Professional Documents
Culture Documents
Situation I: Leo lives in the squatter area. He goes to nearby school. He helps his
mother gather molasses after school. One day, he was absent because of fever,
malaise, anorexia, and abdominal discomfort.
10. The use of another person’s ideas or workings without giving appropriate
credit results from inaccurate or incomplete attribution of materials to its
sources. Which of the following is referred to when another person’s idea is
inappropriately credited as one’s own?
a. Plagiarism
b. Quotation
c. Assumption
d. Paraphrase
Situation 3: Mrs Pichay is admitted to your ward. The MD ordered “prepare for
thoracentesis this pm to remove excess air from the pleural cavity.”
11. Which of the following nursing responsibilities is essential in Mrs. Pichay who
will undergo thracentesis?
a. Support and reassure client during the procedure
b. Ensure that informed consent has been signed
c. Determine if client has allergic reaction to local anesthesia
d. Ascertain if chest x-rays and other tests have been prescribed and completed
12. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the
following positions?
a. Trendelenburg position
b. Supine position
c. Dorsal recumbent position
d. Orthopneic position
13. During thoracentesis, which of the following nursing intervention will be most
crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advise patient to sit perfectly still during needle insertion until it has been
withdrawn from the chest
d. Apply pressure over the puncture site as soon as the needle is withdrawn
14. To prevent leakage of fluid in the thoracic cavity, how will you position the
client after thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
15. Chest x-ray was ordered after thoracentesis. When your client asks what is
the reason for another chest x-ray, you will explain
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body
Situation 4: A computer analyst, Mr. Ricardo J. Santos, 25, was brought to the
hospital for diagnostic workup after he had experienced seizure in his office.
16. Just as the nurse was entering the room, the patient who was sitting on his
chair begins to have a seizure. Which of the following must the nurse do first?
a. Ease the patient to the floor
b. Lift the patient and put him on the bed
c. Insert a padded tongue depressor between his jaws
d. Restrain patient’s body movement
17. Mr. Santos is scheduled for CT Scan for the next day, noon time. Which of
the following is the correct preparation as instructed by the nurse?
a. Shampoo hair thoroughly to remove oil and dirt
b. No special preparation is needed. Instruct the patient to keep his head still
and steady
c. Give a cleansing enema and give fluids until 8AM
d. Shave scalp and securely attach electrodes to it
18. Mr. Santos is placed on seizure precaution. Which of the following would be
contraindicated?
a. Obtain his oral temperature
b. Encourage to perform his own personal hygiene
c. Allow him to wear his own clothing
d. Encourage him to be out of bed
19. Usually, how does the patient behave after his seizure has subsided?
a. Most comfortable walking and moving about
b. Becomes restless and agitated
c. Sleeps for a period of time
d. Say he is thirsty and hungry
20. Before, during and after seizure, the nurse knows that the patient is ALWAYS
placed in what position?
a. Low fowler’s
b. Modified trendelenburg
c. Side lying
d. Supine
21. Choledocholithotomy is
a. The removal of the gallbladder
b. The removal of the stones in the gallbladder
c. The removal of the stones in the common bile duct
d. The removal of the stones in the kidney
22. The simplest pain relieving technique is
a. Distraction
b. Taking aspirin
c. Deep breathing exercise
d. Positioning
Situation 6: You are assigned at a surgical ward and clients have been
complaining of post pain at varying degrees. Pain as you know is very subjective.
27. Pentoxidone 5mg IV every 8 hours was prescribed for post-abdominal pain.
Which will be your priority nursing action?
a. Check abdominal dressing for possible swelling
b. Explain he proper use of PCA to alleviate anxiety
c. Avoid overdosing to prevent dependence/tolerance
d. Monitor VS, more importantly RR
28. The client complained of abdominal distention and pain. Your nursing
intervention that can alleviate pain is?
a. Instruct client to go to sleep and relax
b. Advise the client to close the lips and avoid deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too much talking
29. Surgical pain might be minimized by which nursing action in the O.R.?
a. Skill of surgical team and lesser manipulation
b. Appropriate preparation for the scheduled procedure
c. Use of modern technology in closing the wound
d. Proper positioning and draping of clients
30. Inadequate anesthesia is said to be one the common cause of pain both in
intra and post op patients. If general anesthesia is desired, it will involve loss of
consciousness. Which of the following are the 2 general types of GA?
a. Epidural and spinal
b. Subarachnoid block and intravenous
c. Inhalation and regional
d. Intravenous and inhalation
Situation 7: Nurse’s attitudes toward the pain influence the way they perceive
and interact with clients in pain.
