2. When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize?

3. Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic cause of hypovolemic shock?

4. The student nurse overheard the doctor the different types of shock and ask his clinical instructor about what differentiate circulatory shock from hypovolemic shock. The clinical instructor is correct if he says:

5. The nurse is administering heparin, subcutaneous twice daily, for a patient in cardiogenic shock. The expected action of this drug is as:

Situation:Case:Mr. Ruben, a chronic smoker with malignant growth on the glottis of larynx, is admitted to the hospital for external radiation followed by a total laryngectomy.

6. Mr. Ruben is receiving external radiation therapy and develops anemia, he complains of fatigue and malaise. Which of the following nursing intervention would be most helpful for Miguel?

7. Immediately following the radiation therapy, Mr. Ruben is:

8. The nurse knows that the proper measurement of the size of oral airway to be inserted is done by doing the ff. technique:

9.The client was not weaned off the mechanical ventilator after 3 weeks. The doctors suggested. Tracheostomy tube insertion. The relatives are asking you why there is a need to replace an Endotracheal Tube with a Tracheostomy tube. What would be your best response?

10 .Mr. Ruben with tracheostomy connected to mechanical ventilator and NGT in placed is under your care. You are about to give feeding via NGT. Which of the ff. is NOT a nursing consideration before proceeding with the mentioned procedure?

SITUATION: Lora came to the Medical Center for parathyroidectomy for hyperparathyroidism. Her chief complains are fatigue and muscle weakness accompanied by pain.

11. While doing the admission history and assessment. The client asks the nurse if parathyroid and thyroid glands are the same. The CORRECT response of the nurse is:

12. During the history taking Lora states that she is taking Furosemide (Lasix). You understand that the indication of the medication is to:

13. A nurse develops a plan of care for a client with hyperparathyroidism who is receiving calcitonin salmon (Calcimar). Which of the following outcome criteria has the highest priority regarding this medication?

14. A nurse is preparing to care for a client following

Parathyroidectomy. The nurse plans care anticipating which postoperative order?

15. Which of the following assessment would warrant the nurse that the patients is experiencing complication related to parathyroidectomy?

Situation: Which of the ff. would the nurse identify as the most appropriate nursing diagnosis and normal value.

16. For 70 year old client undergoing surgery with general anesthesia during which the ambient OR temperature is 68 F(20C), which of the following nursing diagnosis is related to this?

17. Post chemotherapy, the patient’s RBC count reveals 3 million per cubic mm. which potential problem may be related to this finding?

18. The adult client who has had preadmission testing before surgery has had blood drawn for determination of serum electrolytes. The nurse would report which of the ff. abnormal values to the surgeon’s office preoperatively.

19. CBC reveals thrombocyte count of 65,00/cu mm. Nursing care related to this findings is:

20. White blood cells count reveals 2500/cumm. Nursing care related to this finding is:

SITUATION: A nurse who successfully passed the Nurse Licensure Examination (NLE) is a registered nurse (R.N). She is responsible and accountable for his/her or inaction and decision or indecision. The ff. questions apply?

21. Which of the ff. statements CORRECTLY describes the primary role of the nurse regarding the clients consent to surgery?

22. The nurse is about to administer the pre-anesthetic medication to a 60 years old client when the client asks the nurse, “Will I be able to see right away after my eye surgery?” The MOST appropriate response of the nurse would be:

23. You are the nurse in charge of receiving clients for surgery from the surgical units. When you greeted the client for bilateral thyroidectomy, she told you to please keep her dentures. So that you will not be liable of any loss or destruction of client’s property you will do which of the MOST appropriate action?

24. Immediately following thyroidectomy, the patient must be monitored for:

1. Increased BP

2. Signs of Respiratory Obstruction

3. Severe Hoarseness of the voice

4. Elevated Body Temperature

25. A pregnant patient is receiving treatment for hyperthyroidism. Which of the following medications would Nurse Daniel expect to see?

SITUATION: Nurse Marie is caring for different patient who has Diabetes Mellitus. One of them just came in from the Recovery Room after an amputation on the right foot below on knee.

26 .When Marie made her rounds, the client complained of severe pain. The client has prescription of an every four hour narcotic. The last dose of the narcotic was given 3 hours ago. The PRIORITY action of the nurse is to:

27. The client verbalized to the nurse, “Could you please check on my twisted right foot? I have so much pain on my right leg.”

28. The Nurse demonstrated the correct stump-wrapping from the distal to the proximal extremity in preparation for the patient’s discharge. This is intended to prevent pooling of fluid by:

29. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?

30. A client with type 1 DM has a blood glucose level of 554 mg/dl. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance?

