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Situation 1 - Because of the serious consequences of severe burns management

requires a multi disciplinary approach. You have important responsibilities as a

While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst
into flames. The most effective way
to extinguish the flames with as little further damage as possible is to:
a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames

RATIONALE: Stop, drop and roll is a simple fire safety technique taught to
children, emergency services personnel and industrial workers as a component of
health and safety training. Primarily, it is a method to extinguish a fire on a
person's clothes or hair without, or in addition to, the use of conventional
firefighting equipment.
In addition to extinguishing the fire, stop, drop and roll is an effective
psychological tool, providing those in a fire situation, particularly children,
with a routine that can be used to focus on in order to avoid panic.
Stop, drop and roll consists of three components.
· Stop - The fire victim must stop still. Ceasing any movement which may fan
the flames or hamper those attempting to put the fire out.
· Drop - The fire victim must 'drop' to the ground, lying down if possible.
· Roll - The fire victim must roll on the ground in an effort to extinguish
the fire by depriving it of oxygen. If the victim is on a rug or one is nearby,
they can roll the rug around themselves to further extinguish the flame.
The effectiveness of stop, drop and roll may be further enhanced by combining it
with other firefighting techniques,including the use of a fire extinguisher,
dousing with water, or fire beating.

2. Once the flames are extinguished, it is most important to:

a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess Sergio's breathing

RATIONALE: Thermal burns are caused by exposure to flames, hot liquids, steam or
hot objects. Like this one, 1st priority should go to the assessment of breathing
if there are no airway problems, possibility of inhalation of the smoke from the
flames may cause smoke poisoning from by products of combustion. A localized
inflammatory reaction may occur, causing a decrease in bronchial ciliary action
and a decrease in surfactant. A compromised breathing may later on lead to
respiratory complications. Assess for mucosal edema in the airways, after several
hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic
bronchitis may develop, ARDS can result.(Source: Saunders Comprehensive Review for
the NCLEX-RN exam 3rd Edition, p. 545)
OPTION A: covering Sergio with a warm blanket will not benefit the situation since
it can only increase heat and compromise comfort that should be provided for
OPTION B: Although giving sips of water may help in the drying of the mucosa of
the patient, it is first essential to assess the airway and breathing of the
patient as mucosal edema may be present and sips of water may result to
OPTION C: Calculating the extent of the burn may be done after assessment of the
ABC’s which is very essential in providing care to the patient.

Sergio is brought to the Emergency Room after the barbecue grill accident. Based
on the assessment of the
physician, Sergio sustained superficial partial thickness bums on his trunk, right
upper extremities ad right
lower extremities. His wife asks what that means. Your most accurate response
would be:
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

RATIONALE: Superficial partial thickness: These burns are superficial with injury
to the epidermis. These are first-degree burns and are characterized by erythema,
edema, and pain; slight fluid loss, especially if less than 15% of the body is
involved. Superficial partial-thickness burns heal spontaneously within 2-3 weeks,
usually without scarring. Injured area is sensitive to cold air. Grafts may be
used if healing process is prolonged.
SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition,p. 544)
OPTION A: is true for Deep Full-thickness burns as it involves injury to the
muscle and bone.
OPTION B: is true for Deep Partial-thickness burns as it involves the epidermis
and superficial dermis causing erythema, pain, vesicles with oozing; fluid loss
slight to moderate.
OPTION C: is true for Full-thickness (3rd Degree) burn affects the epidermis,
entire dermis and at times the subcutaneous tissue, resulting in charred or pearly
white, dry skin and absence of pain; fluid loss usually severe, especially if more
than 2% of body surface is involved.
(SOURCE: Mosby Comprehensive Review of Nursing for the NCLEX-RN exam 18th edition,
p. 169.)

4. During the first 24 hours after thermal injury, you should assess Sergio for
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and Hypernatremia

RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues.
Since most of the potassium in the body is contained in muscle, a severe trauma
that crushes muscle cells results in an immediate increase in the concentration of
potassium in the blood. Hyperkalemia result from severe burns for the 1st 24
hours. Hyponatremia in burns occur due to low plasma osmolarity.
(SOURCE: Silvestri Saunders Online Review Course,Fluid and Electrolyte Imbalance,
p. 18)

5. Teddy, who sustained deep partial thickness and full thickness burns of the
face, whole anterior chest and both
upper extremities two days ago, begins to exhibit extreme restlessness. You
recognize that this most likely indicates that Teddy is developing:
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure .
RATIONALE: Rarely do burn-injured clients suffer neurologic damage. The client
with a major burn injury is most often awake and alert on admission to the
hospital. If alteration in level of consciousness manifests, the client may be
suffering from hypoxemia or hypovolemia and needs further assessment for
identifying the origin of these changes. It is most often related to impaired
perfusion to the brain, hypoxia/hypoxemia (as in a closed space fire), inhalation
injury (as from exposure to asphyxiate or other toxic materials from the fire).
Major burn injuries that may cause severe fluid loss can lead to a decrease in
blood pressure, causing decreased cerebral perfusion, followed by impaired
oxygenation to the brain. Neurologic manifestations may include headache,
dizziness, memory loss, confusion or loss of consciousness, disorientation, visual
changes, hallucinations, combativeness and coma.
(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1441

Situation 2 - You are now working as a staff nurse in a general hospital. You have
to be prepared to handle situations with ethico-legal and moral implications.

