November 2008 NLE Practice IV

- CARE OF THE CLIENT WITH

PHYSIOLOGIC AND
PSYCHOSOCIAL
ALTERATIONS – PART B

NURSING PRACTICE IV – CARE OF THE CLIENT WITH PHYSIOLOGIC AND

PSYCHOSOCIAL ALTERATIONS – PART B

Situation 1: After an abdominal surgery, the circulating and scrub nurses have
critical responsibility about sponges and instrument count.

1. Counting is performed thrice: during the pre-incision phase, the operative

phase and closing phase. Who counts the sponges, needle and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating nurse

2. The layer of the abdomen is divided into 5. Arrange the following from the
first layer going to the deepest layer.
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/fat
5. Skin
a. 5,4,3,2,1
b. 5,4,2,1,3
c. 5,4,1,3,2
d. 5,4,1,2,3

3. When is the first sponge instrument count reported?

a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured

4. Like any nursing interventions, counts should be documented. To whom does

the scrub nurse report any discrepancy of counts so that immediate and
appropriate action is instituted?
a. Anesthesiologist
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse

5. Which of the following are 2 interventions of the surgical team when an

instrument was confirmed missing?
a. MRI and incidence report
b. CT Scan, MRI, Incidence report
c. XRAY and incidence report
d. CT Scan and incidence report

Situation 2: An entry level nurse should be able to apply theoretical knowledge

in the performance of the basic nursing skills.

6. A client has an indwelling urinary catheter and she is suspected of having

urinary infection. How should you collect a urine specimen for culture and
sensitivity?
a. Clamp tubing for 60 minutes and insert a sterile needle into the tubing above
the clamp to aspirate urine
b. Drain urine from the drainage bag into the sterile container
c. Disconnect the tubing from the urinary catheter and let urine flow into a sterile
container
d. Wipe the self sealing aspiration port with antiseptic solution and insert a
sterile needle into the self sealing port

7. To obtain specimen for sputum culture and sensitivity, which of the following
instruction is best?
a. Upon waking up, cough deeply and expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate into a container

8. The best time for collecting the sputum specimen for culture is
a. Before retiring at night
b. Upon waking up in the morning
c. Anytime of the day
d. Before meals

9. When suctioning the endotracheal tube, the nurse should

a. Explain procedure to patient. Insert catheter gently applying suction.
Withdraw using twisting motion
b. Insert catheter until resistance is met then withdraw slightly, applying suction
c. Hyperoxygenate client. Insert catheter using back and forth motion
d. Insert suction catheter four inches into the tube. Suction 30 seconds using
twisting motion as catheter is withdrawn.

10. The purpose of NGT IMMEDIATELY after an operation is:

a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of stomach content
d. For the rapid return of peristalsis

Situation 3: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems

liles scantly urination, hematuria and dysuria.

11. You are the nurse in charge of Mr. Santos. When asked what are the organs
to be examined during cystoscopy, you will enumerate as follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral opening
c. Bladder wall, uterine wall, and urethral opening
d. Urethral opening, ureteral opening bladder

12. In the OR, you will position Mr. Santos who is undergoing cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg

13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of
any kind. What do you tell him?
a. “Cystoscopy is direct visualization and examination by urologist.”
b. “cystoscopy is done by x-ray visualization of the urinary tract.”
c. “Cystoscopy is done by using lasers on the urinary tract.”
d. “Cystoscopy is an endoscopic procedure of the urinary tract.”

14. Withing 24-48 hours post cystoscopy, it is normal to observe one of the
following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria

15. Leg cramps are NOT uncommon post-cystoscopy. Nursing intervention

includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath

Situation 4: Mang Felix, a 79 year old man who is brought to the surgical unit
form PACU after a transurethral resection. You are assigned to receive him. You
noted that he has a 3 way indwelling urinary catheter for continuous fast drip
bladder irritation which is connected to a straight drainage.

