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Annie was diagnosed with Systemic Lupus Erythematosus. It is an immune disease which is characterized by mul -system involvement. Nurse Katarina, the nurse assigned to Annie, is aware of the signs and symptoms of SLE which involves the following, except A. B. C. D. rash on the face across the nose b...

Annie was diagnosed with Systemic Lupus Erythematosus. It is an immune disease which is characterized by mul -system involvement. Nurse Katarina, the nurse assigned to Annie, is aware of the signs and symptoms of SLE which involves the following, except A. B. C. D. rash on the face across the nose bridge of the nose and on the cheeks. blood dyscrasias. demen a. none of the above. The following laboratory findings indicate complica ons of SLE, except: A. B. C. D. increased crea nine. ECG changes. elevated an nuclear an body level. none of the above. Annie is undergoing con nuous treatment of SLE. Which among the following is not an appropriate treatment for SLE? A. B. C. D. Cor costeroids An malarial drugs Plasmapheresis None of the above Annie is undergoing periodic plasmapheresis for the treatment of SLE. The purpose of plasmapheresis is to: A. B. C. D. suppress the immune system of the pa ent. clear the plasma of an bodies of SLE. provide the pa ent with new an bodies. all of the above Annie, with SLE, is scheduled for discharge tomorrow. The following are appropriate discharge instruc ons for Annie, except: A. B. C. D. avoiding sun exposure from 9 – 3 PM. maintain 6-8 hours of sleep a day. making sure to eat fresh vegetables and fruits. applying ice compress to affected joints. Michael Rodriguez is a 45 year old pa ent with history of human immunodeficiency virus who is hospitalized with fever, chills and cough that has lasted for 5 days. The doctor suspects Pneumocyc s jiroveci pneumonia. Which of the following isola on precau ons should be ins tuted for Mr. Rodriguez? A. B. C. D. Standard precau ons Blood and body fluid precau ons Enteric precau ons No isola on precau on care needed at this me Michael Rodriguez is a 45 year old pa ent with history of human immunodeficiency virus who is hospitalized with fever, chills and cough that has lasted for 5 days. The doctor suspects Pneumocyc s jiroveci pneumonia. The nurse noted dime-size, non-blanching macules on Mr. Rodriguez’s legs and no fies the doctor. These macules may indicate A. B. C. D. petechiae from platelet destruc on. cutaneous acquired immunodeficiency syndrome. telangiectasis. Kaposi’s Sarcoma. Mr. Rodriguez begins alpha interferon therapy for Kaposi sarcoma. The nurse discusses adverse effects of interferon therapy, which typically include A. bradycardia. B. thromboembolism. C. influenza-like symptoms. D. hypertension. Michael Rodriguez is a 45 year old pa ent with history of human immunodeficiency virus who is hospitalized with fever, chills and cough that has lasted for 5 days. The doctor suspects Pneumocyc s jiroveci pneumonia. Based on the current condi on of Mr. Rodriguez, you would suspect that the pa ent is in what stage of HIV/AIDS? A. B. C. D. Primary Infec on Symptoma c Stage Asymptoma c Stage Full-blown AIDS Mr. Rodriguez is taking Didanosine for his HIV/AIDS. Which among the following will you monitor? A. B. C. D. Crea nine and BUN AST and ALT Serum Calcium Level Serum Amylase Eddard Stark, 56 years old post thyroidectomy with modified neck dissec on due to papillary carcinoma of the thyroid gland with lymph node metastasis was admi ed for radioac ve therapy. He asks the nurse to explain how the radia on therapy he will be receiving for his cancer is effec ve. What is the nurse’s best response? A. Radia on causes breakage in the strands of DNA helix, which leads to cell death. B. Oxygen cannot enter cells that have been irradiated, so the cell converts to anaerobic metabolism that causes its death. C. Radia on is antagonis c to glucose, which cells need for energy replica on; radia on prevents glucose from entering cells leading to cell death. D. Cell walls are broken down by gamma rays during radia on therapy, leading to cell death. Eddard Stark, 56 years old post thyroidectomy with modified neck dissec on due to papillary carcinoma of the thyroid gland with lymph node metastasis was admi ed for radioac ve therapy. Prior to admission, he underwent a scan with a test amount of radioac ve iodine. If you were the nurse who admi ed him, which of the following will you consider as the reason for this interven on? A. B. C. D. To determine existence of known distant metasta c tumor To mark the site where the radioac ve iodine will be administered To measure size of remaining thyroid ssue To explore the opera ve site for the baseline data Eddard Stark, 56 years old post thyroidectomy with modified neck dissec on due to papillary carcinoma of the thyroid gland with lymph node metastasis was admi ed for radioac ve therapy. You are formula ng a care plan for him, which of the following nursing interven ons is least relevant to ensure a safe environment once treatment has started? A. B. C. D. U lize preferably only disposable items for client’s personal use Have all frequently handed items in the room covered with absorbent material Provide hand sani zers in the corridor outside the client’s room Dispose appropriately garbage bags marked radioac ve As the nurse assigned to care for clients under radia on therapy, you should be aware that you are least protected by the use of A. B. C. D. Rubber gloves Thyroid shield Lead Apron Eye Shield When planning for discharge of the client, safety of other people should also be considered. Which of the following instruc ons will you consider for reduc on of radioac ve exposure to others? 