6. You are on night duty in the surgical ward. One of our patients Martin is
prisoner who sustained an
abdominal gunshot wound. He is being guarded by policemen from the local police
unit. During your rounds
you heard a commotion. You saw the policeman trying to hit Martin. You asked why
he was trying to hurt Martin. He denied the matter. Which among the following
activities will you do first?
a. Write an incident report
b. Call security officer and report the incident
c. Call your nurse supervisor and report the incident:
d. Call the physician on duty

RATIONALE: The incident report is used as a means of identifying risk situations
and improving client care. Specific documentation guidelines are followed in
completion of the incident report. The criteria’s to formulating an incident
report are as follows:
· Accidental omission of ordered therapies
· Circumstances that led to injury or a risk for client injury
· Client falls
· Medication administration errors
· Needlestick injuries
· Procedure-related or equipment-related accidents
· A visitor having symptoms of an illness
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 57)

7. The nurse gives an inaccurate dose of a medication to a client. Following

assessment of the client, the
nurse completes an incident report. The nurse notifies the nursing
supervisor of the medication error and calls
the physician to report the occurrence. The nurse who administered the
inaccurate medication dose
understands that the:
a. error will result in suspension
b. incident report is a method of promoting quality care and risk
c. incident will be reported to the board of nursing
d. incident will be documented in the personnel file.

RATIONALE: Documentation of unusual occurrences, incidents, and accidents and the
nursing actions taken as a result of the occurrence is internal to the institution
or agency and allows the nurse and administration to review the quality of care
and determine any potential risks present. Based on the information provided in
the question, the nurse’s error will not result in suspension nor will it be
documented in the personnel file. The situation and the error presented in the
question are not a reason for notifying the board of nursing.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 62)

8. The nurse hears a client call for help. The nurse hurries down the hallway
to the client’s room and finds the client lying on the floor. The nurse performs
a thorough assessment and assists the client back to bed. The nurse notifies the
physician of the incident and completes an incident report. Which of the following
would the nurse document on the incident report?
a. the client was found lying on the floor
b. the client climbed over the side rails
c. the client fell out of bed
d. the client became restless and tired to get out of bed

RATIONALE: The incident report should contain the client’s name, age, and
diagnosis. The report should contain a factual description of the incident, any
injury experienced by those involved, and the outcome of the situation. Option A
is the only option that describes the facts as observed by the nurse. Options B,
C, and D are interpretations of the situation and not factual data as observed by
the nurse.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 63)

9. You are on duty in the medical ward. The mother of your patient who is also a
nurse came running to the
nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which
among the following will you do first?
a. Start basic life support measures
b. Call for the Code
c. Bring the crash cart to the room
d. Go to see Fiolo and assess for airway patency and breathing problems

RATIONALE: The purpose of primary assessment in cardiopulmonary arrest is to
immediately identify any client problem that poses a threat, what could have
caused the arrest. Airway clearance and breathing should be assured before
anything else after which, immediate interventions such as CPR and advanced life
support must be instituted to aid in preserving the client’s life.
OPTIONS A-C: these are the following interventions that are done after a primary
assessment of the ABC’s had been made.
(SOURCE: Med.-Surg. Nursing by Black and Hawk, 7th edition, vol.2, p.2485)

10. A client is brought to the emergency medical services after being hit by a
car. The name of the client is
not known. The client has sustained a severe head injury, multiple fractures, and
is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure,
which of the following is the best
a. call the police to identify the client and locate the family
b. obtain a court order for the surgical procedure.
c. ask the emergency medical services team to sign the informed consent
d. transport the victim to the operating room for surgery
RATIONALE: Generally, in only 2 instances is an informed consent of an adult
client not needed. One instance is when an emergency is present and delaying
treatment for the purpose of obtaining an informed consent would result in injury
or death o the client. The 2nd instance is when the client waives the right to
give informed consent. OPTION 2, will delay emergency treatment and option 3 is
inappropriate. Although option 1 may be pursued, it is not the best action.

Situation 3 - Colorectal cancer can affect old and younger people. Surgical
procedures and other modes of treatment are done to ensure quality of life. You
are assigned in the Cancer institute to care of patients with this type of cancer.

11. Larry, 55 years old, who is suspected of having colorectal cancer, is

admitted to the CI. After taking the history
and vital signs the physician does which test as a screening test for
colorectal cancer.
a. Barium enema
b. Carcinoembryonic antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy

RATIONALE: Early detection through routine screening is the key to decreasing
mortality. It is recommended that people with an average risk for colon cancer be
screened annually for digital rectal examinations and Fecal occult blood tests
begin at 40 years of age withy sigmoidoscopy every 3-5 years beginning at 50 years
of age.

12. To confirm his impression of colorectal cancer, Larry will require which
diagnostic study?
a. carcinoembryonic antigen
b. incisional biopsy of the colon
c. stool hematologic test
d. abdominal computed tomography (CT) test

Rationale: Incisional biopsy; a selected part of the lesion is removed. This form
of biopsy is commonly completed During endoscopic examination. The Frozen Method
procedure is used to assess for malignant cells from tissue samples. Frozen
sections are used for rapid microscopic diagnosis. A thin slice of tissue is cut
from the frozen specimen and examined. The procedure requires 10-15 minutes. The
pathologist can determine whether malignancy is present and whether the entire
tumor has been removed by looking for a margin of tumor-free tissue.
SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, Vol.1, p. 106)

13. The following are risk factors for colorectal cancer, EXCEPT:
a. inflammatory bowels
b. low fat, high fiber diet
c. smoking
d. genetic factors-familial adenomatous polyposis

RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the
development of cancer of the large bowel. Studies on bulk in stool and the rate of
transit of fecal matter have so far given mixed results. Some researchers propose
that metabolic and bacterial end products are carcinogenic and that constipation
allows a longer contact with the bowel wall, thus raising the probability that
cancer will develop. Increasing fiber in the diet may reduce exposure to
carcinogens by speeding stool transit through the intestines.
(SOURCE: Med-Surg. Nsg Black and Hawk 7th edition, Vol.1 p. 831)