16. Immediately after surgery, what would you expect his urine to be?
a. Light yellow
b. Amber
c. Bright red
d. Pinkish to red
17. The purpose of the continuous bladder irrigation is to:
a. Allow continuous monitoring of the fluid output status
b. Provide continuous flushing of clots and debris from the bladder
c. Allow for proper exchange of electrolytes and fluid
d. Ensure accurate monitoring of intake and output

18. Mang Felix informs you that he feels some discomfort on the hypogastric
area and he has to void. What will be your most appropriate action?
a. Remove his catheter then allow him to void on his own
b. Irrigate his catheter
c. Tell him to “go ahead and void. You have an indwelling catheter.”
d. Assess color and rate of outflow if there is a change, refer to urologist for
possible irrigation

19. You decided to check on Mang Felix’s IV fluid infusion. You noticed a change
in flow rae, pallor and coldness around the insertion site. What is your
assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic rection
d. Air embolism

20. Knowing that proper documentation of assessment findings and interventions

are important responsibilities of the nurse during first post operative day, which
of the following is the LEAST relevant to document in the case of Mang Felix?
a. Chest pain and vital signs
b. Intravenous infusion rate
c. Amount, color, and consistency of bladder irrigation drainage
d. Activities of daily living started

Situation 5: Melamine contamination in milk has brought worldwide crisis both in

the milk production sector as well as the health and economy. Being aware of
the current events is one quality that a nurse should possess to prove that
nursing is a dynamic profession that will adapt depending on the patient’s needs.

21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewelry
box covers due to its fire retardant properties. Milk and food manufacturers add
melamine in order to:
a. It has a bacteriostatic property leading to increase food and milk life as a way
of preserving the foods
b. Gives a glazy and more edible look on foods
c. Make milks tasty and creamy
d. Create an illusion of a high protein content on their product

22. Most of the milks contaminated by Melamine came from which country?
a. India
b. China
c. Philippines
d. Korea
23. Which government agency is responsible for testing the melamine content of
foods and food products?
a. DOH
b. MMDA
c. NBI
d. BFAD

24. Infants are the most vulnerable to melamine poisoning. Which of the
following is NOT a sign of melamine poisoning?
a. Irritability, back ache, urolithiasis
b. High blood pressure, fever
c. Anuria, oliguria or hematuria
d. Fever, irritability and large output of diluted urine

25. What kind of renal failure does melanin poising cause?

a. Chronic, pre-renal
b. Acute, post-renal
c. Chronic, intrarenal
d. Actue, pre-renal

Situation 6: Leukemia is the most common type of childhood cancer. Acute

Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in
children under age 15.

26. The survival rate for Acute Lymphoid Leukemia is approximately

a. 25%
b. 40%
c. 75%
d. 95%

27. Whereas acute non-lymphoid leukemia has a survival rate of

a. 25%
b. 40%
c. 75%
d. 95%

28. The three main consequence of leukemia that causes the most danger is:
a. Neutropenia causing infection, anemia causing impaired oxygenation, and
thrombocytopenia leading to bleeding tendencies
b. Central nervous system infiltration, anemia causing impaired oxygenation and
thrombocytopenia leading to bleeding tendencies
c. Splenomegaly, hepatomegaly, fractures
d. Invasion by the leukemia cells to the bone causing severe bone pain

29. Gold standard in the diagnosis of leukemia is by which of the following?

a. Blood culture and sensitivity
b. Bone marrow biopsy
c. Blood biopsy

30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the

client for long term therapy. One common side effect, especially of adriamycin is
alopecia. The child asks: “Will I get my hair back once again?” The nurse best
response is by saying:
a. “Don’t be silly, of course you will get your hair back.”
b. “We are not sure, let’s hope it’ll grow.”
c. “This side effect is usually permanent, but I will get the doctor to discuss it for
you.”
d. “Your hair will regrow in 3 to 6 months but of different color, usually darker
and of different texture.”

