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Situation 1: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and
abdominal discomfort.
1. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken?
A. Fecal oral
B. Droplet
C. Airborne
D. Sexual contact
A. In
D.
3. Which of the following must be emphasized during mother’s class to Leo’s mother?
4. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority?
C. Health promotion and education to families and communities about the disease it’s cause and transmission.
A. 30 days
B. 60 days
C. 50 days
D. 14 days
Situation 2: As a nurse researcher you must have a very good understanding of the common terms of concept used in research.
6. The information that an investigator collects from the subjects or participants in a research study is usually called:
A. Hypothesis
B. Data
C. Variable
D. Concept
7. Which of the following usually refers to the independent variables in doing research?
A. Result
B. Cause
C. Output
D. Effect
8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called;
A. Setting
B. Subjects
C. Treatment
D. Sample
A. Sample
B. Instrument
C. Hypothesis
D. Concept
10. The use of another persons ideas or wordings giving appropriate credit results from inaccurate attribution of materials to its sources. Which of the following is referred to when
A. Plagiarism
B. Quotation
C. Assumption
D. Paraphrase
Situation 3: Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”
11. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis?
D. Ascertain if chest x-rays and other tests have been prescribed and completed
12. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions?
A. Trendelenburg position
B. Supine position
D. Orthopneic position
13. During thoracentesis, which of the following nursing intervention will be most crucial?
C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
D. Apply pressure over the puncture site as soon as the needle is withdrawn
14. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
D. On bed rest
15. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:
C. to decongest
16.Just as nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
17. Mr. Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
B. No special preparation is needed. Instruct the patient to keep his head still and stead.
18. Mr. Santos is placed on seizure precaution. Which of the following would be contraindicated?
19. Usually, how does the patient behave after his seizure has subsided?
20. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
A. Low fowler’s
B. Modified trendelenburg
C. Side Lying
D. Supine
Situation 5: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site.
A. Distraction
B. Taking aspirin
D. Positioning
24. In a pain assessment, which of the following condition is a more reliable indicator?
C. Physiological responses
Situation 6: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know is very subjective.
26. A one-day post operative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in 1 – 10 pain rating. Your assessment reveals bowel
sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take?
27. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain, which will be your priority nursing action?
28. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is:
B. Advice the client to close the lips and avoid deep breathing and talking
29. Surgical pain might be minimized b which nursing action in the O.R.
30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post-op patients. If general anesthesia is desired, it will involve loss of consciousness. Which
Situation 7: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain.
31. Nurses should be aware of that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following beliefs EXCEPT:
A. Older patients seldom tend to report pain than the younger ones
32. Nurses should understand that when a client responds favourably to a placebo, it is known as the placebo effect. Placebos do not indicate whether or not a client has:
A. Conscience
B. Real pain
C. Disease
D. Drug tolerance
33. You are the nurse in the pain clinic where you have client who has difficulty specify the location of pain. How can you assist such client?
D. Ask the client to point to the painful are by just one finger.
34. What symptom more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain?
A. Forgetfulness
B. Constipation
C. Drowsiness
D. Allergic reactions like pruritus
35. Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice?
D. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms.
Situation 8: The nurse is performing health education activities for Janevi Segovia, a 30 years old Dentist with Insulin dependent diabetes Mellitus.
36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she:
B. Draw insulin from the vial of the intermediate acting insulin first
C. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously
D. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first.
37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry first?
38. Janevi administered regular insulin at 7 A.M. and the nurse should instruct Jane to avoid exercising at around:
A. 9 to 11 A.M.
B. After 8 hours
39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall
A. Glycosylated Hemoglobin
C. Ketone levels
40. Upon the assessment of HbA1C of Mrs. Segovia. The nurse has been informed of a 9 % HbA1C result. In this case, she will teach the patient to:
A. Avoid infection
41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan?
C. Apply a moisturizing lotion to dry feet but not between the toes
D. Always have a podiatrist to cut your toe nails; never cut them yourself
42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately
A. Endotracheal intubation
43. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis?
A. Comatose state
A.
B. Shakiness
C. Blurred vision
45. Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane to eat or drink after midnight. Prior to taking the blood specimen, the nurse noticed that Jane is
holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said yes. Which of the following is the best nursing action?
A. Administer syrup of ipecac to remove the distilled water from the stomach.
D. Continue as usual and have the FBS analysis performed and specimen be taken.
Situation 9: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an
inevitable fact and she must be prepared to care for the growing elderly population.
46. 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 surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation
47. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
48. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity
50. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles
Situation 10 – In the OR, there are safety protocols that should be followed. The OR nurseshould be well
versed with all these to safeguard the safety and quality of patient delivery outcome.
51. Which of the following should be given highest priority when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
D. Check for jewelry, gown, manicure, and dentures
52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but
considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference
53. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care
during the intraoperative phase. As the circulating nurse, you make certain that throughout the
procedure…
A. the surgeon greets his client before induction of anesthesia
B. the surgeon and anesthesiologist are in tandem
C. strap made of strong non-abrasive materials are fastened securely
around the joints of the knees and ankles and around the 2 hands around
an arm board.
D. Client is monitored throughout the surgery by the assistant anaesthesiologist
54. Another nursing check that should not be missed before the induction of general
anesthesia is:
A. check for presence underwear
B. check for presence dentures
C. check patient’s ID
D. check baseline vital signs
55. Some lifetime habits and hobbies affect postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk
for:
A. perioperative anxiety and stress
B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory function
Situation 11: Sterilization is the process of removing ALL living microorganism. To be free of ALL living
microorganism is sterility.
56. There are 3 general types of sterilization use in the hospital which one is not included?
A. Steam sterilization
B. Chemical sterilization
C.
D. Sterilization by boiling
57. Autoclave or steam steam under pressure is the most common method of sterilization in the hospital.
The nurse knows that the temperature and time is set to the optimum level to destroy not only the
microorganism, but also the spores. Which of the following is the ideal setting of the autoclave machine?
A. 10,000 degree Celsius for 1 hour
B. 5,000 degree Celsius for 30 minutes
C. 37 degree Celsius for 15 minutes
D. 121 degree Celsius for 15 minutes
58. It is important that before a nurse prepares the material to be sterilized, A chemical indicator strip
should be placed above the package, preferably, Muslin sheet. What is the color of the striped produced
after autoclaving?
A. Black
B. Blue
C. Gray
D. Purple
60. If a nurse will sterilize a heat and moisture labile instruments, it is according to AORN
recommendation to use which of the following method of sterilization?
A. Ethylene oxide gas
B. Autoclaving
C. Flash sterilizer
D. Alcohol immersion
Situation 12 – Nurses hold a variety of roles when providing care to a perioperative patient.
61. Which of the following role would be the responsibility of the scrub nurse?
A. Assess the readiness of the client prior to surgery
B. Ensure that the airway is adequate
C. Account for the number of sponges, needles, supplies, used during the surgical procedure.
D. Evaluate the type of anesthesia appropriate for the surgical client
62. As a perioperative nurse, how can you best meet the safety need of the client after administering
preoperative narcotic?
A. Put side rails up and ask the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form
63. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing\ surgery. If hair at
the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision
infection?
A. Draped
B. Pulled
C. Clipped
D. Shampooed
64. It is also the nurse’s function to determine when infection is developing in the surgical incision. The
perioperative nurse should observe for what signs of impending infection?
A. Localized heat and redness
B. Serosanguinous exudates and skin blanching
C. Separation of the incision
D. Blood clots and scar tissue are visible
65. Which of the following nursing interventions is done when examining the incision wound and changing
the dressing?
A. Observe the dressing and type and odor of drainage if any
B. Get patient’s consent
C. Wash hands
D. Request the client to expose the incision wound
Situation 13: The preoperative nurse collaborates with the client significant others, and healthcare providers.
66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:
A. Biomedical division
B. Chaplancy services
D. Pathology department
67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last patients will need surgical amputation but there are no sterile surgical equipments. In
A. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures
B. Forwarding the trauma client to the nearest hospital that has available sterile equipment is appropriate
C. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes.
D. In such cases, flash sterilizer will be use at 132 degree Celsius in 3 minutes.
68. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 8 hours after cholecystectomy. Upon checking the chart, Malou found out that
she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with:
A. Nurse supervisor
B. Anesthesiologist
C. Surgeon
D. Intern on duty
69. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as
B. Communicate with the ward nurse to verify if insulin was incorporated or not
70. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.
D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.
71. If you are the nurse in charge for scheduling surgical cases, what important information do you need
to ask the surgeon?
A. Who is your internist
B. Who is your assistant and anesthesiologist, and what is your preferred
time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant
D. Who is your anesthesiologist
72. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses
73. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the
number of people in the room for infection control. Who comprise this team?
A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
74. Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and
pushing/pulling them towards the operating room?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
Situation 15: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes.
76. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse
anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure?
77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe?
A. 5 % dextrose in water
B. 10 % dextrose in water
78. The nurse is making initial rounds on the nursing unit to assess the condition or assigned clients. The nurse notes that the client’s IV site is cool, pale and swollen and the solution is
not infusing. The nurse concludes that which of the following complications has been experienced by the client?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombophlebitis
79. A nurse reviews the client’s electrolytes laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the lectrocardiogram as a
A. U waves
B.
C. Elevated T waves
D. Elevated ST segment
80. One patient has a runaway IV of 50 % dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
order?
B. Isotonic solution
C. Hypertonic solution
D. Hypotonic solution
D. Urethral catheterization
82. Which of the following is not true with regards to the informed consent?
84. A nurse is assigned to care for a group of clients. On review of the client’s medical records the nurse determines that which client is at risk for excess fluid volume?
85. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for deficient fluid volume?
Situation 16: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.
86. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?
88. You have a critical heat labile instrument to sterilize and are considering to use high level of disinfectant. What should you do?
90. Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the following?
Situation 17: The OR is divided in three zones to control traffic flow and contamination.
92. Nursing intervention for a patient on low dose IV insulin therapy includes the following EXCEPT:
93. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going IV. The strength is 500/ml. How much should you incorporate into the IV solution?
A. 10 ml
B. 2 ml
C. 0.5 ml
D. 5 ml
95. Insulin using insulin syringe are given using how many degrees of needle insertion?
A. 45
B. 180
C. 90
D. 15
Situation 18: Maintenance of sterility is an important function a nurse should perform in any OR setting.
B. for 9 months sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers.
D. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization process
97. 2 organizations endorsed that sterility are affected by factors other that the time itself, these are:
98. All of these factors affect the sterility of the OR equipments, these are the following except:
C. Storage
B. The material as well as the equipments are sterilized and had undergone a rigorous sterilization process
D. The material has no microorganism nor spores present that might cause an infection
100. In using liquid sterilizer versus autoclave machine, which of the following is true?
B. They are both capable of sterilizing the equipments, however, it is necessary to soak supplies in the liquid sterilizer for a longer period of time.
D. If liquid sterilizer sterilization process is used, rinsing it before using is not necessary.