31. Nurses should be aware that older adults are at risk of underrated pain.
Nursing assessment and management of pain should address the following
beliefs EXCEPT:
a. Older patients seldom tend to report pain than the younger ones
b. Pain is a sign of weakness
c. Older patients do not believe in analgesics, they are tolerant.
d. Complaining of pain will lead to being labeled a “bad” patient
33. You are the nurse in the pain clinic where you have client who has difficulty
specifying the location of pain. How can you assist such clients?
a. The pain is vague
b. By charting it hurts all over
c. Identify the absence and presence of pain
d. Ask the client to point to the painful area by just one finger
34. What symptom more distressing than pain should the nurse monitor when
giving opioids especially among elderly clients who are in pain?
a. Forgetfulness
b. Constipation
c. Drowsiness
d. Allergic reaction like pruritus
35. Physical dependence occurs in anyone who takes opioid over a period of
time. What do you tell a mother of a ‘dependent’ when asked for advice?
a. Start another drug and slowly lessen the opioid dosage
b. Include in recreational outdoor activities
c. Isolate opioid dependent to a restful resort
d. Instruct slow tapering of the drug dosage and alleviate physical withdrawal
symptoms
36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her
performance when she
a. Draw insulin from the vial of clear insulin first
b. Draw insulin from the vial of the intermediate acting insulin first
c. Fill both syringes with the prescribed insulin dosage then shake the bottle
vigorously
d. Withdraw the intermediate acting insulin first before withdrawing the short
acting insulin first
38. Janevi administers regular insulin at 7 am and the nurse should instruct Jane
to avoid exercising at around
a. 9 – 11 am
b. After 8 hours
c. Between 8 am to 9 am
d. In the afternoon after taking lunch
39. Janevi was brought at the emergency room after four months because she
fainted in her clinic. The nurse should monitor which of the following test to
evaluate the overall therapeutic compliance of a diabetic patient?
a. Glycosylated hemoglobin
b. Fasting blood glucose
c. Ketone levels
d. Urine glucose levels
40. Upon the assessment of Hba1c of Mrs. Segovia, the nurse has been informed
of a 9% Hba1c result. In this case, she will teach the patient to:
a. Avoid infection
b. Take adequate food and nutrition
c. Prevent and recognize hyperglycemia
d. Prevent and recognize hypoglycemia
41. The nurse is teaching a plan of care for Jane with regards to proper foot
care. Which of the following should be included in the plan?
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet but not between the toes
d. Always have a podiatrist to cut your toe nails. Never cut them yourself
43. Jane eventually developed DKA and is being treated in the emergency room.
Which finding would the nurse expect to note as confirming this diagnosis?
a. Comatose state
b. Decreased urine output
c. Increased respiration and an increase in pH
d. Elevated blood glucose level and low plasma bicarbonate level
44. The nurse teaches Jane to know the difference between hypoglycemia and
ketoacidosis. Jane demonstrates understanding of the teaching by stating that
glucose will be taken if which of the following symptoms develops?
a. Polyuria
b. Shakiness
c. Blurred vision
d. Fruit breath odor
45. Jane has been schedule to have a FBS taken in the morning. The nurse tells
Jane not to eat or drink after midnight. Prior to taking the blood specimen, the
nurse noticed that Jane is holding a bottle of distilled water. The nurse asked
Jane if she drank any, and she said “yes.” Which of the following is the best
nursing action?
a. Administer syrup of ipecac to remove the distilled water from the stomach
b. Suction the stomach content using NGT prior to specimen collection
c. Advise to physician to reschedule to diagnostic examination next day
d. Continue as usual and have the FBS analysis performed and specimen be
taken
46. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging?
a. Ineffective airway clearance
b. Decreased alveolar surfaced area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation
48. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
a. Dementia
b. A visual problem
c. Functional decline
d. Drug toxicity
50. The most dependable sign of infection in the older patient is:
a. Change in mental status
b. Fever
c. Pain
d. Decreased breath sounds with crackles
Situation 10: in the OR, there are safety protocols that should be followed. The
OR nurse should be well versed with all these to safeguard the safety and quality
of patient delivery outcome.
