NLE Pre-board December
2007 Practice 3
Situation 1 - Concerted work efforts among
members of the surgical team is essential to
the success of the surgical procedure.
1. 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?
a. Circulating nurse
b. Anesthesiologist
c. Surgeon
d. Nursing aide
2. The OR team performs distinct roles
for one surgical procedure to be
accomplished within a prescribed time
frame and deliver a standard patient
outcome. White the surgeon performs
the surgical procedure, who monitors the
status of the client like urine output,
blood loss?
a. Scrub nurse
b. Surgeon
c. Anesthesiologist
d. Circulating nurse
3. Surgery schedules are communicated
to the OR usually a day prior to the
procedure by the nurse of the floor or
ward where the patient is confined. For
orthopedic cases, what department is
usually informed to be present in the
OR?
a. Rehabilitation department
b. Laboratory department
c. Maintenance department
d. Radiology department
4. Minimally invasive surgery is very
much into technology. Aside from the
usual surgical team who else to be
present when a client undergoes
laparoscopic surgery?
a. Information technician
b. Biomedical technician
c. Electrician
d. Laboratory technicial
5. In massive blood loss, prompt
replacement of compatible blood is
crucial. What department needs to be
alerted to coordinate closely with the
patient's family for immediate blood
component therapy?
a. Security Division
b. Chaplaincy
c. Social Service Section
d. Pathology department
Situation 2 - You are assigned in the
Orthopedic Ward where clients are
complaining of pain in varying degrees upon
movement of body parts.
6. 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?
a. Dressing is intact but partially soiled
b. Left foot is cold to touch and pedal pulse
is absent
c. Left leg in limited functional anatomic
position
d. BP 114/78, pulse of 82 beats/minute
7. There is an order of Demerol 50 mg
I.M. now and every 6 hours p r n. You
injected Demerol at 5 pm. The next dose
of Demerol 50 mg I.M. is given:
a. When the client asks for the next dose
b. When the patient is in severe pain
c. At 11pm
d. At 12pm
8. You continuously evaluate the client's
adaptation to pain. Which of the
following behaviors-indicate appropriate
adaptation?
a. The client reports pain reduction and
decreased activity
b. The client denies existence of pain
c. The client can distract himself during pain
episodes
d. The client reports independence from
watchers
9. Pain in Ortho cases may not be mainly
due to the surgery. There might be other
factors such as cultural or psychological
that influence pain. How can you alter
these factors as the nurse?
a. Explain all the possible interventions that
may cause the client to worry.
b. Establish trusting relationship by giving
his medication on time
c. Stay with the client during pain episodes
d. Promote client's sense of control and
participation in pain control by listening to
his concerns
10. In some hip surgeries, an epidural
catheter for Fentanyl epidural analgesia
is given. What is your nursing priority
care in such a case?
a. Instruct client to observe strict bed rest
b. Check for epidural catheter drainage
c. Administer analgesia through epidural
catheter as prescribed
d. Assess respiratory rate carefully
Situation 3 - Records are vital tools in any
institution and should be properly
maintained for specific use and time.
11. The patient's medical record can work
as a double-edged swords. When can the
medical record become the
doctor's/nurse worst enemy?
a. When the record is voluminous
b. When a medical record is subpoenaed in
court
c. When it is missing
d. When the medical record is inaccurate,
incomplete, and inadequate
12. Disposal of medical records in
government hospitals/institutions must
be done in close coordination with what
agency?
a. Department of Interior and Local
Government (DILG)
b. Metro Manila Development Authority
(MMDA)
c. Records Management Archives Office
(RMAO)
d. Depart of Health (DOH)
13. In the hospital, when you need-the
medical record of a discharged patient
for research, you will request permission
through:
a. Doctor in charge
b. The hospital director
c. The nursing Service
d. Medical records section
14. You readmitted a client who was in
another department a month ago. Since
you will need the previous chart, from
whom do you request the old chart?
a. Central supply section
b. Previous doctor's clinic
c. Department where the patient was
previously admitted
d. Medical records section
15. Records Management and Archives
Offices of the DOH is responsible for
implementing its policies on record,
disposal. You know that your institution
is covered by this policy it;
a. Your hospital is considered tertiary
b. Your hospital is in Metro Manila
c. It obtained permit to operate from DOH
d. Your hospital is Philhealth accredited
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.
