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NURSING PRACTICE 3

Situation 1 - Concerted work efforts among members of the surgical team is


essential to the success of the surgical procedure.

The sterile nurse or sterile personnel touch only sterile supplies and
instruments. When there is a need for
sterile supply which is not in the sterile field, who hands out these items by
opening its outer cover?
Circulating nurse
Anesthesiologist
Surgeon
Nursing aide

CORRECT ANSWER: A
RATIONALE: The circulating nurse is responsible for the overall running of the OR
before, during and after the operative procedure. Also he/she is responsible for
the opening of the outer wrapper of sterile supplies that will be used during the
operative procedure.
OPTION B: The anesthesiologist is the person that administers the anesthetic to
the patient.
OPTION C: The surgeon is responsible in performing the surgical procedure safely
and correctly.
OPTION D: The nursing aide is not a part of the surgical team.
SOURCE: Barela et. al. Operating Room Technique Instructional Manual 1st Ed. pp.
42-44

The OR team performs distinct roles for one surgical procedure to be accomplished
within a prescribed time
frame and deliver a standard patient outcome. Who monitors the status of the
client like urine output, blood loss while the surgeon performs the surgical
procedure?
Scrub nurse
Surgeon
Anesthesiologist
Circulating nurse

CORRECT ANSWER: C
RATIONALE:The anesthesiologist or nurse anesthetist maintains the airway, ensures
adequate gas exchange, monitors circulation and respiration, estimates blood and
fluid loss, infuses blood and fluids, administers medications to maintain
hemodynamic stability, and alerts the surgeon immediately to any complication.
OPTION A: Scrub nurse organize the surgical equipment and hand the surgeon the
appropriate instruments required for the operative procedure.
OPTION B: The surgeon heads the surgical team and makes decision about the
surgical procedure.
OPTION D: the circulating nurse maintains the coordination of all team members.
SOURCE: Black and Hawks. Medical-Surgical Nursing. Volmue 1. 7th ed. p. 284

The following are members of the sterile team EXCEPT for one.
Surgeon
Surgical Assistant
Anesthetist
Scrub nurse

CORRECT ANSWER: C
RATIONALE:Anesthetist is the answer. Sterile team are perioperative caregivers who
provide direct care within the sterile field. Nonsterile team are perioperative
caregivers who provide direct care from the pheripery of the sterile field and
environment. An Anesthetist is a member of the nonsterile team who administers
anesthetics during the surgical procedure
OPTIONS A, B & D: Sterile members of the surgical team
SOURCE: Phillips. p. 50

Before blood transfusion, the nurse started an IV infusion as ordered. Which of


the following is commonly
ordered before BT?
a. Sterile water solution
b. D5LR
c. Dextrose 5% in water
d. Normal saline solution

CORRECT ANSWER: D
RATIONALE:Normal saline solution is the only solution compatible for blood
transfusion
OPTION A: is not for blood transfusion
OPTION B: Solutions containing calcium, such as Ringer’s lactate may cause
clotting.
OPTION C: Dextrose may lead to clumping of red blood cells and hemolysis.
SOURCES: Timby. Clinical Nursing Procedures. p. 138; Luckmann and Sorensen.
Medical Surgical Nursing. 3rd Ed. p. 1029

Situation 2 - You are assigned in the Orthopedic Ward where clients are
complaining of pain in varying degrees upon movement of body parts.

Troy is a one day post open reduction and internal fixation (ORIF) of the left hip
and is in pain. Which of the
following observation would prompt you to call the doctor?
Dressing is intact but partially soiled
Left foot is cold to touch and pedal pulse is absent
Left leg in limited functional anatomic position
BP 114/78, pulse of 82 beats/minute

CORRECT ANSWER: B
RATIONALE: These assessment is a sign of decrease blood flow to the area that may
require immediate intervention before complications (e.g. necrosis) may happen.
OPTION A: Not alarming to report to physician. Reinforcing of dressing can be
done.
OPTION C: it is normal because the patient has just undergone a surgery
OPTION D: Within normal range

There is an order of Demerol 50 mg I.M. now and every 6 hours prn, You injected
Demerol at 5 pm. The next
dose of Demerol 50 mg I.M. is given:
When the client asks for the next dose
When the patient is in severe pain
At 11 pm
At 12 pm

CORRECT ANSWER: C
RATIONALE: Demerol is given at 5pm. If pain is still present, the next dose of
this will be 6 hours after at 11 pm.