14. Symptoms associated with cancer of the colon include:

a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis

RATIONALE: Symptoms include the following: Blood in stools, anorexia, vomiting,
and weight loss, malaise, Anemia, abnormal stools. Ascending colon tumor:
Diarrhea, Descending Colon tumor: constipation or some diarrhea, or flat, ribbon-
like stool resulting from a partial obstruction. Rectal Tumor: alternating
constipation and diarrhea, guarding or abdominal distention, abdominal mass (a
late sign), Cachexia (a late sign). (source: Saunders Comprehensive Review for the
NCLEX-RN exam, 3rd Edition, p.592)

15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and
neomycin primarily to:
a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon

RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug, primarily for the
treatment of asymptomatic mengococcal carrier, can be used as alternative for
penicillin in rheumatic fever. Neomycin, kanamycin sulfate, erythromycin, &
succinylsulfathiazole (Sulfasuxidine) are used pre-operatively to reduce bacterial
number in the GI tract. (Source: Nursing Drug Handbook 2006, 26th Edition, p. 131)
Sulfasuxidine and other antiseptics and antibiotics, as prescribed to decrease the
bacterial content of the colon to reduce the risk of infection from the surgical
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 592)

Situation 4 - ENTEROSTOMAL THERAPY is now considered especially in nursing. You

are participating in the OSTOMY CARE CLASS.

16. You plan to teach Fermin how to irrigate the colostomy when:
a. The perineal wound heals and Fermin can sit comfortably on the commode
b. Fermin can lie on the side comfortably, about the 3rd postoperative day
c. The abdominal incision is close and contamination is no longer a danger
d. The stool starts to become formed, around the 7th postoperative day

RATIONALE: Carefully assess the client’s physical condition, emotional and mental
attitudes toward the colostomy before attempting to teach ostomy self-care. Pace
the teaching to the client’s level of acceptance of the colostomy and ability to
manage it. Teach the client how to apply the pouch to the stoma correctly. The
client first should be taught how to examine the stoma. A healthy stoma and
abdominal incision is a very good indicator that client is now ready for ostomy
care teaching.
(SOURCE: Med-Surg. Nsg. by Black and Hawk, 7th edition, vol.1, p. 837)

17. When preparing to teach Fermin how to irrigate his colostomy, you should plan
to do the procedure:
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. After breakfast
d. After Fermin accepts alteration in body image

RATIONALE: A suitable time for the irrigation is selected that is compatible with
the patient’s posthospital pattern of activity (preferably after a meal).
Irrigation should be performed at the same time each day.
(SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064)

18. When observing a rectum demonstration of colostomy irrigation, you know that
more teaching is
required if Fermin:
a. Lubricates the tip of the catheter prior to inserting into the stoma
b. Hands the irrigating bag on the bathroom door doth hook during fluid insertion
c. Discontinues the insertion of fluid after only 500 ml of fluid had been
d. Clamps off the flow of fluid when feeling uncomfortable

RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate
evacuation, Volume may be increased with subsequent irrigations to 500, 1000, up
to 1, 500 mL as needed by the patient for effective results. Allow tepid fluid to
enter the colon slowly. If cramping occurs, clamp off the tubing and allow the
patient to rest before progressing. Water should flow in over 5 to 10 minute
(SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064)

19. You are aware that teaching about colostomy care is understood when Fermin
states, "I will contact my
physician and report:
a. If I have any difficulty inserting the irrigating tube into the stoma."
b. If I notice a loss of sensation to touch in the stoma tissue."
c. The expulsion of flatus while the irrigating fluid is running out."
d. When mucus is passed from the stoma between irrigation."

Rationale: Any difficulty in the insertion of the irrigating tube into the stoma
may mean an obstruction to the system.

20. You would know after teaching. Fermin that dietary instruction for him is
effective when he states, "It is
important that I eat:
a. Soft foods that are easily digested and absorbed by my large intestine."
b. Bland food so that my intestines do not become irritated."
c. Food low in fiber so that there is less stool."
d. Everything that I ate before the operation, while avoiding foods that cause

RATIONALE: As such there is no specific diet plan for Ostomy patients. The main
point is that you should be able to tolerate the food you are eating. Still
certain foods you need to avoid or include in your diet so as to maintain a good
health after Ostomy. Below is the list of food you need to keep in consideration:
· Food resulting in thickened stools (Low-Fiber): Applesauce, Peanut butter,
boiled milk, Tapioca, Rice, Cheese, Bananas, and Pretzels.
· Food resulting in soft stools (High Fiber): Red wine, Beer, Coffee, Prune
juice, Fresh vegetables, Fruits and Food with high fiber content.
· Foods resulting in incomplete digestion: Broccoli, Cabbage, Raw carrots, Raw
onions, Pineapple, Beans, Spinach, Potato skins, Corn, Coconut, Celery, Whole
grains, Nuts, Raisins, Popcorn, Raw fruits, Chinese vegetables, Seeds and Skins.
· Foods causing odor: Cabbage, Beans, Asparagus, Onions, Garlic, Eggs, Fish,
Alcohol and Vitamins.
· Foods causing gas: Raw apple, Cabbage, Broccoli, Onions, Turnip, Corn, Nuts,
Milk, Beer, Carbonated beverages, iced beverages and Chewing gums.
· Foods causing diarrhea: Fried foods, highly spicy food, Legumes, Grape
juice, Apple juice, Prune juice, Green beans, Spinach, Raw fruits, Cabbage and
SOURCE: Ostomy Nutrition Guide booklet page 1-5

Situation 5 - Ensuring safety is one of your most important responsibilities. You

will need to provide instructions and information to your clients to prevent

21. Randy has chest tubes attached to a pleural drainage system. When caring for
him you should:
a. empty the drainage system at the end of the shift
b. clamp the chest tube when suctioning
c. palpate the surrounding areas for crepitus
d. change the dressing daily using aseptic techniques