16. 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
17. Surgeries like I and D (incision and
drainage) and debribement are relatively
short procedures but considered ‘dirty
cases’. When are these; procedures best
scheduled?
a. Last case
b. In between cases
c. According to availability of
anesthesiologist
d. According to the surgeon's preference
18. 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 anestheriologist 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
19. Another nursing check that should
not be missed before the induction of
general anesthesia is:
a. check for presence underwear
b. check for presence dentures
c. check patient's
d. check baseline vital signs
20. 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
Situation 5 - Nurses hold a variety of roles
when providing care to a perioperative
patient.
21. 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
22. 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 ask client not to get
out of bed
b. Send the client to ORD with the family
c. Allow client to get up to go to the comfort
room
d. Obtain consent form
23. 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 make suturing easy and
lessen chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed
24. It is also the nurse's function to
determine when infection is developing
in the surgical incision. The perioperative
nurse should observe for what signs of
impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin
blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible
25. Which of the following nursing
intervention is done when examining the
incision wound and changing the
dressing?
a. Observe the dressing and type and odor
of drainage if any
b. Get patient's consent
c. Wash hands
d. Request the client to expose the incision
wound
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.
26. Which of She 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
27. Aminophylline was ordered for acute
asthmatic attack. The mother asked the
nurse, what its indication the nurse will
say is:
a. Relax smooth muscles of the bronchial
airway
b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough
28. 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
29. 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
30. 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
Situation 7 - Joint Commission on
Accreditation of Hospital Organization
(JCAHP) patient safety goals and
requirements include the care and efficient
use of technology in the OR arid elsewhere
in the healthcare facility.
31. As the head nurse in the OR, how can
you improve the effectiveness of clinical
alarm systems?
a. limit suppliers to a few so that quality is
maintained
b. implement a regular inventory of supplies
and equipment
c. Adherence to manufacturer's
recommendation
d. Implement a regular maintenance and
testing of alarm systems
32. Over dosage of medication or
anesthetic can happen even with the aid
of technology like infusion pump,
sphymomanometer, and similar
devices/machines. As a staff, how can
you improve the safety of using infusion
pumps?
a. Check the functionality of the pump
before use
b. Select your brand of infusion pump like
you do with your cellphone
C. Allow the technician to set the; infusion
pump before use
d. Verify the flow rate against your
computation
33. JCAHOs universal protocol for
surgical and invasive procedures to
prevent wrong site, wrong person, and
wrong procedures/surgery includes the
following EXCEPT:
a. Mark the operative site if possible
b. Conduct pre-procedure verification
process
c. Take a video of the entire intra-operative
procedure
d. Conduct time out immediately before
starting the procedure
34. You identified a potential risk of pre
and post operative clients. To reduce the
risk of patient harm resulting from fall,
you can implement the following
EXCEPT:
a. Assess potential risk of fail associated
with the patient's the following EXCEPT:
medication regimen
b. Take action to address any identified risks
through Incident Report (IR)
c. Allow client to walk with relative to the
OF?
d. Assess and periodically reassess
individual client's risk for falling
35. As a nurse you know you can
improve on accuracy of patient's
identification by 2 patient identifiers,
EXCEPT:
a. identify the client by his/her wrist tag and
verify with family members
b. identify client by his/her wrist tag and call
his/her by name
c. call the client by his/her case and bed
number
d. call the patient by his/her name and bed
number
Situation 8 - Team efforts is best
demonstrated in the OR
36. If you are the nurse in charge for
scheduling surgical cases, what
important information do you need to ask
the surgeon?
a. Who is your internist
b. Who is your assistant and
anesthesiologist, and what is your preferred
time and type of surgery?
c. Who are your anesthesiologist, internist,
and assistant
d. Who is your anesthesiologist.