1. Use private toilet facili es and flush 2-3 mes a er use 2. Wash ea ng utensils separately from others 3. Maintain adequate fluid intake 4. Bathe daily and wash hands frequently 5. Stay in isola on at home two weeks a er the treatment A. B. C. D. All except 3 2, 3, and 5 2, 4, and 5 1, 2, and 4 Mrs. Pearl is a 75 year old pa ent with a history of hypertension and transient ischemic a ack. She is admi ed to the neurosurgical ward due to cerebrovascular accident involving the le side of the brain. Her husband asked the nurse to differen ate CVA from Transient Ischemic A ack (TIA). The nurse should know that TIA A. B. C. D. has permanent long-term focal deficits. is intermi ent with spontaneous resolu on of the neurological deficit. is intermi ent with permanent and motor deficits. has permanent long term neurologic deficits. Mrs. Pearl is a 75-year-old pa ent with a history of hypertension and transient ischemic a ack. She is admi ed to the neurosurgical ward due to cerebrovascular accident involving the le side of the brain. The nurse evaluates her. The nurse expects to see the following in a le -sided brain damage. 1. Paralyzed right side 2. Aphasia 3. Le -sided neglect 4. Paralyzed le side 5. Depression 6. Denial of Deficits A. B. C. D. 1, 2, 5 3, 4, 5 All except 4 All of the above Mrs. Pearl is a 75 year old pa ent with a history of hypertension and transient ischemic a ack. She is admi ed to the neurosurgical ward due to cerebrovascular accident involving the le side of the brain. During the first 72 hours following a stroke, the nurse should posi on Mrs. Pearl A. B. C. D. in bed and lying on the side. with the head of the bed elevated 30 degrees and her head in a midline neutral posi on. with the head of the bed elevated 60 degrees and the knee elevated. flat on bed with his head elevated on a pillow. Aside from the neurological signs and symptoms of stroke, the nurse also monitors the pa ent for signs of increasing intracranial pressure which includes all of the following, EXCEPT: A. B. C. D. systolic hypertension. unequal pupil size. bradycardia. none of the above. Mrs. Pearl is a 75 year old pa ent with a history of hypertension and transient ischemic a ack. She is admi ed to the neurosurgical ward due to cerebrovascular accident involving the le side of the brain. Nurse Jacob was the nurse assigned to care for Mrs. Pearl the next day. He is about to administer Mannitol to the pa ent. The nurse is aware that the ac on of Mannitol is to decrease A. B. C. D. cerebral edema by increasing drainage of CSF from the ventricles. cerebral edema by decreasing the produc on of CSF. cerebral edema by increasing serum osmolality resul ng in dehydra on of the cerebral ssue. cerebral edema by decreasing leakage of fluid from the blood vessels. Mr. Robert Baratheon is a 48-year-old overweight man who was seen for a rou ne check-up. His fas ng blood glucose is 135 mg/dL so he was scheduled by his p physician for a repeat test. Mr. Baratheon asks the nurse why there is a need for a repeat test. The nurse’s best response is: A. B. C. D. “Your fas ng blood glucose was abnormal and needed to be tested again.” “Your fas ng blood glucose level was normal, but we need a confirma on of the result.” “You have type 2 diabetes mellitus, so the test must be repeated.” “Fas ng blood glucose level tests are always repeated.” Mr. Baratheon is learning about diabe c foot care. Which of the following should you instruct him to avoid? A. B. C. D. Lo ons Nail files An perspirants Foot Soaks When teaching Mr. Baratheon about insulin therapy, the nurse should instruct him to avoid which overthe-counter prepara on that can interact with insulin? A. B. C. D. Salicylate prepara ons Antacids Acetaminophen prepara ons Vitamin with Iron A client with type 2 DM comes to the clinic for a follow up appointment. The physician ordered Glyburide (Micronase) to manage his condi on. Which statement from the client would alert the nurse? A. “I usually stay up late. I have a lot of deadlines to beat so I over me at the office most of the me.” B. ”I usually experience headache a er taking this medica on.” C. “I always remind myself to limit my alcohol intake every me we have a night out. I usually consume 2 glasses.” D. “I am told that my medicine is not recommended for pregnant diabe c clients.” If a client is taking Novolin PH, an intermediate ac ng insulin, you expect that the peak effect will last for: A. B. C. D. 12 to 16 hours. 15 minutes to 1 hour. 6 to 12 hours. 2 to 3 hours. You are preparing discharge instruc ons for a client with chronic syndrome of inappropriate an diure c hormone (SIADH). Which statement indicates that the client understands these instruc ons? A. “I will check all food labels to make sure that I restrict my sodium intake.” B. “I will measure my urine and check the specific gravity with a refractometer. If it begins to gradually rise, l will contact my doctor.” C. “I will keep a diary of my daily weight and call the doctor if I gain 2 lbs or more in a day without changing my ea ng habits.” D. “I will check my pulse every morning and will contact my doctor if it’s irregular or rapid.” Jon Arryn, a client diagnosed with hyperthyroidism is being prepared for surgery. Before his scheduled thyroidectomy, there is an order for Lugol’s solu on. In administering Lugol’s solu on, the precau onary measure should include A. B. C. D. administering the drug with milk and drink it. administering the drug with glass of water only. dilu ng with juice and administering the drug with straw. following drug with milk of magnesia. Jon Arryn has successfully undergone thyroidectomy 12 hours ago. You would be most concerned if which of the following was observed? A. B. C. D. Jon Arryn is drowsy and complains of a sore throat Jon Arryn supports his head and neck when turning his head to the right Jon Arryn spontaneously flexes his wrist when the blood pressure is obtained Blood pressure 138/82, pulse 84, respira ons 16, oral temperature 99oF A client presents to the Emergency Department with muscle weakness, complaints of nausea and decreased appe te, vital signs reveal blood pressure of 90/50 mmHg. The physician suspects Addison’s disease and ordered for a 24-hour urine collec on to confirm the diagnosis. An important nursing responsibility during a 24-hour urine collec on for the client should be to A. B. C. D. assess the client for signs of edema. keep the client quiet and reduce stress. monitor the client for an eleva on of blood pressure. restrict the client’s fluid intake for the next 24 hours. Which of the following statements accurately describes Cushing’s disease? A. B. C. D. It is the overproduc on of adrenal medulla hormone Women ages 20-40 years are five mes more likely than men to develop Cushing’s syndrome This disease is characterized by muscle weakness, anorexia and dark skin pigmenta on In this condi on, there is deple on of sodium and water in the body Chronic Obstruc ve Pulmonary Diseases is one of the condi ons contribu ng to the NCD burden in our country. Among the following statements, which does not reflect COPD? A. B. C. D. Chronic cough for at least a month in 4 consecu ve years Sustained hyperinfla on of alveoli sacs on chest x-ray The most significant risk factor for COPD is smoking. None of the above The management of COPD is complex. It is aimed at increasing quality of life and preven ng exacerba ons. Which among the following treatments can prevent exacerba on? A. B. C. D. Short-ac ng bronchodilators Leg Exercises Inhaled cor costeroids All of the above A pa ent is suffering from Acute Respiratory Distress Syndrome. All of the following are true regarding ARDS, except that: A. B. C. D. sep c shock may lead to ARDS. pa ent may need to be intubated. it is characterized by paradoxical breathing & pleuri c pain. ARDS is a severe life-threatening condi on Susan, 63 years old, is diagnosed with ARDS. She is currently on mechanical ven la on. The following are included in the management of pa ents on mechanical ven lator, except A. B. C. D. placing the pa ent on Semi-Fowler’s posi on. stopping the infusion of diazepam for an hour everyday. providing oral care every 2 hours. All of the above Susan, 63 years old, is diagnosed with ARDS. She is currently on mechanical ven la on. While on mechanical ven lator, the high pressure alarm on Susan’s MV was triggered. The most appropriate ac on to take is to A. assess the pa ent for coughing and bi ng. B. turn off the mechanical ven lator. C. remove the pa ent from the MV and manually ven late the pa ent during the course of admission. D. turn off the alarm only. Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing. Further assessment was done and the pa ent was diagnosed with Asthma. Nurse Vincent was the one who assessed Diana when she was admi ed to the Emergency Department. Nurse Vincent is aware of the signs and symptoms of asthma which include A. B. C. D. tachypnea, wheezing & rales. wheezing, paradoxical breathing & dyspnea. I:E ra o of 1:1, wheezing and tachypnea. pleural fric on rub, dyspnea and tachypnea. Nurse Vincent was doing health history. Which of the following statements of the pa ent may be the possible trigger of her asthma? A. B. C. D. “I just came from Tagaytay 2 weeks ago.” “I was upset I wasn’t able to con nue the concert I was watching.” “I had a cup of concocted lagundi last night.” All of the above Diana is scheduled for ABG analysis today. Two hours later, her ABG result arrived and showed the following results: pH 7.55, pCO2 28 mmHg and HCO3 30 mmol/L. Nurse Vincent will interpret the result as: A. B. C. D. par ally-compensated metabolic alkalosis. par ally-compensated respiratory alkalosis. fully-compensated metabolic alkalosis. fully-compensated respiratory alkalosis. Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing. Further assessment was done and the pa ent was diagnosed with Asthma. She was prescribed with inhaled cor costeroids and a short-ac ng beta-agonist. Which of the following should guide Diana in taking her medica ons? A. B. C. D. Nebulize with the beta-agonist first followed by the inhaled cor costeroids Rinse mouth before nebuliza on Drink plenty of water a er administering the drugs Watch out for bradycardia a er taking a beta-agonist Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing. Further assessment was done and the pa ent was diagnosed with Asthma. Nurse Vincent is preparing the discharge teaching for Diana. This will include all of the following, except A. B. C. D. avoiding exposing yourself to pollens, dust and mites. engaging in exercises for long periods of hours. ea ng a well-balanced diet. taking medica ons as prescribed. Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent pneumonia. On ausculta on of Kennen’s chest, which finding suggests a right pneumothorax? A. B. C. D. Bilateral inspiratory and expiratory crackles Diminished breaths sound in the right thorax Inspiratory wheezes in the right thorax Bilateral pleural fric on rub Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent pneumonia. Two days a er admission, the child suddenly developed severe shortness of breath. His right pneumothorax was converted to tension pneumothorax. In assessing a pa ent with tension pneumothorax, you should know that the trachea will deviate towards the A. contralateral side of the lung with tension pneumothorax. B. affected side. C. contralateral side of the le lung. Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent pneumonia. He had a chest tube in place for lung decompression. When caring for Kennen, the nurse must A. B. C. D. monitor fluctua ons in the water-seal chamber. clamp the chest tube once every shi. encourage coughing and deep breathing. milk the chest tube every two hours. Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent pneumonia. As the nurse caring for Kennen turns the pa ent to his side, the chest tube accidentally disconnects. The ini al nursing ac on is to: A. B. C. D. call the physician. place the tube in a bo le of sterile water. immediately replace the chest tube system. place a sterile dressing over the disconnec on site. Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent pneumonia. While doing her rounds, Nurse Annie noted gentle intermi ent bubbling in the suc on control chamber of Kennen’s chest tube system. The appropriate ac on is to: A. B. C. D. check the suc on chamber. record this as a normal finding. immediately replace the chest tube system. report this finding to the physician. Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it was found that the pa ent has gene c predisposi on. His father, Mang Topacio was diagnosed with Conges ve Heart Failure secondary to hypertension. The Philippine Package of Essen al Non-communicable Diseases Interven ons (Phil-PEN) contains guidelines on the management of Hypertension for Primary Health Care Facili es. Which among the following is not a risk factor for hypertension? A. B. C. D. Smoking Increased BP Obesity Four drinks of alcohol in one occasion Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it was found that the pa ent has gene c predisposi on. His father, Mang Topacio was diagnosed with Conges ve Heart Failure secondary to hypertension. The Philippine Package of Essen al Non-communicable Diseases Interven ons (Phil-PEN) contains guidelines on the management of Hypertension for Primary Health Care Facili es. When the nurse took the BP of Alesso, the result was 167/80. His Hypertension can be classified as A. B. C. D. Stage 1 Hypertension. Stage 2 Hypertension. Stage 3 Hypertension. Borderline Hypertension. Alesso is taking Atenolol (Tenormin) 50 mg orally once daily. The nurse understands that the specific ac on is to block A. B. C. D. beta receptor s mula on of the heart. effects of the angiotensin II on receptors. calcium entry into the myocardium cells. alpha receptors in vascular smooth muscle. Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it was found that the pa ent has gene c predisposi on. His father, Mang Topacio was diagnosed with Conges ve Heart Failure secondary to hypertension. The Philippine Package of Essen al Non-communicable Diseases Interven ons (Phil-PEN) contains guidelines on the management of Hypertension for Primary Health Care Facili es. Mang Topacio was curious how he developed Conges ve Heart Failure from his hypertension. The nurse is correct when he states: A. "There is an increased in peripheral vascular resistance resul ng in increased workload of the heart." B. "There is no exact mechanism to explain the rela onship of the two." C. "There is widening of the lumen of the arteries." D. All of the above 50.0 / 1 point The nurse reviewed the health history of Mang Topacio. The nurse noted that one night, the pa ent was rushed to the ER due to complaints of difficulty breathing and persistent coughing. A er the event, it was also noted that the pa ent cannot sleep on a flat posi on and needs 3 pillows when sleeping. Based on the findings, the pa ent may be suffering from A. le -sided heart failure. B. Acute Respiratory Distress Syndrome. C. orthopnea. right-sided heart failure. Irelia, a 36-year old pregnant mother, was admi ed to a Ter ary Hospital due to hypovolemic shock. Nurse Karmela is assigned to take care of Irelia. She is aware of the signs and symptoms of shock which include all of the following, except: A. B. C. D. urine specific gravity of 1.063. tachycardia. diminished pulse. none of the above. Irelia, a 36-year-old pregnant mother, was admi ed to a Ter ary Hospital due to hypovolemic shock. Karmela is preparing her nursing care plan for the pa ent. Which among the following evalua on outcomes is least appropriate for the pa ent? A. B. C. D. The pa The pa The pa The pa ent will be able to maintain adequate blood pressure. ent will be able to maintain a patent airway. ent will be able to maintain a normal urine output. ent will be able to maintain adequate ssue perfusion. If none of the following bed posi ons is contraindicated, which posi on would be the best choice for Irelia with hypovolemic shock? A. B. C. D. Supine posi on Semi-Fowler’s posi on Supine with the legs elevated 15 degrees Trendelenburg’s posi on Which of the following would be the best indica on that fluid replacement for the client with hypovolemic shock is adequate? A. B. C. D. Urine output greater of 50 cc for 90 minutes Systolic BP above 110 mmHg Diastolic BP above 90mmHg Urine output of 20 to 30 cc per hour The management of shock involves maintaining vascular fluid volume. Which among the following are appropriate in the management of shock? A. B. C. D. Dopamine, Epinephrine IM, Lactated Ringer’s Dopamine, Norepinephrine, Lactated Ringer’s Dobutamine, Epinephrine IM, PRBC Urine output of 20 to 30 cc per hour General Thunder, a 73-year-old re red military general, experiences episodes of knife-like chest pain. The pa ent underwent a thorough physical examina on and findings revealed Atherosclero c Heart Disease with concomitant Angina Pectoris. The nurse is instruc ng General Thunder about the proper intake of Nitroglycerin. General Thunder understands the instruc on when he says, Your Answer: A. “I will take a nitroglycerin tablet twice a day.” B. “I will take a nitroglycerin tablet whenever I feel pain and repeat the dose if pain persists for a maximum of two tablets.” C. “I can take a maximum of three tablets for my persis ng pain with an interval of 5 minutes every tablet.” D. “If a nitroglycerin tablet didn’t relieve my pain, I will go to the hospital immediately.” 0 / 1 point General Thunder, a 73-year-old re red military general, experiences episodes of knife-like chest pain. The pa ent underwent a thorough physical examina on and findings revealed Atherosclero c Heart Disease with concomitant Angina Pectoris. Which among the following health teachings is appropriate for General Thunder? A. B. C. D. Eat a high fiber diet Limit Smoking Limit alcohol intake to 10 bo les a day All of the above One evening, General Thunder, was brought to the emergency department due to severe chest pain. He is diaphore c and his pulse rate is 110 bpm. The admi ng diagnosis is Myocardial Infarc on. General Thunder wants to defecate. The nurse should Your Answer: A. place him on to a bedpan. B. help him into the bathroom. C. roll him on to a bedpan. D. assist him for a bedside commode. One evening, General Thunder, was brought to the emergency department due to severe chest pain. He is diaphore c and his pulse rate is 110 bpm. The admi ng diagnosis is Myocardial Infarc on. General Thunder is on ASA therapy. What is the mechanism of ac on for the use of the drug in General Thunder’s condi on? A. B. C. D. To inhibit prostaglandin synthesis To alter pain percep on in the cerebellum To directly affect the central nervous system To target the pain-producing effect of kinins Nurse Tenten is teaching General Thunder who has recovered from MI how to prevent a future episode. The nurse evaluates that further teaching is needed when General Thunder states, "I should A. B. C. D. restrict my physical ac vity." take one baby aspirin everyday." con nue my smoking cessa on program." try to lose the extra weight I am carrying around." Nurse Daenerys is assigned to care for Drogo, a 23 year old client admi ed recently for a possible diagnosis of Aplas c Anemia. His chief complaints include muscle weakness and fa gue. Which of the following data is most important for Nurse Daenerys to elicit during the interview with the client that can support the diagnosis of Aplas c Anemia? A. B. C. D. Any drug allergies Any recent travel or vaca on outside the country Previous exposure to certain chemicals and drugs History of blood transfusion A diagnosis of Aplas c Anemia has been confirmed to Drogo. When admi ng this client, Nurse Daenerys should assign him in A. B. C. D. a private isola on room equipped with a nega ve flow pressure. a semiprivate room with a client diagnosed with urosepsis a semiprivate room shared with a client experiencing thrombophlebi s. a regular private room at the end of the hall. For clients suffering from Acute Lymphoid Leukemia, the nurse would most likely expect to assess which of the following signs and symptoms? A. B. C. D. Enlarged lymph nodes, low grade fever and night sweats Fever, pallor, bone and joint pain fever, ruddy complexion and petechiae Abdominal pain, cys s and swollen joints A client diagnosed with chronic lymphocy c leukemia is admi ed to the hospital for treatment of hemoly c anemia. Which of the following measures, if incorporated into the nursing care plan, would best address the client’s needs? A. B. C. D. Encourage ac vi es with other clients in the day room Provide a diet high in Vitamin C Provide a quiet environment to promote adequate rest Isolate him from visitors and clients to avoid infec on Henry, 65 years old underwent Transurethral Resec on of the Prostate (TURP). He was admi ed to the Post Anesthe c Care Unit (PACU). The client is on con nuous bladder irriga on with NSS infusing at 200 ml per hour. A er 210 minutes, the nurse obtained an output of 1300 ml from the drainage container. Which among the following will be recorded as the client’s urinary output? A. B. C. D. 1300 ml 700 ml 2000 ml 600 ml Henry, 65 years old underwent Transurethral Resec on of the Prostate (TURP). He was admi ed to the Post Anesthe c Care Unit (PACU). The client is on con nuous bladder irriga on with NSS infusing at 200 ml per hour. While a nurse was doing his rounds, he no ced that the fluid coming from Henry’s Foley catheter is red. It was 7 hours ago since he was transferred to PACU. The best ac on of the nurse is to A. record the finding as normal. B. stop the infusion. C. increase the infusion rate. Henry, 65 years old underwent Transurethral Resec on of the Prostate (TURP). He was admi ed to the Post Anesthe c Care Unit (PACU). The client is on con nuous bladder irriga on with NSS infusing at 200 ml per hour. Henry is now scheduled for discharge. Which of the following instruc ons should the nurse provide to this client as part of the discharge teaching? A. B. C. D. Reduce your fluid intake so you won’t need to void as o en Call the doctor immediately if you no ce blood in your urine You may drive yourself home Avoid strenuous ac vity and heavy li ing for 4-8 weeks Ms. Osorio is diagnosed with renal calculi. She is now on low calcium diet to decrease the total intake of calcium and prevent renal calculi. You instruct the client to avoid foods such as Your Answer: A. B. C. D. oats, potatoes, soybean. oranges, yogurt, spinach. rice. malunggay leaves, carrots. whole grain, leafy vegetables, milk. Ms. Osorio is diagnosed with renal calculi. During a follow-up, the doctor ordered to monitor Ms. Osorio for signs of renal calculi. What is the most appropriate nursing interven on to accomplish the order? A. B. C. D. Visually examine urine a er urina on Use glass container when measuring urinary output Strain all urine output Do nothing Karen, 34 years old, has a history of renal insufficiency. Her renal func on worsened and she is now admi ed due to chronic renal failure. The nurse assesses Karen for signs related to chronic renal failure which includes Your Answer: A. B. C. D. facial flushing. edema and pruritus. dribbling a er voiding. diminished force and caliber of urine stream. In chronic renal failure, symptoms may not become apparent un l later stages of the disease because A. B. C. D. the kidneys have great func onal reserve. liver hormones mask the symptoms. other body systems take over some of the kidney’s func ons. the adrenal glands compensate for the kidney’s decreased func on. Karen, 34 years old, has a history of renal insufficiency. Her renal func on worsened and she is now admi ed due to chronic renal failure. The nurse notes that the latest potassium level of Karen is 6.2 mEq/L. The first ac on by the nurse is to: A. B. C. D. alert the cardiac arrest team. call the laboratory to repeat the test. take the vital signs and no fy the physician. instruct the pa ent to increase fluid intake. Karen is undergoing regular peritoneal dialysis to treat her renal failure. Which of the following statements would the nurse include in a discussion with the client? A. The solutes in the dialysate will enter the blood stream through the peritoneum. B. The peritoneum is more permeable because of the presence of excess metabolites. C. The peritoneum acts as a semi permeable membrane through which wastes move by diffusion and osmosis. D. The metabolites will diffuse from the inters al space to the blood stream mainly through diffusion and ultra-filtra on. While Karen was on peritoneal dialysis, she suddenly developed shortness of breath while infusion of the dialysate solu on was ongoing. In this situa on, the nurse should: A. B. C. D. increase the rate of infusion. auscultate the lungs for breath sounds. drain the fluid from the peritoneal cavity. place the client in a low fowler’s posi on. Altera ons in fluid and electrolyte balance that may produce minor changes in young and middle-aged adults have the poten al to produce profound changes in older adults, accompanied by a rapid onset of signs and symptoms. Which of the following is a contribu ng factor in the development of hypernatremia? A. B. C. D. Syndrome of Inappropriate An diure c Hormone Adrenal insufficiency Diabetes insipidus Loss of GI fluids A client sought medical assistance due to nausea and general muscle weakness. Assessment revealed bradycardia and increased potassium level. When serum potassium levels are dangerously elevated, it may be necessary to administer Your Answer: A. B. C. D. insulin. naloxone. calcium gluconate. epinephrine. Hypophosphatemia may be suspected in which of the following clients? A. B. C. D. Gilly who is suffering from renal failure awai ng the first dialysis to run Osha, a client with osteoporosis taking vitamin D and calcium supplements Davos, a client with hypoparathyroidism secondary to thyroid surgery Podrick, an alcoholic client receiving parenteral nutri on Intravenous calcium has been ordered to a client with hypocalcemia. Nurse Ramsay is aware that IV calcium should be diluted with which solu on? A. B. C. D. Solu ons containing phosphate Solu ons containing bicarbonate D5W PNSS Laboratory results of Mr. Bolton revealed a magnesium level of 1.4 mEq/L. He is currently receiving an intravenous magnesium infusion to correct the imbalance. Which of the following assessments would alert the nurse to immediately stop the infusion? A. B. C. D. Absence of patellar reflex Increase in blood pressure Diarrhea Premature ventricular contrac ons Nurse Pycelle has been assigned to several clients with gastrointes nal disorders. Tommen has a history of Pep c ulcer disease. He has had numerous bleeding episodes in the past. He developed peritoni s related to a perforated duodenal ulcera on. What would Nurse Pycelle expect to find during the assessment? A. B. C. D. Decreased or absent bowel sounds Alterna ng episodes of cons pa on and diarrhea Colicky abdominal pain High pitched bowel sounds Tommen has a history of Pep c ulcer disease. He has had numerous bleeding episodes in the past. He developed peritoni s related to a perforated duodenal ulcera on. Upon browsing Tommen’s chart, you noted that the physician has an order of Tagamet. What is the primary reason for Tommen to take this drug? A. Tagamet releases basal gastric acid. B. Tagamet blocks the secre on of gastric hydrochloric acid. C. Tagamet coats the gastric mucosa with a protec ve membrane. D. Tagamet increases the sensi vity of H2 receptors. Tywin has been placed on steroids and he states that he has heard that taking steroids can be dangerous and asks Nurse Pycelle why steroids are prescribed. Which among the following statements of Nurse Pycelle is correct about the use of steroid therapy in the treatment of ulcera ve coli s? A. B. C. D. The side effects of steroids outweigh their benefits to clients with ulcera ve coli s. Ulcera ve coli s can be cured by the use of steroids. Steroids are used in severe flare-ups because they can decrease the incidence of bleeding. Long-term use of steroids will prolong periods of remission. Hepa c dysfunc on results from damage to the liver’s parenchymal cells, either directly from primary liver diseases or indirectly from obstruc on of bile flow or derangements of hepa c circula on. Bronn has been abusing alcohol for the past 15 years now. He was brought to the Emergency Department because he is increasingly confused and vomi ng blood. His medical diagnosis is cirrhosis of the liver. Upon assessment, Bronn has developed ascites and esophageal varices. Which symptoms will Bronn least likely to have? A. B. C. D. Abdominal disten on Bulging flanks Protruding umblicus Bluish discolora on of the umbilicus Bronn has been abusing alcohol for the past 15 years now. He was brought to the Emergency Department because he is increasingly confused and vomi ng blood. His medical diagnosis is cirrhosis of the liver. Bronn began vomi ng large amounts of dark red blood. A Sengstaken-Blakemore tube was inserted to compress the bleeding esophageal varices. While the balloon tamponade is in place, priority interven on should be: A. B. C. D. performing frequent mouth care. assessing Bronn’s stools for occult blood. evalua ng capillary refill in extremi es. ausculta ng breath sounds. Bronn has been abusing alcohol for the past 15 years now. He was brought to the Emergency Department because he is increasingly confused and vomi ng blood. His medical diagnosis is cirrhosis of the liver. Several days a er admission, Bronn’s condi on was worsening. In the intensive care unit, nursing orders required all nurses to assess regularly for early manifesta ons of portal systemic encephalopathy. Which of the following will the nurse note during her observa on? A. B. C. D. Presence of papilledema Development of disorienta on and incoherence Signs and symptoms of increased intracranial pressure Occurrence of asterixis Serum ammonia of the client remained to be elevated. The following may be considered by the nurse to be true regarding this observa on except that: A. B. C. D. ammonia accumulates in the blood due to inability of the kidney to excrete ammonia. ammonia is formed as proteins and amino acids are broken down by intes nal bacteria. since liver func on is destroyed, ammonia can no longer be converted to a less toxic form. due to bleeding, a blood in the intes nal tract is digested as protein, thereby increasing serum ammonia. Which of the following symptoms can the nurse expect from a client posi ve of viral hepa during the icteric phase of the disease? A. Watery stool B. Shortness of breath C. Yellow sclera s exhibit D. Tarry Stool One of the primary condi ons affec ng the musculoskeletal system is arthri s. The most common types are osteoarthri s, gouty arthri s and rheumatoid arthri s. Mr. Dimasalang is diagnosed with gouty arthri s. Nurse Alex is aware of the pathophysiologic mechanism involved in the disease. Which among the following is true of the condi on? A. B. C. D. There is an increase in the level of uric acid which accumulates in joints, called Heberden’s node. This is a result of “wear and tear.” When urate crystals precipitate within a joint, this results in an inflammatory reac on. All of the above Colchicine is prescribed during the acute phase of gouty arthri s. Nurse Alex is aware that the ac on of the drug is to A. B. C. D. provide fast symptoma c relief. lower serum uric acid. block the conduc on of pain sensa on. interfere with the inflamma on response of uric acid crystals in the joints. Mr. Dimasalang is diagnosed with gouty arthri s. The nurse is preparing his discharge teaching for Mr. Dimasalang to prevent acute a ack. It should include the following, except: A. B. C. D. protec ng yourself from injury. limi ng alcohol intake. ea ng a well-balanced diet. None of the above Lolo Cesar is diagnosed with osteoarthri s. Which statement regarding the condi on is true? A. B. C. D. It significantly affects the quality of life of pa ent. Obesity is yet to be established as a risk factor. The weight of a pa ent is inversely propor onal to the pain and discomfort he/she experiences. None of the above Lolo Cesar is complaining pain on his right knee especially during movement. The pain in osteoarthri s is due to: A. B. C. D. uric acid deposits. autoimmune reac on in the synovium. an inflamed synovium and irrita on of nerve endings by pa ent’s own an bodies. muscle spasm, tendini s and inflamed synovium. Periopera ve registered nurses are relied upon for their professional judgment and cri cal thinking skills. They may work closely with the surgical pa ent, family members, and other health care professionals. They help plan, implement, and evaluate treatment of the pa ent. Nurse Robb was assigned in the OR to a end to Mrs. Talisa who is scheduled for exploratory laparotomy. Which statement made by Mrs. Talisa indicates that she needs more informa on prior to signing an informed consent for abdominal opera on? A. B. C. D. “I will be glad to get back to my gardening when I get home.” “I will have to take deep breaths and cough a er I wake up.” “I should not li more than 5 pounds a er my surgery.” “I should tell the nurse if I am having pain a er my surgery.” Nurse Robb was assigned in the OR to a end to Mrs. Talisa who is scheduled for exploratory laparotomy. In assis ng Mrs. Talisa to prepare for immediate surgery, what would Nurse Robb do? A. B. C. D. Remove Mrs. Talisa’s wedding band Begin exploring Mrs. Talisa’s fears and anxie es about surgery Assist in removing dentures and nail polish Remind the client to void following preopera ve medica on As a peri-opera ve nurse, how can you meet the safety need of the client a er administering preopera ve narco c? A. Obtain consent form B. Put side rails up and ask the client not to get out of bed C. Send the client to OR with the family D. Assist client to get up to go to the comfort room Which of the following roles would be the responsibility of the scrub nurse? A. B. C. D. Assess the readiness of the client prior to procedure Evaluate the type of anesthesia appropriate for the surgical client Ensure that the airways is adequate Account for the number of sponges, needles, supplies used during the surgical procedure The periopera ve period encompasses a pa ent’s total surgical experience including the periopera ve, intraopera ve, and postopera ve phases. The following ques ons apply. The scrub nurse ensures that asep c technique is maintained throughout the procedure. The scrub nurse demonstrated adequate knowledge regarding gloving technique when she serves the right gloves to the surgeon. A. B. C. D. Keeping thumbs away from the cuff Sliding the gloves by holding under the glove cuff and spreading to create wide opening Picking up the gloves and placing the palm towards her Maintaining fingers of the gloves facing her The periopera ve period encompasses a pa ent’s total surgical experience including the periopera ve, intraopera ve, and postopera ve phases. The scrub nurse ensures that asep c technique is maintained throughout the procedure. The scrub nurse demonstrated adequate knowledge regarding gloving technique when she serves the right gloves to the surgeon A. B. C. D. Keeping thumbs away from the cuff Sliding the gloves by holding under the glove cuff and spreading to create wide opening Picking up the gloves and placing the palm towards her Maintaining fingers of the gloves facing her The scrub nurse has to unwrap a sterile linen pack on the back table in prepara on for a cholecystectomy. Which of the following is the correct technique of unwrapping the sterile linen pack? A. B. C. D. Unfold layers gently towards the other side of the table Layers are always pulled away from the person opening the pack Handle only the edge of the linen Place the sterile linen pack on the edge of the table close to the person opening the pack The surgeon is about to finish suturing a er an exploratory laparotomy. The nurse is about to place dressing on the incision. Which of the following techniques should the nurse consider? A. Place the dressing, remove the gloves and place the tape B. Remove the gloves and place the dressing and tape C. Place the dressing and tell the nursing assistant to assist you in placing the tape then remove the gloves D. Place the dressing and tape and remove the gloves