Situation: Barbara, 34 years old is admitted to the hospital with a diagnosis of renal stones. She is experiencing severe flank pain, nauseated and with temperature of 40°C

31.Which is the most immediate goal of the nurse would be given the above observations and assessment

32.While inserting a foley catheter to a client, you noticed that there is no urine flow. When you checked it, the catheter is in the vagina. What will you do?

33. Where would you tape Barbara's indwelling catheter in order to reduce urethral irritation?

34. After IVP, renal stone was confirmed, the doctor’s order states "daily urine specimen to be sent to the laboratory". Barbara has a Foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

35. Barbara is scheduled to undergo extracorporeal shockwave lithotripsy (ESWL), nursing responsibilities after the procedure should include which of the following, select all that applies:

I. Change soaked dressing at a regular basis

II. Careful monitoring for bleeding at the incision site

III. Notifying the physician if signs of infection was noted at the incision site

IV. Strain the patient’s urine

SITUATION: Bessie, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing.

36. The primary purpose for reviewing literature is to:

37. Billy Bong is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following articles would Billy Bong least consider for his review of literature?

38. In formulating the research hypotheses, researcher Bessie should state the research question as:

39. The proposed study shows the relationship between the variables. Which of the following Is the independent variable?

40. Bessie needs to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT:

Situation: Care for the client with Guillain-Barre Syndrome (GBS)

41. Which conditions or factors in a middle-aged woman diagnosed with Guillain-Barré syndrome are most likely to have contributed to this problem?

42. The client has been diagnosed to have Guillain-Barre Syndrome (GBS). Which of the following should the nurse include in the nursing care plan of the client?

43. Which of the following problems in a client with Guillain-Barre Syndrome (GBS) should be given highest priority by the nurse?

44. Which of the following nursing interventions would be included in the care plan for a patient with Guillain-Barre Syndrome (GBS)?

45 .A patient with Guillain-Barre Syndrome (GBS) has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to:

SITUATION: The vague nature of many gastrointestinal symptoms makes diagnosis of GI problems quite difficult. A complete patient history and an adequate physical examination are necessary in order to gather as much information as possible. Although this is routinely done by the admitting physician, a nursing assessment must be completed as well.

46. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse’s best action?

47. A client with chron’s disease says, "I feel so much better now that I've stoppedeating." The nurse realizes that this client is at risk for:

48. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to:

49. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has ulcerative colitis rather than Crohn’s disease when the patient reports experiencing:

50 .Crohn’s disease and ulcerative colitis have similarities and differences. Which of the following statements is accurate about these disorders?

Situation: Nurse Evelyn is on her first duty day in the Left Wing Ward and was given a task of taking care of patients with different condition

51.Richard is scheduled for a kidney transplant. During Nurse's Evelyn's assessment and health teaching, Richard asks how long will he take azathioprine (Imuran), cyclosporine and prednisone. Nurse Evelyn would know that Richard understood the teaching when he states: "I must take these medications....

52 .In the Recovery Room, Nurse Evelyn observes Richard for signs of organ rejection which includes:

53 . When Evelyn administer 1 liter of Dextrose 5% in water to infuse over * hours to her clients, which of the ff. will she consider as a specific precautionary measure to ensure that the right dose is administered to the right client?

54.In a semi-private ward of four patients, which of the ff. clients would Nurse Evelyn move out FIRST in case of fire?

Situation:A nurse is providing discharge instructions to the mother of an 4-year-old child who had a tonsillectomy.

55.The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, the appropriate response to the mother is:

56. The physician has ordered a clear liquid diet for the child. Which items should the nurse include on the child’s lunch tray? (Select all that apply)

1.Broth

2.Apple juice

3.Lemon juice

4.Milk

5.Ice cream

6.Gelatin

57. Following tonsillectomy, the nurse should put the client in which of the following positions?

58. Which of the following indicates that the nurse understands the most indicative way to assess hemorrhage on a conscious client post tonsillectomy:

59.Which of the following is a characteristic of a Chronic Tonsillitis which generally requires removal of the tonsils?

Situation 14 – You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession.

60.Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an:

61. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:

62. As you become socialized into the nursing “culture” you become a patient advocate. Advocacy is explained by the following EXCEPT:

63.Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a:

64. You join a continuing education program to help you:

Situation 17 – You are taking care of Mrs. Santillan a 48 year old woman who is unconscious after a cerebrovascular

accident. You are aware that there are many physical complications due to immobility.

65. You should be alert for the following complications she may experience EXCEPT:

66. Proper positioning of an immobilized unconsciousness client is important for the following reasons EXCEPT:

67. When positioning your client, you should observe good body mechanics for yourself and the client. This means that the nurse:

68. You are going to move Mrs. Santillan, a 150 lbs unconscious woman. Some principls to use when moving the client include the following EXCEPT:

69. After moving Mrs. Santillan to the desired position, which action will you avoid?

70. Items that enter sterile tissue or vascular system are categorized as critical items and should be:

71. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection?

