ARELLANO UNIVERSITY College of Nursing

MS 1 Course Audit 2

Direction: Select the correct answer for each of the following questions. Mark only one answer for each item by shading the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED.

Situation 1: Alma, 24 years old medical student was admitted in the medical ward with the complaint of severe right iliac pain, nausea and vomiting: 1. Almas fear that she will be absent from her classes for several days. The reassurance that you can give to minimize her anxiety is to: a. b. c. d. 2. Observe CBR for one week. Follow the doctors order Follow the health teaching of her nurse Observe Br only for three days.

To ensure early recovery, what should you include in your nursing care plan? a. b. c. d. Allow her to observe CBR Allow her to observe BD only after 3 days Let her ambulate a day after the surgery Allow her to have a shower a day after the surgery

3.

You are her nurse. Your nursing measure to prevent complication of pneumonia is: a. b. c. d. Turn her to sides every one and half houts Assist her in passive exercise Turn her to sides every three hours Encourage deep breathing

4.

You assess alma of the presence of pneumonia, the following are symptoms of pneumonia, except: a. b. c. d. Tactile fremitus is increase over the affected area Crackling sounds are heard over affected areas Percussion is dulled over the affected areas Expansion of the chest wall are equal during inspirations

5.

In determining the antibiotic that Alma will respond best, what test should be prescribed? a. b. c. d. Rubins test Culture and Sensitvity Test Widals test Schicks test

Situation 2: Stella, a dressmaker has Raynauds disease 6. Her nurse let her know that her conditions may improve and response to: a. b. c. d. 7. Calm emotional environment Cool climate Warm weather Hectic schedule

As a head nurse, you have to emphasize to her in your counselling and health teaching to avoid: a. b. c. d. Smoking Alcohol beverages Weight loss Coffee and tea

8.

With her ailment, which of these activities is contraindicated: a. b. c. Swimming in cold water Dancing Driving

d. 9.

Horse riding

An obese client with peripheral vascular disease, diet should contain all of the following, except: a. b. c. d. Minimal weight reduction Rapid weight reduction Increase fat intake Increase carbohydrate intake

10. Stella underwent peripheral arterial bypass graft, the most vital nursing management is to: a. b. c. d. Measure intake and output Apply elastic bandage Take pedal pulse Medicated for incisional pain

Situation 3: Mrs. Sison, 30 year old tuberculosis patient is one of the recipients of the Short Course Chemotherapy (SCC) drugs. Her appointment to take her supply of drugs was 3 days ago but she failed to come. This is the third month of treatment. 11. You plan to visit Mrs. Sison in order to: a. b. c. d. Advice her to consult the physician for changed in her treatment Check whether she is no longer coughing so that she can terminate her treatment Inform her to have another sputum examination as basis for continuing treatment Motivate her to collect her drugs regularly

12. You will explain to Mrs. Sison that the treatment if tuberculosis depend on: a. b. c. d. Rest and hospitalization Special diet Rest Quality and duration of chemotherapy

13. As part of your preparation for the home visit to Mrs. Sison, you review the minor signs of adverse reactions to the SCC drugs and these are: a. b. c. d. Fatigue or weakness and vomiting Loss of appetite, nausea and vomiting, weakness, rashes and fever Loss of appetite, nausea and vomiting Rashes or itchiness and fever

14. A yellowish discoloration of the skin and eyeballs of a patient taking SCC drugs us a sign to discontinue taking the: a. b. c. d. All the SCC drugs and refer patient to physician for evaluation Rifampicin and pyrazinamide for one week Pyrazinamide and refer to physician Rifamcpicin and refer patient

15. In your scheduled visit to Mrs. Sison you will also advise her to bring her school children without BCG to the health center for: a. b. c. d. Chest x-ray Sputum examination Tuberculin testing BCG vaccination

Situation 4: Carding, 50nyears old, has been admitted to the hospital with a diagnosis of cirrhosis of the liver. He has dependent edema and is complaining of jaundice, anorexia, and weakness. The following questions relate to his care. 16. The organic change occurring in cirrhosis of the liver is: a. b. c. d. Infection of hepatic cells Scar formation following cell necrosis Impairment of bile flow due to choledochitis Obliteration of the portal vessels

17. The primary cause of cirrhosis of the liver is: a. b. c. d. Malnutrition Alcoholism Physical damage of the liver Exposure to infection

18. Foods usually omitted from the diet of Carding with cirrhosis of the liver are:

a. b. c. d.

