8. USO DEL EQUIPO DE PROTECCIÓN PERSONAL
8.8. Descripción del retiro del EPP
NURSING PRACTICE IV SET A ________________________________________________________________________
NURSING PRACTICE IV – Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS:
16. This test booklet contains 100 test questions.
17. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
18. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
19. AVOID ERASURES.
20. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable by law. Per RA 8981.
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INSTRUCTIONS:
10. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set .
11. Write the subject title “Nursing Practice IV” on the box provided.
12. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.
MULTIPLE CHOICE
101. You are the nurse in an Adult Care Unit. You over0hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say, that if she refuses to take her medications, she will not be given her favorite dessert. You report your co-staff’s behavior as:
A. Battery C. Negligence
B. Assault D. Malpractice
102. Jake is in the Post Anesthesia Care Unit follwing a colorectal resection. He has an IV of Dextrose 5% Lactated Ringers Solution. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs, moist respiration and tachypnea. Which of the following will you do FIRST?
A. Notify anesthesiologist C. Place on Fowler’s position B. Increase O2 flow rate D. Reduce IV rate
103. As a head nurse of the unit, which of the following sources should you take into consideration when making effective assignments for the next shift?
A. seniority preferences
B. recent performance evaluation C. personality traits
D. client classification data
104. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. As the triage nurse, you would assign the HIGHEST priority to the client with the:
A. severe head injury and no blood pressure B. maxillofacial injury and gurling respirations C. second trimester pregnancy with premature labor D. lumbar spinal cord injury and lower extremity paralysis
105. When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible?
A. volunteer nurse, hospital and the nurse in charge
B. the professional organization which the volunteer nurse represents C. hospital
D. volunteer nurse because there is no employer employee relationship
106. Daniel with multiple myeloma complains of deep bone pain. As his nurse, which of the following will you do FIRST?
A. Assess bone pain
B. Administer prescribed analgesic C. Teach pain relief strategies D. Support position with pillow
107. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should you expect to find?
A. Increased platelet count
B. Altered blood urea nitrogen (BUN) and creatinine levels C. Electrolyte imbalance
D. Elevated erythrocyte sedimentation rate (ESR)
108. Mrs. Paras is receiving total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of the following indicators will tell you that TPN was effective?
A. laboratory work up B. adequate hydration C. weight gain
D. diminish episode of nausea and vomiting
109. While Jayvee, a burn patient is being transferred from the burn unit to the operating room, the IV bottle fell on Jayvee’s head. He sustained a laceration on his forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do?
A. Hold the IV bottle B. Check the IV stand
C. Place the IV stand on the foot part of the stretcher D. Restrain Jayvee
110. While Mrs. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs?
A. administer Compazine before meals B. enrich diet with red meats
C. serve hot soup and food
D. increase the amount of spice in the diet
111. Nurses working in the 35 bed Female Medical Unit were noted to implement new and innovative client care activities long before other units in the hospital. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength?
A. Communication skills C. Vision and passion B. Knowledge and skills D. Interpersonal abilities
112. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. It was started at 8am. At 10am, her relative informed you that the bottle is empty. Which of the following will you do first?
A. refer to nurse manager
B. assess Olga and check level of fluid left in the bottle
C. discontinue IV and assess Olga D. replace IV fluid with prescribed follow-up
113. A research study found out that 60% of patients complains were due to delayed responses of nurses in the emergency department. Which of the following measurement of data was used in this study?
A. Measures of variability C. Frequency distribution B. Measures of central tendency D. Inferential statistics
114. During a meal, a client with hepatitis B dislodges her IV line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
A. Alcohol C. ammonia
B. Acetone D. bleach
115. Nino is being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy?
A. Cover the areas with thick clothing materials B. Apply a heating pad to the site
C. Wash skin with water after the therapy
D. Avoid applying creams and powders to the area
116. You are assigned to the following patients. Which of the following patients is most at risk for metabolic alkalosis?
A. Grace, 30 year old post surgical patient who has continuous nasogastric suction
B. Rachel a 55 year old who has just experienced a stroke
C. Helen, 70 year old with altered level of consciousness who is unable to access water freely
D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution
117. Studies have shown that the highest incidence of Hodgkin’s disease is common among young adults. Juana, 20 years old approaches you and tells you “I am worried about the mass on my neck”. What should you do as a nurse?
