SC TIP: Focus on prioritization, medical-surgical, and fundamentals of nursing. 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? a) Bread and coffee b) Fish and Pork meat c) Cookies and milk d) Oranges and green leafy vegetables 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. a) Heart rate of 105 bpm b) Urinary output of 15 ml c) Respiratory rate of 30 cpm d) Temperature of 39 degree Celsius

5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the client for? a) b) c) d) Signs of tetany Elevated blood glucose Cardiac dysrhythmias Hypoglycemia

6. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for symptoms of? a) Vomiting large amounts b) Watery stool

c)

Projectile vomiting

d) Dark-colored stool 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 patients 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? a) The connection has been taped too tightly b) The connection tubes are kinked c) Lung expansion d) Air leak in the system 9. Which if the following young adolescent and adult male clients are at most risk for testicular cancer? a) Basketball player who wears supportive gear during basketball games b) Teenager who swims on a varsity swim team c) 20-year-old with undescended testis d) Patient with a family history of colon cancer 10. The nurse plans to frequently assess a post-thyroidectomy patient for? 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? a) The child appears to be a normal toddler b) The child is developmentally delayed

c) The child is malnourished d) The childs large head may have neurological problems. 12. A nurse is going to administer 500mg capsule to a patient. Which is the correct route?

A.)

B.)

C.)

D.)

13. An appropriate instruction to be included in the discharge teaching of a patient following a spinal fusion is? a) Dont use the stairs b) Dont bend at the waist c) Dont walk for long hours d) Swimming should be avoided 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? a) Apply ice over the injection site b) Administer drug at a 45 degree angle c) Use a 24-gauge-needle d) Use the z-track technique 15. What should a nurse do prior to taking the patients history? a) Offer the patient a glass of water b) Establish rapport c) Ask the patient to disrobe and put on gown d) Ask pertinent information for insurance purposes 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) c) d) promote renal perfusion To decrease sustained contractions 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 patients head sidewards? a) Pull the pinna back then downwards b) Pull the pinna back then upwards c) Pull the pinna up then backwards d) Pull the pinna down then backwards 18. A nursing student was intervened by the clinical instructor if which of the following is observed?

a) Inserting a nasogastric tube b) Positioning the infant in a sniffing position c) Suctioning first the mouth, then the nose d) Squeezing the bulb syringe to suction mouth 19. Choose amongst the options illustrated below that best describes the angle for an intradermal injection?

A.)

B.)

C.)

D.)

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? a) The mouth is still too small b) The object may be pushed deeper into the throat c) Sharp fingernails might injure the victim d) The infant might bite 21. A nurse enters a room and finds a patient lying on the floor. Which of the following actions should the nurse perform first? a) Call for help b) Establish responsiveness of patient c) Ask the patient what happened d) Assess vital signs 22. A patient with complaints of chest pain was rushed to the emergency department. Which priority action should the nurse do first? a) Administer morphine sulfate intravenously b) Initiate venous access by performing venipunture c) Administer oxygen via nasal cannula d) Complete physical assessment and patient history 23. A rehab nurse reviews a post-stroke patients immunization history. Which immunization is a priority for a 72-year-old patient? 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? a) Inability to move extremities b) Decreased respiratory rate c) Increase in pulse and blood pressure d) Decrease level of consciousness 28. A new nurse is administering an enema to a patient. The senior nurse should intervene if the new nurse? a) Hangs the enema bag 18 inches above the anus b) Positions the client on the right side c) Advances the catheter 4 inches into the anal canal d) Lubricates 4 inches of the catheter tip 29. The medication nurse is going to give a patient his morning medications. What is the primary action a nurse should do before administering the medications? a) Provide privacy b) Raise head of the bed c) Give distilled water d) Check clients identification bracelet 30. A 30-year-old client is admitted with inflammatory bowel syndrome (Crohns disease). Which of the following instructions should the nurse include in the health teaching? Select all that apply

a) Corticosteroid medication is part of the treatment b) Include milk in the diet c) Aspirin should be administered d) Antidiarrheal medication can help

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 patients 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 Its 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 patients name is critical for client-safety. 30.) Answer: A , D Crohns disease is a chronic inflammation of the colon with symptoms of diarrhea, abdominal pain, and weight loss. Corticosteroid is a treatment for Crohns disease. Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can worsen inflammation. Those with Crohns disease are mostly lactose intolerant, so choice no. (2) is incorrect.