Sie sind auf Seite 1von 7


Situation 1: A patient has just arrived in the Oncology Unit

from the PACU following a left modifed radical mastectomy
ecause of in!ammatory reast cancer "#$C%& She has a
pressure dressing over the surgical site and two drains&
Assessment shows her vital signs are stale' fully awa(e and
claims that pain is under control& )ortune is the nurse
assigned to the patient&
1& )rom the following data otained from the chart'
which is not a ris( factor which could have
predisposed the patient to reast cancer*
A& Age + ,, years old
$& -eight + ,./0 1eight + 123 ls&
C& 4enarche at age 15
6& 4other died of colon cancer
/& )ortune read a literature which says that y the time
#$C is diagnosed' ,3789,7 have palpale au:iliary
lymph nodes' as many as 537 have gross distant
metastasis and as few as 537 of patients have an
underlying reast mass& 1hich of the following is the
appropriate interpretation of the research fndings*
A& Au:iliary nodes were palpated on /3 out of
53 women positive for #$C
$& Out of the /3 women who were positive for
#$C' only , have metastasis
C& #f there were 13 women diagnosed with #$C'
5 have positive lymph nodes
6& $reast mass was identifed on ; out of 53
women positive for #$C
5& )ortune recogni<es that adjuvant chemotherapy for
reast cancer may include any of the following
A& 4onoclonal antiody
$& Proton inhiitors
C& Antiiotics
6& Anti8estrogen
=& )ortune understands that when the antineoplastic
agent lea(s through the peripheral vascular access
during chemotherapy' which of the following is
e:pected to e done frst*
A& >efer to the physician
$& Stop the chemotherapy infusion
C& Cleanse site with saline solution
6& Call another nurse to chec( the intravenous
,& A clinical trial is currently underta(en to test
treatments for #$C& ?he research team leader wishes
to include the patient as a participant in the study& As
a patient advocate' which of the following will
)ortune do frst*
A& Otain informed consent from the patient
$& @:plain to the patient the scope of the
clinical trial
C& #nAuire from the team leader enefts for the
6& >ead more related literature
Situation /: 6uring a staB meeting at the #ntensive care unit'
the nurse manager reported a list of procedures that need to
e reviewed and updated& One of these procedures is the
precautionary measure related to ventilator8associated
2& 1hile rainstorming' the group mentioned the use of
evidence8ased techniAues& 1hich of the following
statements given y the memers of the group
re!ect evidence8ased methods*
A& CDet us as( the opinion of e:perts&E
$& C?he e:periences of the nurses must e
C& C>eview of related literature will e very
6& C1e must agree on a common procedure&E
9& ?he nurse manager assigned a group to develop a
project intended to improve the e:isting procedure
related to the prevention of ventilator8associated
pneumonia among #CU patients& A team leader was
selected y the group& 1hich of the following will the
team leader do frst*
A& ?ell the group to state their ojectives
$& )ormulate a list of desired outcomes
C& Set a target
6& State actions to e done y each memer of
the group
;& ?he team leader organi<ed the group& 1hich of the
following actions of the team leader re!ect
organi<ation* ?he team leader:
A& Assigned tas(s to each memer
$& @liminated non8performing memers of the
C& Chec(ed the assignments of each memer of the
6& 6etermined which actions will e done frst
F& 1hich of the following data will e most helpful to
the group to ensure continuous process
A& Gon8conformances to suctioning procedure
$& #ncidences of ventilator8associated pneumonia
during the last month
C& @:periences of nurses when managing care of
intuated patients
6& 6ocumentation of oservation of intuated
13& ?he group developed revisions to the e:isting
procedure& $efore the procedure could e
implemented as a standard procedure' which of the
following will e done frst*
A& Hather relevant data
$& Chec( if procedure is eBective through feedac(
C& Plan for the implementation of the procedure
6& 6o the procedure on selected patients
Situation 5: Duther' a ,38year8old construction wor(er
sustained multiple injuries due to a motorcycle accident&
11& #n the @mergency 6epartment' the physician orderd
diagnostic tests' one of which is lood alcohol level&
1hich of the following is the purpose of this test*
A& 6etermine level of alcohol dependence
$& 6iscover injuries in the rain
C& >ule out alcoholism
6& Assessment of client.s level of consciousness
1/& $lood transfusion must e administered immediately
ecause of loss of lood volume due to trauma&
Duther.s lood type is O' as his nurse' you recogni<e
which of the following statements is true*
A& ?ype O lood has oth types of antiodies
$& Persons with type O lood can also receive ?ype
A lood
C& ?ype O lood has no antiodies
6& Persons with ?ype O lood are also called
universal recipients
15& 1hen assessing Duther for hypovolemic shoc(' which
of the following data indicates that he is in the
irreversile stage of shoc(*
A& >estless' an:ious and confused
$& Anuria
C& S(in moist' pale and moist
6& Pulse rapid and wea(
1=& ?he physician ordered colloid solution such as
6e:tran =3& 6uring the infusion' Duther complained
of dyspnea& Upon auscultation' you noted whee<es&
1hich of the following will you do frst*
A& 6iscontinue the infusion
$& Place Duther on a )owler.s position
C& 6ecrease the infusion rate
6& Call the attending physician
1,& Duther.s central venous pressure is monitored every
hour& 1hen you measure the CIP using a water
manometer' you are e:pected to oserve which of
the following to ensure accuracy of CIP
A& 4aintain the client on a )owler.s position
$& Use a one8way stopcoc( to regulate !ow of #I
!uids to the water manometer
C& #mmoili<e the client.s right arm
6& Jeep the <ero point of the manometer in level
with the client.s right atrium
Situation =: Kou are caring for 1arren' ,; years old' who is
diagnosed with laryngeal cancer&
12& 1arren is scheduled for a total laryngectomy and
radical nec( dissection for cancer of the laryn:& -e
as(s you' C-ow will # tal( after surgery*E As his
nurse' your est response will e
A& CKou will reathe through a permanent opening
in your nec(' ut you will not e ale to
communicate orally&E
$& CKou won.t e ale to tal( right after the surgery'
ut you will e ale to spea( again once the
tracheostomy tue is removed&E
C& CKou will have a permanent opening into your
nec(' and you will need to have rehailitation for
some type of voice restoration&E
6& CKou won.t e ale to spea( as you used to' ut
there are artifcial voice devices that will give
you the aility to spea( normally&E
19& 1arren returns from surgery with a tracheostomy
tue after a total laryngectomy and radical nec(
dissection& #n caring for 1arren during the frst /=
hours after surgery' your priority nursing action is to
A& Avoid changing the tracheostomy ties
$& 4onitor for leeding around the stoma
C& Assess airway patency and reath sounds
6& Clean the inner cannula every ; hours
1;& After doing assessment' one of the nursing diagnosis
you identifed is C$ody image 6isturance related to
loss of control of personal care&E ?o evaluate
eBectiveness of your interventions' the e:pected
outcome for the prolem that 1arren should
demonstrate is that he
A& Dets his wife provide hygiene and stoma care
$& 1ears clothing that minimi<es the disfgurement
caused y the surgery
C& As(s that only family memers e allowed to
6& Dearns to remove and clean the laryngectomy
tue independently
1F& 1arren is scheduled to start radiation therapy& Kou
have just taught 1arren all aout radiation therapy&
1hich of the following statements y 1arren would
indicate that your teaching has een eBective*
A& C# can use lotions to moisturi<e the s(in on my
$& C# will need to uy water ottle to carry with
C& C# need to use alcohol8ased mouthwashes to
help clean oral ulcers&E
6& C# may e:perience diarrhea' # may have diarrhea
until the radiation is complete&E
/3& After completing the discharge instructions for
1arren' you determine that additional instruction is
needed when he says
A& C# can participate in most of my prior ftness
activities e:cept swimming&E
$& C# should wear a 4edic Alert racelet that
identifes me as a nec( reather&E
C& C# must (eep the stoma covered with a loose
sterile dressing at all times&E
6& C# need to eat nutritious meals even though #
can.t smell or taste very well&E
Situation ,: $oy' 11 years old' was admitted ecause of
hematuria& 6iagnosis is 6engue fever&
/1& 1hich of the following is the most li(ely description
of $oy.s fever prior to the onset of hematuria that
supports the physician.s diagnosis of dengue fever*
A& #ntermittent fever for = days
$& Onset of fever was arupt and remained
elevated for = days
C& Arupt onset of fever and sudden drop on the =
6& Hradual increase of ody temperature and
sudden drop on the =
//& ?he nurse understands that the cycle of transmission
of dengue fever virus egins during which of the
A& #nfected mosAuito ites an uninfected human
$& Iirus multiply in the midgut of the mosAuito
C& 4osAuito feeds on an infected human
6& 4osAuito.s saliva is invaded y the virus during
suseAuent iting of infected human
/5& ?he nurse noted that Aspirin and GSA#6 are
contraindicated for $oy& 1hich of the following is
the rationale ehind this order*
A& Patient may e allergic