Situation 7: Breast cancer is the 2nd most common type of cancer after lung
cancer and 99% of which, occurs in woman. Survival rate is 98% if this is
detected early and treated promptly. Carmen is a 53 year old patient in the high
risk group for breast cancer was recently diagnosed with Breast Cancer.

31. All of the following are factors that said to contribute to the development of
breast cancer except:
a. Prolonged exposure to estrogen such as an early menarche or late
menopause, nulliparity, and childbirth after age 30.
b. Genetics
c. Increasing age
d. Prolonged intake of tamoxifen (Nolvadex)

32. Protective factors for the development of breast cancer includes which of the
following except:
a. Exercise
b. Prophylactic tamoxifen
c. Breast feeding
d. Alcohol intake

33. A patient diagnosed with breast cancer has been offered the treatment
choices of breast conservation surgery with radiation or a modified radical
mastectomy. When questioned by the patient about these options, the nurse
informs the patient that the lumpectomy with radiation
a. Reduces the fear and anxiety that accompanies the diagnosis and treatment of
cancer
b. Has about the same 10-year survival rate as the modified radical mastectomy
c. Provides a shorter treatment period with a fewer long term complications
d. Preserves the normal appearance and sensitivity of the breast

34. Carmen, who is asking the nurse the most appropriate time of the month to
do her self-examination of the breast. The MOST appropriate reply by the nurse
would be:
a. The 26th days of the menstrual cycle
b. 7 to 8 days after conclusion of the menstrual period
c. During her menstruation
d. The same day each month

35. Carmen being treated with radiation therapy. What should be included in the
plan of care to minimize skin damage from the radiation therapy?
a. Cover the areas with thick clothing materials
b. Apply a heating pad to the site
c. Wash skin with water after the therapy
d. Avoid applying creams and powders to the area

36. Based on DOH and World Health Organization (WHO) guidelines, the
mainstay for early protection method for breast cancer that is recommended for
developing countries is
a. a monthly breast self examination (BSE) and an annual health worker breast
examination (HWBE)
b. an annual hormone receptor assay
c. an annual mammogram
d. a physician conduct a breast clinical examination every 2 years

37. the purpose of performing the breast self examination (BSE) regularly is to
discover
a. fibrocystic masses
b. cancerous lungs
c. areas of thickness or fullness
d. changes from previous BSE

38. If you are to instruct a post-menopausal woman about BSE, when would you
tell her to do BSE?
a. On the same day of each month
b. Right after the menstrual period
c. On the first day of her menstruation
d. On the last day of her menstruation

39. During breast self-examination, the purpose of standing in front of the mirror
is to observe the breast for
a. Thickening of the tissue
b. Axillary lymphnodes
c. Lumps in the breast tissue
d. Change in size and contour

40. When preparing to examine the left breast in a reclining position, the
purpose of placing a small folded towel under the client’s left shoulder is to
a. Bring the breast closer to the examiner’s right hand
b. Tense the pectoral muscle
c. Balance the breast tissue more evenly on the chest wall
d. Facilitate lateral positioning of the breast

Situation 8: Radiation therapy is another modality of cancer management. With

emphasis on multidisciplinary management, you have important responsibilities
as nurse.

41. Albert is receiving external radiation therapy and he complains of fatigue and
malaise. Which of the following nursing interventions would be most helpful for
Albert?
a. Tell him that sometimes these feelings can be psychogenic
b. Refer him to the physician
c. Reassure him that these feelings are normal
d. Help him plan his activities

42. Immediately following the radiation teletherapy, Albert is

a. Considered radioactive for 24 hours
b. Given an complete bath
c. Placed on isolation for 6 hours
d. Free from radiation

43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse,

you should observe the following symptoms:
a. Petechiae, ecchymosis, epistaxis
b. Weakness, easy fatigability, pallor
c. Headache, dizziness, blurred vision
d. Severe sore throat, bacteremia, hepatomegaly