A. Tell her there is nothing to worry if it does not bother her B. Palpate Juana’s neck and explain the possible cause
C. Tell her Hodgkin’s disease is common among young adults like her D. Tell her to see a doctor
118. As a nurse, you accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, you should:
A. complete an incident report B. call the hospital attorney C. inform the client’s family
D. do nothing because the client’s condition is stable
119. You are the nurse manager of the Medical Unit. Which of the following is a priority for you to consider when planning for the care of a group of clients utilizing evidence-based practice?
A. Client’s care is planned based on the nurse’s clinical expertise and latest research findings
B. Standardized care plans are used on all of the nurse’s clients.
C. Standards of care are developed by the hospital nursing service and should be followed
D. Client’s needs are assessed and individualized care plan are developed for each client.
120. Because of increase incidents of medication error due to wrong transcription of physician medication orders by the nurse, a tertiary hospital utilized a computerized medication order system. Which of the following procedures may be done through the said system?
A. Correct errors in the physician medication order B. Eliminate drug interaction
C. Provide a list of drugs with their generic name D. Document drug administration
SITUATIONAL
Situation 1 – P. Cruz, 65 years old, was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. You are expected to recognize
electrocardiographic readings on the cardiac monitor.
121. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium?
A. QRS interval C. P wave
B. ST segment D. PR interval
122. From an ECG reading, a QRS complex represents:
A. Venticular depolarization C. End of ventricular
depolarization
B. Ventricular repolarization D. Atrial depolarization 123. Which of the following represents ventricular repolarization?
A. T wave C. QRS complex
B. ST segment D. PR interval
124. It is important that the nurse measures intervals of QRS complex. Which of the following represent the normal interval of QRS complex?
A. greater than .20 sec C. .10 sec
B. .20 sec D. .12 sec to .20 sec
125. Later in the acute phase of Myocardial Infarction, which of the following typically appears as the first sign of tissue death?
A. ST segment suppression C. Prolonged PR interval
B. Short T wave D. Pathologic Q wave
Situation 2 – To be able to help our clients with their psychological concerns, we have to explore how they view themselves and their body image.
126. When assessing patient’s body image, which of the following would be most important to ask?
A. What are your hobbies?
B. What kind of work did you do prior to this illness?
C. Are your living accommodation all on one level?
D. What kind of food do you like?
127. The most appropriate nursing intervention to facilitate client’s acceptance of a change in body image would be to:
A. encourage dependence
B. establish a therapeutic relationship
C. joke with the client
D. establish a social relationship
128. Which of the following responses would indicate that the client is beginning to accept change in his/her body image?
A. Feeling of the dressing over the incisional site B. Stating he/she is too tired to have visitors
C. Discussing his.her stamp collection with the nurse D. Showing no interest in the dressing change
129. It is important for you to remember, that a sudden change in body image would occur from:
A. Weight gain
B. Side effects of medication on skin C. Radiation treatment of the breast D. Surgical removal of an eyeball
130. Before you can help Lorna accept a change in body image you must FIRST:
A. be in agreement with the philosophy of therapy for the client
B. become aware of her own attitude toward mutilation and disfigurement C. be aware of the attitudes and feelings of the client and her family
D. accept the fact that a person can live with a body part missing
Situation 3 – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as nurse.
131. Albert is receiving external radiation therapy and he complains of fatigue and malaise.
Which of the following nursing interventions would be most helpful for Albert?
A. Tell him that sometimes these feelings can be psychogenic B. Refer him to the physician
C. Reassure him that these feelings are normal D. Help him plan his activities
132. Immediately following the radiation teletherapy, Albert is
A. considered radioactive for 24 hrs B. given a complete bath
C. placed on isolation for 6 hours D. free from radiation
133. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms:
A. petechiae, ecchymosis, epistaxis B. weakness, easy fatigability, pallor C. headache, dizziness, blurred vision
D. severe sore throat, bacteremia, hepatomegaly 134. What nursing diagnosis should be of highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal
135. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38C