Beruflich Dokumente
Kultur Dokumente
1.The nurse is teaching a mother whose daughter has iron deficiency anemia. The nurse
determines the parent understood the dietary modifications, if she selects?
2.Which of the following is the most common clinical manifestation of G6PD following
ingestion of aspirin?
a) Kidney failure
b) Acute hemolytic anemia
c) Hemophilia A
d) Thalassemia
3.The nurse assesses a client with an ileostomy for possible development of which of the
following acid-base imbalances?
a) Respiratory acidosis
b) Metabolic acidosis
c) Metabolic alkalosis
d) Respiratory alkalosis
4.The nurse anticipates which of the following responses in a client who develops metabolic
acidosis.
5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the client for?
a) Signs of tetany
b) Elevated blood glucose
c) Cardiac dysrhythmias
d) Hypoglycemia
6. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for
symptoms of?
7.The nurse responder finds a patient unresponsive in his house. Arrange steps for adult
CPR.
a) Assess consciousness
b) Give 2 breaths
c) Perform chest compression
d) Check for serious bleeding and shock
e) Open patient’s airway
f) Check breathing
8.Which of the following has mostly likely occurred when there is continuous bubbling in the
water seal chamber of the closed chest drainage system?
9.Which if the following young adolescent and adult male clients are at most risk for
testicular cancer?
a) Polyuria
b) Hypoactive deep tendon reflex
c) Hypertension
d) Laryngospasm
11.An 18-month-old baby appears to have a rounded belly, bowlegs and slightly large head.
The nurse concludes?
12.A nurse is going to administer 500mg capsule to a patient. Which is the correct route?
14.A nurse is preparing to give an IM injection of Iron Dextran that is irritating to the
subcutaneous tissue. To prevent irritation to the tissue, what is the best action to be taken?
16.A pregnant woman is admitted for pre-eclampsia. The nurse would include in the health
teaching that magnesium will be part of the medical management to accomplish the
following?
a) Control seizures
b) promote renal perfusion
c) To decrease sustained contractions
d) Maintain intrauterine homeostasis
17.A nurse is going to administer ear drops to a 4-year-old child. What is the correct way of
instilling the medicine after tilting the patient’s head sidewards?
18.A nursing student was intervened by the clinical instructor if which of the following is
observed?
19.Choose amongst the options illustrated below that best describes the angle for an
intradermal injection?
20.During a basic life support class, the instructor said that blind finger sweeping is not
advisable for infants. Which among the following could be the reason?
21.A nurse enters a room and finds a patient lying on the floor. Which of the following
actions should the nurse perform first?
22.A patient with complaints of chest pain was rushed to the emergency department. Which
priority action should the nurse do first?
a) Hepatitis A vaccine
b) Hepatitis B vaccine
c) Rotavirus Vaccine
d) Pneumococcal Vaccine
24.Several patients from a reported condominium fire incident were rushed to the
emergency room. Which should the nurse attend to first?
a) A 15-year-old girl, with burns on the face and chest, reports hoarseness of the voice
b) A 28-year-old man with burns on all extremities
c) A 4-year-old child who is crying inconsolably and reports severe headache
d) A 40-year-old woman with complaints of severe pain on the left thigh
25.The doctor ordered 1 pack of red blood cells (PRBC) to be transfused to a patient. The
nurse prepares the proper IV tubing. The IV tubing appropriate for blood transfusion comes
with?
a) Air vent
b) Microdrip chamber
c) In-line filter
d) Soluset
26.The expected yet negative (harmful ) result for posthemodialysis is a decrease in?
a) Creatinine
b) BUN
c) Phosphorus
d) Red blood cell count
27.A patient was brought to the emergency room after she fell down the stairs. Which of the
following is the best indicator for increased intracranial pressure in head and spinal injury?
28.A new nurse is administering an enema to a patient. The senior nurse should intervene if
the new nurse?
a) Provide privacy
b) Raise head of the bed
c) Give distilled water
d) Check client’s identification bracelet
30.A 30-year-old client is admitted with inflammatory bowel syndrome (Crohn’s disease).
Which of the following instructions should the nurse include in the health teaching? Select
all that apply
1.) Answer: D
Dark green leafy vegetables are good sources of iron. Oranges are good sources of vitamin C that enhances iron
absorption in the small intestines.
2.) Answer: B
Individuals with G6PD may exhibit hemolytic anemia when exposed to infection, certain medications or chemicals.
Salicylates such as Aspirin damages plasma membranes of erythrocytes, leading to hemolytic anemia.
3.) Answer: B
Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of HCO3, results to metabolic acidosis.
4.) Answer: C
Initially, respiratory system will try to compensate metabolic acidosis. Patients with metabolic acidosis have high
respiratory rate.
5.) Answer: A
Normal phosphorus level is 2.5 – 4.5 mg/dL .The level reflects hyperphosphatemia which is inversely proportional to
calcium. Client should be assessed for tetany which is a prominent symptom of hypocalcemia.
6.) Answer: C
Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, constipation, and signs of dehydration,
including a decrease in urine output.
7.) Answer: A, E, F, C, B, D
In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing normally? − C-chest compression A-
airway open B-breathing for patient S-serious bleeding, shock, spinal injury. The nurse should first assess consciousness of
the patient. Next, open patient’s airway to check for breathing. When there is no breathing, immediately perform chest
compression then give 2 breaths, do the cycle of care over. Finally, check for serious bleeding, shock, and spinal injury.
8.) Answer: D
Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or loose connection, and air is sucked
continuously into the closed chest drainage system.
9.) Answer: C
Testicular cancer is most likely to affect males in late adolescence. Undescended testis is also one major risk for testicular
cancer.
10.) Answer: D
Hypocalcemia occurs when there is accidental removal or destruction of parathyroid tissue during surgical removal of the
thyroid gland. Laryngospasm is one of the clinical manifestations of tetany, an indicator of hypocalcemia.
11.) Answer: A
It’s normal for a toddler to have bowlegs and a protruding belly. The head still appears somewhat large in proportion from
the rest of the body.
12.) Answer: D
13.) Answer: B
There is 6-8 months activity restriction following a spinal fusion. Sitting, lying, standing, normal stair climbing, walking,
and gentle swimming is allowed. Bending and twisting at the waist should be avoided, along with lifting more than 10 lbs.
14.) Answer: D
Z-track technique is used to administer drugs especially irritating to the subcutaneous tissue. This method promotes
absorption of the drug by preventing drug leakage into the subcutaneous layer.
15.) Answer: B
Establishing rapport is a way to gain trust that will lead for a patient to relax. You can get more insights and information
from a patient when rapport is established.
16.) Answer: A
Low magnesium (hypomagnesemia) produces clinical manifestations like increased reflexes, tremors, and seizures.
Magnesium Sulfate is the drug of choice to prevent seizures in pre-eclampsia and eclampsia.
17.) Answer: C
Ear canal of children ages 3years and above can be straightened by pulling the pinna up then backwards. For children
below 3 years of age, the ear canal can be straightened by pulling the pinna down then backwards.
18.) Answer: A
Infants are nose breathers. A gastric tube may be inserted to facilitate lung expansion and stomach decompression, but
not a nasogastric tube as it can occlude the nare, thus, making breathing difficult for the infant.
19.) Answer: B
20.) Answer: B
Blind finger sweeps are not recommended in all CPR cases especially for infants and children because the foreign object
may be pushed back into the airway.
21.) Answer: B
First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the patient.
22.) Answer: C
Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is caused by insufficient myocardial
oxygenation.
23.) Answer: D
Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65 years old and above, have higher risk for
serious pneumococcal infection and likely have low immunity. This is administered every 5 years.
24.) Answer: A
Burns on the face and neck can cause swelling of the respiratory mucosa that can lead to airway obstruction manifested by
hoarseness of voice and difficulty in breathing. Maintaining an airway patency is the main concern.
25.) Answer: C
An in-line filter is required for blood transfusions.
26.) Answer: D
Negative outcome: Hemodialysis decreases red blood cell count which worsens anemia, because RBCs are lost in dialysis
from anticoagulation during the procedure, and from residual blood that is left in the dialyzer.
27.) Answer: D
Decrease in level of consciousness and headache are early signs of increase in intracranial pressure (ICP). Altered level of
consciousness is the most common symptom that indicates a deficit in brain function.
28.) Answer: B
Recall the anatomy of the colon. The appropriate position is left lateral to facilitate flow of enema by gravity into the colon.
29.) Answer: D
Recall the 12 Rights of administration. Checking the patient’s name is critical for client-safety.
30.) Answer: A , D
Crohn’s disease is a chronic inflammation of the colon with symptoms of diarrhea, abdominal pain, and weight loss.
Corticosteroid is a treatment for Crohn’s disease. Antidiarrheal can give relief to diarrheal episodes. Aspirin should be
avoided as it can worsen inflammation. Those with Crohn’s disease are mostly lactose intolerant, so choice no. (2) is
incorrect.