44. What nursing diagnosis should be of highest priority?

a. Knowledge deficit regarding thrombocytopenia precautions
b. Activity intolerance
c. Impaired tissue integrity
d. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular,
gastrointestinal, renal

45. What intervention should you include in your care plan?

a. Inspect his skin for petechiae, bruising, GI bleeding regularly
b. Place Albert on strict isolation precautions
c. Provide rest in between activities
d. Administer antipyretics if his temperature exceeds 38C

Situation 9: Burns are caused by transfer of heat source to the body. It can be
thermal, electrical, radiation or chemical.

46. A burn characterized by pale white appearance, charred or with fat exposed
and painlessness is
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn

47. Which of the following BEST describes superficial partial thickness burn or
first degree burn?
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

48. A burn that is said to be “WEEPING” is classified as

a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn

49. During the acute phase of the burn injury, which of the following is a
priority?
a. Wound healing
b. Reconstructive surgery
c. Emotional support
d. Fluid resuscitation

50. While in the emergent phase, the nurse knows that the priority is to:
a. prevent infection
b. control pain
c. prevent deformities and contractures
d. return the hemodynamic stability via fluid resuscitation

51. The MOST effective method of delivering pain medication during the
emergent phase is
a. Intramuscularly
b. Subcutaneously
c. Orally
d. Intravenously

52. When a client accidentally splashes chemicals to his eyes, the initial priority
care following the chemical burn is to
a. Irrigate with normal saline for 1 to 15 minutes
b. Transport a physician immediately
c. Irrigate with water for 15 minutes or longer
d. Cover the eyes with a sterile gauze

53. Which of the following can be a fatal complication of upper airway burns?
a. Stress ulcers
b. Hemorrhage
c. Shock
d. Laryngeal spasms and swelling

54. When a client will rush towards you and he has burning clothes on, it is your
priority to do which of the following first?
a. Log roll on the grass/ground
b. Slap the flames with his hands
c. Try to remove the burning clothes
d. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most important to

a. Cover client with a warm blanket
b. Give him sips of water
c. Calculate the extent of his burns
d. Assess Sergio’s breathing

56. During the first 24 hours after the thermal injury, you should assess Sergio
for
a. Hypokalemia and hypernatremia
b. Hypokalemia and hyponatremia
c. Hyperkalemia and hyponatremia
d. Hyperkalemia and hypernatremia

57. A client who sustained deep partial thickness and full thickness burns of the
face, whole anterior chest and both upper extremities two days ago begins to
exhibit extreme restlessness. You recognize that this most likely indicates that
the client is developing
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure

58. A 165 lbs trauma client was rushed to the emergency room with full
thickness burns on the whole face, right and left arm, and at the anterior part of
chest sparing the abdominal area. He also has superficial partial thickness burn
at the posterior trunk and at the half upper portion of the left leg. He is in the
emergent phase of burn. Using the parkland’s formula, you know that during the
first 8 hours of burn, the amount of fluid will be given is:
a. 5,400 ml
b. 10,600 ml
c. 9,450 ml
d. 6,750 ml

59. The doctor incorporated insulin on the client’s fluid during the emergent
phase. The nurse knows that insulin is given because
a. Clients with burn also develops metabolic acidosis
b. Clients with burn also develops hyperglycemia
c. Insulin is needed for additional energy and glucose burning after the stressful
incident to hasten wound healing, regain of consciousness and rapid return of
hemodynamic stability
d. For hyperkalemia

60. The IV fluid of choice for burn as well as dehydration is:

a. 0.45% Na CL
b. NSS
c. Sterile water
d. D5LR

SITUATION 10: Enterostomal Therapy is now considered a specialty in nursing.

You are participating in the OSTOMY CARE CLASS.

