SET 3

SITUATION: Mang Roberto was long diagnosed with chronic renal failure. You are his nurse and the following question assesses your knowledge in the different fluid and electrolyte imbalances that are associated with chronic renal failure. 1. Disequilibrium syndrome is always a risk in all clients undergoing hemodialysis for chronic renal failure. The nurse should assess Mang Roberto for which of the following sign and symptom associated with Disequilibrium syndrome? A. Hypertension, Tachycardia and Fever B. Imbalance, gait abnormality and inability to stand up C. Restlessness, irritability and generalized weakness D. Headache, deteriorating level of consciousness and twitching 2. After Mang Roberto completed his hemodialysis, The nurse should use which indicators to evaluate the clients status after dialysis? A. Potassium level and weight level B. Vital signs and Blood Urea Nitrogen D. Vital signs and weight C. Blood Urea Nitrogen and Creatinine

3. Mang Robertos chronic renal failure was caused by a crush injury to the lower leg right after an accident. The acute renal failure progresses to chronic renal failure until now, his case is irreversible. The nurse is correct in determining that the cause of Mang Robertos Acute renal failure before was: A. Pre renal B. Post renal C. Renal D. Extra renal

4. Mang Roberto misses 2 sessions of hemodialysis. Blood was drawn and is sent for analysis. Which electrolyte disturbance is expected in a client with chronic renal failure? A. Hypernatremia B. Hyperkalemia C. Hypokalemia D. Alkalemia

5. In Mang Robertos ECG tracing, you would expect to find: A. Depressed T wave B. Presence of U wave C. A peaked T wave D. Inverted T wave

6. The main indicator of the need for hemodialysis is: A. Ascites Hyperkalemia 7. To gain access to the vein and artery, an AV shunt was used for Mang Roberto. The most serious problem with regards to the AV shunt is: A. Septicemia Vessel sclerosis 8. When caring for Mang Robertos AV shunt on his right arm, you should: A. Cover the entire cannula with an elastic bandage B. Notify the physician if a bruit and thrill are present C. User surgical aseptic technique when giving shunt care D. Take the blood pressure on the right arm instead 9. Mang Roberto Complains of tingling in the finger and twitching of the muscles. This is caused by: A. Acidosis B. Potassium retention C. Calcium Depletion D. Sodium chloride depletion B. Clot formation C. Exsanguination D. B. Acidosis C. Hypertension D.

10. Which of the following is an appropriate instruction for Mang Roberto? A. Follow a high potassium diet B. Strictly follow the hemodialysis schedule C. Use salt substitute instead of the normal table salt D. Use alcohol on the skin to clean it due to integumentary changes SITUATION: Mang Robertos condition continues to worsen and the doctor suggested Kidney Transplantation. 11. Mang Roberto has just received a renal transplant and has started cyclosporine therapy to prevent graft rejection. Which of the following condition is a major complication of this drug therapy? A. Depression C. Infection

B. Hemorrhage

D. Peptic ulcer disease

12. Which of the following is the rationale why Azathioprine (Imuran), Prednisone or Cyclosporine (SandImmune) is given in a client that has undergone Kidney Transplantation? A. To enhance the immune system preventing rejection B. To suppress the immune system preventing rejection C. To enhance kidney function D. To protect the newly transplanted kidney from invading pathogens 13. Immunosuppression following Kidney transplantation is continued: A. For life transplantation B. 24 hours after transplantation rejected 14. Steroids, if used following kidney transplantation would cause which of the following side effects? A. Alopecia Hypotension B. Increase Cholesterol Level D. Increase Blood Glucose Level C. Orthostatic D. Until the kidney is not anymore C. A week after

15. Mang Roberto was readmitted to the hospital with acute graft rejection. Which of the following assessment finding would be expected? A. Hypotension B. Normal Body Temperature C. Decreased WBC D. Elevated BUN and Creatinine