RATIONALE: Assessment actions to check for signs of extended pneumothorax or
hemothorax should be performed such as palpating surrounding areas for crepitus.
It may also be an indication for a chest tube complication known as subcutaneous
emphysema. Subcutaneous emphysema occurs when air gets into tissues under the skin
covering the chest wall or neck. This can happen due to stabbing, gun shot wounds,
other penetrations, or blunt trauma. Air can also be found in between skin layers
on the arms and legs during certain infections, including gas gangrene.
Subcutaneous emphysema can often be seen as a smooth bulging of the skin. When a
health care provider feels (palpates) the skin, it produces an unusual crackling
sensation as the gas is pushed through the tissue.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN, 3rd edition, p. 242)

22. Fanny came in from PACK after pelvic surgery. As Fanny's nurse you know that
the sign that would be
indicative of a developing thrombophlebitis would be:
a. a tender, painful area on the leg
b. a pitting edema of the ankle
c. a reddened area at the ankle
d. pruritus on the calf and ankle

RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall
as a result of the inflammation of the vessel wall. It has 3 Types: Superficial,
Femoral, and Pelvic. Assessment findings for a developing Superficial
Thrombophlebitis are tenderness and pain in the affected lower extremity. Also
includes the following symptoms: warm and pinkish red color over the thrombus
area, palpable thrombus that feels bumpy and hard. (SOURCE: Saunders Comprehensive
Review for the NCLEX-RN exam, 3rd Edition, p.329)

23. To prevent recurrent attacks on Terry who has acute glomerulonephritis, you
should instruct her to:
a. seek early treatment for respiratory infections
b. take showers instead of tub bath
c. continue to take the same restrictions on fluid intake
d. avoid situations that involve physical activity

RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or
tonsillitis 2 – 3 weeks before symptoms. Usually a streptococcal infection may
precede it. It is very important to seek treatment for respiratory infections
existing to stop the progress of the disease. And it is usually with untreated
respiratory infections (Group A β-hemolytic streptococcus) that this sequelae
OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria
from entering the urethra, however is indicated for UTI.
OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is
more of an intervention rather than a preventive measure for recurrence.
OPTION D: Avoiding physical activity is also an intervention for

24. Herbert has a laryngectomy and he is now for discharge. He verbalized his
concern regarding his
laryngectomy tube being dislodged, what should you teach him first?
a. Recognize that prompt closure of the tracheal opening may occur
b. Keep calm because there is no immediate emergency
c. Reinsert another tubing immediately
d. Notify the physician at once

RATIONALE: If the patient verbalizes his concerns regarding dislodgement it would
mean then that the patient has not been well educated about the process of having
a laryngectomy. It is stated that the patient is now for discharge and it is
expected that by this time the patient should be having all the information he has
to know regarding the laryngectomy. Preoperative teaching is done so that patient
will be able to correct misconceptions and fears about the reason for having the
surgery, nature of the surgical procedure. Postoperatively, the nurse reviews
equipment and treatments for care with the patient, patients’ family. It means
that after essential information and teaching had been offered, patient still lack
the knowledge and confidence to carry out self care and important procedure
(SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing 10th Edition,
p. 510-511)

25. When caring for Larry after an exploratory chest surgery and pneumonectomy,
your priority would be to maintain:
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement

RATIONALE: After surgery, the vital signs are checked frequently. Oxygen is
administered via a mechanical ventilator, nasal cannula, or mask for as long as
necessary. A reduction in lung capacity requires a period of physiologic
adjustment, and fluids may be given at a low hourly rate to prevent fluid overload
and pulmonary edema.
OPTION B and C: ventilation exchange may also be important as it is the goal of
the surgery to promote a better gas exchange and oxygenation. Chest Tube drainage
is already a precursor of the surgery as it is needed to facilitate recuperation
of lung expansion functions and avoid further complications such as pneumothorax
and hemothorax.
OPTION D: Blood replacement is a standing order in cases that bleeding problem may
arise within the surgical procedure.
(SOURCE: Brunner and Suddarth’s Textbook of Med.-Surg. Nursing 10th edition, vol.1
p. 628)

Situation 6 - Infection can cause debilitating consequences when host resistance

is compromised and virulence of microorganisms and environmental factors are
favorable. Infection control is one important responsibility of the nurse to
ensure quality of care.

26. Honrad, who has been complaining of anorexia and feeling tired, develops
jaundice. After a workup he
is diagnosed of having Hepatitis A. His wife asks you about gamma globulin for
herself and her household
help. Your most appropriate response would be:
a. "Don't worry your husband's type of hepatitis is no longer communicable"
b. "Gamma globulin provides passive immunity for Hepatitis B"
c. "You should contact your physician immediately about getting gamma globulin."
d. "A vaccine has been developed for this type of hepatitis"

RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM, IgG, IgA,
IgD, and IgE, which are essential in the body’s defense against microorganisms.
Household and personal contacts of clients with HAV should be given immune
globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and
after exposure. However a specific vaccine had been developed for Hepatitis A
which is the inactivated hepatitis A vaccine (active), which is given two doses of
at least 6 months apart for persons who reside in a community that has a high rate
of hepatitis A virus infection, who are at risk because of foreign travel, or who
have chronic liver disease. (SOURCE: Med.-Surg. Nsg. By Black and Hawk, 7th
edition, vol.1, p. 427, Vol.2 p. 2241)

27. Voltaire develops a nosocomial respiratory tract infection. He asks you what
that means.
a. "You acquired the infection after you have been admitted to the hospital."
b. "This is a highly contagious infection requiring complete isolation."
c. "The infection you had prior to hospitalization flared up."
d. "As a result of medical treatment, you have acquired a secondary infection."