Whole grain cereals Milk product Cereal products Rich gravies and sauces

19. Carding develop ascites. This is causd by: a. b. c. d. Pulmonary failure Portal obstruction Capillary obstruction Arterial obstruction

20. Clay colored stool are caused by: a. b. c. d. Improper utilization of Vit K by the body The absence of bile salts in the feces The absence of bile pigments in the feces Faulty diet

Situation 5: Mr. Ben, 35 years old underwent cholycestectomy and was brought to the ward with T-tube and NGT. 21. Immediately, you connect the nasogastric tube to the suction apparatus. In this case, you should be observant to any indication of: a. b. c. d. Metabolic acidosis Tetany Metabolic alkalosis Cardiac arrest

22. NGT tube was removed 2 days after surgery and he began to have diarrhea. D5LR 1 liter and D5n5NSS 1 liter was ordered for intravenous infusion. If each bottle has to run for 12 hours, how many drops will be there in one minute? a. b. c. d. 32 gtts. 41 gtts. 20 gtts. 50 ggts.

23. If his diarrhea persists and not controlled right away, he might develop: a. b. c. d. Metabolic acidosis Metabolic alkalosis Cardiac arrest Tetany

24. You cautioned him that if intravenous infusion is regulated faster than the prescribed rate, he may be apt to have: a. b. c. d. Respiratory overload Metabolic acidosis Cardiac arrest Tetany

25. He has been informed the rationale of his having I.V. the following are the signs of dehydration, except: a. b. c. d. Sunken eyeballs Concentrated urine Puffy eyelids Thirst

Situation 6: Gabriel, 18-year-old is suffering from asthma after he returned home from mountaineering. 26. Upon auscultation, you hear: a. b. c. d. Dull sound of the affected area Wheezing sound Murmur sound Gurgling sound

27. Which of these manifestations is not expected to occur: a. b. c. Bradycardia Apprehension Tachypnea

d.

Cool and moist skin

28. Initially, the physician order aminophylline 350mg STAT IV push with 10 cc of D5%W. Drug on hand is 500mg/5cc in a vial. How many cc of the drug will you aspirate? a. b. c. d. 1.5 cc 3.0 cc 3.5 cc 2.5 cc

29. One toxic effect of aminophylline: a. b. c. d. Nystagmus Ringing of the ears Cardiac arrest Cardiac arrhythmias

30. The priority of your nursing care is: a. b. c. d. Administration of aminophylline Force fluid intake Give bronchodilator Keep the bed elevated

Situation 7: Ms Felis, 19 years old, single, the only child is scheduled for mastectomy. 31. You are her nurse. Which of these is not included in your preoperative care? a. b. c. d. Instructing exercises that will benefit her postoperatively Allay her fear about the surgery Giving health teaching to client and relatives regarding her surgery Giving him health teaching what to do when discharged.

32. You informed her that the most common breast tumor occurring in young women is a. b. c. d. Fibrocystic Papilloma Gynecomastia Fribroadenoma

33. Which of these work-up is not related to her surgery? a. b. c. d. CBC Urinalysis B.T. C.T.

34. Which of these activity should you encourage her to do in early A.M. prior to the surgery? a. b. c. d. Sign the consent for surgery Take a bath Sponge bath only Take her temperature

35. How would you allay her/their fear for the surgery? Tell her/them that: a. b. Your doctor is the best in town, he does all kinds of surgery Your doctor is the topnotcher in the board examination for medicine that would make him very capable to do the surgery. c. d. Your doctor is a thoracic surgeon and have a lot of breast surgery Your doctor will specialize breast surgery.

Situation 8: Ms Liza, 35-years old is experiencing intermittent abdominal pain for the past few days. Her physician recommends STAT exploratory laparotomy after blood examination. 36. Preoperative medications were ordered. Which of these drugs is given to suppress salivation? a. b. c. d. Benadryl Scopolamine Demerol Valium

37. In preoperative patient like Liza, which of these is given the last priority to be accomplished 30 minutes before the scheduled time: a. b. c. d. Signing consent for surgery Giving pre-operative medications Instructing the patient to empty the bladder Taking vital signs

38. Which of the following techniques is best applied to minimize pain when asking post-operative patient to do coughing exercise? a. b. c. d. Support her abdomen with a small pillow Cover her mouth when coughing Support her chest with your hands Put her in Fowlers position with knee flexed

39. Post-operative order is 1 bottle D5% in water 500cc with 1 ampule Solucortef incorporated to run 10 hours using a microdrip tubing. Find the number of drops per minutes: a. b. c. d. 100 gtts. 22 gtts. 80 gtts. 20 gtts.