SITUATION: Nanette was rushed to the hospital due to burns. Witnesses told the emergency team that Nanette fell asleep while she is holding her cigarette thus, burning the bed sheets and herself. 2nd and 3rd degree burns are on the face, neck, anterior and posterior trunk as well as the anterior of the left leg and the whole right arm was burned. First degree burns are located on the anterior portion of the right leg and the anterior portion of the right and left arm. Nanette is a 110 lbs female client. 16. The priority nursing intervention for Nanette is to:

A. Assess airway, breathing and circulation C. Apply ointment over the burned surface B. Check Nanettes Vital Signs D. Administer oxygen inhalation

17. Using the rule of nine, the percentage of the burned area on Nanettes skin is: A. 63% 72% 18. The rationale in giving IV fluids for Miss Nanette is to prevent: A. Cardiogenic shock B. Septic Shock C. Hypovolemic shock D. Neurogenic Shock B. 81% C. 90% D.

19. A second degree burn on Nanette is characterized by: A. Eschars B. Broken skin with fat exposed C. Blisters and Edema D. Insensate wound draining purple fluid

20. During the first 48 hours, Burn victims is observed for metabolic acidosis resulting from loss of bicarbonate ions that arises from: A. Potassium loss B. Calcium loss C. Sodium loss D. Magnesium loss

21. IV fluid that is commonly used in clients with dehydration, diarrhea and burns is: A. Lactated Ringers B. D5 NSS C. Normal Saline Solution D. NSS Plus potassium

22. The doctor uses Parkland/Baxter formula in computing the amount of fluid needed for Nanettes resuscitation. You would expect that the doctor will order how many milliliters of IV fluids? A. 6 liters during the first 8 hours, 3 liters on the next 8 hours and another 3 liters on another 8 hours. B. 12 liters during the first 8 hours and another 12 liters on the succeeding 16 hours C. 8 liters during the first 8 hours, 4 liters on the next 8 hours and another 8 liters on another 8 hours D. 10 liters during the first 8 hours and another 10 liters on the succeeding 16 hours

23. During the emergent phase of burn, which of the following is an expected finding on Nanette? A. Decreased heart rate B. Elevated hematocrit levels C. Increased blood pressure D. Increased urinary output

24. Which electrolyte disturbance is the most lethal in client with burn? A. Hyponatremia B. Hypercalcemia C. Hyperkalemia D. Hypokalemia

25. The priority consideration for Nanette during the early phase of burn is: A. Pain B. Body Image C. Fluid status D. Infection of the wound

SITUATION: Joanna Marie, a 40 year old client was diagnosed with breast cancer. 26. The nurse is instruction Joanna about breast self examination. The nurse instructs Joanna to perform Breast Self Examination: A. At the onset of menstruation B. 1 week after menstruation begins C. Every month during ovulation D. Weekly at the same time each day

27. Joanna is taking Adriamycin together with tamoxifen. You know that Adriamycin works by: A. Inhibiting DNA Synthesis gradient of the cell B. Preventing Folic acid synthesis D. Increase cell wall permeability C. Changing the osmotic

28. Joannas tumor is said to be ERP+. You know that Estrogen receptor positive tumor is: A. A good indicator of the possibility of breast reconstruction B. A good indicator for giving an estrogen replacement therapy to decrease the tumor size C. An indicator that the client might respond to tamoxifen D. An indicator that metastasis has already occured 29. Which of the following maybe use to her post operatively?