RATIONALE: Nosocomial Infections also are referred to as hospital-acquired
infections. Such infections are infections acquired in a hospital or other health
care facility that were not present or incubating at the time of a client’s
admission. The hospital environment provides exposure to a variety of virulent
organisms that the client has not been exposed to in the past; therefore the
client has not developed resistance to these organisms. (SOURCE: Saunders
Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 180)

28. As a nurse you know that one of the complications that you have to watch out
for when caring for Omar
who is receiving total parenteral nutrition is:
a. stomatitis
b. hepatitis
c. dysrhythmia
d. infection

RATIONALE: It is most important to watch out for signs of infection because a
patient in TPN is most prone to infection because of an open venous access that
can be easily contaminated; furthermore, microorganisms can easily find its way to
enter the body through the bloodstream. A strict aseptic technique must be used
because the TPN solution has a high concentration of glucose, which is a medium
for bacterial growth. Signs of an infection are as follows: Chills, elevated WBC
count, erythema or drainage at the insertion site, and fever. Assess IV site for
redness, swelling, tenderness, or drainage. Change IV tubing every 24 hours or
according to agency protocol. If signs of infection occur at the site, the
following must be done:

· IV line must be removed and restarted at a different site

· Remove the tip of the IV catheter and send it to the laboratory for culture
· Prepare the client for blood cultures

29. A solution used to treat Pseudomonas wound infection is:

Dakin's solution
Half-strength hydrogen peroxide
Acetic acid

RATIONALE: Acetic Acid is effective for irrigating, cleansing, and packing wounds
infected by Pseudomonas Aeruginosa. Healthy skin surrounding the wound must be
protected with a petroleum barrier because acetic acid excoriates the skin.
(Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.
566)The use of acetic acid to treat Pseudomonas aeruginosa in superficial wounds
dates back to 1916 when it was discovered that a 1% solution applied to war wounds
led to elimination of this organism then called Bacillus pyocyaneas. In 1992 a
prospective study involving the use of 5% acetic acid was undertaken in 9
patients. No patients complained of discomfort after the soaks which were applied
daily. Two wounds lost Pseudomonas species within 2 days and a further four within
one week. Only one patient remained contaminated after three weeks. Following
eradication of the organism, healing occurred rapidly. Milner-S;Acetic acid to
treat Pseudomonas aeruginosa in superficial wounds and burns - (letter);The
Lancet;Vol 340 (1992):61. It is possible the application of acetic acid may confer
other benefits to the healing process as well as the removal of bacteria.
Acidification of a wound would also increase the pO2 and reduces the histotoxicity
of ammonia which may be present (Ammonia is less toxic in an acid environment).
OPTION A: Dakin’s Solution or more commonly known as Bleach is a chloride solution
that loosens, dissolves, and deodorizes necrotic tissue and blood clots. The
solution must not be in contact with healing or normal tissue.
OPTION B: Half strength hydrogen peroxide is a 3% solution has effervescent action
that releases gas and breaks up necrotic tissue. However, it is not used to pack
wounds because it decomposes too rapidly.
OPTION D: Betadine is a brand name of povidone-iodine which is a water-soluble
complex of iodine with polyvinylpyrrolidone (PVP), with from 9.0% to 12.0%
available iodine, calculated on a dry basis[1].It is used in hospitals for
cleansing and disinfecting the skin, preparing the skin preoperatively and
treating infections susceptible to iodine.It works through disruption of pathogen
cell walls.

30. Which of the following is most reliable in diagnosing a wound infection?

a. Culture and sensitivity
b. Purulent drainage from a wound
c. WBC count of 20,000/pL
d. Gram stain testing

RATIONALE: The Gram-Stain is the most important of all bacteriologic differential
stains to diagnose a wound infection. It divides bacteria into two physiologic
groups: Gram – and Gram + organisms, thus determining the type of medication to be
given to the patient. Infectious diseases or processes can be diagnosed by
detection of an immunologic response specific to an infecting agent in a patient’s
serum. Normal humans produce both IgM ( first-response antibodies) and IgG
(antibodies that may persist long after an infection) to most pathogens. (Frances
Fischbach’s A manual of Laboratory and Diagnostic Tests 7th edition, p. 500)

Situation 7 - As a nurse you need to anticipate the occurrence of complications of

stroke so that life threatening situations can be prevented.

31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her
Glasgow Coma Scale is 6
on admission. A central venous catheter was inserted and an I.V. infusion was
started. As a nurse assigned
to Wendy what will he your priority goal?
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway

RATIONALE: In a pt. that has a GCS of 6, it is very essential that airway must be
maintained since deficient O2 delivery to the brain can cause irreversible brain
damage in only 6 minutes. Taking into consideration the ABC’s of emergency and
medical management Airway must be established first followed by Breathing, and
last is circulation. If patient have already manifestations of brain injury,
patient may fail to initiate his own breathing and thus airway patency can be
compromised resulting to a more severe condition.
(SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing Vol.1 10th
Edition, p. 201-202)

32. Knowing that for a comatose patient hearing is the best last sense to be lost,
as Judy's nurse, what should
you do?
a. Tell her family that probably she can't hear them
b. Talk loudly so that Wendy can hear you
c. Tell her family who are in the room not to talk
d. Speak softly then hold her hands gently

RATIONALE: It is important to get the attention of the client before beginning to
speak despite it’s inability to respond or to react, nurse must move close to the
client and speak slowly and clearly, talking in lower tones is advised as shouting
may not help and may only disturb other clients inside the unit. Source: Saunders
Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p. 910-911)

33. Which among the following interventions should you consider as the highest
priority when caring for June
who has hemiparersis secondary to stroke?
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support

RATIONALE: Hemiparesis is the partial paralysis of one side of the body. It is
generally caused by lesions of the corticospinal tract, which runs down from the
cortical neurons of the frontal lobe to the motor neurons of the spinal cord) and
is responsible for the movements of the muscles of the body and its limbs. ROM
exercises are the highest priority of all the interventions because for a patient
with hemiparesis, rehabilitation and restoration of functional capability is very
important. ROM exercises may be done with assistance or guidance of a physical
therapist and a rehabilitation nurse. Exercise when performed correctly assists in
maintaining and building muscle strength, maintaining joint function, preventing
deformity, stimulating circulation, developing endurance and promoting relaxation.
Some disabilites, such as spinal cord injury, acute brain injury, and other
conditions that cause muscle weakness or hemiparesis require extended periods in
the recumbent position, thus may be assisted to an alternative 90-degree position
such as a reclining wheelchair with elevated leg rests.
(SOURCE: Brunner and Suddarths textbook for Medical Surgical Nursing Vol.1, 10th
edition, p.163)

34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck
and photophobia. She was diagnosed
with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting
for surgery, you can provide a
therapeutic by doing which of the following?
a. honoring her request for a television
b. placing her bed near the window
c. dimming the light in her room
d. allowing the family unrestricted visiting privileges

RATIONALE: Prior to surgery it is important that medical management be maintained,
includes: maintaining cerebral perfusion pressure, controlling ICP, minimizing
effects of vasospasm. The client with intracranial aneurysm is at great risk for
the development of increased ICP. (Normal ICP 0-15mmHg). A therapeutic nursing
management is to decrease environmental stimuli which can increase ICP.

Dim all lights

Speak softly
Touch gently and only when needed
Space all interventions
Limit noxious stimuli such as suctioning to only as needed

OPTIONS A, B and D are distractive and are examples of environmental stimuli that
may aggravate the condition of the patient.(Source: Med.-Surg. Nsg. By Black and
Hawk 7th edition Vol.2, p.2095)

35. When performing a neurological assessment on Walter, you find that his pupils
are fixed and dilated.
This indicated that he:
a. probably has meningitis
b. is going to be blind because of trauma
c. is permanently paralyzed
d. has received a significant brain injury

RATIONALE: Fixed, Dilated pupils (unilateral or bilateral) or midposition fixed
pupils indicate an upper midbrain involvement of brain injury. .
(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition Vol.2,p. 2055)

Situation 8 - With the improvement in life expectancies and the emphasis in the
quality of life it is important to provide quality care to our older patients.
There are frequently encountered situations and issues relevant to the older,

36. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated
with aging.
a Ineffective airway clearance
b. Decreased alveolar surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation

RATIONALE: A 70-year-old expends 70% of the total elastic work of breathing on the
chest wall compared with 40% for a 20-year-old. While there is great variation
between individual and genders, there are age-related decrements of respiratory
muscle strength and endurance of approximately 20% by the age of 70 years.
Beginning in early adulthood, there is a progressive enlargement of the alveolar
ducts and respiratory bronchioles. The effect of the enlargement of the terminal
respiratory units is a decrease of functional alveolar surface area by 15% by the
age of 70 years. The decrease in alveolar surface area reduces alveolar surface
tension with consequential negative effect on alveolar gas exchange and forced
expiratory flow.

37. The older patient is at higher risk for in incontinence because of:
a. dilated urethra
b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity

RATIONALE: Aging causes a number of changes in urinary tract physiology, all of
which can affect continence. These changes include:
A decrease in bladder elasticity, which decreases bladder capacity and requires
the older adult to void more frequently
A decrease in the strength of the detrusor muscle, resulting in incomplete bladder
An increase in spontaneous detrusor muscle contractions
A decrease in the ability to postpone urination
A decrease in urethral closing pressure

38. Merle, age 86, is complaining of dizziness when she stands up. This may
a. dementia
b. a visual problem
c. functional decline
d. drug toxicity

RATIONALE : Visual information is of particular importance to maintaining balance.
The visual systems most involved are the optokinetic and pursuit systems. The
optokinetic system is the motor impulse responsible for moving the eyes when the
head moves, so that the field of vision remains clear. The pursuit system allows a
person to focus on a moving object while the head remains stationary. Both of
these systems feed information about the person's position relative to the
surroundings to the brainstem. A specific type of eye movement called nystagmus,
which is repetitive jerky movements of the eye, most often in the horizontal
direction, may cause dizziness. Nystagmus may indicate that neurologic signals
from the optokinetic or pursuit systems are not in agreement with the other
balance information received by the brain. If the eyes do not move in parallel or
if the upper eyelid covers more than a tiny portion of the iris, note the
conditions as abnormal findings.
(SOURCE: Med.-Surg. Nsg. by Black and Hawk 7th edition, vol.2, p. 1924)

39. Cardiac ischemia in an older patient usually produces:

a. ST-T wave changes
b. Very high creatinine kinase level
c. chest pain radiating to the left arm
d. acute confusion

RATIONALE: A classical manifestation of Myocardial ischemia is angina that can
develop quickly or slowly. Some ignore the chest pain, thinking that it will go
away or that it is indigestion. Its location is usually retrosternal or slightly
to the left of the sternum, as reported by 90% of incidents. The pain usually
radiates to the left shoulder and upper arm and may then travel down the inner
aspect of the left arm to the elbow, wrist, and 4th-5th finger. (SOURCE: Med.-
Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1703)

40. The nurse is providing medication instructions to an older adult who is taking
digoxin (Lanoxin) daily.
The nurse bears in mind that which age-related body changes could place the client
at risk for digoxin toxicity?
a. decreased cough efficiency and decreased vital capacity
b. decreased lean body mass and decreased glomerular filtration rate
c. decreased salivation and decreased gastrointestinal motility
d. decreased muscle strength and loss of bone density