$& 6rug contains anticoagulant properties
C& 6ue to stomach upset eBects of the drug
6& 6rugs enhance production of maculopapular
/=& ?he condition of $oy is closely watched for signs of
hypovolemic shoc(& 1hich of the following should the
nurse report as early signs of hypovolemic shoc(*
1& Dethargy
/& >apid pulse
5& Clammy s(in
=& Cyanosis
,& >estlessness
2& -ematemesis
A& /' 5' = and ,
$& 1' /' 5 and ,
C& 1' /' , and 2
6& 1' 5' = and 2
/,& ?o prevent transmission of the virus to others' which
of the following is the most appropriate isolation
measure the nurse should implement in the care of
A& Screen the environment
$& $lood and ody secretion isolation
C& Use gown' gloves and mas(
6& Use strict universal isolation techniAue
Situation 2: Agua $endita' 5, years old' was admitted to the
hospital ecause of near drowning& #n the #CU where she was
admitted for oservation' her o:ygen saturation dropped to
;=7 and suseAuent lood gases showed PaO/ of ,,mm-g&
6iagnosis is proaly Acute >espiratory 6istress Syndrome
"A>6S%& @ndotracheal intuation and mechanical ventilation
were ordered&
/2& ?he nurse is aware that in A>6S' the asic changes
in the lungs result from the injury to the alveolar wall
and capillary memrane leading to the following
pathological changes' e:cept
A& )luid and protein lea(s into alveoli and
interstitial tissue
$& 6amaged surfactant producing cells
C& #ncreased surfactant production
6& #ncreased alveolar capillary permeaility
/9& 1hich of the following ventilator settings re!ect the
amount of air delivered within each ventilator
A& #nspiration to e:piration ratio
$& Pressure limit
C& ?idal volume
D. O:ygen concentration ")iO/%
/;& 1hich of the following will the nurse closely monitor
to ensure that the percentage of o:ygen delivered
with ventilator reaths is adeAuate*
A& >espiratory rate
$& Central venous pressure
C& Pulse o:imeter.s reading
6& Cardiac monitor
/F& ?he nurse is e:pected to closely watch the client for
complications related to mechanical ventilation&
1hich of the following will the nurse do to assess
sucutaneous emphysema*
A& Oserve for signs of uneAual chest e:pansion
$& Auscultate the lungs and oserve for crac(les
C& Palpate nec( for air ule8popping sensation
6& Percuss for hyperresonant percussion tone
53& ?he nurse oserved air lea(s from the endotracheal
tue and decreased reath sounds& 1hich of the
following will the nurse do frst*
A& >eport to the physician
$& Call the respiratory therapist
C& Place patient on semi8fowlers position
6& >eposition the endotracheal tue
Situation 9: Kou admitted @ngleert' 93 years old' ecause of
pulmonary edema& -e has a history of congestive heart
failure' type / diaetes mellitus and hypertension&
51& $ased on the history' you specifcally noted that
@ngleert regularly too( Dano:in "6igo:in%& 1hich of
the following is the specifc action of this drug on the
A& #mproves myocardial contractility' decreases the
heart rate' and reduces o:ygen consumption
$& Causes vasoconstriction' increased resistance
preload and dilation of the ventricles
C& >educes peripheral vascular resistance and
afterload' reducing myocardial wor(load
6& #nterfered with the production of angiotensin ##
resulting in improved cardiac output and
reducing pulmonary congestion
5/& 1hich of the following specifc positions would e
most helpful for @ngleert to facilitate and trap
e:cess !uids in the lower e:tremities*
A& -ead ent forward on an overed tale
supported with pillows
$& Upright sitting position with the legs dangling
C& Dateral position with the upper leg !e:ed and
lower leg e:tended
6& )owler.s position with the patient lying on the
left side
55& )urosemide "Dasi:% /3 mg was administered y #I
push at 13 am with urinary output from indwelling
catheter at the level of 1/3 cc& At 13:1, A4' the
nurse oserved that the urinary output did not
change& 1hich of the following will you chec( frst*
A& )oley cathter connecting tue for (in(s
$& Patient.s hypogastrium for urinary retention
C& #ntravenous site for swelling
6& )oley catheter for lea(age
5=& 1hile preparing the medication' you chec(ed the
medication which was dispensed y the pharmacist
with the written order of the physician& 1hich of the
following actions will you do frst if you found out that
instead of >egular insulin' the pharmacist dispensed
GP- insulin*
A& Ialidate the order with the physician
$& 6ocument the error
C& As( the pharmacist to change the drug
6& >eport the error to the unit manager
5,& Kou administered morphine Sulfate 1 mg
intravenously as ordered& ?he following are the
intended actions of this drug e:cept
A& #mproved eLcacy of reathing
$& >educe preload
C& 6ecrease an:iety