A. Cystoclysis bottle B. 3 way bottle system

C. Jackson Pratt Drain D. Pleural drainage

30. All of the following are applicable nursing diagnosis for Joanna except: A. Pain upon lying down B. Body Image Disturbance immobility of the arm 31. Rationale for elevating the arm of Joanna post operatively is to: A. Improve coping ability B. Prevent infection drainage 32. After Modified radical mastectomy, which assessment finding indicates that Joanna is experiencing a complication related to surgery? A. Sanguineous drainage in the Jackson Pratt drain B. Pain at the incision site C. Complaints of decrease sensation in the operative site D. edema on the operative arm 33. Allowing Joanna to perform deep breathing exercise will prevent: A. Pneumonia B. Bronchitis C. Atelectasis D. Lymph edema C. Improve Edema D. Decrease bleeding and C. Potential for sexual dysfunction D. Self care deficit r/t

34. The nurse is teaching the sisters of Joanna about Mammography, The nurse tells the client that: A. Mammography takes about 1 hour B. To avoid the use of deodorant, powders and creams on the day of the test C. There is no discomfort associated with the procedure D. To maintain an NPO status 8 hours before the procedure

35. Joanna was brought to the hospice. During your visit, Joanna expresses that If I can just live a little longer to see my 3 sons finish college, I will be ready to die. Which phase of the grieving process Is Joanna experiencing? A. Denial Depression B. Bargaining D. Anger C.

36. In the Philippines, The use of this method is strongly suggested and recommended than any other methods to decrease death due to breast cancer: A. BSE Surgery 37. The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: A. Thickness and Fullness B. Malignant or Benign Lumps C. changes from previous self-examinations. D. Fibrocystic masses 38. Anita, Joannas sister is performing BSE and she stands in front of the Mirror. The rationale for standing in front of the mirror is to check for: A. Unusual discharges coming out from the breast B. Any obvious malignancy C. The Size and Contour of the breast D. Thickness and lumps in the breast 39. The nurse puts a folded towel under the Left shoulder of the Client to be examined for clinical BSE. Why is this so? A. To make the left shoulder nearer to the hands of the clinician for palpation B. To make the pectoralis muscle prominent, toning the breast tissue for better palpation C. To put the breast in a more lateral position to better ease the palpation D. To balance and spread the breast tissue thus easing palpation B. Mammography C. Breast Biopsy D.

40. 30. A 52-year-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this clients lump is cancerous? 1. Non capsulated mass 2. Fixed, irregular and hard 3. Presence of Orange peel skin 4. Soft and mobile A. 1,2,3 1,3,4 SITUATION: Agnes, a client with Leukemia is in the clinic for her routine check up. 41. Which finding is unlikely when assessing Agnes? A. Small abdomen B. Bruises and Petechiae C. Increased WBC Counts D. Dyspnea during exercise or exertion B. 1,2 C. 1,2,4 D.

42. The most appropriate diagnostic examination for Agnes is: A. RBC Exam B. WBC Count C. Complete Blood Count D. Bone Marrow Aspiration

43. What should you encourage her to use in order to maintain her oral hygiene? A. Use regular toothbrush B. Gargle with mouthwash only C. Use cotton pledget only D. Use soft toothbrush

44. Which of the following complications are the three main consequence of leukemia? A. Bone deformities, Infection and Anemia B. Anemia, Infection and Bleeding tendencies C. Leukopenia, Thrombocytopenia and Anemia D. Leukocytosis, Thrombocytosis and Polycythemia 45. You noticed that Agnes nose is bleeding, You would instruct Agnes to:

A. lie supine with his neck extended. pressure on his nose. B. sit upright, leaning slightly forward. forward at the waist.

C. blow his nose and then put lateral D. hold his nose while bending

SITUATION: Mr. Ramos is a 60 year old male client admitted to the hospital with the diagnosis of pneumonia. He complains of pain when coughing. 46. What action should the nurse take in assisting Mr. Ramos in doing deep breathing and coughing exercise? A. Recognize that the patient is too sick to cough at this time B. Splint the patients chest while he coughs C. Turn Mr. Ramos to the unaffected side and ask him to cough D. Encourage her to cough and then give her pain medication as ordered 47. A sputum specimen was collected from Mr. Ramos for culture and sensitivity. This study is to ascertain which of the following facts? A. The virulence of microorganism involved B. The antibiotics which would be most helpful C. The patients probably reaction to the causative microorganism D. The patients sensitivity to antibiotics 48. Laboratory reports shows RBC : 2,000,000, WBC: 5,000 and Platelets : 300,000. Considering the above findings which of the following clinical manifestation is the most likely manifestation Mr. Ramos is to exhibit? A. Decrease respiration and increase pulse B. Normal Respiration and increase pulse respiration 49. Because of these laboratory findings, the nurse is aware that her most appropriate action is to prevent which of the following? A. Infections and cross contamination C. Injury might lead to bleeding B. Over activity that might lead to exhaustion D. Hypercoagulation that might lead to thrombus formation C. Increase respiration and normal pulse D. Increase pulse and increase