61. You plan to teach Fermin how to irrigate the colostomy when
a. The perineal wound heals and Fermin can sit comfortable on the commode
b. Fermin can lie on the side comfortable, about the 3rd post-operative day
c. The abdominal incision is closed and contamination is no longer a danger
d. The stools starts to become formed around the 7th post-operative day
62. When preparing to teach Fermin how to irrigate colostomy, you should plan
to do the procedure:
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. Prior to breakfast and morning care
d. After Fermin accepts alteration in body image

63. When observing a return demonstration of a colostomy irrigation, you know

that more teaching is required if Fermin
a. Lubricates the tip of the catheter prior to inserting into the stoma
b. Hangs the irrigating bag on the bathroom door cloth hook during fluid
insertion
c. Discontinues the insertion of fluid after 500 ml of fluid has been instilled
d. Clamps off the flow of fluid when feeling uncomfortable

64. You are aware that teaching about colostomy care is understood when
Fermin states, “I will contact my physician and report:
a. If I have any difficulty inserting the irrigating tube into the stoma.”
b. If I noticed a loss of sensation to touch in the stoma tissue.”
c. The expulsion of flatus while the irrigating fluid is running out.”
d. When mucus is passed from the stoma between the irrigation.”

65. You would know after teaching Fermin that dietary instruction for him is
effective when he states, “it is important that I eat:
a. Soft food that is easily digested and absorbed by the large intestines.”
b. Bland food so that my intestines do not become irritated.”
c. Food low in fiber so that there are fewer stools.”
d. Everything that I ate before the operation, while avoiding foods that cause
gas.”

Situation 11: Based on studies of nurses working in special units like the
intensive care unit and coronary care unit, it is important for nurses to gather as
much information to be able to address their needs for nursing care.

66. Critically ill patients frequently complain about which of the following when
hospitalized?
a. Hospital food
b. Lack of blankets
c. Lack of privacy
d. Inadequate nursing staff

67. Who of the following is at greatest risk of developing sensory problem?

a. Female patient
b. Adolescent
c. Transplant patient
d. Unresponsive patient

68. Which of the following factors may inhibit learning in critically ill patients?
a. Gender
b. Medication
c. Educational level
d. Previous knowledge of illness

69. Which of the following statements does not apply to critically ill patients?
a. Majority need extensive rehabilitation
b. All have been hospitalized previously
c. Are physically unstable
d. Most have chronic illness

70. Families of critically ill patients desire which of the following needs to be met
first by the nurse?
a. Provision of comfortable space
b. Emotional support
c. Updated information on client’s status
d. Spiritual counseling

Situation 12: Johnny sough consultation to the hospital because of irritability,

jittery and he has been experiencing these signs and symptoms for several
months.

71. His diagnosis was hyperthyroidism. The following are expected symptoms
except
a. Anorexia
b. Palpitation
c. Fine tremors of the hands
d. Hyperalertness

72. She has to take drugs to treat her hyperthyroidism. Which of the following
will you NOT expect that the doctor will prescribe?
a. Colace (Docusate)
b. Cytomel (llothyronine)
c. Tapazole

73. The nurse knows that Tapazole has which of the following side effects that
will warrant immediate withholding of the medication?
a. Death
b. Sore throat
c. Hyperthermia
d. Thrombocytosis

74. You asked questions as soon as she regained consciousness from

thyroidectomy primarily to assess the evidence of
a. Thyroid storm
b. Mediastinal shift
c. Damage to the laryngeal nerve
d. Hypocalcemia tetany

75. Should you check for hemorrhage, you will

a. Slip you hand under the nape of the neck
b. Check for hypotension
c. Apply neck collar to prevent hemorrhage
d. Observe the dressing if it is soaked with blood

76. Basal metabolic rate is assessed on Johnny to determine his metabolic rate.
In assessing the BMR using the standard procedure, you need to tell Johnny
that:
a. Obstructing his vision
b. Restraining his upper and lower extremities
c. Obstructing his hearing
d. Obstructing his nostrils with a clamp