72. Before you use a disinfected instrument it is essential that you:

73. You have a critical heat labile instrument to sterilize and are considering touse high level disinfectant. What should you do?

74. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin should be:

Situation: Compliance to the standards of safe intravenous therapy is essential to the nursing practice. The following questions pertain to these.

75. Which of the following if noted during IV insertion would indicate to refrain from advancing the catheter?

76. While on duty, the nurse assessed a client’s intravenous line and notes that the area is swollen, cool, pale, and causes client’s discomfort. Nurse Ken should document this as to which of the following complications of IV therapy?

77. The client is receiving 5% dextrose and 0.45% sodium chloride intravenously and is complaining of pain at the IV site. Nurse Ken assessed the site and noted erythema and edema. Which of the following would be his appropriate nursing action?

78. Nurse Ken is starting a new peripheral intravenous (IV) line in a client. The client reports a latex allergy. Nurse Kenneth has a typical IV start kit. Because of the latex allea. Obtain a new tourniquet

79. The doctor’s order regarding IV infusion should include the ff:

Situation: Mrs. Tan, a 37-year-old cook, was brought to the ER due to partial and full thickness burns of her right lower extremity, buttocks, 2 palm size on the chest and the anterior right upper extremity. Her respiratory status is compromised and she is in pain and anxious.

80. When Mrs. Tan arrives in the ER, the nurse’s first responsibility should be to:

81. Performing an immediate appraisal using the Rule of Nine. The nurse estimates the percent of body surface that is burned is:

82. The nurse applies Mafenide Acetate (Sulfamylon Cream) to the burned area. This medication will:

83. A temporary heterograft (pig skin) is used on some of Mrs. Tan’s burns. These grafts will:

a. Debride necrotic epithelium

84. Provided that mrs. Tan weighs 187lbs, using the Baxter-Parkland formula compute for the solution to be infused for 24hr period for fluid resuscitation?

Situation: Nurse Alvin is assigned in the medical ward and is caring for Ben, a 5-year-old child diagnosed with glomerulonephritis. He is providing health teachings to Leo’s mother regarding the disease.

85. Nurse Alvin is aware that in most cases, the major stimulus to acute glomerulonephritis is:

86. Ben is to undergo series of laboratory exams. Nurse Alvin expects that Ben’s laboratory findings will reveal:

87. Which of the following interventions might be most effective in preventing glomerulonephritis?

88. Nurse Alvin would most likely note which of the following in a child with acute glomerulonephrritis?

89. Nurse Alvin is correct when he states that the agent of choice when residual streptococcal infection is suspected is:

Situation: Nurse Bet is assigned in caring for a client who is receiving total parenteral nutrition as part of her treatment. She is reviewing the nursing considerations involved to competently provide parenteral nutrition to this client.

90. Clients suffering from profound malnutrition may experience the refeeding syndrome when first initiating total parenteral nutrition (TPN). To determine if this occurs, Nurse Bet must do which of the following?

91. Prior to hanging a total parenteral nutrition, Nurse Bet checks the content of the solution. Which of the following ingredients would she expect to be included?

1. Trace minerals

2. insulin

3. Electrolytes

4. Macronutrients

5. Glucose

92. A client is receiving an infusion of TPN at 83 mL/hr. The infusion is stopped for 4 hours while client is off the nursing unit. When the client returns, the standing order indicates the infusion should be started at a rate of 10% greater than the baseline rate. The infusion should be run by Nurse Bet at ___ mL/hr.

93. A runaway TPN solution contains 25% glucose. Which of the

following is an expected solution to replace the TPN if another TPN solution is not available?

94. A client with IBD is receiving TPN. When administering TPN the nurse must take care to maintain the prescribed flow rate because giving TPN too rapid may cause:

Situation: Mrs. Cruz, a 44-year-old client, was admitted at Bulacan Medical Center after having been diagnosed with cholelithiasis. She underwent cholecystectomy and is transferred to the surgical ward where Nurse Lyn is assigned to care for her.

95. Mrs. Cruz was admitted three days prior to cholecystectomy. Which of the following new assessment findings indicates to Nurse Lyn that the stone has probably obstructed the common bile duct?

96. Nurse Lyn anticipates that Mrs. Cruz’s laboratory test results will show an elevation in which of the following?

97. In caring for Mrs. Cruz 4 days post-cholecystectomy, Nurse Lyn notices that the drainage from the T-tube is 600 mL in 24 hours. Which is the appropriate action by Nurse Lyn?

98. The husband of the post-cholecystectomy client asks the nurse when the T-tube will be removed. Which of the following responses by Nurse Lyn would be appropriate?

99. How will Nurse Lyn position Mrs. Cruz who have had T-tube placement?

100.A client is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered: