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PEAK EXCELLENCE REVIEW CENTER, INC. 1 (4) Seriousness of diagnosis...

PEAK EXCELLENCE REVIEW CENTER, INC. 1 (4) Seriousness of diagnosis A. 2, 3 & 4 C. 1, 2, 3 & 4 B. 1, 2 & 4 D. 1, 2 & 3 MATERNITY NURSING 7) Appropriate nursing diagnoses for patient with Situation: Erin, 32 weeks pregnant, G1P0, expelled developmental problems are, EXCEPT: bloody tinged mucus over 24 hours ago. About 15 A. Delayed growth and development ago, a sudden gush of warm liquid flowed, B. Compromised family coping accompanied by stronger painful and regular uterine C. Impaired Social Interaction contractions. Erin was taken to the hospital D. Altered Sleeping Pattern immediately. 8) Patient’s participation in the planning phase of the 1) Erin informs the nurse that her bag of water (BOW) nursing diagnosis depends on_____. (Select All broke. The MOST appropriate questions to ask That Apply) would be: (1) Developmental status A. “Describe the appearance of the fluid” (2) Psychological condition B. “How much water did you lose?” (3) Level of intelligence C. “Was it accompanied by bloody show?” (4) Comprehension of his disease D. “How frequent are your contraction now?” A. 2 & 3 C. 1, 2, 3 & 4 2) Since the membranes ruptured, the nurse project B. 1 & 2 D. 3 & 4 Erin from increased risk for: 9) When 15–year–old female patient is so engrossed A. Hemorrhage C. Intrauterine infection and worried as to what her friends think about her, B. Precipitate labor D. Prolonged dry labor she is categorized to be in the psychosocial 3) Upon admission to the labor room, the nurse development stage. Nurse Nene needs to inform monitored the fetus and Erin’s contractions which the mother that this is a normal behavior. In what are now intense, regular and lasting for 60 to 80 stage of the psychosocial development is the seconds at 2-3 minutes interval. Within an hour patient in? from admission, a baby girl was delivered A. Identity versus Role Confusion spontaneously. The nurse records this as: B. Autonomy versus Doubt and Shame A. Emergency child birth C. Industry versus Inferiority B. Precipitous labor D. Initiative versus Guilt C. Precipitous delivery 10) The head nurse of Pediatric Ward asked a staff D. Hypotonic labor and delivery nurse who is assigned to a 3-month old infant. At 4) Attention to Erin and the preterm baby is of what age will her patient start to drink from a cup? paramount importance. The nurse’s immediate The staff nurse’s answer should be ____. action upon expulsion of the fetus would be to: A. 12 C. 9 A. Hold the infant’s feet up to drain any fluids B. 24 D. 5 that may clog the airway B. Dry the infant and wipe off the white cheesy Situation: You are a staff nurse in the Out-Patient material Department. Mrs. D brought her 9-year old daughter C. Receive the infant in a warn blanket to prevent Bianca for consultation. Bianca is complaining of sore heat loss throat, muscle tenderness, weakness of the arms and D. Clamp then cut the umbilical cord a general feeling of not being well. The attending 5) Considering Erin’s rapid labor and delivery, the physician’s impression is Infectious Polyneuritis. nurse’s PRIORITY intervention would be focused on 11) Initially, what assessment data would be the MOST the following outcomes EXCEPT: IMPORTANT for you to make? A. Stable maternal vital signs A. Exposure to an infectious disease B. Minimal tissue injuries and lacerations B. Difficulty in swallowing C. Uterus is contracted and firm after delivery C. Difficulty in urinating D. Uterine position and size D. Diet intake for the last 24 hours 12) Bianca was admitted to the Pediatric Ward. What PEDIATRIC NURSING would be your PRIORITY nursing action when Situation: Nursing assessment of individuals across caring for her? the life span require nurse to be familiar with the A. Providing a diversional activity for Bianca physiological, cognitive, and psychosocial changes B. Evaluating Bianca’s bilateral muscle strength that occur during each stage of development. C. Making a game of range-of-motion exercises 6) The factors that affect the ability of individuals to D. Assessing Bianca’s ability to follow simple cope are _______ (Select All That Apply) commands (1) Level of development (2) Coping skills (3) Previous experiences with illness and hospitalization Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 2 13) The pediatric ward nurse asks Bianca to cough 19) When checking the general danger signs in a 4 every now and then. She also assesses Bianca’s month old child, the following questions are asked speech for decreased volume and clarity. The EXCEPT: underlying rationale for these two assessments is A. Did the child have convulsion? to determine the ________ B. Is the child eating well during illness? A. Regression to an earlier developmental phase C. Is the child able to breastfeed? B. Involvement of facial and cranial nerves D. Has the child had diarrhea? C. Increased intracranial pressure 20) “Treating the child” in the health center includes D. Inflammation of the larynx and epiglottis the following EXCEPT: 14) Assessment finding revealed that Bianca has weak A. Checking mother’s understanding of gag and cough reflexes. During this acute phase of instructions Bianca’s illness, which of the following problems B. Recognizing signs indicating that the child should receive the HIGHEST PRIORITY? should be returned immediately to the health A. Impaired swallowing related to neuromuscular facility impairment C. Teaching how to give fluid during illness B. Risk for infection due to an altered immune D. Demonstrating how to give oral treatment and system antibiotics C. Ineffective breathing pattern related to neuromuscular impairment Situation: The nurse in the Pediatric Unit is preparing D. Total urinary incontinence related to fluid medications a child for surgery. His weight is 22.9 kg. losses The physician ordered Atropine Sulfate 0.2 mg to be 15) Bianca was placed on mechanical ventilator. Which administered subcutaneously. An Intravenous infusion of the following nursing actions should the ward of 0.9% Normal Saline solution 500 ml was started to nurse give emphasis to? run for 24 hours. A. Turning Bianca slowly and gently from side to 21) In determining the volume for subcutaneous side to prevent respiratory complications. injection for infants and small children the nurse B. Engaging Bianca in vigorous passive range-of- should be guided that the maximum amount is: motion exercises to prevent loss of muscle A. 1.5 ml C. 1 ml function. B. 0.1 ml D. 0.5 ml C. Maintaining Bianca in a supine position to 22) The safe dose of Atropine Sulfate for children is prevent unnecessary nerve stimulation. 0.01 mg/kg. The nurse computed the safe dose for D. Transferring Bianca to a bedside chair three the prescribed Atropine Sulfate. She computed the times a day to prevent postural hypotension. correct dose if she obtained: A. 0.3 mg C. 0.1 mg Situation: Your assessment skills and interventions B. 0.4 mg D. 0.2 mg when taking care of infants are important for the 23) After arriving at the safe dose of Atropine Sulfate, management of the client’s conditions. the nurse analyzes the desired dose ordered. 16) An 8 month old child is brought to the health Which of the following conclusions should guide facility for “fast breathing”. Your correct the nurse in administering the drug? interpretation of “fast breathing” in this situation A. Desired dose is within safe dose range MEANS: B. Weight of child is not proportional to the A. 40 breaths per minute desired dose B. 45 breaths per minute C. Desired dose is more or less adequate for the C. 38 breaths per minute child’s weight D. 55 breaths per minute D. Computed dose is more than the desired dose 17) Whenever the child is brought to the health center 24) The nurse is using an IV infusion device for the for a new problem, using the Integrated intravenous fluid. A total of 500 ml of 0.9% Normal Management of Childhood Illness (IMCI) strategy, Saline solution is to infuse over 24 hours. At what this is rightfully termed: hourly rate should the nurse program the IV A. Follow-up visit C. Final visit infusion device? B. Initial visit D. Check-up A. 30 ml/hr C. 15 ml/hr 18) When asking the mother about the child’s problem B. 41 ml/hr D. 21 ml/hr the following communication skills should be used 25) While the nurse changes the patient’s gown, the EXCEPT: infusion pump alarm turned on. The nurse’s A. Ask checking question priority should be to check first the : B. Listen attentively A. Container if empty C. Use words that the mother understands B. Intravenous site for occlusion D. Give time for the mother answer the question C. Tubing for kinks D. Presence of air in the tubing Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 3 Situation: Nurse Nena admitted a 15 month old child D. Technical competence in the spirit of service with cryptorchidism. The child was brought to the that is obtained mainly from specialized hospital by his mother. graduate institution 26) While the nurse was taking the history of the child 32) Some areas of health have been identified as being from the mother, she should be guided by the interrelated and multidimensional. Which is NOT knowledge that the incidence of this disorder is correct? directly related to which of the following? A. Interrelationships C. Professional A. Full term in high risk mothers B. Emotional D. Physical B. Dry labor and prematurity 33) New graduate nurse. Tim has been working on C. Birth weight and gestational age extra shifts at the medical-surgical unit for three D. Prolonged labor and forceps delivery months. He believes he is sleep deprived. Some 27) During the initial assessment, which major negative effects of sleep deprivation are listed manifestation should the nurse note in children below EXCEPT: with cryptorchidism? A. Increased risk of motor vehicles accidents A. Absence of one or both testes in the scrotum B. Increased risk of medical errors B. Testes are retracted into the inguinal ring C. A period of 24 hours of wakefulness is C. Enlarged one or both testes equivalent to a 0.001% blood alcohol level D. Testes are palpable in the abdomen D. Difficulty remembering and concentrating 28) The child was scheduled for repair of 34) Stress management techniques are listed below. cryptorchidism. The surgical procedure being Which is a good technique for nurses to use when referred to is: seeking to relieve stress? A. Hydrocoelectomy C. Orchiopexy A. Set realistic goals B. Circumcision D. Herniotomy B. Keep things to yourself 29) The mother, aware of the age of her child, asks the C. Be polite to all nurse what is usually the BEST time that this D. Do not procrastinate procedure is done. The correct response of the 35) The nurse should have some strategies to maintain nurse would be: professional health. Which of the following is the A. Before the child starts to walk LEAST appropriate? B. Between 6 and 24 months A. Join a professional organization C. Before the child goes to school B. Goal setting D. Between 2 and 3 years of age. C. Networking with others in the health care field 30) Considering the sequelae of testicular cancer and D. Read fiction and nonfiction materials infertility among male children with cryptorchidism, the nurse include in her discharge COMMUNITY HEALTH NURSING/ COMMUNICABLE plan which of the following? DISEASE NURSING A. Use of scrotal support Situation: Health education is the process whereby B. Long-life follow-up knowledge, attitudes and practices are changed to C. Periodic ultrasonography of the testes improve individual, family and community health. D. Life-ling hormonal therapy 36) The goals of health education include the following: FUNDAMENTALS OF NURSING (1) Client participation in health decision making Situation: Personal, Professional, and even Spiritual (2) Increased potential to comply with health dimensions of care are important concerns in nursing recommendations. intervention and essential ingredients in the (3) Reliance on the health care system development in the total character of the professional (4) Adoption of healthier lifestyle nurse. The following situations/questions apply. (5) Provide clients with as many options on health 31) As a professional nurse there are essential care as possible requisites that you must possess that include the A. 1, 2 and 4 C. 2, 3 and 5 following EXCEPT: B. 2, 4 and 5 D. 1, 3 and 4 A. Provides services that are vital to human and 37) The nurse is designing a health education program social welfare within the limits of the scope of for the community. Show the correct sequence of practice and own competence the process that the nurse would have to B. Commitment to ethical and professional undertake. standards (1) Write the specific outcomes C. Accepts accountability for own actions, (2) Assess the community outcomes of care and continued competence (3) Prioritize learning needs in accordance with scope of practice increasing (4) Select teaching strategies responsibility and legislative acts A. 1, 4, 2, 3 C. 2, 3, 1, 4 B. 4, 1, 3, 2 D. 1, 2, 4, 3 Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 4 38) The BEST example of how the nurse can create a (1) Use survey questionnaire climate in which clients do not feel threatened is (2) Collect data through informal methods to by teaching a topic about: gather data more effectively A. Stress, where the nurse play pop music (3) Validate data regularly throughout the first session. (4) Secondary data should be the least priority for B. Good nutrition, where the nurse provides a gathering information meal A. 2, 3, 4 are correct C. 1, 3, 4 are correct C. Exercise, where the nurse begins to share her B. 1, 2, 3 are correct D. 1, 2, 4 are correct difficulties she sometimes finds it trying to exercise. Situation: For Safety and Quality purposes, it is D. Diabetes, where the nurse asks diabetics to equality important to be mindful of the roles and talk to the class during the first session functions and the instituted system and procedures in 39) The nurse is working in a clinic that is designed to relation to the practices of Community Health Nursing provide health education and immunization. As (CHN). The following questions apply. such, the clinic aims to provide ______. 46) The basic unit of care in CHN is; A. Diagnosis and treatment A. Community C. Family B. Primary prevention B. Groups D. Individual client C. Secondary prevention 47) The most important role of a community health D. Tertiary prevention nurse is in the area of: 40) Clients who are taught a variety of skills such as A. Change agent C. Health education measuring blood glucose, taking blood pressure, B. Advocacy D. Care provider changing dressings, and bathing infants belong to 48) The focus of activities in specific protection is a which domain of learning? level of prevention classified is: A. Psychomotor domain C. Cognitive domain A. Secondary intervention B. Social domain D. Affective domain B. Tertiary prevention C. Intervention prevention Situation: Mrs. Santos used to be a barangay council D. Primary prevention member but has expressed dissatisfaction with her job 49) In-patient and diagnostic care including surgery and has refused to perform her tasks. Her actions belongs to what level of health care? affect the community organization. A. Secondary level C. Primary level 41) The dissatisfaction and job performance of Mrs. B. Tertiary level D. Specialized level Santos is influenced by which of the following 50) PRIMARY HEALTH CARE embraces all of the factors? following concepts, EXCEPT: A. Organizational practices A. People’s participation is essential B. Motivation practices B. Community organizing as the core of PHC C. Characteristics of the job C. Use of appropriate technology D. Individual characteristics D. It is approach to provide the basic needs of the 42) An effective community organization is community characterized by the following EXCEPT: A. Recognition Situation: One effective means of addressing B. Quick problem solving inadequacy of treatment and health measures at the C. Relationship and communication community level is through collaboration and D. Flexibility teamwork. First, among health workers and second 43) Which of the following is NOT considered a health through the cooperation of community residents. group norm? Preventive health care can be achieved via this A. Everybody works for the group strategy. The following questions apply. B. No one talks about conflicts 51) Which of the following strategies implemented C. Intimacy and trust with the Department of Health to prevent D. Everyone comes to meetings prepared transmission of malaria? 44) Community facilitators attempt to resolve the (1) Chemoprophylaxis of pregnant women in problems in the barangay. These facilitators have endemic areas the following characteristics EXCEPT: (2) Chemoprophylaxis of non-immune person A. Enthusiastic going to endemic areas B. Makes decisions for the group (3) Teaching of people in endemic areas to use C. Willingness to spend time in building chemically treated mosquito net relationships (4) Teaching families to use adequate protective D. Acts more like a coach than a scientist clothing when the biting period of the 45) In social investigations of cases like that of Mrs. mosquito vector is expected Santos, which of the following certainly impact this A. 1 and 2 C. 1, 2 and 3 community? B. 3 and 4 D. 1, 2, 3 and 4 Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 5 52) Secondary prevention of malaria may be achieved D. A two-day post radical mastectomy patient through cooperation of community residents by: with IV infusion A. Growing larva-eating fish in mosquito breeding 59) You are preparing to discharge a 70 year old client places who lives alone. You determine if there are fire B. Determining whether a place is an endemic hazards at home. Which of the following area statements by the client should alert you to C. Residual spraying of insecticides at night explore further? D. Planting of neem or eucalyptus trees A. “I cook my food occasionally" 53) Which can be the BEST preventive measure for B. “I should attend fire drills conducted by the schistosomiasis? Red Cross" A. Environmental sanitation C. “I keep my matches on a high shelf" B. Destruction of snails D. “My refrigerator is 3 feet from the wall. C. Use of protective footwear 60) The essential requisites of a fire extinguisher that a D. Irrigation of snail breeding places nurse should be aware of are the following except? 54) From January to September, there were two A. Disposal of the fire extinguisher outbreaks of typhoid fever in Cavite City. As a B. Indication public health nurse, you know that typhoid fever is C. Location of the fire extinguisher caused by: D. Expiry date A. Fomites B. Poor personal hygiene practices PALMER NURSING C. Inhalation of contaminated air Situation: Interdisciplinary teamwork is an important D. Intake of unsafe food and water model for delivering health care to patient. 55) Even the conduct of epidemiologic investigation Integrating services among many health providers requires collaboration and teamwork and purpose leads to better outcomes delivered to underserved of which is to: populations and communities with limited access to A. Delineate the etiology of epidemics health care. B. Encourage cooperation and support of the 61) Professional group productivity and member community satisfaction are best achieved by which of the C. Identify geographical location of cases in the following leadership styles? community A. Democratic C. Laissez-faire D. Identify who are at risk of contracting the B. Authoritarian D. Autocratic disease 62) As a member of a professional work-related group you know that: Situation: The hospital can be hazardous to fire like A. Functional goals are assigned by management any other establishments. B. The leader is responsible for overall 56) Which of the elements present in the workplace functioning would support combustion most? C. The members summarize progress and allocate A. Oxygen tank, suction machine, water cylinder assignments. B. Disposable drapes, gas tanks, open windows D. The cooperation of all members is required. C. Disposable drapes, gases, people 63) The nurse is making a referral for the client. What D. Linen, vials of drugs, syringes should be the first consideration for the nurse to 57) A staff nurse is called to a client's room. When the do? nurse arrived in the room, she noted that the A. Acceptability of the referral to the client. waste basket is on fire. However the client has B. Cost of the referral service been moved out of the room. Which of the C. Barriers to making a referral following is the PRIORITY action of the nurse? D. Client’s eligibility for the service. A. Confine the fire 64) Groups with a Laissez faire leader are likely to be B. Extinguish the fire A. More structured. C. Activate the fire alarm B. Less productive D. Evacuate the unit C. More productive 58) In a semi-private ward of four patients, which of D. More satisfying to members. the following clients would you move out first in 65) You have volunteered to be part of a work group case of fire? whose purpose is to look at ways to prevent A. A post below-knee amputation patient with medication errors. You know that: referral for crutches walking. A. Teamwork enhances the probability of goal B. A post herniorrhaphy patient under spinal achievement anesthesia and maintained flat on bed for two B. Group process is not important in a task. hours C. The leader assume responsibility for the overall C. A post thyroidectomy patient with discharge group functioning order D. The goals should be set by the management. Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 6 Situation: Nurse Miriam Kate is the Charge Nurse of practice where teamwork and collaboration is highly the Obstetrics & Gynecology Ward of a government needed. hospital. Nurse Angelina is one of the staff nurse in 71) Nurse Josie is a graduate nurse assigned in the that ward. The Ward is beset by problems such as cardiac rehabilitation unit after she has undergone having inadequate supplies. a special training program in rehabilitation nursing. 66) What is the BEST initiative that Nurse Angelina can She is aware that working in this unit needs do, should there be non-availability of supply of collaborative practice. Which of the following is alcohol used for hand hygiene that is vital in NOT an acceptable behavior in teamwork? preventing cross-infection? A. Actively engaging in care planning and A. Requisition of the item from Central Supply management including audit before the supply runs out. B. Contributing to decision making regarding B. Inform the head nurse of its non-availability. patient's needs and concerns C. Have your own alcohol until hospital supply is C. Respecting the role of the members of the available. health team in care management D. Request the patients to provide their own D. Questioning therapeutic interventions by the alcohol. health team despite evidences 67) One major way of preventing cross-infection is 72) In the Cardiac rehabilitation program, the team frequent handwashing. However, today, Nurse members emphasizes to the patient and family the Angelina just found out there is water interruption. importance of education and lifestyle changes. In The INITIAL step that Nurse Angelina ought to do is which phase of the cardiac rehabilitation includes report the problem to low level exercise, physical activity and changes for A. Head nurse C. Chief Nurse the resumption of an active lifestyle? B. Manila Water D. Nurse Supervisor A. Phase 2 C. Phase 3 68) Nurse Angelina as a beginning nurse assigned in B. Phase 1.5 D. Phase 1 the Obstetric Ward was asked by Head nurse Mimi 73) The implementation of course of action from an example of how she will be able to manage her several alternatives are usually done by the team environment. Which of her responses are when designing a program for the rehabilitation of CORRECT? Select all that apply. cardiac patients. The steps for an EFFECTIVE (1) Check availability and expiry date of fire decision-making include which of the following extinguishers in the Obstetric Ward. (1) Determine the goal of the outcome. (2) Compliance to Republic Act 9003. (2) Identify the need for the decision (3) Provision of a separate container for each type (3) Evaluate the alternative action/s chosen, if it of waste for on-sit collection properly marked was achieved. as “compostable”, “non-recyclable”, (4) Identify alternative actions, with each benefits “recyclable”, or “special waste”. and consequences (4) Proper isolation of patients known or (5) Choose an alternative action/s suspected of harboring infectious disease. A. 2, 1, 4, 5 & 3 C. 3, 2, 1, 4 & 5 A. 1, 2 & 4 C. 1, 2, 3 & 4 B. 1, 3, 2, 4 & 5 D. 4, 1, 3, 2 & 5 B. 1, 3 & 4 D. 2, 3 & 4 74) The interdisciplinary team of cardiac rehabilitation 69) Should Nurse Angeline request for Alcohol-based professionals works with each patients to help hand rub to be effective for application to the attain mutually established goals. Which of the hands for reducing the number of viable following is NOT included in the Short term goals_? microorganisms on the hands, the ethyl content A. Limiting the physiological and psychological should be ______. effects of the heart disease. A. 60 C. 70 B. Reconditioning the patient to assume activities B. 90 D. 95 of the daily living. 70) Nurse Angeline discovered that the bed mattresses C. Reversing completely the atherosclerotic in the Pay Ward slide easily, either to the left or disease process. right side of the bed causing patient to fall. What D. Decreasing the risk and symptoms of cardiac would be Nurse Angeline’s MOST appropriate way disease. to provide patient’ safety? 75) Nurse Josie, as a member of the rehabilitation A. Use restraint on Patient team promote wellness and help cardiovascular B. Raise upper and preferably lower rails at all patients and those at risk alter their lifestyles times. through which of the following EXCEPT: C. Frequent monitoring of patient. A. Smoking cessation D. Ensure 24-hour responsible watcher. B. Stress management C. Vigorous exercise Situation: The role of the Health professionals in the D. Low fat, low cholesterol diet care delivery system has been very challenging especially with the contemporary approach to Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 7 Situation: Nurse Edna a change nurse of an oncology 80) Nurse Edna is aware that patient care unit attends a semi on evidence-based nursing improvement must be based on which of the practice. following? 76) The conference speaker explained the difference A. Total cost health care. between evidence-based practice and evidence- B. Building and applying knowledge. based nursing practice. Which of the following is C. Hospital policy on how to staff a nursing unit. NOT TRUE regarding evidence-based nursing D. Accreditation standards. practice? Evidence-based nursing practice A. has a medical focus. Situation: Charting is part of the professional nurse’s B. uses a theory-derived and research-based responsibility related to records management. The information in making decisions about nursing following questions refer to this statement. care delivery. 81) One of the characteristics of charting is brevity. C. considers the patient’s needs and preferences Which of the following examples of charting shows based on nursing theory and research. this characteristics? D. is a strategy used to improve patient care A. Nurse brought the patient to OR via stretcher outcomes. at 10:15 77) The speaker encouraged the nurses to participate B. Patient left for surgery via stretcher at 10:15 in the use of evidence-based nursing practice. The am speaker said that nurses must C. To surgery via stretcher at 10:15 (1) Participate in the development, use, or D. Patient brought by the nurse to OR via evaluation of practice guidelines. stretcher at 10:15 accompanied by the (2) Read and analyst outcomes of research “bantay” studies. 82) Which of the following is NOT a requirement for a (3) Involve themselves in everyday patient care late entry in charting? and nursing practice. A. Nurse’s initial above the time (4) Know why are doing what they are doing. B. May be made if something has been forgotten A. 2, 3 & 4 C. 1, 2, 3 & 4 C. Circle it and write “late entry” B. 1 & 2 D. 1, 3 & 4 D. Reason for the late entry 78) Nurse Edna is aware of the importance of patient 83) There is a blank space after your last entry in your outcomes as a measure of quality care. Which of charting. You will _____. the following statements is TRUE regarding A. Draw a double line after your last entry patient–focused outcome indicators? To B. Sign your full name after your last entry (1) achieve safe, quality, cost–effective care for C. Draw a horizontal line through the center of an patients in daily practice. empty line (2) realize that individual nursing practice styles D. Daw a perpendicular line across the empty directly affect the rates at which patients space. recover. 84) Which of the following should the nurse’s notes (3) prevent development of unnecessary focus on? complications and injury. A. Immediate past and the present (4) determine satisfaction rate from patients or B. The present only family care received from nursing staff. C. The future A. 1, 2, 3 & 4 C. 2 & 4 D. The recent past B. 1 & 3 D. 1, 3 & 4 85) Which of the following sample charting would 79) A model for using evidence–based practice was show the characteristic of ACCURACY? presented. The model has the following elements: A. Intake from 700-1000ml: 80 ml of coffee; 240 Plan, Do, Study and Act (PDSA). If Nurse Edna ml of orange juice; 500 ml of water wants to utilize this model to improve ward B. Patient on forced fluid but refused to take it management, what questions will she ask? most of the time. (1) What are we trying to accomplish? C. Patient on forced fluids. Observed (2) How well do we know that a change is an D. Given fluid at frequent intervals but takes only improvement? a few sips. (3) Will the patient be satisfied with the improvement? Situation: Using team approach when providing care (4) What change/changes can we make that will helps promote quality and continuity of care for the result in an improvement? client from the pre-admission phase to discharge and A. 2 & 4 C. 1 & 3 follow-up care. B. 3 & 4 D. 1, 2, 3 & 4 86) The nurse discusses with the client’s wife health promoting activities that can help the client with cirrhosis of the liver in his activities of daily living at Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 8 home. Which among the following is the most C. Review literature appropriate measure the nurse can suggest? D. State the problem A. Avoid crowded areas 92) When the researcher predicted that therapeutic B. Good nutrition, avoid infection and abstain touch significantly affects level of comfort of the from alcohol client, the researcher was doing which step of the C. Ensure adequate rest, sleep and exercise conceptual phase of the research process? D. Take a glass of milk at bedtime A. Delimiting the problem 87) The staff nurses in the medical unit planning total B. Stating relationships of variables parenteral nutrition prevent complication when C. Formulating hypothesis administered through a central line. Which of the D. Developing protocol for intervention following interventions are most appropriate? 93) The researcher used an interview schedule to (1) Follow strict clean technique for all dressing ascertain the feeling of the clients when touched change therapeutically by a nurse. If you were the (2) Promote adequate rest and limited activities researcher who among the following will you (3) Observe strict aseptic technique consult to evaluate the content validity of the (4) Cover insertion site with air occlusive dressing instrument? (5) Cover the insertion site with moisture-proof A. Research adviser C. Experts in the field dressing B. Subjects of the study D. Statistician A. 1, 3 and 5 C. 2 and 3 94) In the selection of the size of the sample, which of B. 2, 4, 5 D. 3 and 4 the following statements show the correct use of 88) The nurse is assigned to a client with a diagnosis of sampling principles in the selection of the sample cancer of the bladder, with attachment to an size? appliance for a standard urine collection at night. A. The smaller the sample size, the more accurate The nurse discusses with the wife the reason for the inferences drawn from a sample the attachment. The best explanation should be to: B. The greater the sample size the greater will be A. Prevent urine leakage the uncertainty for a given sample size B. Prevent urine reflux into the stoma and ureters C. The greater the sample size, the more accurate C. Prevent urine drainage into the stoma will be the estimate of the true population D. Restrict fluid intake mean 89) The nurses in the renal unit are reviewing the D. The smaller the sample size, the more accurate laboratory result of the clients. Which of the the difference between the statistics and the following laboratory blood results will NOT true population mean improve by dialysis treatment? 95) Which of the following is considered the final step A. Elevated sodium level of the research process? B. Elevated potassium level A. Research critique C. Low hemoglobin B. Communication of findings D. Elevated BUN and creatinine C. Recommendation and implication 90) The incoming nurses in the renal unit are D. Putting research evidence into nursing practice discussing the assessment findings of a 66 year old client, male, with chronic renal failure, and Situation: In an effort to maintain the quality of hypertension. He has crackles in the lungs and health care provided to client’s evaluation is needed. weight gain from 145lbs to 160lbs. the nursing This evaluation may be limited to the performance of diagnosis that is appropriate for the above findings one nurse or by the whole agency. This is done by is: looking into the structure, process and outcome of A. Fluid volume excess related to inability of the care provided. kidney to maintain fluid balance 96) This process of evaluation is called: B. Increase fluid intake related to chronic renal A. Quality assurance C. Quality insurance failure B. Nursing audit D. Process evaluation C. Fluid volume deficit related to renal failure 97) A client is confined in your unit. He says that he has D. Fluid volume excess related to malfunctioning difficulty sleeping because of the “ambience” in kidneys the unit. When evaluating the effect the setting has on the quality of care provided to the client the Situation: The nurse researcher determined the effect evaluation being done is called: of therapeutic touch on the client’s comfort. Quasi- A. Quality assurance experimental design was used. B. Outcome evaluation 91) Of the following preliminary tasks, which of the C. Structure evaluation following should the research do to obtain D. Quality improvement available knowledge in her area of interest? A. Select the variables B. Identify the population Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 9 98) The client is given a sponge bath, vital signs are 104) The nurse is taking care of an elderly client checked and medications are given on time. The who is restless and tense. To protect the nurse evaluation of the care provided to him by the nurse from being sued for unlawful restraints which of is referred to as: the following should be her appropriate action? A. Process evaluation A. Explain to the family that a restraint is needed B. Nursing audit for the protection of the client C. Outcome evaluation B. Tell the client that a restraint is to be applied D. Quality improvement for his own protection 99) As a result of the comfort measure done and C. Contact the physician for orders and document medications administered to the client some the reason for using restraints demonstrable changes are observed. These D. Ask the family to be on the alert to protect the changes in the client’s condition when evaluated is client from harming himself referred to as: 105) The nurse calls the physician to report a A. Outcome evaluation change in the condition of the client. The nurse is B. Nursing evaluation unable to reach the attending physician but left the C. Quality improvement massage to his secretary. After an hour the D. Outcome identification secretary called back and relayed the verbal order 100) The head nurse wants to evaluate the time it of the physician. Which of the following is the takes for the nurse to respond to client’s call. This MOST appropriate action of the nurse? type of quality evaluation is called: A. Take the message and ask for the physician A. Nursing audit during the visit B. Structure evaluation B. Insist on talking to the physician C. Process evaluation C. Refuse to take order from the secretary D. Quality improvement D. Accept the verbal order as it comes from the physician and record appropriately Situation: Health care professionals are faced with many issues in their day-to-day practice. To address Situation: Patient's records are the best evidence of these issues nurses should provide services that will care received by clients while in the health care positively affect patient treatment and institutional facility. outcome. 106) This is your first assignment in the unit. While 101) An elderly client in the Medical Unit tells the reviewing the patient's record, which of the nurse that he is tired of the treatment, sees no following observations violate the patient's improvement and he would rather take all his privacy? medication to end his sufferings. Which of the A. Allergies of patient noted in the admission following should be the initial action of the nurse? notes. A. Assess the client and make the appropriate B. Personal data sheet attached referrals C. All records identified with patient's name B. Recommend to the client to seek advocacy D. Patient's diagnosis posted on the chart cover support 107) A nursing student came to you asking if she can C. Communicate the client’s wishes to his family photocopy the patient's record for their case D. Call the attention of the wife and watch the presentation. How will you best handle the client closely student's request? 102) A middle age client is frantic and uptight. The A. Allow the student to photocopy the chart, client has an order of Benadryl 25 mg p.o.p.r.n. for anyway she is in-charge of the patient itching. The nurse administered Benadryl. The best B. Tell the student to do it discreetly description for the nurse’s action is: C. Allow the student to just read and take note of A. Malpractice C. Battery the information that she needs B. Negligence D. Appropriate D. Tell the student to talk and ask permission 103) A female client has an order of repositioning from the client himself. every 2 hours. The nurse failed to change the 108) A client's visitor requested to take pictures of position of the client as specified in plan of care. the bulletin board. The appropriate response is: The nurse’s action constitutes a violation of: A. Pictures may be taken only during hospital A. Standardized Nursing Care Plan week celebration B. Nurse Practice Act B. Pictures can only be taken by the hospital staff C. Medical Practice Act C. Pictures cannot be published without the D. Standards of Practice medical director's permission D. Pictures can be published if colored. Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 10 109) You observed that a clinical instructor was A. Health care workers who render detailed and intently reading the chart of a client who skillful work underwent bilateral mammoplasty. This client was B. Those who are so busy with technical not assigned to any of her students. You evaluate processes this action of the C.I. as: C. Those who are very demonstrative of their A. Not a violation to client's privacy authority B. Permissible because she is also a nurse D. Nurses who are very slow but respectful. C. Gaining information to assist learning 115) If the nurse encounters a client who refuses D. Inappropriate because she is not assigned to therapeutic treatment despite explanation from the client. the health care worker, the CORRECT action of the 110) An elderly client signed a document outlining nurse so that she would not be held liable is; selected medical treatments when he loses his A. delay treatment until the client is convinced ability to decide. The document is referred to as: B. call the nurse supervisor on duty A. Consent form C. NCP C. respect the decision of the client B. Advance directive D. Treatment sheet D. notify the physician in charge Situation: Professional nurses' fear of being involved Situation: The rapidly changing health care modality in legal suites is increasing with the growth in has directly impacted the professional nurse and must complexity of health care and awareness of the clients expand role to include analytical decision making of their rights. process in serious consideration to ethical and moral 111) The rule of personal liability means: scenario. A. Every person is liable for his own tortuous 116) Which statement best describes morality? conduct A. Being dependent on the 4 Principles of B. The staff and supervisor are both answerable behavior C. Ignorance of the law excuses no one. B. Commitment to an individual value system. D. Nobody is above the law C. Adherance to defined institution defined rules 112) Carmela, a registered nurse, performed of behavior venipuncture. The client complained of severe pain D. Adherance to specific Codes of Conduct and hematoma around the puncture site. Carmela 117) When a nurse makes a decision based on the was being charged of malpractice because of the reasoning that "good consequences will outweigh following: bad consequences" she is following which theory? A. Supervision was not sought by Carmela A. Utilitarian theory B. Carmela was in charge of the patient B. Moralist theory C. Carmela did not perform the procedure with C. Formalist theory due care D. Deontological theory D. Carmela did not currently certified as IV 118) During the nurse tour of duty, very often they therapist are confronted with ethical dilemma. In their 113) The doctor's order is "Garamycin 1 gm IV decision making, which of the following would initially after a negative skin test; then 500 mg IV require application of the Principle of Beneficence? push every 6 hours for 23 days". The order was A. A confused 70 year old lady needs restraints countersigned by the head nurse. When the doctor for protection from fall even if this makes her made his rounds the following day, he found out more agitated that 1 gm Garamycin was given IV push every 6 B. A young father of three boys with advanced hours. Which among the following may be held lung cancer asks that all known regimen be liable? done to prolong his life despite no A. The head nurse and the nurse who gave the improvement. first dose for having erroneously transcribed C. A young patient who has asked not to receive the order. tube feeding due to intense pain. B. All the nurses who administer the drug every D. A 3rd day post cholecystectomy client requests six hours narcotic injection every 4 hours. C. Only the head nurse under the principle of 119) A client who is under your care is with a "DO command responsibility NOT RESUSCITATE" order. The patient requires D. All nurses involved including the head nurse. frequent dose of narcotic for excruciating pain. 114) Clients are sensitive of the kind of patient- After the client request for pain medication the nurse relationship they observe during their nurse assessed a decreasing respiratory rate. The confinement in the hospital. Which health worker most appropriate action of the nurse would be to; behavior would likely prompt a client to file a case A. Ask the client to wait some more minutes and in court against a health care worker even with the reassess the respiratory rate. SLIGHTEST form of misconduct? B. Give a fraction of the prescribed dose Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 11 C. Give pain medication as requested by the 125) The staff nurses were called to a meeting by client the Unit Manager because she observed during the D. Withhold the pain medication until the doctor past two weeks that nurses’ documentation were is contacted incomplete. To ensure improvement of the process 120) One of your terminally ill clients ask you if she of documentation, which of the following is the is dying. Which of the following is the MOST MOST appropriate purpose of the meeting? appropriate action of the nurse? A. Enumerate all types of errors in documentation A. confer with the family first B. Identify the nurses who need training for B. provide the true information to the client documentation C. consult to the attending physician C. Brainstorm on probable causes of non- D. refer to chaplain conformance D. Develop new system to identify non- Situation: In the Intensive Care Unit, effective conformance to documentation utilization of management principles is very important because of the critical needs of the patients. MEDICAL-SURGICAL NURSING 121) The afternoon shift nurse receives Situation: Thelma, a mother of a 6-year-old boy endorsement from the morning shift nurse. Which Marco has arrived at school to take her child home of the following complaints will an incoming nurse because the school nurse James has verified that he attend to FIRST? has inflamed throat. Nurse James urges his mother to A. Pain unrelieved by pain medication given an seek treatment because if the causative agent is beta hour ago hemolytic streptococcus, he may develop a disorder B. Urine drainage bag not emptied characterized by inflamed joints, fever, and the C. Infiltrated intravenous infusion possibility of endocarditis. D. Nasal prong for oxygenation pulled-out by 126) Which of the following would be the possible patient disorder? 122) The ICU unit Manager observed increased A. Tetanus C. Scarlet fever incidence of absences among the staff nurse during B. Rheumatic fever D. Influenza the last two weeks schedule. Which of the 127) Alice’s mother question whether her other following is the MOST appropriate action of the children can catch the same disease. Which of the Unit Manager to solve the identified problem? following should be the nurse’s response? A. Assign those who were absent on morning shift A. Your other children should be taking antibiotics B. Implement disciplinary action per hospital to prevent them from catching the same policy disease. C. Talk to the staff nurses concerned individually B. It is caused by an autoimmune reaction and is D. Identify causes of absences not contagious. 123) A newly hired staff nurse approached the C. You appear concerned that your daughter’s charge nurse and asked to be taught regarding disease is contagious. pulmonary wedge pressure reading. She has not D. The fact that you brought Alice to the hospital done the procedure before. Which of the following early enough will decrease the chance for is the MOST appropriate action of the charge siblings getting it. nurse? 128) In addition to carditis, which of the following A. Let the staff nurse do the procedure and should the nurse assess the child? It should be for observe the presence of______. B. Do the procedure while the staff observes A. Olguria and edema C. Assist the staff nurse while she performs the B. Malabsorption and diarrhea procedure C. Arthralgia and low grade fever D. Start the procedure and let the staff nurse D. Bronchitis and pneumonia finish it. 129) After throat swab for culture and sensitivity, 124) The relative of the patient complained to the the nurse would expect the physician to prescribe charge nurse. She requested that the staff nurse be an appropriate antibiotic. Which of the following is changed. Which of the following should the charge the purpose of the medication? It is to prevent nurse do FIRST? A. Recurrence C. Inhalation A. Have another nurse work with the staff nurse B. Transmission D. Inflammation concerned 130) If left untreated, such condition can progress B. Talk the staff nurse concerned to which of the following compilations? C. Relieve the staff nurse A. Kidney failure D. Talk to the patient B. Left-sided heart failure C. Right-sided heart failure D. Angina pectoris Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 12 Situation: Rowena is a student nurse who has been sternum. suspected to have a mitral valve prolapsed (MVP) C. Determine if the person can make any verbal during the annual physical examination of students sounds. enrolled in X university. She was referred to a D. Hit the middle of the person’s back firmly. cardiologist for further work-up. You are assigned to 137) You prepare to perform the Heimlich take care of her. maneuver on the conscious adult male. What are 131) As a nurse, which of the following do you the steps to be followed? Arrange the procedure in expect to be manifested by Rowena as an early sequence. sign of Mitral Valve prolapsed during your physical (1) Place the thumb side of the first just above the assessment? A _____. umbilicus and well below the xiphoid process. A. Diastolic click of the valve leaflet as a result of (2) Make a fist. the ballooning of the right atrium (3) Stand behind the victim. B. Diastolic click of the valve leaflet as a result of (4) Place arms around the victim’s waist. the ballooning of the left atrium (5) Perform five quick in and up thrust (between C. Systolic click of the valve leaflet as a result of the umbilicus and xiphoid process). the ballooning of the left atrium A. 2, 5, 3, 4, 1 C. 4, 3, 1, 2, 5 D. Systolic click of the valve leaflet as a result of B. 1, 2, 3, 4, 5 D. 3, 4, 2, 1, 5 the ballooning of the right atrium 138) If the victim is unconscious, the sequence is: 132) The patient remains to be asymptomatic for six (1) Place the heel of one hand on top of the other months and was very carefree in complying with between the umbilicus and xiphoid process. the preventive measures instructed by the health (2) Straddle the victim’s thighs. team. Choose from the following the signs and (3) Give five thrusts in and up with the heel of the symptoms that you further expect from Rowena to bottom hand. manifest. (4) Make a first. (1) Fatigue (4) Anxiety A. 1, 2, 3 C. 2, 1, 3 (2) Dizziness (5) Shortness of breath B. 1, 2, 3, 4 D. 2, 4, 1, 3 (3) Palpitation 139) When you perform abdominal thrusts during A. 3, 4 & 5 C. 3 & 4 the Heimlich maneuver, you are trying to _____ B. 1 & 2 D. 1, 2, 3, 4 & 5 A. Procedure a burp to expel the foreign body 133) The BEST approach in assessing the EARLY sign B. Pump the heart to push air out of the lungs of Mitral valve prolapse is through ______. C. Produce a rush of air that expels the foreign A. Percussion C. Inspection body B. Palpation D. Auscultation D. Put pressure on the stomach to expel the 134) When an individual is suffering from MVP like foreign body Rowena you should emphasize to her to AVOID the 140) If the victim is pregnant or obese, which following EXCEPT modification of the Heimlich maneuver would be A. Smoking C. Caffeine appropriate for this person? B. Alcoholic beverages D. Light exercises A. Thrust against the middle of the sternum 135) One of the nursing diagnoses that you have rather than between the umbilicus and xiphoid included in your care plan for Ms. Rowena is process. “Excess volume R/T decreased Cardiac output B. Perform thrust gently, rather than forcefully, secondary to valvular disease.” Which of the and discontinue the thrusts after 6 tries, if following is the POTENTIAL outcome if medical and unsuccessful. nursing interventions have been effectively C. Place the fist with the pinkie finger, rather than implemented? the thumb against the person’s body. (1) Adequate fluid volume is maintained. D. Perform the thrusts with the person in the (2) Vital Signs within normal limits. supine, rather than standing position. (3) Clear lung sounds. (4) Pulmonary congestion absent. Situation: In a normal health center activity, your task A. 1, 2 & 3 C. 1 & 2 includes health assessment of several clients. B. 2 & 3 D. 1, 2, 3 & 4 141) You are doing breast assessment on a post- menopausal woman. In your assessment, what Situation: You and your friends are enjoying a quiet finding warrants further attention? meal in restaurant. Suddenly you noticed that an A. Presence of striae and superficial veins noted adult male customer was holding his throat and in both breasts apparently choking on his food. B. Left breast slightly smaller compared with the 136) You approach the person who is apparently right breast choking. What should you do FIRST? C. Inverted nipples A. Sweep the person’s mouth with your finger. D. Small dimple palpated in the upper outer B. Apply sharp upward thrusts over the person’s quadrant of the right breast Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 13 142) You are counseling a 52-year old client 149) Oxygen administration at 2 L/min through regarding hormone replacement therapy (HRT). A nasal cannula is prescribed for this client. When physician needs to be notified when she the client asks why he needs oxygen therapy, your experiences: most appropriate response is that in his condition A. Vaginal dryness C. Leg pain low oxygen level serves to: B. Hot flashes D. Urinary frequency A. Eliminate respiratory drive 143) Which of the following observations will make B. Balance carbon dioxide content you suspect that the client may have osteoporosis? C. Restore normal breathing pattern A. Change in posture D. Act as stimulus for breathing B. Decrease in height 150) The nurse teaches the client how to conserve C. Recent fracture due to trauma energy. To meet this goal the nurse instructs the D. Complaints of joint pain client to: 144) You are doing history taking on a post- A. Exhale then inhale with pursed lips when lifting menopausal woman. One risk factor to watch out objects for that is associated with breast cancer is: B. Inhale then exhale with pursed lips when lifting A. Nulliparity C. Late menarche objects B. Age less than 40 D. Early menopause C. Draw a deep breath through pursed lips when 145) Further evaluation of a 64 years old lifting objects menopausal who is NOT on hormone replacement D. Blow slowly through pursed lips when lifting therapy (HRT) is warranted when she complains of: objects A. Thinning of the public hair B. Vaginal bleeding Situation: Physical examination is performed to C. Loss of vaginal lubrication gather comprehensive pertinent assessment data. D. Low back pain Health history ascertains the client’s complaints and directs the focus of physical examination. Situation: The nurse is taking care of a 45 year old 151) While taking the health history of the client, male client diagnosed with chronic obstructive she tells the nurse that she has occasional episodes pulmonary disease (COPD). of palpitations that would last for about 45 146) The client has difficulty raising respiratory minutes to an hour. To further explore this secretions. Which of the following actions should information, the BEST question that the nurse the nurse perform to reduce the tenacity of the would ask the client would be: secretions? A. “What are you doing or what’s going on A. Serve low salt low fat diet around you when this happens?” B. Encourage fluid intake from 2 to 3 liters per B. “Does the heart problem occur at any specific day time of the day?” C. Maintain client semi-Fowler’s position C. “Are there other symptoms you experience D. Administer oxygen inhalation along with this?” 147) The client asks the nurse why postural drainage D. “How frequently does this episode of the is ordered by the physician. The nurse informs the palpitation happen to you?” client that this procedure is done to: 152) A female client is in the emergency unit with A. Move secretions from lower to the upper chief complaints of difficulty of breathing and is segment of the lungs improve respiration by receiving oxygen inhalation. To obtain a complete cleaning the alveoli health history of the client, the BEST nursing B. Improve respiration by clearing the alveoli approached is to: C. Help decongest the lungs through drainage of A. Call family members to provide additional all lung segments information about the client D. Facilitate drainage after percussion has B. Focus on the physical examination and obtain loosened the secretions other data from the client 148) The nurse knows that the principle used in C. Have several short sessions with the client to postural drainage, cause the secretions to move gather data needed. through: D. Use medical history taken by the physician A. Sweeping motion during respiration 153) A client has just transferred to the surgical unit B. Force of gravity after a knee surgery. The nurse needs to assess the C. Pleural space to the apical lung segment circulation of the right lower leg. Which of the D. Anterior to posterior lung segment following is the INITIAL approach of the nurse? A. Inspect color of the foot. B. Check pedal pulse with your fingertips C. Take the blood pressure at the ankle D. Touch affected leg to check temperature Compiled by: PEAK EXCELLENCE REVIEW CENTER, INC **This material is printed for the exclusive use of the students of PEAK EXCELLENCE REVIEW CENTER, INC. taking the PEAK SURE PASS PROGRAM. Any illegal reproduction of this material or acts of the same nature is prohibited.  PEAK EXCELLENCE REVIEW CENTER, INC. 14 154) While performing a physical examination to an A. Participates willingly in the preoperative 82 years old male client, the nurse modifies her preparation examination to consider the client’s general B. Verbalizes his or her fears to the family and weakness and reduce ability to move in the bed. significant others Which of the following is the MOST appropriate C. Ask if he/she will be awake during surgery nursing action? D. Expresses concern about postoperative pain A. Sequencing the examination to minimize 160) Because clients who undergo anesthesia or changing client’s position. moderate sedation experience temporary B. Speaking loudly and close to the ear when sensory/perceptual alteration or loss, the nurse talking to client MOST critical