50. Upon discharge, the health teaching of the nurse to Mr. Ramos should include which of the following except: A. Avoid fatigue B. Maintain hygiene C. Maintain the usual exercise D. Avoid drafts

SITUATION: Blood transfusion was ordered for Andre after an episode of severe bleeding. 51. Before blood transfusion, The nurse priority is to assess Andre for which of the following? A. Clotting time Sodium B. Vital Signs D. Weight C.

52. Before administering the transfusion, The nurse must start an IV infusion of which of the following? A. Sterile water D5W B. NSS D. D5LR C.

53. Which of the following is an appropriate needle for Blood transfusion? A. A butterfly needle B. An 18 gauge angiocatheter C. A 25 gauge angiocatheter D. A 21 gauge angiocatheter

54. Which of the following is not expected to be done by the nurse in case of a whole blood transfusion? A. Assess the venipuncture for any signs of bleeding or hematoma B. Prepare the blood transfusion using a microdrip tubing C. Assess the patient closely for any reaction D. Make sure that the drip chamber of the IV fluid is partially filled with blood 55. Which of the following is the recommended flow rate for the first 20 minutes of blood transfusion? A. 10 40 B. 20 D. 60 C.

56. Solutions that are said to be compatible with the osmolarity of the body are called: A. Isotonic B. Hypotonic C. Normosol D. Hypertonic 57. Which of the following are signs of hemolytic reaction during blood transfusion? A. Itching, urticaria and wheezing B. Cough, dyspnea, pulmonary congestion C. High fever and chills D. Fever and backache 58. In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention should focus on: A. Slow the infusion, Call the physician and assess the patient B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the physician C. Stop the infusion, Call the physician and assess the client D. Slow the confusion and keep a patent IV line open for administration of medication 59. The nurse knows that after receiving the blood from the blood bank, it should be administered within: A. 1 hour hours B. 2 hours D. 6 hours C. 4

60. During blood administration, the nurse should carefully monitor adverse reaction. To monitor this, it is essential for the nurse to: A. Stay with the client for the first 15 minutes of blood administration B. Stay with the client for the entire period of blood administration C. Run the infusion at a faster rate during the first 15 minutes D. Tell the client to notify the staff immediately for any adverse reaction SITUATION : John Mark is a 21 year old male client who was rushed following an automobile accident. He is very anxious, dyspneic and in severe pain.

61. The nurse notices that Johns chest tube was dislodged from the chest. The most appropriate nursing intervention is to: A. Notify the physician B. Cover the insertion site with petrolatum gauze C. Immersed the tube into a bottle of sterile water D. Clamp the tube 62. To ensure that the system is functioning effectively, the nurse should: A. Observe for intermittent bubbling in the water seal chamber B. Flush the chest tube with 30 to 60 ml of NSS every 4 hours C. Maintain the client in a sidelying position always D. Strip the chest tube in the direction towards the client 63. JMs chest tube is said to be functioning correctly when which of the following is observed? A. Continuous bubbling in the water seal chamber B. Fluctuation in the water seal chamber C. Suction tubing attached to the wall unit D. Vesicular breath sounds heard in all lung fields 64. He is intubated with an endotracheal tube and is placed on a mechanical ventilator. Which findings alerts the nurse to an additional problem with regards to the respiratory function? A. Dull of percussion in the 3rd to 5th intercostals space, midclavicular line B. Decreased paradoxical motion C. Louder breath sounds on the right chest D. Vesicular breath sound heard at the lung bases 65. The right chest wall of peter moves in during inspiration and balloons out when he exhales. He is very dyspneic. The nurse understands that this symptom is indicative of: A. Hemothorax Pleural effusion B. Flail Chest C. Atelectasis D.

SITUATION : Rene is a 3 y/o boy brought to the health center for fever and cough. You noted grayish pinpoint dots located at the buccal mucosa. A maculopapular rash was noted on his face. Questions 20-25 refer to this. 66. The patients disease is most likely: A. Rubeola B. Diptheria 67. The lesion in his buccal mucosa is called: A. Forchheimers spot B. Pseudomembrane 68. What is the exanthem of measles? A. Maculopapular rash B. Pseudomembrane B. Forchheimers spot D. Kopliks spot C. Ghons tubercle D. Kopliks spot C. Rubella D. Pneumonia

69. The nurse knows that the most common complication of Measles is: A Pneumonia and larynigotracheitis B. Encephalitis C. Otitis Media D. Bronchiectasis 70. Measles vaccine is given at how many months? A. At birth months B. 1 months D. 9 months C. 6

71. All of the following are necessary household management in preventing the spread of Measles at home except: A. Boil foods that are not eaten by the patient B. Separate eating utensils of the patient from that of other members of the family C. Isolate the patient when symptoms start to appear D. Children should be watch out for complications of the disease

72. A client suspected of having tetanus asks the nurse about immunizations against tetanus. The nurse explains that the major benefit in using tetanus antitoxin is that it: A. Stimulates plasma cells directly B. Provides a high titer of antibodies C. Provide immediate active immunity D. Stimulates long-lasting passive immunity 73. Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives and changes money and then hold the bread without washing her hand. As a nurse, What will you say to Miss Kate? A. Miss, Dont touch the bread Ill be the one to pick it up B. Miss, Please wash your hands before you pick up those breads C. Miss, Use a pick up forceps when picking up those breads D. Miss, Your hands are dirty I guess Ill try another bread shop 74. The Causative agent of Tuberculosis is said to be: A. Mycobacterium Tuberculosis B. Hansens Bacilli C. Bacillus Anthraces D. Group A Beta Hemolytic Streptococcus 75. A client who was exposed to hepatitis A is given gamma globulin to provide passive immunity which: A. Increases the production of short lived antibodies B. Provides antibodies that neutralize the antigen C. Accelerates antigen-antibody union at the hepatic sites D. Stimulates the lymphatic system to produce large number of antibodies 76. They are the proteins in the body that are produced in response to the invasion to pathogens and microorganisms. A. Antigen B. Amino Acids C. Agglutinogen D. Antibody

77. A nursing instructor asks a nursing student to describe human immunoglobulin. The student correctly states that these types of vaccine are: A. Vaccine that have their virulence diminished so as to not produce a full blown clinical illness B. Vaccine that contains pathogens made inactive by either chemicals or heat C. Bacterial toxins that have been made inactive by either chemicals or heat D. Vaccines collected from pooled blood of people and provide antibodies to variety of diseases 78. Mode of transmission of leprosy aside from skin contact is by: A. Oral fecal B. Sexual contact C. Borrowing utensil D. Droplet infection

79. Which of the following is not a late sign and symptoms of leprosy? A. Paralysis B. Contractures C. Madarosis D. Gynecomastia

80. Which among the following person is most susceptible to leprosy? A. Mark, 21 year old athlete B. Arvinn, 16 year old student C. JC, 12 year old student D. Clarence, 9 year old student 81. The nurse is documenting her care for a client with iron deficiency anemia. Which of the following nursing diagnoses is most appropriate? A. Impaired gas exchange B. Deficient fluid volume pattern 82. The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that hell be undesirable to his wife, and he becomes tearful. He expresses that he has spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes? C. Ineffective airway clearance D. Ineffective breathing