A patient is in pain following surgery. Which of the following instructions should


the nurse give to the patient
regarding pain management?
“Try to bear the pain as long as you can.”
“Pain should be reported in the early stages.”
“Higher levels of pain are easier to reduce than lower levels.”
“Our goal is to keep you pain free.”

CORRECT ANSWER: B
RATIONALE: Medicating before pain begins will require less medication. Therefore,
the nurse should advise the postoperative patient that pain should be reported in
the early stages to best manage the pain.
OPTION A: Trying to bear as long as possible will only require more medication
and/or greater frequency to get the pain under control.
OPTION C: Higher levels of pain are not easier to reduce than lower levels.
OPTION D: It is not always realistic to expect to keep the patient totally pain
free at all times. But through frequent assessment, reassessment and proper
intervention, the nurse should be able to manage the patient’s pain throughout the
healing process until pain relief is no longer needed.
SOURCE: CGFNS Qualifying Exam. 5th ed. p. 134

When assessing a patient for pain, the nurse observes facial grimacing with
movement, and blood pressure
and pulse elevation. Which of the following measures should the nurse take next?
Realize that patient has the right to refuse medication.
Explain the reasons for taking pain medication.
Tell the patient to notify the nurse when the pain becomes severe.
Leave the medication at the bedside in case the patient desires it later.

CORRECT ANSWER: B
RATIONALE: Regardless of its source, pain that is inadequately treated as harmful
has harmful effects beyond the discomforts it causes. Unrelieved pain affects
various body systems, including the cardiovascular system, and can initiate the
stress response, resulting in increased pulse and BP and a distressed appearance.
By providing an explanation such as this, the nurse can help the patient to accept
the drugs needed to relieve pain.
OPTION A: Patients have the right to refuse therapy. The nurse can play an
important role in determining the reason for refusal and should first make that
attempt before accepting refusal.
OPTION C: A general principle for administering analgesics is to administer them
before pain increases in severity.
OPTION D: Medications should never be left at the bedside for the patient to take
later.
SOURCE: CGFNS Qualifying Exam 5th ed. p. 141

In some hip surgeries, an epidural catheter for fentanyl epidural analgesia is


given. What is your nursing
priority care in such a case?
Instruct client to observe strict bed rest
Check for epidural catheter drainage
Administer analgesia through epidural catheter as prescribed
Assess respiratory rate carefully

CORRECT ANSWER: D
RATIONALE: fentanyl (sublimaze) is a narcotic agonist analgesic (Other name:
Neuroleptanalgesic) It is 75-100 times more potent than morphine! In very high
doses it can cause respiratory depression.
Assess respiratory rate to monitor impending signs of respiratory depression.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 426

Situation 3 – Rita just retired from government service and was admitted for
pneumonectomy.

As the nurse on duty, you should check for the medical clearance of your client
for surgery among other
pre-op requirements. This clearance primarily covers:
Stress-coping mechanism of the client
Socio-economic status of the client
Smoking and eating habits of the client
Cardio-pulmonary system

CORRECT ANSWER: D
RATIONALE: The goal in preparing any patient for surgery is to ensure a well-
functioning cardiovascular system to meet the oxygen, fluid and nutritional needs
of the perioperative period. Also a goal for potential surgical patients is
optimal respiratory function.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 403

Preoperative tests were done. Particularly, the nurse should assess the lung
capacity by checking the:
Serum creatinine level
Chest x-ray
Serum protein levels
Arterial blood gas

CORRECT ANSWER: D
RATIONALE: Arterial blood gases provide information about alveolar ventilation,
oxygenation, and acid-base balance.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 281
OPTION A: this blood test is essential in the evaluation of renal function
OPTION B: chest x-ray identify various abnormalities of the lungs and structures
in the thorax, including the heart, great vessels, ribs or diaphragm.
OPTION C: this blood test helps diagnose hepatic, gastrointestinal, and renal
disease; protein abnormalities; cancer and blood dyscrasias.
SOURCE: Gaedeke. Laboratory and Diagnostic Test Handbook

The main objective in postoperative pneumonectomy is to:


Maintain a patent airway
Provide maximum remaining lung capacity
Provide early rehabilitation measures
Recognize early symptoms of complications

