sign, brudzinski’s sign ANSWER: Immobilize
346. Breast exams 374. Milwaukee brace
ANSWER: 5-7 days after onset of mens ANSWER: wear it for 23 hours and 1 hour intended for bathing
347. GCS score of a patient who is moaning and mumbling 375. Plaster of Paris
ANSWER: 2 ANSWER: 24 to 72 hours
348. GCS score, highest 376. synthetic/ fiber glass
ANSWER: 15 ANSWER: 20 minutes
349. GCS score, coma 377. Patient has weak side, where to place the wheelchair during
ANSWER: 7 and below transfer?
a. Unaffected/ STRONG SIDE
350. GCS, the higher the score b. Affected
ANSWER: the deeper the level of consciousness
378. Transfer from surgical bed to wheelchair, position of the
351. Manifestation of ICP wheelchair?
ANSWER: Bradycardia a. Foot of the bed
b. Facing the client
352. Pernicious anemia – CORRECT UNDERSTANDING: c. Middle of the bed
ANSWER: Vitamin B12 for life – IM d. Parallel to the bed
353. Urine output per hour 379. First to check if patient has 1000 mL blood loss:
ANSWER: 30 – 60 ml a. VS
b. Soaked dressing
354. What substance is produced by the kidneys that assists in c. Pain
blood pressure control
ANSWER: Renin 380. Patient on NPO complains of thirst, how to alleviate?
a. Wet cotton put on lips
355. A patient has had a sudden 5-kg weight gain. How much fluid b. Gargle but don’t swallow
has been retained? c. Sip water
ANSWER: 5L
381. Promote safety to a patient in a bed without siderails
356. The functional unit of the kidney is called a(n) ANSWER:
ANSWER: Nephron lower the bed
357. “What is oliguria?” 382. Most common type of goiter is related to deficiency of
ANSWER: ANSWER: Iodine
c. “Oliguria is a urine output less than 400 mL in 24 hours.”
383. Earliest sign of skin reaction to radiation therapy is
358. Anuria is a urine output of ANSWER: Erythema
ANSWER: 50 to 100 mL/24 hours
384. Waste disposal like biological wastes disposal should be
359. most reliable pain indicator coordinated to
ANSWER: Subjective complaint of patient; DIAPHORESIS ANSWER: DILG, MMDA
360. Analgesics 385. 3 TYPES OF JAUNDICE
ANSWER: Before formation of prostaglandin ANSWER:
1. Hepatic jaundice – inability of the liver to conjugated
361. Position cord prolapse unconjugated bilirubin to conjugated bilirubin)
ANSWER: Trendelenurg/ knee chest 2. Obstructive jaundice – due to cholelithiasis
3. Hepatic jaundice – due to RBC hemolysis
362. Acute Renal Failure:
ANSWER: decrease urine output 386. Last step in research process
ANSWER: utilization of the research into practice
363. Creatinine clearance
ANSWER: 24 hour urine collection 387. Incident report, not included
ANSWER: derogatory comments of patient
364. Most common post op complication
ANSWER: Hemorrhage 388. Final step in nursing process
ANSWER: putting research evidence into nursing practice
365. Most common triggering factor of asthma
ANSWER: Dust mites 389. Correct understanding about sampling technique
ANSWER: the greater the sample size, the more accurate will be
366. Most common type of liver cirrhosis the estimate of the true population mean
ANSWER: Laennec’s (due to alcohol)
390. Client with hearing impairment
367. The worst of all fears among clients undergoing surgery is: ANSWER: speak slowly in front of the patient
ANSWER: Fear of unknown
391. Patient is teary eyed and stops talking
368. HYPERCALCEMIA,S/SX: ANSWER: remain silent, sit with the client
ANSWER: muscle weakness
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392. fight free radicals
ANSWER: antioxidants and phytochemicals
393. Signs of dysphagia
ANSWER:
Coughing while eating
Delayed swallowing
Abnormal movements of tongue and mouth
Uncoordinated speech
394. Positioning patient into lithotomy position
ANSWER: place both legs slowly and simultaneously on well-
padded stirrups
395. Document outlining selected medical treatment to be done to
a patient when he/ she losses his/ her ability to decide
ANSWER: advance directives
396. Chest pain in patient with pneumonia is due to
ANSWER: pleuritic friction rub
397. Peptic ulcer disease, cause
ANSWER: H. pylori, NSAIDs smoking, alcohol
398. Sign of gastric ulcer perforation
ANSWER: rigid, board-like abdomen
399. Grafts used in CABG
ANSWER:
Saphaneous vein
Internal mammary artery
Radial artery
400. Pain during coughing exercises
ANSWER: splint using “cough pillow”
401. Antacids
ANSWER: neutralize gastric acidity
402. Ezomeprazole magnesium (Nexium)
ANSWER: Proton pump inhibitor
403. Cushing syndrome
ANSWER: OVERSECRETION of glucocorticoids
404. 3 elements of fire
ANSWER:
Oxygen (open windows
Combustible material (leaking gas stove)
Friction (disposable drapes)
405. Furosemide, excrete what electrolytes in urine
ANSWER: sodium, potassium and calcium
406. Renal stones
ANSWER:
Flank pain/ costovertebral pain
Strain urine
407. Swelling of leg due to congestion
ANSWER: elevate leg
408. Phatom limb pain caused by
ANSWER: severing peripheral nerves
409. Laboratory result in patient with pericarditis
ANSWER: Erythrocyte sedimentation rate
410. OHA (Metformin) and NSAIDS or ASA
ANSWER: hypoglycemia
411. Insertion of foley catheter
ANSWER: sterile technique
412. White pulp of spleen
ANSWER: lymphocyte production
413. Kidney function, indicator
ANSWER: creatinine clearance
414. increased hematocrit
ANSWER: polycythemia, dehydration