37. In the OR, the nursing tandem for
every surgery is:
a. Instrument technician and circulating
nurse
b. Nurse anesthetist, nurse assistant, and
instrument technician
c. Scrub nurse and nurse anesthetist
d. Scrub and circulating nurses
38. While team effort is needed in the OR
for efficient and quality patient care
delivery, we should limit the number of
people in the room for infection control.
Who comprise this team?
a. Surgeon, anesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse,
circulating nurse, anesthesiologist
c. Surgeon, assistant surgeon,
anesthesiologist, scrub nurse, pathologist
d. Surgeon, assistant surgeon,
anesthesiologist, intern, scrub nurse
39. When surgery is on-going, who
coordinates the activities outside,
including the family?
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anaesthesiologist
40. The breakdown in teamwork is often
times a failure in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
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 paste and rings around the
stoma
c. Clean the area daily with soap and water
before applying bag
d. Apply talcum powder twice a day
42. What health instruction will enhance
regulation of a colostomy (defecation) of
clients?
a. Irrigate after lunch everyday
b. Eat fruits and vegetables in all three
meals
c. Eat balanced meals at regular intervals
d. Restrict exercise to walking only
43. After ileostomy, which of the
following condition is NOT expected?
a. increased weight
b. Irritation of skin around the stoma
c. Liquid stool
d. Establishment of regular bowel movement
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
45. What sensation is used as a gauge so
that patients with ileostomy can
determine how often their pouch should
be drained?
a. Sensation of taste
b. Sensation of pressure
c. Sensation of smell
d. Urge to defecate
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 subjects
c. General population
d. Universe
47. What is the most important
characteristics of a sample?
a. Randomization
b. Appropriate location
c. Appropriate number
d. Representativeness
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
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
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. Stratifies sampling
d. Systematic sampling
Situation 11 -After an abdominal surgery, the
circulating and scrub nurses have critical
responsibility about sponge and Instrument
count.
51. When is the first sponge/instrument
count reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before dosing the skin
d. Before the fascia is sutured
52. What major supportive layer of the
abdominal wall must be sutured with
long tensile strength such as cotton or
nylon or silk suture?
a. Fascia
b. Muscle
c. Peritoneum
d. Skin
53. Like sutures, needles also vary in
shape and uses. If you are the scrub
nurse for a patient who is prone to keloid
formation and has a low threshold of
pain, what needle would you prepare?
a. Round needle
b. A traumatic needle
c. Reverse cutting needle
d. Tapered needle
54. Another alternative "suture" for skin
closure is the use of _______________:
a. Staple
b. Therapeutic glue
c. Absorbent dressing
d. invisible suture
55. Like any nursing interventions,
counts should be documented. To whom
does the scrub nurse report any
discrepancy of country so that immediate
'and appropriate action in instituted?
a. Anesthesiologist
b. Surgeon
c. Or nurse supervisor
d. Circulating nurse

Situation 12 - As a nurse, you should be
aware and prepared of the different roles
you play.
56. What role do you play, when you hold
all clients’ information entrusted to you
in the strictest confidence?
a. Patient's advocate
b. Educator
c. Patient's Liaison
d. Patient's arbiter
57. As a nurse, you can help improve the
effectiveness of communication among
healthcare givers
a. Use of reminders of what to do
b. Using standardized list of abbreviations,
acronyms, and symbols
c. One-on-one oral endorsement
d. Text messaging and e-mail
58. As a nurse, your primary focus in the
workplace is the client's safety. However,
personal safety is also a concern. You
can communicate hazards to your co-
workers through the use of the following
EXCEPT:
a. Formal training
b. Posters
c. Posting IR in the bulletin board
d. Use of labels and signs
59. As a nurse, what is one of the best
way to reconcile medications across the
continuum of care?
a. Endorse on a case-to-case basis
b. Communication a complete list of the
patient's medication to the next provider of
service
c. Endorse in writing
d. Endorse the routine and 'stat' medications
every shift
60. As a nurse, you protect yourself and
co-workers from misinformation and
misrepresentations through the following
EXCEPT:
a. Provide information to clients about a
variety of services that can help alleviate the
client's pain and other conditions
b. Advising the client, by virtue of your
expertise, that which can contribute to the
client's well-being
c. Health education among clients and
significant others regarding the use of
chemical disinfectant
d. Endorsement thru trimedia to advertise
your favorite disinfectant solution
61. A one-day postoperative abdominal
surgery client has been complaining of
severe throbbing abdominal pain
described as 9 in a 1-10 pain rating. Your
assessment reveals bowel sounds on all
quadrants and the dressing is dry and
intact. What nursing intervention would
you take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
62. Pentoxicodone 5 mg IV every 8 hours
was prescribed for post abdominal pain.
Which will be your priority nursing
action?
a. Check abdominal dressing for possible
swelling
b. Explain the proper use of PCA to alleviate
anxiety
c. Avoid overdosing to prevent
dependence/tolerance
d. Monitor VS, more importantly RR .
63. The client complained of abdominal
and pain. Your nursing intervention that
can alleviate pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and
avoid deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too
much talking
64. Surgical pain might be minimized by
which nursing action in the OR:
a. Skill of surgical team and lesser
manipulation
b. Appropriate preparation For the
scheduled procedure
c. Use of modem technology in closing the
wound
d. Proper positioning and draping of clients
65. One very common cause of
postoperative pain is:
a. Forceful traction during surgery
b. Prolonged surgery
c. Break in aseptic technique
d. Inadequate anesthetic
Situation 14 - You were on duty at the
medical ward when Zeny came in for
admission for tiredness, cold intolerance,
constipation, and weight gain. Upon
examination, the doctor's diagnosis was
hypothyroidism.
66. Your independent nursing care for
hypothyroidism includes:
a. administer sedative round the clock
b. administer thyroid hormone replacement
c. providing a cool, quiet, and comfortable
environment
d. encourage to drink 6-8 glasses of water
67. As the nurse, you should anticipate to
administer which of the following
medications to Zeny who is diagnosed to
be suffering from hypothyroidism?
a. Levothyroxine
b. Lidocaine
c. Lipitor
d. Levophed
68. Your appropriate nursing diagnosis
for Zeny who is suffering from
hypothyroidism would probably include
which of the following?
a. Activity intolerance related to tiredness
associated with disorder
b. Risk to injury related to incomplete eyelid
closure
c. Imbalance nutrition related to
hypermetabolism
d. Deficient fluid volume related to diarrhea
69. Myxedema coma is a life threatening
complication of long standing and
untreated hypothyroidism with one of the
following characteristics.
a. Hyperglycemia
b. hypothermia
c. hyperthermia
d. hypoglycemia
70. As a nurse, you know that the most
common type of goiter is related to a
deficiency
a. thyroxine
b. thyrotropin
c. iron
d. iodine
Situation 15 - Mrs. Pichay is admitted to
your ward. The MD ordered "Prepared for
thoracentesis this pm to remove excess air
from the pleural cavity."
71. Which of the following nursing
responsibility is essential in Mrs. Pichay
who will undergo thoracentesis?
a. Support, and reassure client during the
procedure
b. Ensure that informed consent has been
signed
c. Determine if client has allergic reaction to
local anesthesia
d. Ascertain if chest x-rays and other tests
have been prescribed and completed
72. Mrs. Pichay who is for thoracentesis
is assisted by the nurse to any of the
following positions, EXCEPT:
a. straddling a chair with arms and head
resting on the back of the chair
b. lying on the unaffected side with the bed
elevated 30-40 degrees
c. lying prone with the head of the bed
lowered 15-30 degrees
d. sitting on the edge of the bed with her feet
supported and arms and head on a padded
overhead table
73. During thoracentesis, which of the
following nursing intervention will be
most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still during
needle insertion until it has been withdrawn
from the chest
d. Apply pressure over the puncture site as
soon as the needle is withdrawn
74. To prevent leakage of fluid in the
thoracic cavity, how wilt you position the
client after thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
75. Chest x-ray was ordered after
thoracentesis. When you client asks what
is the reason for another chest x-ray, you
will explain:
a. to rule out pneumothorax
b. to rule out any possible perforation
c. to decongest
d. to rule out any foreign: body
Situation 16 - In the hospital, you are aware
that we are helped by the .use of a variety of
equipment/devices to enhance quality
patient care delivery;
76. You are initiate an IV line to your
patient, Kyle, 5, who is febrile. What IV
administration set will you prepare?
a. Blood transfusion set
b. Macroset
c. Volumetric chamber
d. Microset
77. Kyle is diagnosed to have measles.
What will your protective personal attire
include?
a. Gown
b. Eyewear
c. Face mask
d. Gloves
78. What will you do to ensure that Kyle,
who is febrile, will have a liberal oral fluid
intake?
a. Provide a glass of fruit every meal
b. Regulate his IV to 30 drops per minute
c. Provide a calibrated pitcher of drinking
water and juice at the bedside and monitor
intake and output
d. Provide a writing pad to record his intake
79. Before bedtime, you went to ensure
Kyle's safety in 'bed. You will do which of
the following:
a. Put the lights on
b. Put the side rails up
c. Test the call system
d. Lock the doors
80. Kyle's room is fully mechanized. What
do you teach the watcher and Kyle to
alert the nurse for help?
a. How to lock side rails
b. Number of the telephone operator
c. Call system
d. Remote control
Situation 17 - Tony, 11 years old, has
'kissing tonsils' and is scheduled for
tonsillectomy and adenoidectomy or T and
A.
81. You are the nurse of Tony who will
undergo T and A in the morning. His
mother asked you if Tony will be put to
sleep. Your teaching will focus on:
a. spinal anesthesia
b. anesthesiologist’s preference
c. local anesthesia
d. general anesthesia
82. Mothers of children undergoing
tonsillectomy and adenoidectomy
usually ask what food prepared and give
their children after surgery. You as the
nurse will say:
a. balanced diet when fully awake
b. hot soup when awake
c. ice cream when fully awake
d. soft diet when fully awake
83. The RR nurse should monitor for the
most common postoperative
complication of:
a. hemorrhage
b. endotracheal tube perforation
c. esopharyngeal edema
d. epiglottis
84. The PACU nurse will maintain
postoperative T and A client in what
position?
a. Supine with neck hyperextended and
supported with pillow
b. Prone with the head on pillow and tuned
to the side
c. Semi-Fowler's with neck flexed
d. Reverse trendelenburg with extended
neck
85. Tony is to be discharged in the
afternoon of the same day after
tonsillectomy and adenoidectomy. You as
the RN will make sure that the family
knows to:
a. offer osteorized feeding
b. offer soft foods for a week to minimize
discomfort while swallowing
c. supplement his diet with vitamin C rich
juices to enhance heating
d. offer clear liquid for 3 days to prevent
irritation
Situation 18 - Rudy was diagnosed to have
chronic renal failure. Hemodialysis is
ordered that an A-V shunt was surgically
created.
86. Which of the following action would
be of highest priority with regards to the
external shunt?
a. Avoid taking BP or blood sample from the
arm with shunt
b. Instruct the client not to exercise the arm
with the shunt
c. Heparinize the shunt daily
d. Change dressing of the shunt daily
87. Diet therapy for Rudy, who has acute
renal failure, is tow-protein, low
potassium and sodium. The nutrition
instruction should include:
a. Recommend protein of high biologic value
like eggs, poultry and lean meat
b. Encourage client to include raw
cucumbers, carrot, cabbage, and tomatoes
c. Allowing the client cheese, canned foods,
and other processed food
d. Bananas, cantaloupe, orange and other
fresh fruits can be included in the diet
88. Rudy undergoes hemodialysis for the
first time and was scared of
disequilibrium syndrome. He asked you
how this can be prevented. Your
response is:
a. maintain a conducive comfortable and
cool environment
b. maintain fluid and electrolyte balance
c. initial hemodialysis shall be done for 30
minutes only so as not to rapidly remove the
waste from the blood than from the brain
d. maintain aseptic technique throughout the
hemodialysis
89. You are assisted by a nursing aide
with the care of the client with renal
failure. Which delegated function to the
aide would you particularly check?
a. Monitoring and recording I and O
b. Checking bowel movement
c. Obtaining vital signs
d. Monitoring diet
90. A renal failure patient was ordered for
creatinine clearance. As the nurse you
will collect
a. 48 jour urine specimen
b. first morning urine
c. 24 hour urine specimen
d. random urine specimen
Situation 19 - Fe is experiencing left sharp
pain and occasional hematuria. She was
advised to undergo IVP by her physician.
91. Fe was so anxious about the
procedure and particularly expressed her
low pain threshold. Nursing health
instruction will include:
a. assure the client that the pain is
associated with the warm sensation during
the administration of the Hypaque by IV
b. assure the client that the procedure
painless
c. assure the client that contrast medium will
be given orally
d. assure the client that x-ray procedure like
IVP is only done by experts
92. What will the nurse monitor and
instruct the client and significant others,
post IVP?
a. Report signs and symptoms for delayed
allergic reactions
b. Observe NPO for 6 hours
c. Increase fluid intake
d. Monitor intake and output
93. Post IVP, Fe should excrete the
contrast medium. You instructed the
family to include more vegetables in the
diet and
a. increase fluid intake
b. barium enema
c. cleansing enema
d. gastric lavage
94. The IVP reveals that Fe has small
renal calculus that can be passed out
spontaneously. To increase the chance of
passing the stones, you instructed her to
force fluids and do which of the
following?
a. Balanced diet
b. Ambulance more
c. Strain all urine
d. Bed rest
95. The presence of calculi in the urinary
tract is called:
a. Colelithiasis
b. Nephrolithiasis
c. Ureterolithiasis
d. Urolithiasis
Situation 20 - At the medical-surgical ward,
the nurse must also be concerned about
drug interactions.
96. You have a client with TPN. You know
that in TPN, like blood transfusion, there
should be no drug incorporation.
However, the MD's order read;
incorporate insulin to present TPN. Will
you follow the order?
a. No, because insulin will induce
hyperglycemia in patients with TPN
b. Yes, because insulin is chemically stable
with TPN and can enhance blood glucose
level
c. No, because insulin is not compatible with
TPN
d. Yes, because it was ordered by the MD
97. The RN should also know that some
drugs have increased absorption when
infused in PVC container. How will you
administer drugs such as insulin,
nitroglycerine hydralazine to promote
better therapeutic drug effects?
a. Administer by fast drip
b. Inject the drugs as close to the IV
injection site
c. Incorporate to the IV solution
d. Use volumetric chamber
98. One patient has a 'runaway' IV of 50%
dextrose. To prevent temporary excess of
insulin transient hyperinsulin reaction,
what solution should you prepare in
anticipation of the doctors order?
a. Any IV solution available to KVO
b. Isotonic solution
c. Hypertonic solution
d. Hypotonic solution
99. How can nurse prevent drug
interaction including absorption?
a. Always flush with NSS after IV
administration
b. Administering drugs with more diluents
c. Improving on preparation techniques
d. Referring to manufacturer's guidelines
100. In insulin administration, it should
be understood that our body normally
releases insulin according to our blood
glucose level. When is insulin and
glucose level highest?
a. After excitement
b. After a good night's rest
c. After an exercise
d. After ingestion of food
ANSWER KEY
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