A. Situational low self-esteem B. Unilateral neglect

C. Social isolation D. Risk for loneliness

83. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesnt want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the clients advance directive, the nursing plan of care should include which intervention? A. Check on the client once per shift. B. Provide mouth and skin care only if the family requests it. C. Turn the client only if hes uncomfortable. D. Provide emotional support and pain relief. 84. Which of these findings is an early sign of bladder cancer? A. Painless Hematuria B. Occasional Polyuria C. Nocturia D. Dysuria

85. During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis? A. Bathing or hygiene self-care deficit B. Ineffective cerebral tissue perfusion C. Dysfunctional grieving D. Risk for injury

86. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately? A. Complaints of intense thirst 1st hour B. Moderate to severe pain D. Hoarseness of the voice C. Urine output of 70 ml the

87. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurses primary concern should be: A. fluid resuscitation. B. infection. C. body image. D. pain management.

88. client is admitted to the hospital following a burn injury to the left hand and arm. The clients burn is described as white and leathery with no blisters. Which degree of severity is this burn? A. First degree burn B. Second degree burn C. Third degree burn D. Fourth degree burn

89. A client with end-stage liver cancer tells the nurse he doesnt want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client? A. Tell him that its a legal question beyond the scope of nursing practice. B. Give him a copy of the clients bill of rights. C. Provide information on active euthanasia. D. Discuss documenting his wishes in an advance directive. 90. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isnt answered immediately. The most appropriate response to her would be: A. You seem angry. Would you like to talk about it? B. Calm down. You know that stress will make your symptoms worse. C. Would you like to talk about the problem with the nursing supervisor? D. I can see youre angry. Ill come back when youve calmed down. SITUATION: Consider the following hypothesis: The Job turnover rate and job dissatisfaction levels of graduate nurses who have worked less than 2 years is higher than for those graduate nurses who have worked for more than 2 years 91. A systematic, objective, process of analyzing phenomena importance to nursing is termed as: A. Nursing research B. Research 92. The major reason for conducting nursing research is to: A. Improve nursing care for clients B. Promote the growth of the nursing profession C. Document to cost effectiveness of nursing care C. Scientific research D. Research process

D. Ensure accountability of nursing practice 93. Which is you independent variable? A. Job dissatisfaction B. Job turn over rate 94. Which is your dependent variable? A. Job dissatisfaction B. Job turn over rate C. Job dissatisfaction and Job turn over rate D. Length of employment C. Job dissatisfaction and Job turn over rate D. Length of employment

95. The type of hypothesis in this situation is classified as: A. Simple, Directional B. Simple, Non Directional C. Complex, Directional D. Complex, Research

96. The problem that a researcher would like to give emphasis Is there a relationship between timing of the administration of psychological support and feelings of wellbeing among terminally ill patients. The appropriate null hypothesis for this problem is: A. Feelings of wellbeing of terminally ill patients who received psychological support is similar to the feelings of wellbeing of those terminally ill patients who did receive said psychological support. B. There is no relationship between the timing of administration of psychological support and feelings of well-being among terminally ill patients C. Factors are not appropriate to determine any desired results D. There is no relationship between the timing of the administration of psychological support and feelings of adequacy among terminally ill patients 97. In the above number, your dependent variable is: A. Terminally ill patients B. Feelings of wellbeing C. Timing of psychological support D. Time

98. In the recent technological innovations, which of the following describe researches that are made to improve and make human life easier? A. Pure research C. Basic research

B. Applied research

D. Experimental research

99. After the researcher has determined and read relevant literature, she has to: A. Write down the review B. Organized the relevant literature C. Analyze potential literature D. Integrate the review of literature 100. The final product of review of related literature is: A. Pool of related literature B. Organized relevant literature C. Analyzed potential literature D. Written review of literature