77. The BMR is based on the measurement that:

a. Rate of respiration under different condition of activities and rest
b. Amount of oxygen consumption under resting condition over a measured
period of time
c. Amount of oxygen consumption under stressed condition over a measured
period of time
d. Ration of respiration to pulse rate over a measured period of time

78. Her physician ordered lugol’s solution in order to

a. decrease the vascularity and size of the thyroid gland
b. decrease the size of the thyroid gland only
c. increase the vascularity and size of the thyroid gland
d. increase the size of the thyroid gland only

79. Which of the following is a side effect of Lugol’s solution?

a. Hypokalemia
b. Nystagmus
c. Enlargement of the thyroid gland
d. Excessive salivation

80. In administering Lugol’s solution, the precautionary measure should include:

a. Administer with glass only
b. Dilute with juice and administer with a straw
c. Administer it with milk and drink it
d. Follow it with milk of magnesia

Situation 13: Pharmacological treatment was not effective for Johnny’s

hyperthyroidism and now, he is scheduled for thyroidectomy.

81. Instruments in the surgical suite for surgery are classified as either
CRITICAL, SEMI-CRITICAL and NON-CRITICAL. If the instrument is introduced
directly into the blood stream or into any normally sterile cavity or area of the
body, it is classified as:
a. Critical
b. Semi critical
c. Non-critical
d. Ultra critical

82. Instruments that do not touch the paitnet or have contact only to intact skin
is classified as:
a. Critical
b. Semi critical
c. Non critical
d. Ultra critical

83. If an instrument is classified as semi critical, an acceptable method of

making the instrument ready for surgery is through
a. Sterilization
b. Decontamination
c. Disinfection
d. Cleaning

84. While critical items should be

a. Clean
b. Decontaminated
c. Sterilized
d. Disinfected

85. As a nurse, you know that intact skin acts as an effective barrier to most
microorganisms. Therefore, items that come in contact with the intact skin or
mucus membranes should be
a. Disinfected
b. Sterile
c. Clean
d. Alcoholized

86. You are caring for Johnny who is scheduled to undergo total thyroidectomy
because of diagnosis of thyroid cancer. Prior to total thyroidectomy, you should
instruct Johnny to
a. Perform range and motion exercise on the head and neck
b. Apply gentle pressure against the incision when swallowing
c. Cough and deep breath every 2 hours
d. Support head with the hands when changing position

87. As Johnny’s nurse, you plan to set up an emergency equipment at the

bedside following thyroidectiomy. You should include
a. An airway and rebreathing tube
b. A tracheostomy set and oxygen
c. A crush chart with bed board
d. Two ampoules of sodium bicarbonate

88. Which of the following nursing interventions is appropriate after a total

thyroidectomy?
a. Place pillows under your patient’s shoulders
b. Raise the knee gatch to 30 degrees
c. Keep your patient in a high-fowler’s position
d. Support the patient’s head and neck with pillows and sandbags

89. If there is an accidental injury to the parathyroid gland during a

thyroidectomy, which of the following might Leda develop post-operatively?
a. Cardiac arrest
b. Dyspnea
c. Respiratory failure
d. Tetany

90. After surgery, Johnny develops peripheral numbness, tingling and muscle
twitching, and spasm. What would you anticipate to administer?
a. Magnesium sulfate
b. Calcium gluconate
c. Potassium iodides
d. Potassium chloride

Situation 14: Budgeting is an important part of a nurse managerial activity. The

correct allocation and distribution of resources is vital in the harmonious
operation of the financial balance of the agency.