40. Liza made queries to the charge nurse during the rounds, when will her stitches be removed? Your answer is: a. b. c. d. Normally seven days after surgery. Normally three days after operations. Alternating stitches will be removed after four days. Two weeks from now.

Situation 9: A retired operation manager, Mr. Solis, is confined with peripheral vascular disease of the lower extremities. 41. After a series of examinations, he is diagnosed as having complete arterial obstructions of the left leg. Most likely the clinical manifestation would be: a. b. c. d. Aching back Burning sensations Numbness and tingling Coldness

42. He underwent below knee amputation. From the OR the stump was dry, but 30 minutes later, a small amount of bloody drainage was noticed. Prioritize your nursing action: a. b. c. d. Reinforce the dressing Change the dressing Mark the area of the drainage with a ballpen Notify the doctor

43. During the first 24 hours postoperatively, your nursing care is to: a. b. c. d. Keep stump flat on bed Apply traction to the stump Elevate the stump on a pillow Abduct the stump on a scheduled basis

44. Which of these nursing goals take priority when considering Mr. Solis physical mobility following amputation? a. b. c. d. Assess phantom limb pain Assess phantom limb sensation Assess edema Prevent contractures

45. The patients wife who will prepare his meals is given dietary instructions. His diet is low cholesterol low sodium. Your first step in giving Mr. Solis specific instruction is: a. b. c. d. Explain the importance of complying his prescribed diet Ask how to name foods high in fat and salt Determine her knowledge about cholesterol Assess the patients food preference

Situation 10: Mr. Jaime , a senior executive is admitted in the CCU with a diagnosis of CHF.

46. The best indicator of clients condition if he has CHF: a. b. c. d. Cardiac rate Pulse rate Respiration Blood pressure

47. The symptoms that Mr. Jaime is expected to manifest would be: a. b. c. d. Edema of the affected extremity Edema of the abdominal cavity Eupnea, cyanosis and hemoptysis Orthopnea, moist rales and cough

48. He has now acute pulmonary edema, rotating tourniquets is ordered. The desired of this is to: a. b. c. d. Increased temporarily the total volume of circulating blood. Increase the blood flow in order to rest the heart Reduce blood flow to the extremities in order to rest the heart. Reduce temporarily the total volume of circulating blood

49. The most comfortable position for him is: a. b. c. d. Low-Fowlers Prone Jack-knife Sims

50. Since he is suffering from pulmonary edema. Digoxin was prescribed this is primarily to: a. b. c. d. Decrease cardiac rate Increase cardiac output Increase cardiac rate Increase urinary output

Situation 11: Marmie is the OR nurse manager of MMC. 51. How would she position Ela who is scheduled for throidectomy: a. b. c. d. Supine Trendelenburgs Reverse Trendelenburgs Fowlers

52. To expose her thyroid for surgery, which of these is use? a. b. c. d. Trochanter roll Small pillow Elevator bridge Donut

53. Halothane is the anesthetic agent that will be used for Elas anesthesia. The disadvantage of this anesthetic agent is: a. b. c. d. Induces bronchodilation Depressant to the cardiovascular system Non flammable Non-irritating to respiratory tract

54. The following are antiemetics sedatives premedication, except: a. b. c. d. Inapsin Vistaril Phenergen Valium

55. The following antimuscarinics premedication use to decrease secretions and provides amnesia is a. b. c. d. Scopolamine Glycopyriolate Robinul Atropine sulphate

Situation 12: Mr. Chit5o, 72, businessman with 8 siblings. The two youngest ages 3 and 1 year old is suffering from cirrhosis of the liver.

56. One of your finding in assessment upon admission is: a. b. c. d. Pneumothorax Transitory weakness Abdominal distention Ascites

57. Since cirrhosis of the liver progresses slowly, the most stressful condition in the part of the family is to learn that he has: a. b. c. d. Anemia Decrease prothrombin time Encephalopathy Increase SGPT

58. One your concerns in caring for Mr. Chito is prevention of infection, which could be attained by the following, except a. b. c. d. Adequate exercise Adequate diet Control of the environment Adequate rest

59. Stress response is the opposite of relaxation response. Which of these occurs during relaxation response? a. b. c. d. The heart rate become irregular Breathing is shallow Breathing is deeper The cardiac rate increase