RATIONALE: The older client is at risk for medication toxicity because of
decreased lean body mass and age-associated decreased glomerular filtration rate.
Although options A, C and D identify age-related changes that occur in the older
client, they are not associated specifically with this risk.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 394)

Situation 9 - A "disaster" is a large-scale emergency—even a small emergency left

unmanaged may turn into a disaster. Disaster preparedness is crucial and is
everybody's business. There are agencies that are in charge of ensuring prompt
response. Comprehensive Emergency Management (CEM) is an integrated approach to
the management of emergency program and activities for all four emergency phases
(mitigation, preparedness, response, and recovery), for all type of emergencies
and disasters (natural, man-made, and attack) and for all levels of government and
the private sector.

41. Which of the four phases of emergency management is defined as "sustained

action that reduces or eliminates
long-term risk to people and properly from natural hazards and the effect"?
a. Recovery
b. Mitigation
c. Response
d. Preparedness

RATIONALE: Mitigation - actions or measures that can prevent the occurrence of a
disaster or reduce the damaging effects of one
· Involves determining community hazards and risks (actual and potential
threats) for the occurrence of a disaster
· Involves identifying available community resources and community-health
· Involves determining the resources available for care of infants, older
clients, the disabled, and those with chronic health problems
Recovery: Includes actions taken to return to normal after the disaster. Includes
prevention of debilitating effects and restoration of personal, economic, and
environmental health and stability to the community
Response: Involves putting disaster-planning services into action and enumerating
the actions needed to save lives and prevent further damage. Primary concerns
include the safety and physical and mental health of both the victims and the
members of the disaster-response team
Preparedness: Includes plans for rescue, evacuation, and care of disaster victims
· Includes plans for training disaster personnel and gathering resources,
equipment, and other materials needed for dealing with the disaster
· Includes identification of specific responsibilities for various disaster-
response personnel
· Establishes a community disaster plan and an effective public-communication
· Involves setting up an emergency medical system and a plan for its
· Includes checking proper functioning of emergency equipment
· Involves making anticipatory provisions and setting up a location for
distribution of food, water, clothing, shelter, other supplies, and medicine
· Includes checking supplies on a regular basis and replenishing those that
have become outdated
· Includes practicing community disaster plans (mock-disaster drills)
SOURCE: Saunders Comprehensive Review for the NCLEX-RN Exam, 3rd Edition, p. 73-
42. You are a community health nurse collaborating with the Red Cross and working
with disaster relief following a
typhoon which flooded and devastated the whole province. Finding safe
housing for survivors, organizing support
for the family, organizing counseling debriefing sessions and securing
physical care are the services you are
involved with. To which type of prevention are these activities included.
a. Tertiary prevention
b. Primary prevention
c. Aggregate care prevention
d. Secondary prevention

RATIONALE: Tertiary prevention combats the complications of disaster.
Primary prevention of disaster is possible through technical, organizational and
judicial means
Secondary prevention implies the optimal management of disaster itself.
Aggregate care prevention:

43. During the disaster you see a victim with a green tag, you know that the
a. has injuries that are significant and require medical care but can wait hours
will threat to life or limb
b. has injuries that are life threatening but survival is good with minimal
c. indicates injuries that are extensive and chances of survival are unlikely even
with definitive care
d. has injuries that are minor and treatment can be delayed from hours to days
RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical
care at some point, after more critical injuries have been treated. They will
require a doctor's care in several hours or days but not immediately, may wait for
a number of hours or be told to go home and come back the next day (examples:
broken bones without compound fractures, many soft tissue injuries). Option
A:Yellow Tag: Their condition is stable for the moment but requires watching by
trained persons and frequent re-triage, will need hospital care (and would receive
immediate priority care under "normal" circumstances).
OPTION B: Red Tag: They require immediate surgery or other life-saving
intervention, and have first priority for surgical teams or transport to advanced
facilities; they "cannot wait" but are likely to survive with immediate treatment.

OPTION C: Black Tag: They are so severely injured that they will die of their
injuries, possibly in hours or days (large-body burns, severe trauma, lethal
radiation dose), or in life-threatening medical crisis that they are unlikely to
survive given the care available (cardiac arrest, septic shock, severe head or
chest wounds); they should be taken to a holding area and given painkillers as
required to reduce suffering.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition p.75)

44. The term given to a category of triage that refers to life threatening or
potentially life threatening injury or illness
requiring immediate treatment:
a. Immediate
b. Emergent
c. Non-acute
d. Urgent

RATIONALE: Urgent Category are conditions that could potentially progress to a
serious problem requiring emergency intervention. May be associated with
significant discomfort or affecting ability to function at work or activities of
daily living. Usually victim must be treated within 30-60 minutes. These are
patients who have a trauma score of 10 or 11 and can wait for a short time before
transport to definitive medical attention. Some examples of conditions that can be
treated at urgent care include: accidents and falls, broken bones, breathing
difficulties, severe abdominal pain, bleeding/cuts, high fever and

Immediate - are used to label those who cannot survive without immediate treatment
but who have a chance of survival. patients who have a trauma score of 3 to 10
(RTS) and need immediate attention. they need advanced medical care at once or
within 1 hour. These people are in critical condition and would die without
immediate assistance. They require immediate surgery or other life-saving
intervention, and have first priority for surgical teams or transport to advanced
facilities; they "cannot wait" but are likely to survive with immediate treatment.
Examples: Talking, not walking (severe distress with dyspnea, twitching, and/or
nausea and vomiting);moderate-to-severe effects in two or more systems (eg,
respiratory, gastrointestinal, muscular);circulation intact
Emergent – Clients with life-threatening injuries, who need immediate attention
and continuous evaluation, yet have a high probability of survival once their
condition is stabilized. Examples: clients with trauma, chest pain, severe
respiratory distress or cardiac arrest, limb amputation, or acute neurological
deficits and those who have sustained chemical splashes to the eye.
Non-acute – Clients with local injuries who do not have immediate complications
and who can wait several hours for medical treatment; these clients require
evaluation every 1 to 2 hours thereafter. Examples: clients with minor
lacerations, sprains, or cold symptom
(SOURCE:Saunders Comprehensive Review for the NCLEX-RN exam 3rd edition, p.74-75)

45. Which of the following terms refer to a process by which the individual
receives education about recognition
of stress reactions and management strategies for handling stress which may be
instituted after a disaster?
a. Critical incident stress management
b. Follow-up
c. Debriefing
d. Defusion

RATIONALE: It is an adaptive short term helping process that focuses solely on an
immediate and identifiable problem to enable the individual/s affected to return
to their daily routine(s) more quickly and with a lessened likelihood of
experiencing post-traumatic stress disorder. Critical Incident Stress Management
is designed to help people deal with their trauma one incident at a time by
allowing the individual to talk about the incident when it happens without
judgment or criticism. Follow-up can be held weeks or months later if needed to
address any unresolved issues Debriefings are usually the second level of
intervention for those directly affected by the incident and often the first for
those not directly involved. Defusings are limited only to individuals directly
involved in the incident and are often done informally, sometimes at the scene.
They are designed to assist individuals in coping in the short term and address
immediate needs

Situation 10 - As a member of the health and nursing team you have a crucial role
to play in ensuring that all the members participate actively is the various tasks
agreed upon,

46. While eating his meal, Matthew accidentally dislodges his IV line and bleeds.
Blood oozes on the surface of the
over-bed table. It is most appropriate that you instruct the housekeeper to
clean the table with:
a. Acetone
b. Alcohol
c. Ammonia
d. Bleach

RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated
cautiously. Gloves shall be worn when cleaning up blood spills or other bodily
fluid spills. These spills shall be disinfected with a ten percent bleach solution
or an approved cleansing solution. Bleach primarily is used to disinfect blood
spills on various surfaces, they are composed of various chemical components one
of which is Sodium Hypochlorite. A 1 in 5 dilution of household bleach with water
(1 part bleach to 4 parts water) is effective against many bacteria and some
viruses, and is often the disinfectant of choice in cleaning surfaces in
hospitals. The solution is corrosive, and needs to be thoroughly removed
afterwards, so the bleach disinfection is sometimes followed by an ethanol

47. The nurse manager has implemented a change in the method of the nursing
delivery system from functional team
nursing. A nursing assistant is resistant to the change and is not taking an
active part in facilitating the process of
change. Which of the following would be the best approach in dealing with
the nursing assistant?
a. ignore the resistance
b. exert coercion with the nursing assistant.
c. provide a positive reward system for the nursing assistant
d. confront the nursing assistant to encourage verbalization of feelings regarding
the change.

RATIONALE: Confrontation is an important strategy to meet resistance head-on.
Face-to-face meetings to confront the issue at hand will allow verbalization of
feelings, identification of problems and issues, and development of strategies to
solve the problem. Option A will not address the problem. Option B may produce
additional resistance. Option C may provide problem solving measures.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.78)

48. Part of your responsibility as a member of the diabetes core group is to get
referrals from the various wards
regarding diabetic patients needing diabetes education. Prior to discharge
today 4 patients are referred to you.
How would you start prioritizing your activities?
a. Bring your diabetes teaching kit and start your session taking into
consideration their distance from your office
b. Contact the nurse-in-charge and find out from her the reason for the referral
c. Determine their learning needs then prioritize
d. involve the whole family in the teaching class

RATIONALE: Learning need is a desire or a requirement to know something that is
presently unknown to the learner. A comprehensive assessment of learning needs
incorporates data from the nursing history and physical assessment and addresses
the client’s support system. It also considers client characteristics that may
influence the learning process: readiness to learn, motivation to learn, and
reading or comprehension level, for example.
Assessment of learning need is done first before developing a teaching plan.
OPTION D may be done at later part of learning.

49. The nurse is working in a long-term care facility and is administering

medications to assigned clients. A client
refuses to take the prescribed medication, and the nurse threatens the client and
tells the client that if the
medication is not taken orally, then restraints will be applied and the medication
will be given by injection.
This statement by the nurse constitutes which legal tort?
a. invasion of privacy
b. negligence
c. assault

RATIONALE: An assault occurs when a person puts another person in fear of a
harmful or offensive contact. For this intentional tort to be actionable, the
victim must be aware of the threat of harmful or offensive contact. Battery is the
actual contact with one’s body. Negligence involves actions below the standards of
care. Invasion of privacy occurs with unreasonable intrusion into the individual’s
private affairs.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.64)

50. The nurse is reviewing the critical paths of the clients on the nursing unit.
In performing a variance analysis, which
of the following would indicate the need for further action and analysis?
a. a client’s family attending a diabetic teaching session
b. canceling physical therapy sessions on the weekend
c. normal vital signs and absence of wound infection in a postoperative client
d. a client demonstrating accurate medication administration following teaching

RATIONALE: Variances are actual deviations or detours from the critical paths.
Variances can be positive or negative, avoidable or unavoidable, and can be caused
by a variety of things. Positive variance occurs when the client achieves maximum
benefit and is discharged earlier than anticipated. Negative variance occurs when
untoward events prevent a timely discharge. Variance analysis occurs continually
to anticipate and recognize negative variance early so that appropriate action can
be taken.
(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.76)