51. Which of the following should be given highest priority when receiving
patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure, and dentures
52. Surgeries like I and D (incision and drainage) and debridement are relatively
short procedures but considered ‘dirty cases’. When are there procedures best
scheduled?
a. Last case
b. In between cases
c. According to availability of anesthesiologist
d. According to the surgeon’s preference
53. OR nurses should be aware that maintaining the client’s safety is the overall
goal of nursing care during the intraopertive phase. As the circulating nurse, you
make certain that throughout the procedure
a. The surgeon greets his client before induction of anesthesia
b. The surgeon and anesthesiologist are in tandem
c. Strap made of strong non-abrasive materials are fastened securely around the
joints of knees and ankles and around the 2 hands around an arm board
d. Client is monitored throughout the surgery by the assistant anesthesiologist
54. Another nursing check that should not be missed before the induction of
general anesthesia is
a. Check for presence of underwear
b. Check for presence of dentures
c. Check patient’s ID
d. Check baseline vital signs
55. Some lifetime habits and hobbies affect post-operative respiratory function.
If you client smokes 3 packs of cigarettes a day for the past 10 years, you will
anticipate increased risk for
a. Perioperative anxiety and stress
b. Delayed coagulation time
c. Delayed wound healing
d. Post-operative respiratory infection
56. There are 3 general types of sterilization used in the hospital. Which one is
not included?
a. Steam sterilization
b. Chemical sterilization
c. Sterilization
d. Sterilization by boiling
60. If a nurse will sterilize a heat and moisture labile instrument, it is according
the AORN recommendation to use which of the following method of sterilization?
a. Ethylene oxide gas
b. Autoclaving
c. Flash sterilizer
d. Alcohol immersion
61. Which of the following role would be the responsibility of the scrub nurse?
a. Assess the readiness of the client prior to surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges, needles, supplies used during the surgical
procedure
d. Evaluate the type of anesthesia appropriate for the surgical client
62. As a peiroperative nurse, how can you best meet the safety need of the
client after administering pre-operative narcotic?
a. Put side rails up and ask the client not to get out of bed
b. Send the client to OR with the family
c. Allow client to get up to go to the comfort room
d. Obtain consent form
63. It is the responsibility of the pre-op nurse to do skin prep for patient
undergoing surgery. If hair at the operative site is not shaved, what should be
done to make suturing easy and lessen chance of incision infection?
a. Drape
b. Pulled
c. Clipped
d. Shampooed
65. Which of the following nursing interventions is done when examining the
incision would and changing the dressing?
a. Observe the dressing and type and odor of drainage if any
b. Get patient’s consent
c. Wash hands
d. Request the client to expose the incision wound
Situation 13: The pre-operative nurse collaborates with the client significant
others, and healthcare providers.
66. To control environmental hazards in the OR, the nurse collaborates with the
following departments EXCEPT:
a. Biomedical division
b. Chaplaincy services
c. Infection control committee
d. Pathology department
67. An air crash occurred near the hospital leading to a surge of trauma patient.
One of the last patients will need surgical amputation but there are no sterile
surgical equipments. In this case, which of the following will the nurse expect?
a. Equipments needed for surgery need not be sterilized if this is an emergency
necessitating life saving measures
b. Forwarding the trauma client to the nearest hospital that has available sterile
equipments is appropriate
c. The nurse will need to sterilize the item before using it to the client using the
regular sterilization setting at 121 degree Celsius in 15 minutes
d. In such cases, flash sterilizer will be used at 132 degrees Celsius in 3 minutes
68. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs. prior to
surgery, is in severe pain 3 hours after cholecystectomy. Upon checking the
chart, Malou found out that she has an order of Demerol 100mg I.M. prn for
pain. Tess should verify the order with
a. nurse supervisor
b. anesthesiologist
c. surgeon
d. intern on duty
69. Rosie, 57, who is diabetic, is for debridement for incision of wound. When
the circulating nurse checked the present IV fluid, she found out that there is no
insulin incorporated as ordered. What should the circulating nurse do?
a. Double check the doctor’s order and call the attending MD
b. Communicate with the ward nurse to verify if insulin was incorporated or not
c. Communicate with the client to verify if insulin was incorporated
d. Incorporate insulin as ordered
71. If you are the nurse in charge for scheduling surgical cases, what important
information do you need to ask the surgeon?
a. Who is your internist?
b. Who is your assistant and anesthesiologist, and what is your preferred time
and type of surgery?
c. Who are your anesthesiologist, internist and assistant?
d. Who is your anesthesiologist?
72. In the OR< the nursing tandem for every surgery is:
a. Instrument technician and circulating nurse
b. Nurse anesthetist, nurse assistant, and instrument technician
c. Scrub nurse and nurse anesthetist
d. Scrub and circulating nurses
73. While team effort is needed in the OR for efficient and quality patient care
delivery, we should limit the number of people in the room for infection control.
Who comprises this team?
a. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
b. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
74. Who usually act as an important part of the OR personnel by getting the
wheelchair or stretcher, and pushing them towards the operating room?
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anesthesiologist
77. The physician orders the nurse to prepare an isotonic solution. Which of the
following IV solution would the nurse expect the intern to prescribe?
a. 5% dextrose in water
b. 10% dextrose in water
c. 0.45% sodium chloride
d. 5% dextrose in 0.9% sodium chloride
78. The nurse is making initial rounds on the nursing unit to assess if the
condition of assigned clients. The nurse notes that the client’s IV site is cool,
pale, and swollen and the solution is not infusing. The nurse concludes that
which of the following complications has been experienced by the client?
a. Infection
b. Phlebitis
c. Infiltration
d. Thrombophlebitis
79. A nurse reviews the client’s electrolyte laboratory report and notes that the
potassium level is 3.2 mEq/L. Which of the following would the nurse note on the
electrocardiogram as a result of the laboratory value?
a. U waves
b. Absent P waves
c. Elevated T waves
d. Elevates ST segment
82. Which of the following is not true with regards to the informed consent?
a. It should describe different treatment alternatives
b. It should contain a thorough and detailed explanation of the procedure to be
done
c. It should describe the client’s diagnosis
d. It should give an explanation of the client’s prognosis
84. A nurse is assigned to care for a group of clients. On review of the client’s
medical records, the nurse determined that which client is at risk for excess fluid
volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal suctioning
85. A nurse is assigned to care for a group of clients. On review of the client’s
medical records, the nurse determines that which client is at risk for deficient
fluid volume?
a. A client with colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound irrigation
Situation 16: As a perioperative nurse, you are aware of the correct processing
methods for preparing instruments and other devices for patient use to prevent
infection.
88. You have a critical heat labile instrument to sterilize and are considering to
use high level disinfectant. What should you do?
a. Cover the soaking vessel to contain the vapor
b. Double the amount of high level disinfectant
c. Test the potency of the high level disinfectant
d. Prolong the exposure time according to manufacture’s direction
Situation 17: The OR is divided into three zones to control traffic flow and
contamination.
92. Nursing intervention for a patient on low dose IV insulin therapy includes the
following EXCEPT:
a. Elevation of serum ketones to monitor ketosis
b. Vital signs including BP
c. Estimates serum potassium
d. Elevation of blood glucose levels
93. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going
IV. The strength is 500/ml. How much should you incorporate into the IV
solution?
a. 10 ml
b. 2 ml
c. 0.5 ml
d. 5 ml
95. Insulins using insulin syringe are given using how many degrees of needle
insertion?
a. 45
b. 180
c. 90
d. 15
97. 2 organizations endorsed that sterility are affected by factors other than the
time itself. These are:
a. The PNA and the PRC
b. AORN and JCAHO
c. ORNAP and MCNAP
d. MMDA and DILG
98. All of this factors affect the sterility of the OR equipments. These are the
following except:
a. The material used for packaging
b. The handling of the materials as well as its transport
c. Storage
d. The chemical or process used in sterilizing the material
ANSWER KEY:
1. A
2. B
3. B
4. C
5. A
6. B
7. B
8. B
9. B
10. A
11.D
12. D
13. C
14. B
15. A
16. A
17. B
18. A
19. C
20. C
21. C
22. D
23.C
24. D
25. B
26. A
27. D
28. D
29.B
30. D
31.C
32. B
33.D
34. D
35.D
36. A
37. B
38.A
39. A
40. C
41.C
42.C
43. D
44.B
45.D
46.B
47.D
48.C
49.D
50.C
51. B
52. A
53. C
54. D
55. D
56. D
57. D
58. A
59. B
60. A
61. C
62. A
63. C
64. A
65. A
66. B
67. D
68. C
69. A
70. C
71. B
72. D
73. B
74. A
75. D
76. D
77. A
78. C
79. A
80. C
81. A
82. B
83. A
84. B
85. A
86. A
87. D
88. D
89.D
90. D
91. B
92. A
93. B
94. A
95. A
96. C
97. B
98. D
99. D
100. B