60. One of the queries of the relative and significant others of which of these, triggers to cirrhosis of the liver. Your response is: a. b. c. d. Malnutrition Life style Faulty diet Alcohol

Situation 13: Mila a cafeteria owner, went for check-up due to fatigue, exertional dyspnea and dizziness. 61. Her doctor suspects anemia. The blood examinations that would help diagnosis her condition is: a. b. c. d. Hematocrit count Platelets count White blood cell count Haemoglobin count

62. Blood examination revealed anemia. The drug preparation that would be appropriate is: a. b. c. d. Hematemic ferrous sulphate antihistaminic revicon

63. The intrinsic factor necessary for the manufacture of red blood cells is found in the: a. b. c. d. Intestine Liver Blood Stomach

64. The cause of pernicious anemia is: a. b. c. d. An absence of the intrinsic factor An absence of extrinsic factor Over production of red blood cells Poor diet

65. The following are characteristics of pernicious anemia except: a. b. c. d. Neurologic symptoms A fatal outcome unless lifelong injections of vitamin B is given Abnormally large erythrocytes Hypochlorhydia

Situation 14: Tommy, 39 years old, labourer is often readmitted to the hospital for acute upper respiratory infection.

66. When assessing breath sound, you perform: a. b. c. d. Percussions Auscultation, percussion and inspection Auscultation and percussion Consultation

67. When assessing the quality of respiration you will note the: a. b. c. d. Breath sounds and effort exerted on breathing Effort exerted on breathing Respiratory rate and chest movement Breath sounds and respiratory rate

68. This describes an abnormal breath sounds: a. b. c. d. Hollow Crackling Dull Silent

69. A self care principle to teach him before discharge is: a. b. c. d. Breathing exercise to develop living potential Prevent outcleaning a cold Take antibodies as prophylaxis Intake of protein to increase resistance

70. You know that your teaching is effective if Tommy will: a. b. c. d. Practice diaphragmatic breathing Takes breathing exercises daily Keeps clinic appointment regularly Seeks consultation when symptoms recover

Situation 15: Mang Caloy, a carpenter was rushed to the hospital in semi-conscious condition after a fall from a building under construction. He was place under observation. 71. During the immediate minutes of trauma, your first goal is to: a. b. c. d. Assess extent of injury Call the physician on duty Check for bleeding Establish an open airway

72. He should sign shock. To prevent irreversible shock, your priority goal is to: a. b. c. d. Prevent chilling Restore blood volume Increase oral fluid Allay apprehension

73. For a patient in shock, you would expect: a. b. c. d. Increase capillary permeability Hypoxia A pH less than 7.35 Hypercapnia

74. You monitored his blood pressure. Intracranial pressure is increasing when there is: a. b. c. d. Decrease in respiratory rate Decrease in pulse rate Low level of consciousness A widening pulse pressure

75. The code blue team was called after his B/P became zero. The cardiopulmonary resuscitation is effective when the: a. b. c. d. Pupils are dilated Carotid pulse is palpable The skin is normal in color Easily nailbeds blanched

Situation 16: Bong, a wrestler, 50-year-old was found unconscious in the morning and was rushed to the hospital. 76. Lumbar puncture disclosed that he is suffering from cerebral hemorrhage. The finding would be: a. b. c. d. Spinal fluid is cloudy and under decrease pressure Spinal fluid is clear and under increase pressure Spinal fluid is bloody and under increase pressure Spinal fluid is clear

77. Bongs present symptoms probably occurred from rupture of a branch of the: a. b. c. d. Middle cerebral artery Anterior cerebral artery Posterior cerebral artery Vertebral artery

78. Bong would be most apt to demonstrate which type of paralysis upon awaking from coma: a. b. c. d. Flaccid Bilateral Spastic Periodic

79. In caring for Bong while his aphasis is severe, the nurse should: a. b. c. d. Anticipate his desire to be alone Encourage him to communicate with you by gesture Encourage him to talk at every possible opportunity Communicate by means of gesture

80. In teaching Bong to speak again, you should begin his instruction with: a. b. c. d. Title of his favourite book Numbers and alphabet Names of famous personality Newspaper headline

Situation 17: From Honeymoon, Ms. Enya Romas sought consultations with probable diagnosis of acute cystitis. 81. Your assessment for acute cystitis would be: a. b. c. d. Fever, chills, and lumbar pain Hematuria Nocturia Burning sensation and frequency of urination

82. Instruction from her nurse on how to secure a clean catch urine, specimen is to: a. b. c. d. Save the first urine voided Discard the first urine and then void directly into the specimen bottle. Void directly into the specimen bottle and stop collection of urine when bladder is empty Void directly into the specimen bottle.

83. The common cause of cystitis is: a. b. c. d. Complete emptying of the bladder after each voiding Infection from the ureter and kidney Ascending infection from the urethra Descending infection to the urethra

84. The nurse health teaching to Ms. Cathy for fast recovery should include: a. b. c. d. At least a glass of water after each day Force fluids At least 10 glasses each day A lot of juices and water each day

85. After successful water therapy while preparing for her discharge, which statement would indicate that she is at risk for recurrence of cystitis? a. b. c. I can tolerate 6 to 8 hours, without needing to empty bladder. I drink a lot of juices during the day. After voiding I flushed, washed from back to front.

d.

I take a bath every morning.

Situation 18: Manie, a manager of the CSR for the local hospital has develop anorexia, nausea, epigastric irritation and slight yellowish discoloration of the skin. He was admitted and was diagnosed as infectious hepatitis. 86. The doctors orders for urobilinogen evaluation which has been excreted from Manie. What must be the nurses first action? a. b. c. d. Shake the tube Store the specimen in the refrigerator Take blood sample Protect the specimen

87. Which of these understanding about infectious hepatitis should the nurse know in order to help prepare Manie for discharge? a. b. c. d. Normal liver function tests are prerequisite for going home Liver abscess is a frequent complication of infectious hepatitis Prophylactic antibiotic therapy will be instituted. The convalescent period at home is likely to be relatively long

88. Which of these drugs is used to protect individuals who have been exposed to infectious hepatitis? a. b. c. d. Heap vaccine Eltroxin 100 mg tablet Immune serum globulin (human) Tapazole

89. It is important for the nurse to know the mode of transmission of the organisms responsible for infectious hepatitis because this knowledge provides the basis for: a. b. c. d. Determining the type of isolation precautions Preventing auto infection Planning a rehabilitative program Estimating the length of isolation period

90. The diet most likely to be ordered for Manie during the acute phase of his illness would most probably be: a. b. c. d. High carbohydrate, high protein, fat free High carbohydrate, low protein, high fat High carbohydrate, low protein, low fat Low carbohydrate, low protein, high fat

Situation 19: Mang Beloy, 26 years old labourer, fell from a 4-storey building under construction. He was rushed to the emergency room and admitted. He became unconscious after two hours. 91. The priority nursing goal of patient with sensory alteration is: a. b. c. d. Maintaining adequate communication Ensuring proper nutrition Providing a safe environment Promoting social interaction

92. In the case of Mang Beboy, you will consider the following goals. The one to receive first priority is to: a. b. c. d. Monitor neurological status including vital signs Maintain his fluid-electrolyte balance Maintain an open airway Control his pain and restlessness

93. An unconscious patient is unable to: a. b. c. d. Move spontaneously React to painful stimuli Hear voices Control elimination

94. You should refrain from discussing an unconscious patients condition at his bedside because: a. b. c. d. Critical condition of an unconscious patient is confidential information Level of awareness of patient is high It is unethical to discuss a critical condition of patient The hearing sense is not entirely lost when unconscious

95. The most sensitive indicator of an unconscious patient with head injury is the:

a. b. c. d.

Muscle twisting Papillary changes Blood pressure and pulse Motor functions

Situation 20: You were newly assigned to Mang Macoy, an unconscious patient with right-sided paralysis. You noted reddening of his skin over the coccygeal area. 96. What is the first sign that decubitus ulcer is developing? a. b. c. d. Rash appearance Skin is taut Skin is blanched Papules appear

97. How often should the patient be repositioned? a. b. c. d. As often as necessary Every 2 to 3 hours Every 4 to 6 hours Every shift

98. Which of the following techniques of moving would most likely cause bedsore formation? a. b. c. d. Moving a patient to a chair without support Rolling patient to his side with a draw sheet Lifting patient from bed to stretcher Sliding patient on a sheet to move him up on bed

99. When transferring patient from bed to stretcher, where should the stretcher be placed in relation to the bed? a. b. c. d. At right angle at foot of bed Parallel to the side of the bed At a 45 degree angle near the middle of the bed Diagonally at the foot of the bed

100. What is the diet of the patient with developing decubitus ulcer? a. b. c. d. Low fat diet High calorie diet High protein diet high vitamin diet.