CORRECT ANSWER: A
RATIONALE: Using ABC, airway patency is the priority during postoperative
pneumonectomy
OPTIONS B, C & D: correct intervention but airway patency is still the priority

There is an order of central venous pressure (CVP) reading. As a nurse, you should
know that this is a measure
observing signs of:
Hypoxia
Hypovolemia
Hypothermia
Hypoxemia

CORRECT ANSWER: B
RATIONALE: The CVP is an indirect method of determining right ventricular filing
pressure (preload). This makes the CVP a useful hemodynamic parameter to observe
when managing an unstable patient’s fluid volume status.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 678

Pulmonary edema is a potential danger that we nurses should monitor in post


pneumonectomy. This is
usually due to:
Cardiac output goes to the remaining lung
Liberal fluid intake
Rapid infusion of IV fluids
Fluid retention due to prolonged bed rest

CORRECT ANSWER: A
RATIONALE: Pulmonary edema most commonly occurs as a result of increased
microvascular pressure from abnormal cardiac function. The backup of blood into
the pulmonary vasculature resulting from inadequate left ventricular function
causes a increased microvascular pressure, and fluid begin to leak into the
interstitial space and alveoli. Other causes of pulmonary edema are hypervolemia
or a sudden increase in the intravascular pressure in the lung. One example of
this is in the patient who has undergone a pneumonectomy. When one lung has been
removed, all the cardiac output then goes to the remaining lung. If the patient’s
fluid status is not monitored closely, pulmonary edema can quickly develop in the
post operative period as the patient’s pulmonary vasculature attempt to adapt.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 542

Situation 4 - In the OR, there are safety protocols that should be followed. The
OR nurse should be well versed with all these to safeguard the safety and quality
to patient delivery outcome.

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

CORRECT ANSWER: B
RATIONALE: Patient safety in the preoperative area is a priority. Using process to
verify patient identification, the surgical procedure, and the surgical site
maximizes patient safety and allows for early identification and intervention if
any discrepancies are identified.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 414

In the OR, you will position a patient for TURP in:


Supine
Lithotomy
Semi-fowler
Trendelenburg

CORRECT ANSWER: B
RATIONALE: Surgery is performed in lithotomy position - Keep in mind: Functional
residual capacity decreases, predisposing patients to atelectasis and hypoxia.
Rapid lowering of the legs at the end of the operation acutely decreases venous
return and can result in severe hypotension, especially when combined with blood
loss during surgery.
SOURCE: http://www.rph.wa.gov.au/anaesth/downloads/TURP_Titze.pdf

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 material 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 anesthesiologist

CORRECT ANSWER: C
RATIONALE: Preventing physical injury includes using safety straps and bed rails
and not leaving the sedated patient unattended.
OPTIONS A & B: does not answer safety question
OPTION D: inappropriate
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 435

You refer postoperative patients under general anesthesia to the doctor when he
has:
Cold clammy skin and filiform pulse
Snoring respiration and rapid pulse
Accidental removal of the airway
A drop in blood pressure and rapid pulse

CORRECT ANSWER: D
RATIONALE: It is the responsibility of the surgeon and the anesthetist or
anesthesiologist to monitor and manage complications. However, a nurse plays an
important role. Being alert to and reporting changes in vital signs and symptoms
of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyperthermia
and disseminated intravascular coagulation and assisting with their management is
an important factor (Smeltzer, 434). The anesthesia provider functions as the
guardian of the patient throughout the entire care period, the anesthesia provider
manage the patient’s physiology using the principle of aseptic technique
(Phillips, 51). Maintaining the patency of airway is the responsibility of the
anesthesia provider, an accidental removal of airway is negligent.
SOURCES: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434
Phillips. p. 51

Some different habits and hobbies affect postoperative respiratory function. If


your client smokes 3 packs
of cigarettes a day for the part 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

CORRECT ANSWER: D
RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery.
These patients should be counseled to stop smoking at least 24 hours prior to
surgery. Research suggest that counseling has a positive effect on the patient’s
smoking behavior 24 hors preceding surgery, helping reduce the potential for
adverse effect associated with smoking such as increased airway reactivity,
decreased mucocilliary clearance, as well as physiologic changes in the
cardiovascular and immune systems.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 403

Situation 5 - Nurses hold a variety of roles when providing care to a


perioperative patient.

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

CORRECT ANSWER: C
RATIONALE: The duties of the scrub nurse include gathering all equipment for the
procedure, preparing all supplies and instruments using sterile technique,
maintaining sterility within the sterile field during surgery, handling
instruments and supplies during surgery, and cleaning up after the case. During
surgery, the scrub nurse maintains an accurate counting of sponges, sharps and
instruments on the sterile field and counts the same materials with the
circulating nurse before and after the surgery.
OPTIONS B & D – These are the roles of the anesthesiologist
SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. pp. 284-285

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 not leaving the sedated patient
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

CORRECT ANSWER: A
RATIONALE: Preventing physical injury includes using safety straps and bed rails
and not leaving the sedated patient unattended.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434

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 lessen chance of incision
infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed

CORRECT ANSWER: D
RATIONALE: Immediate preoperative nursing care:
Preparing the skin: Explain shower and bathing protocols for the night before the
planned surgical procedure. Usually the operative area is cleaned the night before
surgery with soap and water or an antimicrobial solution to reduce the number of
microbes on the skin.
OPTION A: inappropriate
OPTION B: inappropriate
OPTION C: Electric clippers are used for safe hair removal immediately before the
operation if hair must be removed.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 413;
Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 277

A nurse is assessing the operative site in a client who underwent a breast


reconstruction. The nurse is
inspecting the flap and the areola of the nipple and notes that the areola is a
deep red color around the edge.
The nurse takes which action first?
Document the findings
Elevate the breast
Encourage nipple massage
Notify the physician

CORRECT ANSWER: D
RATIONALE: Following breast reconstruction, the flap is inspected for color,
temperature, and capillary refill. Assessment of the nipple areola is made, and
dressings are designed so this area can be observed. An areola that is deep red,
purple, dusky, or black around the edge is reported to the physician immediately
because this may indicate a decreased blood supply to the area. The nurse would
also document the findings once the physician is notified.
OPTIONS B & C: are incorrect actions.

When performing a surgical dressing change of a client’s abdominal dressing, a


nurse notes an increase in
the amount of drainage and separation of the incision line. The underlying tissue
is visible to the nurse.
The nurse would do which of the following in the initial care of this wound?
a. Leave the incision open to the air to dry the area
b. Apply a sterile dressing soaked in povidone-iodine (Betadine)
c. Irrigate the wound and apply sterile dressing
d. Apply a sterile dressing soaked with normal saline.

CORRECT ANSWER: D
RATIONALE: Wound dehiscence is the separation of wound edges at the suture line.
Signs and symptoms include increased drainage and the appearance of underlying
tissues. Dehiscence usually occurs 6-8 days after surgery. The client should be
instructed to remain quiet and to avoid coughing and straining. The client should
be positioned to prevent further stress on the wound. The nurse must notify the
physician after applying a sterile dressing soaked with normal saline.
OPTION A: will dry and will be prone to infection if exposed to air
OPTION B: Betadine will irritate the tissues
SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed.

Situation 6 - Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR
is 46/min and he appears to be in acute respiratory distress,

Which of the following nursing actions should be initiated first?


a. Promote emotional support
b. Administer oxygen at 6L/min
c. Suction the client every 30 min
d. Administer bronchodilator by nebulizer

CORRECT ANSWER: D
RATIONALE: Asthma exacerbations are best managed by early treatment and education
of the patient. Quick-acting beta-adrenergic medications are first used to prompt
relief of airflow obstruction.
OPTION A: This is not a priority
OPTION B: Should only be at 2L/min
OPTION C: Suctioning the client increases respiratory distress
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. Volume I. p. 592

Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse,
“what is its indication?”
the nurse will say:
a. Relax smooth muscles of the bronchial airway
b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough
CORRECT ANSWER: A
RATIONALE: Classification: Bronchodilator
Mechanism of action: relaxes smooth muscle of bronchial airways and pulmonary
blood vessels.
OPTION B: Expectorants
OPTION C: Mucolytic – reduces the viscosity of pulmonary secretions.
OPTION D: Antitussive – suppresses the cough reflex by direct action on the cough
center in the medulla.
SOURCE: Nursing 2006 Drug handbook 26th ed.

You will give health instructions to Carlo, a case of bronchial asthma. The health
instruction will include
the following EXCEPT:
a. Avoid emotional stress and extreme temperature
b. Avoid pollution like smoking
c. Avoid pollens, dust seafood
d. Practice respiratory isolation

CORRECT ANSWER: D
RATIONALE: Asthma is not an infectious disease. Practicing respiratory isolation
is a wrong teaching instruction.