6& >elieve pain
Situation ;: -elen' a Pediatric #ntensive Care Unit staB nurse'
is assigned to a =8year8old female unconscious patient due to
an acute head injury sustained from a vehicular accident&
52& -elen identifes which of the following nursing
diagnosis to e of highest priority*
A& >is( for injury related to increased intracranial
$& 6istured sensory perception relation to central
nervous system impairment
C& >is( for aspiration related to impaired motor
6& #neBective airway clearance related to
depressed sensorium
59& 1hen interpreting the patient.s degree of depressed
coma' the pediatric Hlasgow Coma Scale is used&
1hich of the following is not included in the three8
part assessment of the scale*
A& 4otor responses
$& >esponse to auditory and veral stimuli
C& Pupil si<e and reaction
6& @ye opening
5;& 1hen assessing the level of consciousness of the
patient' which of the following should the nurse
consider most appropriate in eliciting a desired
A& @nvironment should e Auiet' well8lighted and
$& Jeep eAuipment at the edside
C& Parent should e present
6& -ave record readily availale for accurate
5F& 6uring assessment' the nurse oserves asence of
doll.s eye movement& 1hich of the following is the
correct interpretation of this oservation*
A& >uptures aneurysm
$& 4eningeal in!ammation
C& $rainstem injury
6& Sudural hematoma
=3& 6ue to hypothalamic dysfunction' a syndrome of
inappropriate antidiuretic hormone develops& 1hich
of the following manifestations should the nurse
watch closely*
A& #ncreased urine output' decreased specifc
gravity' decreased serum sodium
$& #ncreased urine output' increased urine specifc
gravity' increased serum sodium
C& 6ecreased urine output' decreased urine specifc
gravity' decreased serum sodium
6& 6ecreased urine output' increased urine specifc
gravity' increased serum sodium
Situation F: ?eddy' ; years old' was playing in the garden
when all of a sudden he stopped playing and started
scratching his legs& ?eddy.s mother washed his legs ut ?eddy
complained of diLculty of reathing0 was nauseated and had
cold moist s(in& #n the emergency department' anaphyla:is
was suspected& #nsect ites were noted on ?eddy.s legs&
=1& ?he health team suspects that ?eddy e:perienced a
sting at some previous time& 1hich of the following
could e the rationale for the itchy s(in*
A& #rritation caused y digestive sustance released
y the insect
$& #nfltration of in!ammatory cells into the
C& Sensory nerve endings irritated y histamine
6& Accumulation of histamine at the insect ite
=/& 1hich of the following drugs will the nurse e:pect
the physician to prescrie initially*
A& Corticosteroids
$& Aminophylline
C& @pinephrine
6& 6ipenhydramine
=5& ?he mother as(ed the nurse what could have caused
her son to e:perience diLculty of reathing& 1hich of
the following is the most appropriate response of the
A& C#t was an early sympatetic response to the
insect ite&E
$& CChemical mediators due to hypersensitivity
reactions caused y edema in the ronchioles&E
C& C-istamine released due to allergic reaction
caused narrowing of the airway&E
6& C#t was due to threatening laryngeal edema&E
==& ?he mother claimed that this is the frst time it
happened& 1hich of the following should e given
priority y the nurse*
A& #nstruct the mother on emergency measures in
care recurrence
$& >ecommend desensiti<ation
C& #dentifcation of allergens
6& #dentifcation of environmental ha<ards
=,& Since ?eddy is allergic to insect venom' which of the
following is the most appropriate measure to ensure
that ?eddy gets immediate treatment during
A& -ave ?eddy carry an emergency (it all the time
$& ?each ?eddy how to use an emergency (it
C& Use of a medical information such as racelet or
6& ?each ?eddy to get help when symptoms develop
Situation 13: >adiation therapy is another modality of cancer
management& 1ith the emphasis on multi8disciplinary
management' you have important responsiilities when caring
for patients receiving radiation therapy&
=2& ?hromocytopenia often results from one marrow
depression& As a nurse' you should oserve for the
following symptoms that include
A& -eadache' di<<iness' lurred vision
$& Severe sore throat' acteremia' hepatomegaly
C& Petechiae' ecchymosis' epista:is
6& 1ea(ness' easy fatigaility' pallor
=9& 1hen caring for a client who has thromocytopenia'
which of the following intervention should you
include in the care plan*
A& Provide rest etween activities
$& Place the patient on strict isolation precaution
C& #nspect the patient.s s(in for petechiae' ruising'
H# leeding regularly
6& Administer antipyretics if the patient.s
temperature 5;MC
=;& A patient is receiving e:ternal radiation therapy and
he complains of fatigue and malaise& 1hich of the
following nursing interventions would e most
A& >efer the patient to the physician
$& -elp the patient plan activities and rest periods
C& >eassure the patient that these feelings are
6& ?ell the patient that sometimes these feelings
can e psychogenic
=F& @:ternal eam radiation is planned for a patient with
endometrial cancer& Kou teach her that the important
measure to prevent complications from the eBects of
radiation is to
A& 4aintain a high8residue and high8fat diet
$& Perform perineal care with sit< ath and
meticulous cleaning
C& ?est all stools for the presence of lood
6& #nspect the mouth and throat daily for the
appearance of thrush
,3& A post total hysterectomy ilateral salphyngo8
oophorectomy patient had chemotherapy and
radiation therapy& ?he nurse oriented her on the
rationale and the measures to e done to prevent
movement of the radioactive source which include
the following' e:cept:
A& Complete ed rest while source is implanted
$& Spinal anesthesia while source is implanted
C& $owel cleansing prior to insertion of source
6& Placement of urinary )oley catheter while source
is implanted
Situation 11: #t is important and necessary that the nurse is
well8educated aout Severe Acute >espiratory Syndrome
"SA>S%' an emerging gloal threat&
,1& #f you were a nurse who wor(s in a health clinic' and
you suspect that a patient has SA>S' which of the
following will you do frst*
A& Contact the hospital
$& Protect self y putting on an GF, disposale
C& >efer the patient to the physician for medical
6& -ave your patient put on surgical face mas(
,/& 1hich of the following confrms the diagnosis of
A& ?ravel to an area with (nown SA>S outrea(
$& Signs and symptoms
C& -istory of contact with someone suspected of
6& Presence of antiody to SA>S
,5& ?he SA>S virus is transmitted through
A& Airorne droplets
$& Contact with urine
C& 4osAuito ites
6& Contaminated needle
,=& #f the nurse has an unprotected e:posure to SA>S
during incuation' which of the following will e
A& Ioluntary Auarantine of 13 days
$& Gurse is placed on vacation from wor(
C& Gurse will e given a high dose of gamma
6& Administer vaccine to the nurse
,,& After e:posure to a patient with SA>S' it is e:pected
that SA>S can develop in
A& /813 days
$& 2 wee(s + 2 months
C& 53 days
6& 1/81= days
Situation 1/: Kou are assigned at the medical ward caring for
clients with !uid and electrolyte imalances& Kou (now that
you have very important collaoration responsiilities when
you give your patients their medications to correct their
,2& Samson is ta(ing -ydrochlorothia<ide' a potassium8
wasting diuretic' for treatment of hypertension& As a
nurse' you will teach him to report symptoms of
adverse eBects such as
A& )acial muscle spasms
$& )reAuent loose stools
C& 4ood changes
6& Henerali<ed wea(ness
,9& Spironolactone "Aldactone%' an aldosterone
antagonist' is prescried for -ermin as a diuretic&
1hich statement made y -ermin indicated that the
teaching aout his medication has een eBective*
A& C# can use a salt8sustituteE
$& C# can have apple juice instead of orange juice&E
C& C# can have low8fat cheeseE
6& C# will drin( at least 2 glasses of water every
,;& Noseph has een receiving diuretic therapy and is
admitted to the hospital with a serum potassium
level of 5&1 m@AOD& Of the following medications that
he has een ta(ing at home' which you e most
concerned aout*
A& Oral digo:in "Dano:in% 3&/, mg daily
$& Dantus insulin /5 U sucutaneously every
C& #uprofen "4otrrin% =33 mg every 2 hours
6& 4etoprolol "Dopressor% 1/&, mg orally daily
,F& Kou administered 57 Saline to 1anda who has
hyponatremia& As her nurse' which one of your
assessment fndings will reAuire your most rapid
A& -er lood pressure increased from 1/3O;3 to
1=/OF= mm-g
$& ?here is sediment and lood in 1anda.s urine
C& 1anda.s radial pulse is 13, eats per minute
6& ?here are crac(les audile throughout her oth
lung felds
23& 1hen caring for @dna who has just een admitted
with septic choc(' which of these assessment data
will e your greatest concern*
A& Arterial o:ygen saturation of F37
$& $P of ;;O,2
C& Apical pulse of 113 eats per minute
6& Urine output of 1, mD for / hours
Situation 15: ?imothy' ,2 years old' was admitted ecause of
aortic dissection type $&
21& ?he nurse recogni<es which of the following as the
correct description of the patient.s diagnosis*
A& ?ear in the intima of the aorta with hemorrhage
into the tunica media
$& Stretching of the walls of the aorta involving one
layer of the aorta
C& One8sided protrusions of one distinct area of the
6& Pulsating hematoma on three layers of the aorta
2/& Of the following diagnostic tests prescried y the
physician' which of the following will the nurse
e:pect to show precise measurement of the
A& Angiography
$& Chest P8ray
C& ?ransesophageal echocardiography
6& Adominal ultrasonography
25& ?he physician initially treated ?imothy with
Propanolol "#nderal%& ?he nurse noted in her nursing
care plan that this drug will
A& #ncrease contractility of the heart
$& @nhance electrical conduction of the heart
C& 6ecrease release of epinephrine
6& >educe heart rate
2=& $ased on an understanding of -eparin therapy' the
nurse administers it to ?imothy who has undergone
repair of aneurysm fro which of the following
A& ?o prevent recurrence of aneurysm
$& ?o control hemorrhage
C& ?o maintain arterial pressure
6& ?o prevent clot formation
2,& ?o counteract reactions to overdosage of intravenous
infusion of -eparin' which of the following drugs will
the nurse e:pect the physician to prescrie*
A& Protamine sulfate
$& @pinephrine
C& Iitamin J
6& Atropine Sulfate
Situation 1=: Kou are caring for >olando' ,; years old' who
was admitted ecause of diLculty of swallowing and stiBening
of the nec(& -e has a history of a wound laceration on his
right hand sustained while gardening& ?he physician suspects
tetanus infection&
22& 1hile you were preparing to administer o:ygen
inhalation' >olando had sei<ures assumed an
opisthotonic position& 1hich of the following correctly
descries this position*
A& -ead retracted' ac( arched' and feet e:tended
$& Gec(' hip' (nee and feet plantar !e:ed
C& -ead !e:ed forward' jaw clenched' arms
pronated and feet plantar !e:ed&
6& -ead hypere:tended hip !e:ed' and feet
29& ?a(ing into consideration the incuation period'
which of the following data in >olando.s health
history will you consider relevant*
A& Positive for type / diaetes mellitus
$& #mmuni<ation status unceratain0 no ooster dose
C& 1ound laceration sustained a wee( ago was
treated at home
6& 1ound pain' unearale and unrelieved y
2;& ?o decrease stimuli that cause spasms and sei<ures'
which of the following nursing interventions is least
relevant for you to do*
A& 4aintain a Auiet' well8ventilated and dar(ened
$& Administer sedatives as prescried
C& 4onitor for ha<ards of immoility
6& Perform physical care during time of ma:imal
2F& ?he priority nursing diagnosis for >olando is C>is( for
ineBective airway clearance related to which of the
A& StiBness of the jaw
$& $ac( muscle spasms
C& Sei<ures
6& #nfection
93& 6uring a sei<ure' which of the following are you
e:pected to do frst*
A& 4onitor vital signs especially the respiratory rate
$& Provide a padded tongue lade in the patient.s
C& Provide mechanical ventilation
6& ?urn patient to his side
Situation 1,: #n the medical unit' Connie was assigned to wor(
with Sandy' a staB nurse with / years e:perience
91& 1hich of the following reports of Connie will Sandy
attend to immediately*
A& A 2,8year8old unconscious due to e turned to
prevent ed sores
$& A ,,8year8old diaetic' frst day post8operative
for elow8the8(nee amputation' complains of
severe pain
C& A 9,8year8old with hepatic encephalopathy'
intravenous infusion due in = hours consumed
6& A =,8year8old scheduled for partial
thyroidectomy wishes to go home
9/& Connie oserves Sandy perform peripheral catheter
insertion for intravenous infusion& ?he patient
insisted to sit on the edge of the ed& After a second
unsuccessful attempt on cannulation' the patient
suddenly ecame an:ious' diaphoretic' nauseated
and di<<y& 1hich of the following will Sandy do frst*
A& Place the patient on a supine position
$& #nstruct Connie to call the physician
C& Chec( vital signs
6& 6iscontinue the #I !uids
95& Sandy e:plained to Connie that the patient
e:periences a vasovagal reaction& 1hich of the
following vital signs will the nurse e:pect*
A& Gormal lood pressure and increased pulse
$& 6ecreased lood pressure and decreased cardiac
C& #ncreased lood pressure and tachycardia
6& Gormal pulse and increased lood pressure
9=& One of Connie.s patients is Hreg who just had
ronchoscopy& Sandy as(ed Connie what she should
e alert for in oserving Hreg*
A& Sore throat and hoarseness
$& $lood tinged sputum and coughing
C& Gausea and vomiting
6& Shortness of reath and laryngeal stridor
9,& At the end of the shift' Sandy told Connie to do self8
evaluation of competencies developed during the
wee(& 1hich of the following indicators will Connie
consider as an improvement of her aility to respond
to the urgency of her patient.s conditions*
A& Ale to identify adverse reactions of drugs
$& >esponds to inAuiries promptly
C& >ecogni<e anormal laoratory results
6& Administer medications on time
Situation 12: Gurse have crucial legal responsiilities in the
e:ercise of her profession
92& 4ary Nane' a 5
year nursing student assigned to the
surgical unit as(s your permission to photocopy the
surgical record from a patient.s chart for an
assignment that she must write& 1hich of the
following is your appropriate nursing action*
A& Allow 4ary Nane to photocopy the pages without
the client.s name
$& Photocopy the pages for 4ary Nane
C& As( the physician for permission to photocopy
the pages
6& Allow 4ary Nane to write down pertinent
information ut not identifying
99& Kou are caring for )elisa who has dementia and is
soiled with feces ut you failed to clean and athe
her ecause it is endorsement time already& Kou
endorse her to the ne:t shift nurse& ?he nurse reports
that you are guilty of
A& 4alpractice
$& Gonmalefcence
C& Assault
6& Gegligence
9;& Kou are invited to tal( to new graduate nurses aout
negligence& 1hich of the following situations is a
priority for you to include as an e:ample of
A& ?al(ing aout client outside of the health care
$& Got allowing a family memer to awa(en an
adult client who is sleeping
C& Got giving a prescried medication to an older
6& Got turning oB the o:ygen at the edside when a
client wants to smo(e in ed
9F& Kou call the physician of your patient @rlinda' 92
years old' to report a change in her condition and to
reAuest orders for a pain medication& ?he physician is
unale to ta(e the call and the message is left with
the oLce secretary who repeats a veral order from
the physician& 1hich of the following is your most
appropriate nursing action*
A& >efuse to accept the order from the oLce
secretary and call ac( later
$& Accept the order form the oLce secretary and
document it appropriately
C& Accept the order as it comes from the physician
as interpreted y the oLce secretary
6& #nsist on spea(ing to the physician personally
;3& Kou oserve ruises and s(in tears on Agatha' an ;38
year8old client& She does not ma(e eye contact and
appears fearful& 1hich of the following is your priority
nursing action*
A& As( the client aout the ruises and s(in tears
$& As( the family memers what has happened
C& 6ocument your fndings
6& Call the physician
Situation 19: Kou are assigned in the Pediatric #CU and your
critical decisions and proper documentation are important&
Kou are caring for Charlie' , years old' who was admitted
following a vehicular accident& Clinical data otained were0 $P
;3O,; mm-g' heart rate 1/3' respirations 5/' peripheral pulse
slightly diminished' hematocrit 537' pulse o:imeter F=7'
serum electrolytes normal& C? scan is positive for anormal
leeding& 1eight /3 (g&
;1& $ased on the aove data' which of the following
nursing diagnosis would you select as eing
appropriate in Charlie.s care*
A& )luid volume defcit
$& #neBective airway clearance
C& #mpaired gas e:change
6& Altered cardiac output: decreased
Answer: A
;/& Charlie is placed on a cardiac monitor and a urinary
catheter is inserted& One peripheral #I line in the left
arm is infltrated and discontinued& An indirect $P
reading is 93O=3 mm-g and a heart rate of 1=3 is
noted& 1hich of the following orders should e
initiated frst*
A& #I access
$& Serum hematocrit and hemogloin
C& Arterial line set8up
6& 6opamine continuous infusion
;5& 1hat parenteral solution would you anticipate to
prepare for Charlie.s volume replacement*
A& ,7 6e:trose in 3&/,7 normal saline
$& /,7 alumin
C& 3&F7 Gormal Saline
6& ,7 6e:trose in water
;=& Charlie.s mother verali<es her concerns regarding
Charlie.s condition& She informs you that Charlie is
their only child and that her husand is wor(ing
overseas& 1hat would e your est response*
A& -old her hand' and have an eye contact with her
and reassure her that you are doing your est&
$& As( one of your con8staB to assist Charlie.s
C& ?ell her you understand how she feels ut your
priority is to ta(e care of Charlie
6& ?ell her to pray and leave everything to Hod
;,& Charlie.s condition worsens& -e develops respiratory
arrest& 1hat nursing intervention should you perform
A& Assemle intuation (it
$& Administer o:ygen
C& 6o chest compression
6& Ientilate with a ag8valve mas( device
Situation 1;: Jevin' // years old' swerved his car and hit a
tree head8on when he avoided a dog crossing the street& Jevil
loss consciousness' sustained several cuts on his forehead
and was leeding from his nose and mouth& -e was diagnosed
in the @mergency 6epartment with ?raumatic $rain #njury
;2& Since volume resuscitation was necessary for Jevin'
intravenous 3&F7 normal saline solution was started&
?he nurse who admitted the patient understands that
the intravenous solution was considered y the
physician ecause it
A& 1ill reduce intracranial pressure
$& 1ill easily maintain hydration
C& 1ill promote !uid shift into the vascular space
6& 1on.t aggravate cereral edema
;9& ?o determine level of consciousness' the Hlasgow
Coma Scale "HCS% is used& 1hich of the following is a
correct interpretation of the nurse of the HCS score
of Jevin*
A& ?he higher the score' the higher is the
proaility of permanent damage
$& ?he lower the score is' the lower is the
proaility of delayed recovery
C& ?he higher the score' the greater is the
impairment in the rain
6& ?he lower the score' the more serious is the
rain injury
;;& ?he nurse maintains the ody temperature of Jevin
within normal limits& ?his intervention is signifcant in
preventing which of the following*
A& Cereral ischemia
$& #nfection
C& Sei<ures
6& 6ehydration
;F& 1hen intracranial pressure increases' which of the
following nursing diagnosis is appropriate*
A& >is( for ineBective reathing pattern
$& 6istured sensory perception
C& >is( for cardiac dysfunction
6& #neBective airway clearance
F3& 1hich of the following interventions can the nurse
include in the plan of care for Jevin to control
intracranial pressure*
1& 4aintain his head and nec( in neutral alignment
/& #nitiate measures to enhance valsalva maneuver
5& Administer O:ygen to maintain PaO/ QF3 mm-g
=& @levate head of the ed as prescried
A& 1 and/
$& All e:cept /
C& 5 and =
6& All of the aove
Situation 1F: Kou are caring for Angelo' 2; years old' who was
diagnosed with acute heart failure& Angelo has a history of
acute myocardial infarction and underwent coronary artery
ypass surgery& -e is complaining of severe shortness of
reath and hemoptysis&
F1& Kou recogni<e that pulmonary edema may develop
ecause of which of the following*
A& Dow plasma protein levels decreasing plasma
oncotic pressure
$& #ncrease capillary permeaility due to lung
C& #ncreased hydrostatic pressure in the pulmonary
6& #ncreased surface tension in the alveoli
F/& 1hich of the following assessment fndings would
you consider as priority for immediate nursing
A& -emoptysis
$& $P F,O9/' s(in cool' and diaphoretic
C& Signifcant jugular vein distention
6& Severe orthopnea
F5& Cardiac assessment reveals apical pulse is lateral to
midclavicular line& Kou understand that this fnding
A& 4itral valve regurgitation
$& ?he heart is enlarged
C& ?hat cardiac output is adeAuateR
6& 6ilated heart
F=& Kou oserved for frillation on the cardiac monitor&
1hich of the following @CH characteristics did you
oserve on the cardiac monitor*
A& CsawtoothE appearance of P waves
$& P waves oserved efore' during' and after S>S
C& P wave hidden in the S>S comple:
6& P waves unidentifale
F,& ?he physician prescried )urosemide to e
administered intravenously& 1hich of the following
nursing orders is least appropriate to ensure that
adverse eBects of the drug are closely monitored on
A& >eport signifcant weight changes
$& 4onitor laoratory results on electrolytes
C& 4easure hourly urine output
6& #ntegrate foods rich in potassium in the diet
Situation /3: Dilette' =8year8old girl with a recent history of
nausea' vomiting and diarrhea is admitted to the Pediatric
Unit with a diagnosis of acute gastroenteritis& Kour signifcant
physical e:amination includes dry s(in with turgor' sun(en
soft eyealls' parched lips' adominal distention& She has
tachycardia and fever "5;C%
F2& $ased on your assessment fndings' which of the
following is your nursing diagnosis*
A& #neBective peripheral tissue perfusion related to
!uid volume defcit
$& )luid volume defcit related to anormal loss and
decrease inta(e
C& Activity intolerance related to malaise
6& #mpaired s(in integrity related to freAuent
F9& ?he following management goals for Dilette are most
important for you to include in your plan e:cept
A& AdeAuate rehydration and !uid maintenance
$& Gothing per orem at all times
C& Continue assessment of !uid and electrolyte
6& >eintroduction of adeAuate diet
F;& ?o ensure adeAuate !uid and electrolyte pelacement'
the doctor ordered ,33 ml of alanced electrolyte
solution for 13 hours& ?he #I set delivers 23 gttOmin
to administer the ,33 ml #I solution' you should set
the #I drip rate at
A& 5, gttOmin
$& 2/ gttOmin
C& ,3 gttOmin
6& =1 gttOmin
FF& 1hich of the following fndings would est indicate
that Dilette.s hydration level has improved*
A& Go further weight loss
$& Dower hematocrit
C& Dower creatinine
6& Dower 1$C
133&Dilette cries whenever her 4ommy and Hrandma
leave her& 1hich of the following interventions can
reduce her an:iety*
A& -ave the same nurse care for her
$& Provide her with some new toys and ring her
favorite toys
C& >estrict visiting hours to decrease her crying
6& @ncourage her playmates to visit her