91. Which of the following best defines budget?

a. Plan for the allocation of resources for future use
b. The process of allocating resources for future use
c. Estimate cost and expense
d. Continuous process in seeing that the goals and objectives of the agency is
met

92. Which of the following best defines Capital Budget?

a. Budgeting estimates the cost of direct labor, number of staff to be hired, and
necessary number of workers to meet the general patient’s needs
b. Includes the monthly and daily expenses and expected revenue and expenses
c. These are related to long term planning and includes major replacement of
expenses of the plant, major equipments and inventories
d. These are expenses that are not dependent of the level of production or sales.
These tend to be time-related, such as salaries or rents being paid per month

93. Which of the following best describes Operational Budget?

a. Budget to estimate the cost of direct labor, number of staff to be hired and
necessary number of workers to meet the general patient needs
b. Includes the monthly and daily expenses and expected revenue and expenses
c. These are related long term planning and includes major replacement or
expenses of the plant, major equipments and inventories
d. These are expenses that are not dependent on the level of production or
sales. These tend to be time related, such as salaries or rents being paid per
month

94. Which of the following accurately describes Fixed Cost in budgeting?

a. These are usually the raw materials and labor salaries that depend on the
production or sales
b. These are expenses that change in proportion to the activity of a business
c. These are expenses that are not dependent on the level of production or sales.
They tend to be time-related, such as rent
d. This is the summation of the Variable Cost and the fixed cost
95. Which of the following accurately describes Variable cost in budgeting?
a. These are related to long term planning and include major replacement or
expansion of the plant, major equipment and inventories
b. These are expenses that change in proportion to the activity of a business
c. These are expenses that are not dependent on the level of production or sales.
They tend to be time related such as rent
d. This is the summation of variable cost and the fixed cost.

Situation 15: Andrea is admitted to the ER following an assault where she was
hit in the face and head. She was brought to the ER by a policewoman.
Emergency measures were started.

96. Andrea’s respiration is described as waxing and waning. You know that this
rhythm of respiration is defined as
a. Biot’s
b. Kussmaul’s
c. Cheyne stokes
d. Eupnea

97. What do you call the triad of sign and symptoms seen in a client with
increasing ICP?
a. Virchow’s triad
b. The Chinese triad
c. Cushing’s triad
d. Charcot’s triad

98. Which of the following is true with the Triad seed in the head injuries?
a. Narrowing of pulse pressure, cheyne stokes respiration, tachycardia
b. Widening pulse pressure, irregular respiration, bradycardia
c. Hypertension, kussmaul’s respiration, tachycardia
d. Hypotension, irregular respiration, bradycardia

99. In a client with a Cheyne stokes respiration, which of the following is the
most appropriate nursing diagnosis?
a. Ineffective airway clearance
b. Ineffective breathing pattern
c. Impaired gas exchange
d. Activity intolerance

100. You know that apnea is seen in client with Cheyne Stokes respiration,
APNEA is defined as:
a. Inability to breath in a supine position so the patient sits up in bed to breathe
b. The patient is dead, the breathing stops
c. There is an absence of breathing for a period of time, usually 15 seconds or
more
d. A period of hypercapnea and hypoxia due to the cessation of respiratory effort
in spite of normal respiratory functioning
ANSWER KEY:

1. D
2. D
3. B
4. B
5. C
6. D
7. A
8. B
9. B
10. B
11. B
12. B
13. D
14. A
15. B
16. D
17. B
18. D
19. B
20. D
21. D
22. B
23. D
24. D
25. B
26. C
27. B
28. A
29. B
30. D
31. D
32. D
33. D
34. B
35. D
36. A
37.B
38. A
39. A
40. C
41. D
42. D
43. A
44. C
45. A
46. C
47. B
48. B
49. A
50. D
51. D
52. C
53. D
54. A
55. D
56. C
57. A
58. A
59. D
60. D
61. D
62. A
63. B
64. A
65. D
66. C
67. D
68. B
69. B
70. B
71. A
72. A
73. B
74. C
75. A
76. D
77. B
78. A
79. D
80. B
81. A
82. C
83. C
84. C
85. A
86. D
87. B
88. D
89. D
90. B
91. A
92. C
93. B
94. C
95. B
96. C
97. C
98. B
99. B
100. C