The asthmatic client asked you what breathing technique he can best practice when
asthmatic attack starts.
What will be the best position?
a. Sit in high-Fowler's position with extended legs
b. Sit-up with shoulders back
c. Push on abdomen during exhalation
d. Lean forward 30-40 degrees with each exhalation

CORRECT ANSWER: D
RATIONALE: Orthopneic position provides maximum lung expansion

As a nurse you are always alerted to monitor status asthmaticus who will likely
and initially manifest symptoms of:
a. metabolic alkalosis
b. respiratory acidosis
c. respiratory alkalosis
d. metabolic acidosis

CORRECT ANSWER: C
RATIONALE: Status asthmaticus is severe persistent asthma that does not respond to
conventional therapy. The attacks last longer than 24 hours. The basic
characteristic of asthma decreases the diameter of the bronchi and is apparent in
status asthmaticus. A ventilation-perfusion abnormality results in hypoxemia and
respiratory alkalosis initially, followed by respiratory acidosis. There is a
reduced PaO2 and an initial respiratory alkalosis, with a decreased PaCO2 and an
increased pH. As status asthmaticus worsens, the PaCO2 increases and pH falls,
reflecting respiratory acidosis.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 595

Situation 7 – P. Cruz, 65 years old, was admitted in the hospital because of signs
and symptoms of acute MI. You are expected to recognize ECG readings on the
cardiac monitor.

Which of the following will appear abnormal in the ECG when ischemia and injury
occur in the myocardium?
a. QRS interval
b. ST segment and T wave
c. P wave
d. PR interval

CORRECT ANSWER: B
RATIONALE: The first ECG signs of acute MI are from myocardial ischemia and
injury. Myocardial injury causes a T wave to become enlarged and symmetric. As the
area of injury becomes ischemic, myocardial repolarization is altered and delayed,
causing the T wave to invert. The ischemic region may remain depolarized while
adjacent areas of the myocardium return to resting state. Myocardial injury also
causes ST-segment changes. The injured myocardial cells depolarize normally but
repolarize more rapidly than normal cells, causing the ST segment to rise at least
1 mm above the isoelectric line (area between the T wave and the next P wave is
used as a reference for isoelectric line) when measured 0.08 seconds after the end
of the QRS.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 726

From an ECG reading, a QRS complex represents;


Ventricular depolarization
Ventricular repolarization
End of ventricular depolarization
Atrial depolarization

CORRECT ANSWER: A
RATIONALE: QRS complex represents ventricular muscle depolarization
OPTION B: T wave represents ventricular muscle repolarization
OPTION D:P wave represents atrial muscle depolarization
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686

33. Which of the following represents ventricular repolarization?


T wave
ST segment
QRS complex
PR interval

CORRECT ANSWER: A
RATIONALE: T wave represents ventricular muscle repolarization
OPTION B: ST segment represents early ventricular repolarization
OPTION C: QRS complex represents ventricular muscle depolarization
OPTION D: PR interval represents the time needed for sinus node stimulation,
atrial depolarization, and conduction through the AV node before ventricular
depolarization
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686

It is important that the nurse measures interval of QRS complex. Which if the
following represent the normal
interval of QRS complex?
a. Greater than .20 sec
b. .20 sec
c. .10 sec
d. .12 sec to .20 sec

CORRECT ANSWER: C
RATIONALE:The QRS is normally less than 0.12 seconds in duration
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686

35. Later in the acute phase of MI, which of the following typically appears as
the first sign of tissue death?
a. ST segment suppression
Short T wave
Prolonged PR interval
Pathologic Q wave

CORRECT ANSWER: A
RATIONALE:Typically, an evolving acute myocardial infarction will show ST segment
elevation on an ECG, which indicate acute, evolving myocardial necrosis.
OPTION D – the emergence of Q wave may be an indication of worsening ischemia and
necrosis.
SOURCE: Schumacher & Chernecky. Critical Care and Emergency Nursing. p. 132

Situation 8 - Mrs. Cruz was admitted in the Medical Floor due to pyrosis,
dyspepsia and difficulty of swallowing.

36. Based from the symptoms presented, Nurse Yoshi might suspect:
a. Esophagitis
b. Hiatal hernia
c. GERD
d. Gastric Ulcer

CORRECT ANSWER: C
RATIONALE: GERD is the backflow of gastric or duodenal contents into the esophagus
caused by incompetent lower esophageal sphincter. Pyrosis or heartburn, dyspepsia
and dysphagia are cardinal symptoms.

37. What diagnostic test would confirm the type of problem Mrs. Cruz have?
a. Barium enema
b. Barium swallow
c. Colonoscopy
d. Lower GI series

CORRECT ANSWER: B
RATIONALE: Barium swallow or upper GI series would confirm GERD. Endoscopy is
another diagnostic test.
OPTIONS A and D: are the same
OPTION C: is incorrect

38. Mrs. Cruz complained of pain and difficulty in swallowing. This term is
referred as:
Odynophagia
Dysphagia
Pyrosis
Dyspepsia

CORRECT ANSWER: A
RATIONALE: When difficulty of swallowing is accompanied with pain this is now
referred as odynophagia
OPTION D – Dysphagia is difficulty of swallowing alone.

39. To avoid acid reflux, Nurse Yoshi should advice Mrs. Cruz to avoid which type
of diet?
Cola, coffee and tea
High fat, carbonated and caffeinated beverages
Beer and green tea
Lechon paksiw and bicol express
CORRECT ANSWER: B
RATIONALE: All are correct but OPTION B is the best answer. In patients with GERD,
this type of diet must be avoided to avoid backflow of gastric contents. Excessive
caffeine reduces the tone of lower esophageal sphincter.
Test Taking Skills: look for the umbrella effect

40. Mrs. Cruz’ body mass index (BMI) is 25. You can categorize her as:
Normal
Overweight
Underweight
Obese

CORRECT ANSWER: B
RATIONALE: Mr. Cruz’ BMI belongs to the overweight category (24 – 26),
malnourished (less than 17), underweight (17 – 19), normal (20 – 23), obese (27 –
30) and morbidly obese (greater than 30). BMI is weight in kilograms divided by
height in square meters

Situation 9 - Colostomy is a surgically created anus. It can be temporary or


permanent, depending on the disease condition.

41. Skin care around the stoma is critical. Which of the following is not
indicated as a skin care barriers?
a. Apply liberal amount of mineral oil to the area
b. Use karaya powder and rings around the stoma
c. Clean the area daily with soap and water before applying bag
d. Apply talcum powder twice a day

CORRECT ANSWER: A
RATIONALE:
OPTION B: Mild skin irritation may require the use of karaya powder before
attaching the pouch.
OPTION C: Soap acts as a mild abrasive agent to remove enzyme residue from fecal
spillage. The nurse advises the patient to protect the peristomal skin by washing
the area with gently with a moist, soft cloth and mils soap.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. pp.1062-1063

42. A nurse instructs the patient who had an ileostomy to avoid which of the
following foods?
Potatoes
Beef
Popcorn
Yogurt

CORRECT ANSWER: C
RATIONALE: Food which can cause a potential obstruction in an ileostomy includes
nuts, raisins, popcorn, seeds, chocolate, raw vegetables, celery and corn.
OPTIONS A, B & D – These foods are not contraindicated for patients who have an
ileostomy
SOURCE: CGFNS qualifying exam. 5th ed. p. 194

43. The patient who has had an ileostomy says to the nurse, “I will have to be
isolated for the rest of my life
because no one will be able to stand this terrible odor.” Which of the following
responses by the nurse
would most likely be reassuring?
“The odor will gradually become less noticeable.”
“I can understand your concern, but remaining in isolation does not reduce the
odor.”
“There are techniques that can reduce the odor.”
“The odor is a normal part of your condition and will not offend people.”

CORRECT ANSWER: C
RATIONALE: There are techniques that the nurse can use to reduce odor of the
ileostomy, such as placing charcoal in the ileostomy bag. The charcoal will absorb
the odor in the bag.
OPTION A – the odor does not gradually become less noticeable unless steps are
taken to reduce it.
OPTION B – While it is important to help the patient ventilate, this response does
not answer the issue of the odor.
OPTION D – This statement is not necessarily true. Others may be offended by the
odor. Teaching the patient measures that will help to reduce odor will be most
beneficial.
SOURCE: CGFNS qualifying exam 5th ed. p. 194

44. The following are appropriate nursing interventions during colostomy


irrigation EXCEPT:
a. Increase the irrigating solution flow rate when abdominal cramps is felt
b. Insert 2-4 inches of an adequately lubricated catheter to the stoma
c. Position client in semi-Fowler
d. Hand the solution 18 inches above the stoma

CORRECT ANSWER: A
RATIONALE: If cramping occurs, clamp off the tubing and allow the patient to rest
before progressing. Painful cramps are often caused by too rapid flow or by too
much solution. 300 ml of fluid maybe all that is needed to stimulate evacuation.
Volume may be increased with subsequent irrigation to 500, 1000, or 1500ml as
needed by the patient for effective results.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 1065

The nurse is assessing the colostomy of a client who had an abdominal perineal
resection for a bowel tumor.
Which of the following assessment findings indicate that the colostomy is
beginning to function?
Blood drainage from the colostomy
Change the dressing as prescribed
Absent bowel sounds
The passage of flatus

CORRECT ANSWER: D
RATIONALE: Following abdominal perineal resection, the nurse would expect the
colostomy to begin to function within 72 hours after surgery, although it may take
up to 5 days. The nurse should assess for the return of peristalsis and listen for
bowel sounds and check for the passage of flatus. Absent bowel sounds would not
indicate the return of peristalsis. The client would remain NPO until bowel sounds
return and the colostomy is functioning. Bloody drainage is not expected in a
colostomy.
SOURCE: Silvestri. Saunders NCLEX-RN Examination.3rd ed. P. 612

Situation 10 - As a beginner in research, you are aware that sampling is an


essential element of the research process.

46. What does a sample group represent?


a. Control group
b. Study participants
c. General population
d. Universe

CORRECT ANSWER: B
RATIONALE: Study participants are the people who are being studied; such study
participants comprise the sample.
SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed. p. 26

This kind of research gathers data in detail about individual or groups and
presented in narrative form, which is
Case study
Historical
Analytical
Experimental

CORRECT ANSWER: A
RATIONALE: Case studies are in-depth investigations of a single entity or a small
number of entities. The entity may be an individual, family, group, institution,
community or other social unit. In case study, researchers obtain a wealth of
descriptive information and may examine relationships among different phenomena,
or may examine trends over time.
OPTION B: Historical research- systematic studies designed to discover facts and
relationship about past events
Analytical epidemiologic studies are most useful for testing an hypothesized
association between human exposure and adverse health effects.
OPTIION D: Experimental is a study in which the researcher controls (manipulates)
the independent variable and randomly assigns subjects to different conditions.
SOURCE: Polit,D.E. and Beck C.T. Nursing Research principles and methods. 7th ed.
pp. 259, 716, 718

48. Random sampling ensures that each subject has:


a. Been selected systematically
b. An equal change of selection
c. Been selected based on set criteria
d. Characteristics that match other samples

CORRECT ANSWER: B
RATIONALE: Random sampling is a selection of the sample such that each member of
the population has an equal probability of being included.
SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed. p. 730

49. Which of the following sampling methods allows the use of any group of
research subject?
a. Purposive
b. Convenience
c. Snow-bail
d. Quota

CORRECT ANSWER: B
RATIONALE: Convenience sampling – selection of the most readily available persons
as participants in the study; also known as accidental sampling.
OPTION A: Purposive sampling – a non-probability sampling method in which the
researcher selects participants based on personal judgment about which one will be
most representative or informative; also known as judgmental sampling
OPTION C: Snowball sampling is the selection of participants through referrals
from other participants; also known as network sampling
OPTION D: Quota sampling – a nonrandom selection of participants in which the
researcher prespecifies characteristics of the sample to increase its
representative
SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed

50. You decided to include 5 barangays in your municipality and chose a sampling
method that would get
representative samples from each barangay. What should be the appropriate
method for you to use in this care?
a. Cluster sampling
b. Random sampling
c. Stratified random sampling
d. Systematic sampling

CORRECT ANSWER: A
RATIONALE: Cluster sampling – a form of sampling in which large groupings
(“clusters”) are selected first (e.g. nursing schools) with successive sampling of
smaller units (e.g. nursing students)
OPTION B: Random sampling – the selection of the sample such that each member of
the population has an equal probability of being included
OPTION C: The random selection of study participants from two or more strata in
the population independently
OPTION D: Systematic sampling – the selection of the study participants such that
every nth person (or element) in a sampling frame is chosen
SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed