Nursing Practice Iv - Care of Clients
September 17, 2022 | Author: Anonymous | Category: N/A
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NURSING PRACTICE IV – CARE OF CLIENTS
INSTRUCTION: Select the correct answer for each of the following following quesons. Mark only one answer for each item by shading the box corresponding to the leer of your choice c hoice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED. SITUATIONAL Situaon 1 – Nurse Yolan cares for terminally ill client with cancer. 1. Nurse Yo Yolan lan assesses assesses the the client of depressio depression. n. Which of of the following following interven intervenons ons is LEA LEAST ST helpful for Nurse Yolan to incorporate in her plan? A. Ang Anger er due due tto o pain pain experi experienc ence. e. B. Fee Feeli ling ng of exc exces essi sive ve guil guilt. t. C. An Anor orexi exia a and and weig weight ht los loss. s. D. Inabi Inability lity to care for one’s physical physical self. 2. The clie client nt has di diculty culty sleepin sleeping. g. Which of of the follo following wing invenon invenonss is LEAST hel helpful pful of Nurse Nurse Yolan to incorporate in her care plan? A. Ins Instru truct ct the cclie lient nt to drin drink k herbal herbal te tea. a. B. Give Give war warm m mi milk lk at bed bedm me. e. C. Perfor Perform m relaxaon relaxaon roune roune such as massage massage , image image or music. music. D. Ins Instru truct ct the cclie lient nt to drin drink k black black te tea. a. 3. The care pl plan an for the client client includes includes fami family ly support. support. Whi Which ch of the followin following g is MOST appropri appropriate ate for the family to establish a relaonship relaonship with the health care team? Nurse Yolan should : A. Give perm permissi ission on to the family family to take me to maintai maintain n friend friendship ship with with health health care team. B. Discus Discusss the ro roles les of the family family members members to the health health care care team team.. C. Expla Explain in the rroles oles of of all members members of the interdi interdiscipl sciplinary inary team. D. Provi Provide de a brief explanao explanaon n to the family family member about about the care being being delivered delivered to the client. 4. The clie client nt appea appears rs to be dehydrated. dehydrated. The The family family members members are discussing discussing whether whether their their loved one should be given intravenous uid. Which of the following concepts about dehydraon in terminally ill clients should guide Nurse Yolan? A. Periph Peripheral eral edema edema occurs occurs because because of uid uid overl overload. oad. B. Thi Thirst rst is is an indi indicao caon n of dehyd dehydra raon. on. C. Termin Terminally ally ill ill clients clients are hydrated hydrated throug through h oral and and intravenous intravenous routes. routes. D. All inte interveno rvenons ns for terminall terminally y ill client client should should be directe directed d towards towards comfort comfort and reducon of symptoms. 5. The clien clientt show signs of imminent imminent death. death. Nurs Nurse e Yolan recognizes recognizes cardiova cardiovascul scular ar indicators indicators of imminent death which are the following EXCEPT EXCEPT ________ : A. Br Brad ady ycard cardia ia B. Ir Irre regu gula larr hear heartt rate rate C. Tach chy ycardia D. Lower Lowered ed blo blood od pres pressu sure re
Situaon 2 – A 65- year old male is admied for prostate prostate cancer. On assessment, the nurse determines that the paent has experienced inconnence. The nurse knows that inconnence is the rst most common symptom of prostate cancer. 6. Based on in informa formaon on gathered, gathered, the nurse nurse writes a nursin nursing g diagno diagnosis. sis. Which Which of the followin following g diagnoses is MOST appropriate? A. Decie Decient nt knowledge knowledge relate related d to self-ca self-care re and risk prevenon prevenon B. Fear ssecon econdar dary y to th the e diagno diagnosis sis o off cancer cancer C. Ri Risk sk of of urin urinar ary y inf infec eco on n D. Ris Risk k for impai impaired red ur urina inary ry eli elimin minao aon n 7. To help m manage anage inconn inconnence, ence, the nurse nurse instruc instructs ts the paent paent to do w which hich o off the foll following owing : A. Ea Eatt ffoo ood d ric rich h iin n be ber. r. B. In Incr creas ease e u uid id inta intake ke C. Tak Take e in medica medicaon onss to manage manage pain pain.. D. Perf Perform orm peri perinea neall muscle muscle ex exerci ercises ses.. 8. The paen paentt ask for treatment treatment opons opons for his his condi condion. on. The nurse nurse explains explains that that treatmen treatmentt opons are based on which of the following: A. Gender B. Abili Ability ty of the paent paent to manage physic physical al and emoonal emoonal im implica plicaons ons of in inconn connence. ence. C. Soci Socioo- econ econom omic ic st statu atus. s. D. Gra Grade de and and stage stage o off the the disea disease. se. 9. The pa paent ent asks the the nurse nurse what the physi physician cian meant meant about about this pr prostat ostate e cancer as sstage tage C or T3. T3. The nurse explains that the tumor is ______ : A. Palpa Palpable ble and has has spread to other other organs organs and oen to distant distant sites sites such as b bones ones or lymph nodes. B. Palpa Palpable ble and and has sspread pread beyon beyond d the prostat prostate e but not not to other other organs. organs. C. Conn Conned ed to the prostat prostate e and was palpab palpable le during during digital digital rectal rectal exam examinao inaon. n. D. Conn Conned ed to the the prostate prostate and and was not not palp palpable able du during ring di digital gital rectal rectal examina examinaon. on. 10. The nurse recalls the st staging aging and classicaon of prostate cancer. Which of the following statement is TRUE? A. The Gleas Gleason on grading grading system system is usually usually used for for hematologi hematological cal cancer but but not prostate prostate cancer. B. The nor normal mal Prostate Prostate Specic Specic Angen Angen (PSA) (PSA) range range for under under 40 years of of age is less less than 4 to 6 ng/ mL. C. At least ttwo wo separate separate biopsy biopsy specimen specimenss are grad graded ed based on on their d dieren ierenaon aon from from normal prostate cells. D. A scores o off D is less invas invasive ive than than a score o off B in the cancer cancer staging staging system. system. Situaon 3 – You are newly promoted charge nurse of a department in a terary hospital. You review management concepts to prepare you for the posion. The following quesons pertain to management of resources.
11. You are oriented on health care economics. The The study of economi economics cs focuses on how choices are made to overcome a scarcity of resources. Which of the following statements BEST illustrates health care economics: 1. Provi Providing ding less less heal health th care service service that that is opmal opmal in order order to contain contain costs. costs. 2. Using in individ dividuals uals with with less kno knowledg wledge e and skil skills ls to perform perform health care care servi services ces usually usually performed by people with advanced knowledge and training. 3. Tak Takin ing g econ economi omicc risks risks as a health health care care provid provider. er. 4. Provi Providing ding adequate adequate or or appropriat appropriate e care min minimiz imize e risk of expensiv expensive e uliz ulizaon. aon. A. 1 and 2 B. 3 and 4 C. 1 and 4 D. 2 and 3 12. Which of th the e following statements is TRUE TRUE regarding health care economics? A. Contem Contemporar porary y health care care is characteriz characterized ed as business business stru strugglin ggling g to balance balance cost and quality. B. Prot in health health care is synony synonymous mous with bill billing ing p privil rivillages. lages. C. Health care economi economics cs is new cconcept onceptss in nursing. nursing. D. Health ccare are is becoming becoming aordabl aordable e and client clientss are demanding demanding quality quality care. care. 13. You understand th that at a key factor that inuence inuence client care is the cost cost involved in the delivery of health services. Which of the following resources is NOT required to support the services delivered by nurses? A. Time B. Clie Client nt’s ’s envi enviro ronm nment ent C. People D. Equipment 14. You are aware that th there ere is a need for you to understand how to manage the cost of client client care as it relates to clinical pracce. Which of the followin following g are nurses accountable for? A. Deci Decisio sion n regardi regarding ng cos costt eecve eecve pracc pracces. es. B. The client client’s ’s hospit hospital al cha charges rges.. C. Distri Distribuon buon and and consump consumpon on of resources resources such such as me, suppl supplies, ies, dru drugs, gs, sta a and nd personnel. D. Finan Financial cial viabilit viability y of nursing nursing d departm epartment. ent. 15. While touring the departm department ent where you are assigned, you noced that the supply room is stacked with medical supplies and equipment. Which of the following is the BEST acon you will take? A. Create a task task force force to assess the situao situaon n and and rep report ort the the n ndings dings.. B. Take an iinvent nventory ory o off the supplies supplies a and nd equipm equipment. ent. C. Reques Requestt maintenanc maintenance e to sort out out the supplies supplies and and check tthe he medical medical equi equipment pment tto o determine if they are sll funconal. D. Call for ssta ta meeng meeng and discus discusss how best best to ulized ulized the av availab ailable le reso resources. urces. Situaon 4 – A 34 year old female client client complains of experiencing experiencing double vision vision and frequent headaches. The client claims to be forgeul and has mood swings. A diagnosis of right frontal lobe lesion was made and the client was admied for craniotomy.
16. The client clai claims ms to have have a diagnosc work work up in the out paent unit before she was admied. admied. The adming nurse prepares the client for which of the procedure that will MOST likely conrm the presence of brain tumor? A. Myel elo ogram B. CT scan C. Lumb Lumbar ar punc punctu ture re D. Sk Sku ull x- ray ray 17. While the client is b being eing interviewed, she had a seizure. The inial inial intervenon of the the nurses must be directed towards : A. Pr Prot otec ecng ng the the ccli lien ent. t. B. Con Contr trol olli ling ng the the sei seizu zure. re. C. Red Reduci ucing ng ccirc ircula ulaon on to the the brai brain. n. D. Restr Restrai aini ning ng the the cli clien ent. t. 18. Aer the surgery, it is im important portant for the nurse to posion the head of the client properly to : A. Faci Facilit litate ate venous venous draina drainage. ge. B. Prev Prevent ent hemorr hemorrhag hage e on tthe he sutur suture e lin line. e. C. Pr Prov ovid ide e for for clie client nt com comfo fort rt.. D. Main Mainta tain in pa paen entt airway airway.. 19. The nurses is aware th that at one of the measures measures listed below is contraindicated in postpost- operave pulmonary toilet. A. Su Succoning B. De Deep ep bre breat athi hing ng C. Turning D. Coughing 20. The surgeon orders glucocorcoid Dexamethason (Decadron) to be given following following craniotomy. The nurses recognizes that this drug : A. Creates a feel feeling ing of euphoria euphoria,, which is benecial benecial iin n the early postpost- oper operave ave peri period. od. B. Promo Promotes tes excreon excreon of water water which aids in reducin reducing g ICP. C. Enh Enhanc ances es venou venouss return return and and thus thus reduce reduce ICP. ICP. D. Red Reduces uces cereb cerebral ral e edem dema a thus thus reducin reducing g ICP. Situaon 5 – A nurse in the intensive care unit aends to a 20 – year old female who was involved in vehicular accident three days prior to admission. The prognosis is very poor. No brain acvity was detected aer two electro encephalograms e ncephalograms (EEGs) were taken. 21. The family decides tov wean wean the paent from the venlator support. support. The family talks to the nurse about their decision to get the nurses’ support. Which of the following acons is NOT appropriate? The ______ . A. Checks th the e physician’ physician’ss orders ffor or sedaon sedaon and a analg nalgesia esia and and make sure sure that th the e ancipated death is comfortable and dignied. B. Expla Explains ins to the fa family mily what what will happen happen at each ph phase ase of the weaning weaning and o oer er support. support. C. Tells th the e family family that death will will occur almost almost immediat immediately ely aer the pa paent ent is rem removed oved from the venlator support. D. Parci Parcipates pates in the decision decision making making process by oering oering the family family informaon informaon about about the advantages and disadvantages of connued venlator support.
22. Two hours aer the v venlator enlator support was disconnued, disconnued, the paent di dies. es. The nurse discusses discusses with the family the possibility of donang the deceased person’s organs. The following are guidelines in organ or ssue donaon. 1. Religi Religious ous beliefs beliefs in organ organ donaon donaon and and transpla transplantaon ntaon m must ust be res respected pected.. 2. Donor Donorss must must be free of iinfeco nfecous us d diseas isease e and cancer. 3. Consen Consentt or wrie wrien n orders by by physician physician are necessa necessary ry for ref referral erral to an an organ procurement organizaon. 4. The fam family ily of the the deceased deceased should should be oered oered an opportun opportunity ity to speak speak with a knowledgeable organ procurement coordinator. 5. The pers person on requesng requesng fo forr organ donaon donaon does does not have have to believe believe in in the benets benets of organ donaon but should support the process with a posive atude. Which of the guidelines should the nurse observe? A. 1, 2, 3, 4, 5 B. 1, 2, 4 C. 2, 3, 4 D. 1, 3 ,5 23. The legal denion o off death that facilitates facilitates organ donaon is the cessaon of _______ _______ : A. Fun Func con on of of the the enr enre e br brai ain n B. Pulse C. Cir Circul culato atory ry an and d res respir pirato atory ry fu func ncons ons D. Re Resp spir ira ao on 24. The paent is prono pronounced unced dead by the physician. physician. Which of the following nursing acons VIOLATES the standards of care for a dead person? A. Remo Removin ving g soi soiled led dress dressing ing and and tu tubes bes.. B. Keepin Keeping g the dead person person in a sin sing g posion posion unl the famiy famiy has arrived arrived and said said their goodbyes. C. Placin Placing g idencao idencaon n tags on both both the shroud shroud and the ankle. ankle. D. Prepar Preparing ing to to tra transfer nsfer the b body ody to the the morgue. morgue. 25. The family goes th through rough the stages of grieving. grieving. What are the stages in the grieving process? 1. Accep epttance 2. Depression 3. Denial 4. Bargaining 5. Anger A. 3, 5, 1 ,4 ,2 B. 3, 5, 4, 2, 1 C. 1, 5, 3, 4, 2 D. 1, 2, 5, 4, 3 Situaon 6 – A male teenager was wheeled w heeled in the Emergency Department (ED) for stab wound. The ED nurses suspects the kidneys may have been injured. 26. The nurses assesses th the e paent for complicaons. Which are the MOST COM COMMON MON complicaon?
1. 2. 3. 4. 5.
Urin Urinar ary y leak leakag age e Delaye Delayed d blee bleedin ding g from from the dam damage age Absc Absces esss fo form rma aon on Pa Para rally ycc iilleu euss Re Ren nal fa fail ilur ure e A. 4 & 5 B. 3 &4 C. 1 & 2 D. 2 & 3 27. The nurses knows th that at with renal trauma further complicaons may occur such as: 1. Second Secondary ary hem hemorr orrhag hage e usua usually lly due due to inf infeco econ. n. 2. Rena Renall ar arte tery ry ste steno nosi siss 3. Re Ren nal at atro roph phy y 4. Hypoten enssion 5. Hydr Hydron onep ephr hros osis is Which are the POSSIBLE complicaons? A. 2, 3, 4, 5 B. 1, 2, 3, 4, 5 C. 1, 2, 3, 5 D. 1, 3, 4, 5 28. The nurse assesses th the e paent to determine the extent o off injury. Which of the following signs is a CARDINAL sign of renal trauma? A. Shock B. Lumbar pa pain C. Ab Abdo domi mina nall pai pain D. Hematuria 29. The nurses writes a n nursing ursing diagnosis for the paent with stab stab wound. The MOST appropriate nursing diagnosis is _____________ _____________ . A. Nutri Nutrion on imbalanc imbalance, e, less than body body requiremen requirements, ts, relat related ed to nause nausea a from renal trauma trauma.. B. Decie Decient nt uid uid volum volume e related related to blood blood in in th the e urine. urine. C. Acute p pain ain in in the abdo abdominal minal area related related to ren renal al trauma. trauma. D. Acute p pain ain in in the lumb lumbar ar area area related related to renal traum trauma. a. 30. The physician pres prescribes cribes Magnec Resonance Imaging (MRI) of both kidneys kidneys to conrm clinical clinical suspicion and determine the severity of the injury. Which of the following acvies is a PRIMARY nursing consideraon in preparing the paent for MRI? A. Admin Administer ister all m medica edicaons ons sschedu cheduled led before before the the test. test. B. Report ndin ndings gs of meta metall screening; screening; sedate sedate th the e paent before before se sendin nding g him for M MRI. RI. C. Coordi Coordinate nate the MRI MRI with ot other her paent paent care ac acvies vies and and inf inform orm the paent paent about about the test. D. Ensur Ensure e the paent paent is on NPO NPO and h hold old all medica medicaons ons un unl l test is ccompl ompleted. eted. Situaon 7 – Nurse Ashley is a sta nurse in the oncology unit of a terary hospital. She reads literature on anneoplasc medicaons.
31. Nurse Ashley und understands erstands the importance of connuing professional professional development. Which of the following is the MAIN purpose of connuing professional development. A. Updat Update e one’s one’s profess professional ional knowledge knowledge and ccompet ompetence ence B. Acqui Acquire re a cercate cercate of aendance aendance to add to one’s curricu curriculum lum vitae. vitae. C. Estab Establish lish networking networking withi within n the nursi nursing ng professi profession. on. D. Full Fullll requiremen requirements ts for for an advan advanced ced degree degree in nursing. nursing. 32. Nurse Ashley reads th that at the drug Cyclophosp Cyclophosphamide hamide (Cytoxan) is given to paents wit with h breast cancer. Nurse Ashley understands that this t his drug is _________ : A. Cell cyc cycle le phas phasee- non non – sspec pecic ic B. A h hor ormo mona nall medic medica aon on C. An an anm met etab abol olit ite e D. Cell Cell cycl cycle e phas phasee- speci specic c 33. Nurse Ashley reads in the literature that a paent with breast cancer taking Cytoxan Cytoxan should observe the following. Given a case, what should nurse Ashley instruct a paent to do? A. Decr Decreas ease e sodium sodium intake intake while while on medi medica caon. on. B. Tak Take e tthe he medica medicaon on with with ffood ood.. C. Increas Increase e potass potassium ium inta intake ke while while on medicaon. medicaon. D. Increas Increase e uid uid intake intake 2000 to to 300 3000 0 m L daily. daily. 34. Nurse Ashley und understands erstands that paents receiving anneoplasc medicaons should do which of the following? 1. Drink beverages beverages contai containing ning alcohol alcohol iin n mod moderate erate amounts. amounts. 2. Consult Consult with with the the physician physician before before receiving receiving immun immunizao izaons. ns. 3. Be sure sure to rreceive eceive u a and nd p pneumo neumonia nia immuniza immunizaons. ons. 4. Take aspirin aspirin (Acetyl (Acetylsalicy salicylic lic Acid, Acid, ASA) ASA) as for headac headache. he. A. 2 only B. 3 and 4 C. Al Alll of the the op opon onss D. 1 & 2 35. An incident was d described escribed in the literature where a paent developed stomas aer receiving a course of anneoplasc medicaons. Which of the following acons would be BEST for a nurse to do? A. Swab the mouth mouth daily daily with with lemon lemon and and gl glycerin ycerine. e. B. Avo Avoid id foods foods and and uids uids ffor or the the next 24 24 hou hours. rs. C. Brush the tteeth eeth and used waxed dental oss 3x a day. D. Rinse the mouth mouth with with diluted diluted baki baking ng soda soda or salin saline. e. Situaon 8 – The head nurse of trauma unit introduces introduces changes to improve the quality of care of trauma paents. 36. The head nurse presented a set of goals to the sta nurses. Which of the following goals goals is NOT relevant to improving quality of care? No____ : A. Le Lega gall suits uits.. B. Need Needle less ss deat deaths hs.. C. Wa Wast ste e of of rres esou ourc rces es.. D. Need Needles lesss pain pain o orr sue suerin ring. g.
37. The head nurse reviews reports on nurse medicaon medicaon errors in the trauma unit. unit. She recognizes that medicaon errors oen occur in relaon to the following following EXCEPT: A higher ____ : A. Nurse to p paent aent rao rao shortens shortens lengths lengths of paent paent stay stay in th the e hospital. hospital. B. Nurse to paent paent rao rao results results to reduced reduced p paent aent m mortal ortality. ity. C. Num Number ber to pae paent nt rao rao increas increases es ffALL ALL.. D. Nur Nurses ses to pae paent nt rao rao in increa creases ses ccost osts. s. 38. The head nurse determines to reduce medicaon errors in the trauma unit. She recognizes that medicaon errors oen occur in relaon to the following EXCEPT : A. Prepar Preparing ing the wrong wrong concentraon concentraon an and d administer administering ing the medi medicaon caon via th the e correct route. B. Fai Failur lure e to queson queson unclea unclearr medica medicaon on errors errors.. C. Lack of know knowled ledge ge about about a me medi dicao caon. n. D. Failu Failure re to identy identy non- therapeuc therapeuc client responses. responses. 39. The head nurse su suggests ggests that to reduce medicaon errors, errors, several measures will be be instuted. Which of the following is MOST appropriate? A. Use poi pointnt- of – care technolo technology gy to a access ccess drug drug reference reference inform informaon aon.. B. Us Use e of of dru drug g ind index ex.. C. Nurse Nursess must help educate educate paents paents and their their families families regarding regarding proper proper medicaon medicaon administraon. D. Paent Paentss must become become more involv involved ed in managin managing g their ca care. re. 40. The head nurse is aware that managing and improving quality quality care in the trauma unit requires which of the following? A. Person Personaliz alized ed aenon aenon to paent’s paent’s needs needs and theirs families. families. B. A bl blam ame e – free free env envir iron onme ment nt.. C. Al Alll o off the the choi choice cess D. A cl clean ean and ord orderl erly y traum trauma a unit. unit. Situaon 9 – Nurse Mirasol is the aending nurse of a 40 – year old female admied in the medical unit with a probable diagnosis of Scleroderma. 41. The paent complains of the pain iin n her ngerps and pallor pallor followed by blanching blanching of the extremies and redness. Nurse Mirasol knows that these symptoms are characterisc of which of the following disorders? A. Sw Swan an-n -neck eck de defo form rmit ity y B. Rayn Raynau aud’ d’ss ph phen enom omen enon on C. Jo Join intt swel swelli ling ng a and nd eus eusio ion n D. Symm Symmet etri ricc Polya Polyarth rthri ris s 42. Nurse Mirasol assess assesses es the skin of the the paent. Which phase phase of skin changes o occur ccur FIRST and are usually painless and symmetrical? A. In Ind durave B. Primary C. Curave D. Edematous 43. Nurse Mirasol writes a nursing diagnosi diagnosiss for the paent. Whi Which ch of the followi following ng is a PRIORITY nursing diagnosis?
A. B. C. D.
Soci Social al Is Isol ola aon on Imp Impai aired red skin skin IInt ntegr egrit ity y Dist Distur urbe bed d Bo Body dy Im Imag age e Low Low S Sel elff- es este teem em
44. Nurse Mirasol assi assists sts the paent in coping coping with the disorder. disorder. During the early stages stages of chronic disease, paents tend to focus on which of the following behaviors? A. Und Unders erstan tandin ding g the dis diseas ease e process process B. Imp Impac actt on life lifest styl yle e chang changes es C. Int Interp erpret reta aon on of of symp sympto toms ms D. Schedu Schedule le of of me medi dica caon onss 45. Nurse Mirasol prepares a discharge plan of of care for the paent. Which Which of the followi following ng objecves are MOST appropriate? The paent should____ should_________. _____. 1. Try to to preven preventt bre breakd akdown own o off skin skin and u ulce lcera raon on 2. Avoid Avoid acvi acvies es tthat hat trigge triggerr p pain ain 3. Modify Modify diet diet tto o incl include ude leg legume umess 4. Avoid Avoid expos exposure ure to to extrem extreme e cold cold tempera temperatur ture e A. 1, 2, 3, 4 B. 1, 2, 3 C. 1, 2, 4 D. 2, 3, 4 Situaon 10 – Nurse Bessie is nurse manager of trauma unit. She supervises the sta nurses and regularly hold conferences with them and other unit personnel. In one meeng she reorients re orients the sta nurses on their various funcons. She cites clinical situaons related to a nurse dependent, independent, independent and collaborave funcons. 46. An interdependent fun funcon con of nurse is when the nurse __________ __________ . A. Irrigat Irrigates es a feeding feeding tube tube th that at appears appears obstructed obstructed.. B. Gives ice cchips hips to cl client ient who has an o order rder o off NPO. NPO. C. Appli Applies es a dry dry sterile sterile dressi dressing ng to an ab abdomi dominal nal incisi incision. on. D. Helps a client client choos choose e food rich rich in protein protein from an ordered ordered diet. diet. 47. A nurse decides to gi give ve a paral bath to client instead of complete complete bath. The nurse nurse is working _________ ________ _: A. In Inde depe pend nden entl tly y B. In Inte terd rdep epen ende dent ntly ly C. Depe ependently D. Coll Collab abor ora ave vely ly 48. A nurse works with a skin care team. Th The e nurse is funconing funconing ________ __________ __ : A. De Dep pen ende den ntly tly B. In Inte terd rdep epen ende dent ntly ly C. Coll Collab abor ora ave vely ly D. In Inde depe pend nden entl tly y 49. A nurse iniates a v visit isit from member of the the clergy for terminally ill client. The nurse nurse is funconing __________ :
50.
51.
52.
53.
54.
A. In Inte terd rdep epen ende dent ntly ly B. Col Colleg egiial allly C. In Ind dep epen end den entl tly y D. De Dep pen ende den ntly tly When a nurse uses a straight catheter to obtain a urine specimen for la laboratory boratory test, the nurse is funconing ________ : A. De Dep pen ende den ntly tly B. In Inte terd rdep epen ende dent ntly ly C. In Ind dep epen end den entl tly y D. Col Colleg egiial allly One of her paents is a 50- year old female female named Marcela is in the terminal st stage age of breast cancer. She tells Nurse Marie, “ I have given up. I have no hope le, I am ready to die.” Which of the following responses of nurse Marie is MOST therapeuc? A. “ Yo You u have have g giv iven en u up p ho hope pe?” ?” B. “ You sshoul hould d talk tto o your physician physician a about bout y your our fea fears rs of dying. dying. “ C. “ You sshoul hould d talk a about bout dying dying with with your your spir spiritual itual adviser.” adviser.” D. “ You should should not give give up hope. Th There ere are research research studies studies bein being g done to cure can cancer.” cer.” Marcela says to Nurse Marie, “ I don’t like to spend my n nal al days on earth in hospital.” hospital.” The BEST response of Nurse Marie would be: A. “Can y you ou please please ttell ell more more how how you are feeling feeling right now?” B. “ I know how yo you u feel. It must must be hard hard to know know tha thatt you are are dyi dying.” ng.” C. “ If I were in yo your ur place place , I shoul should d have refused refused b being eing admied admied to the hospital hospital k knowi nowing ng that I will die soon.” D. “ What iiss it that that you don’t don’t llike ike being being in the the hospital hospital?” ?” Marcela tells Nurse M Marie arie that her younger sis sister ter was recently diagnosed w with ith cancer. She is concerned because she is aware that the breast cancer “runs in the family” but she could not recall any family member diagnosed with bone or lung cancer. Nurse Marie’s BEST response would be: A. “I am sorry to hea hearr about your your sister. sister. I think you should should meet meet with all of of your family family members and share with them their increased risk for developing lung and bone cancer.” B. “Appa “Apparently rently your your sister sister is so unfortunat unfortunate. e. It is rare to hav have e three such unrelate unrelated d cancer at one me.” C. “I thin think k it is impo important rtant for for you to to be tested tested for lung lung cancer cancer as soo soon n as possib possible, le, be because cause it has a strong hereditary link.” D. “I am sorry to hea hearr about your your sister’s sister’s recent diagnosi diagnosis. s. Most pr probabl obably y your sister sister has breast cancer that has metastasized or spread to the bone and lungs.” Nurse Marie has an another other paent, Cena who has has recently diagnosed with ductal cell carcinoma of the breast. Her oncologist describe4d Cena’s cancer as T2, N1, Mx. Cena asked Nurse Marie to repeat to her what “all those leers and number mean. “ Nurse Marie replies that it means the following: A. Two tumours tumours present, present, one lymph lymph node invo involved, lved, and many sites of m metasta etastasis. sis. B. One lar large ge tumour tumour present, present, nodal invol involvemen vementt in one region, region, and and metas metastasis tasis.. C. Two tum tumour our present, present, one one lymph node node involved involved,, and metastasi metastasiss was pres present. ent.
D. One tomo tomour ur present present which is larger larger than 2.5 2.5 cenmeters, cenmeters, nodal nodal invo involveme lvement nt in one region, and metastasis was unable to be determined. 55. Paent Cena tells Nurse M Marie arie “ how did I acq acquire uire breast cancer?” Nurse Marie Marie explains that there are risk factors that may have contributed c ontributed to her condion. Which of the following statement is TRUE concerning the risk factors for breast cancer? A. Hormo Hormones nes are are not not risk risk factors factors for breast breast cancer. cancer. B. Other types of cancer cancer history history have have no no co correla rrelaon on wi with th breast breast cancer cancer.. C. Et Ethn hnic icit ity y is is a ris risk k ffac acto tor. r. D. Envir Environmen onmentt is not risk risk factor for breast breast cancer. cancer. Situaon 12 – A 35- years old female client presents herself in the out paent department with complaints of rashes parcularly on the face, across the bridge of the nose and on the cheeks. The client is suspected of having systemic lupus erythematous (SLE). She is admied to the female medical unit. 56. The nurse writes a care p plan lan for the client. The nurse is aware that this disorder is a/an ___ . A. Diseas Disease e caused caused by over exposure exposure to sunlig sunlight. ht. B. Loca Locall rash rash that that occurs occurs as as a result result of of allerg allergy y C. Inam Inammatory matory disease disease of collage collagen n cont contained ained in connecve connecve ssue ssues. s. D. Diseas Disease e caused by by the connues connues release release of histami histamine ne in the b body. ody. 57. The nurse includes in the care plan di dietary etary instrucons. Which of of the food items should should the nurse instruct the client to AVOID? A. Steak B. Broccoli C. Legumes D. Fish 58. The nurse is aware th that at fague is experienced by paents with SLE. Which Which of the followi following ng acvies should be a component in the care plan for the client to manage fague? To______ . 1. Sit Sit when whenev ever er po poss ssib ible le 2. Take Take a ho hott showe showerr in in the the mornin morning g 3. Av Avoi oid d llon ong g peri period odss of re rest st 4. Engage Engage in moderate moderate llow ow iimpact mpact exercises exercises when when not not fa fagued gued 5. Main Mainta tain in a b bal alan ance ce die diet. t. A. 2, 3, 5 B. 1, 2, 3 C. 1, 2, 3, 4, 5 D. 1, 4, 5 59. The physician sch schedules edules the client for plasmapheresis. plasmapheresis. The client asks the nurses what is plasmapheresis. The nurse explains that it is a method that will ______. A. Preven Preventt foreign foreign anbodi anbodies es from damaging damaging variou variouss body ssue ssuess B. Decreas Decrease e the damage damage to to organs organs caused caused by aackin aacking g T- ly lympho mphocytes cytes C. Elim Eliminate inate eosin eosinophi ophils ls a and nd basoph basophils ils from the blood blood D. Remove Remove anbodyanbody- angen compl complexes exes form form circul circulaon aon 60. The nurse monitors the client undergoing undergoing plasmapheresis. plasmapheresis. Which of the following reacons should the nurse observe? A. Sh Shor ortn tnes esss of br brea eath th
B. Numb Numbne ness ss an and d ngl nglin ing g C. Tr Tran ansf sfus usio ion n re reac aco ons ns D. High High bloo blood d pre press ssur ure e Situaon 13 – The nurses assists in the care of clients c lients with chronic obstrucve pulmonary disease (COPD). 61. The nurse is aware th that at the clients with CO COPD PD are at risk for in ineecve eecve respiraons EXCEPT which of the following _______ : A. Clien Clients ts undergo undergoing ing thoracic thoracic or abdomi abdominal nal surgery surgery B. Cli Client entss wit with h rib ffrac ractur tures es an and d kyphos kyphosis is C. Clien Clients ts with neuromu neuromuscula scularr diso disorders rders such such as Guillain Guillain-- Barre’ syndro syndrome me D. Cli Client entss wi with th uid uid vol volume ume decit decit 62. Nursing intervenons fo forr clients with respiratory acidosis include the following EXCEPT EXCEPT to _______ : A. Moni Monitor tor arteria arteriall blood blood gases (ABGs), (ABGs), p H, PCO2 PCO2 , and HCO3 B. Admini Administe sterr oxygen oxygen and and medica medicaon on a ass orde ordered red C. Moni Monitor tor hourly hourly vital signs and respir respiratory atory status status D. Administer Administer sedao sedaon n as orde ordered red by the physici physician an to rel relax ax the client client 63. The nurse understands that excess acid in the body acts as CNS depressant. depressant. Clients with acidosis may exhibit which of the following symptoms : 1. Reduce Reduced d llevel evel of consci conscious ousnes nesss 2. Confusion 3. Lethargy 4. Coma A. Al Alll o off the the op opo ons ns B. 1, 2, 3 an and 4 C. 1, 2, and 3 D. 1 and 3 64. The goal for treatment for respiratory acidosis iiss improve venlaon. Which of the fol following lowing measures is appropriate for clients with COPD experiencing respiratory acidosis? A. Bron Bronch chod odil ilat ator orss B. Admini Administe sterr medi medica caons ons as orde ordered red C. Ambulaon D. Spi Spiro rome mete ters rs 65. The nurse understands that respiratory acidosis occurs occurs when ________ ________ : A. The The bod body y ret retain ainss too m much uch carb carbon on di dioxi oxide de B. The The clie client nt is unab unable le to exhal exhale e carb carbon on dioxi dioxide de C. Th The e clien clientt hype hyperv rven enl late atess D. There is loss loss of acid or retenon retenon of base base in the body body Situaon 14 – Nurse Mark is assigned in in the Oncology unit of a terary hospital, He is aware of the increase in the number of colorectal cancer paents in his unit. He and a colleague plans to conduct a study on the incidence of colorectal cancer in the Philippines.
66. Nurse Mark formulates possible tle for the study. Which of the following is the MOST appropriate tle? A. “Inci “Incidence dence of Co Colorecta lorectall Cancer Cancer in the the Philipp Philippines” ines” B. “Percep “Percepons ons of Filipino Filipinoss o on n Colore Colorectal ctal Cancer” Cancer” C. “Colo “Colorectal rectal Cancer Cancer in the the Philippi Philippines nes : It’s R Risk isk Fac Factors tors and Interve Intervenons nons”” D. “A Comparav Comparave e Study of G Gastro astrointes intesnal nal Cancer Cancer Cases A Among mong Filipi Filipinos” nos” 67. What research design is the MO MOST ST suitable to gather data for the study? A. Quas Quasii expe experi rime ment ntal al B. Co Corr rrel ela aon onal al st stud udy y C. Des Descrip cripv ve e ssur urve vey y D. De Deve velo lopm pmen enta tall stu study dy 68. In gathering data for the study, ethical guid guidelines elines on basic human human rights will be be observed. Which of the ethical principles is applicable? 1. Jusce 2. Pr Priv ivac acy y and and dig digni nity ty 3. Respect 4. Con Conden dena ali lity ty A. 1, 2, 3, 4 B. 2, 3, 4 C. 1, 2, 3 D. 2, 3 69. Nurse Mark formulates an assumpon for the study. Which of the following is MOST acceptable? A. Liver ca cancer ncer cases cases have decrease decreased d in 2017 due due to intensiv intensive e publi publicc awaren awareness. ess. B. More Fil Filipin ipinos os regard regardless less of g gender ender ar are e diagnosed diagnosed with with colorectal colorectal cancer. cancer. C. Male Fi Filipi lipinos nos are prone to colorectal colorectal cancer cancer than than liver liver can cancer. cer. D. The leading leading cause cause of colorectal colorectal cancer among among Filipinos Filipinos is is high consumpo consumpon n of alcohol. 70. Which of the follo following wing is the MOST appropriate recommendaon Nurse Nurse Mark should propose? A. Warni Warning ng sign signss of the eects eects of alcohol alcohol shoul should d be prin printed ted on boles boles and and cans of alcoholic beverages. B. Healt Health h profe profession ssionals als should should educate educate the the public public on the ri risk sk factors factors of CRC. C. DOH onl only y should should intensif intensify y its campaign campaign on colore colorectal ctal cancer cancer awareness. awareness. D. Congress Congress should should pass a bill bill banni banning ng all canc cancerer- producing producing food food and beverages beverages Situaon 15 – The nurse cares for a 30 years old female paent who is admied for severe voming. The diagnosis of the paent is hypernatremia . 71. The nurse reads the llaboratory aboratory results. Which of the following values indicate that the paent is experiencing hypernatremia? A. Potass Potassium ium lev level el of of 5. 5 mE mEq/L q/L B. Urine Urine sspec pecic ic gravit gravity y be below low 1. 0008 0008 C. Seru Serum m osmol osmolali ality ty belo below w 280 280 mo mosm/ sm/kg kg D. Serum Serum osmol osmolali ality ty above above 295 295 mosm/ mosm/kg kg
72. The nurse monitors tthe he paent for signs and symptoms of complicaons. The nurse knows that one of the PRIMARY risk when treang hypernatremia is ________ : A. Re Ren nal shu shutd tdo own B. Cere Cerebr bral al edem dema C. Cel Cellu lula larr de dehy hydr dra aon on D. RBC RBC dest destru ruc con on 73. In planning the care for this paent the nurse nurse includes the following following intervenons. Which Which of the following acons should the nurse NOT include in the plan of care? A. Observ Observe e for for possible possible increa increase se in temper temperature. ature. B. Observ Observe e and prepar prepare e for pos possib sible le sei seizur zure e aack aack C. Mo Moni nito torr inta intake ke and and out outpu putt D. Restri Restrict ct uid uidss to 1,200 1,200 m L per per day. day. 74. The nurse understands that a paent with hypernatremia hypernatremia is at high risk for seizures. Whi Which ch of the following safety measures is MOST appropriate? Use of _______ . A. Pi Pill llow owss plac placed ed at at th the e head head B. Padd Padded ed to tong ngue ue blad blades es C. Pa Padd dded ed re rest stra rain ints ts D. Pa Padd dded ed ssid ide e rail railss 75. The nurse formulates a nursing diagnosis for the paent. Which of the following nursing diagnosis is NOT appropriate for this paent? A. Impai Impaired red Electr Electrolyte olytes, s, Sodium Sodium related related to voming voming B. Imbal Imbalanced anced Nutri Nutrion on , more than than body body requirement requirements, s, relat related ed to exces excesss intake intake of foods rich in sodium C. Risk fo forr injury, injury, bleeding bleeding , related related to th the e interference interference with with bloo blood d coagulaon coagulaon secondary to sodium excess. D. Impaired Impaired Skin Integrity Integrity,, related to periph peripheral eral edema edema second secondary ary to sodi sodium um and wat water er excess. Situaon 16 - You are a nurse manager of terary hospital. One One of your responsibilies is to keep a record of all paents admied in the hospital. 76. You are aware of the iimportance mportance of keeping hos hospital pital records, Which of of the following statements statements is NOT true about hospital records rec ords ? Hospital records _________ . A. Provi Provide de data on health health iinform nformaon aon syst system em B. Are ke key y source source of data for for medical medical research research or stasc stascal al rep reports orts C. Provi Provide de personal personal informao informaon n about the the physicians physicians an and d nurses as assigne signed d to care for the paents. D. Provide Provide eviden evidence ce of hospital’s hospital’s accountabi accountability lity 77. You are oriented on the hospital policy policy that when a paent is readmied, the pa paent’s ent’s le maybe retrieved from the hospital records department. From which le may readmied paent’s record be retrieved? A. Phys Physic icia ian’ n’ss ledg ledger er B. Mast Master er pa pae ent nt inde indexx le le C. Civi Civill ser servi vice ce le le D. Hosp Hospit ital al li libr brar ary y record recordss
78. You orient your sta on the common sy system stem used in recording nursing nursing intervenons. The The system used is a nursing card index or Kardex. What informaon is NOT included in the Kardex? A. Dr Drug ug regi regime men n of the the pae paent nt.. B. All Allergi ergies es if if any any of the paent paent.. C. Pro Progre gress ss note notess o off the the physi physicia cian. n. D. Dietar Dietary y requir requireme ements nts of of the paent paent.. 79. A paent’s record contains iinformaon nformaon of the medicaons medicaons and treatments ad administered, ministered, and observaons of the paent’s condion. Which of the following data MUST be lled up in the paent’s chart when he/she is discharged from the hospital? A. Religion B. Nu Nurs rsin ing g diag diagno nosi siss C. Fina Finall medi medica call di diag agno nosi siss D. Ed Educ uca aon onal al aa aain inme ment nt 80. You are familiar wi with th the ethical aspects o off paents and hos hospital pital records. Which of the following statements is NOT true? A. Healt Health h record recordss are the pr property operty of of the locality locality where where the pa paent ent is ttreated reated B. Hospi Hospital tal records records maybe maybe released released without without the the paent’s paent’s conse consent nt when requir required ed in invesgaon for serious criminal oense. C. Cond Condenal enal rrecord ecord mu must st be protected protected agains againstt loss, d damage, amage, unauth unauthorized orized a access, ccess, modicaon and disclosure. D. Paents Paents hav have e the right right to con condenal denal treatment treatment of informaon informaon they they pr provide ovide to health professionals. Situaon 17 – Ms. Gina is a sta nurse in a medical unit of x hospital. She is collaborates with other members of the health team to provide safe and quality paent care. 81. Which of the follo following wing statements BEST explains explains the role of the nurse in collaborang collaborang with others to plan for the paent’s care? The nurse _________________ _________________ . A. Colla Collaborat borates es with coll colleagues eagues and the the paen paent’s t’s fa family mily to prov provide ide combin combined ed experse in planning care B. Works iindepe ndependentl ndently y to plan and and deliver deliver care an and d does no nott depen depend d on othe otherr sta for assistance C. Consu Consults lts the physi physician cian for for direcon direcon in establi establishing shing goals goals for clients clients D. Depends Depends on the latest latest literatur literature e to complete complete an excellent excellent plan plan of car care e 82. Nurse Gina is awar aware e that collaborave interveno intervenons ns are therapies that require the following : Which of the collaborave intervenons is the MOST therapeuc? A. Nurse Nurse and pa paent ent int interv erven enon on B. Mulpl Mulple e health health care profes professio sional nalss C. Phy Physic sician ian and nur nurse se iinte nterven rvenon on D. Paent Paent and and phys physici ician an inte interve rveno non n 83. To iniate an int intervenon ervenon in collaboraon with the health team, Nurse Gina must be be competent in which of the following areas? A. Leader Leadershi ship, p, auton autonomy omy,, and and sk skill illss B. Experi Experienc ence e , advance advanced d educa educaon, on, and and skills skills C. Kno Knowle wledge dge,, fun funco con, n, and and speci specicc skills skills
D. Leader Leadershi ship p , nanc nances, es, and and skil skills ls 84. Nurse Gina is awar aware e that there are nursing acvies that maybe delegated to other health care team members. Which principle should guide the nurse in delegang tasks? A. Delega Delegaon on occurs occurs only upon a ph physici ysician’s an’s order. B. The d delegat elegated ed personn personnel el iiss acco accountab untable le for for the the care. care. C. Del Delega egaon on may may reduce reduce the the paent’ paent’ss cost of of care. care. D. The nurse nurse has th the e primary primary responsibi responsibility lity fo forr the qua quality lity of p paent aent care. care. 85. Nurse Gina is po potenal tenal team leader of the health team. Which of of the following skills skills should sshe he develop? A. Co Coll llab abor ora ave ve skil skills ls B. Manageme ement C. Supe Superv rvis isor ory y ski skill llss D. Pa Pae ent nt ad advo voca cacy cy Situaon 18 – Nurse Rolly , a triage nurse admits clients in the Emergency Deparment (ED) of X hospital. The following are situaons in the ED Nurse Rolly encounters. 86. Four vicms are brought to the ED aer a motor vehicle crash. Who among among the following vicms require the HIGHEST priority for treatment? A. 21 yearyear- o old ld ma male le with with fr fract acture ure of of the face face jaw jaw B. 20 year-o year-old ld fe femal male e with a misa misalig ligned ned right right leg leg C. 35 ye yearar- o old ld m male ale ccompl omplainin aining g of abdom abdominal inal pain D. 62 year-ol year-old d fem female ale with palp palpaon aon and chest pain 87. Four vicms of a car crash are brought to the ED. Nurse Rolly assesses the vicms. Select who among the following has the HIGHEST priority for treatment. A. Absenc Absence e of of peri periphe pheral ral pulses pulses B. A suc suckl klin ing g cche hest st woun wound d C. Sev Severe ere bleed bleeding ing of faci facial al and and head head lacera laceraon onss D. An open open femur fracture fracture with with p profus rofuse e bleedin bleeding g 88. Nurse Rolly performs primary assessment on one of the trauma vicms, and determines that the client has a patent airway. The NEXT assessment by Nurse Rolly should be to ______ . A. Palpa Palpate te for for the the presence presence of peripheral peripheral pulses pulses B. Check Check the the level level o off co consc nsciou iousne sness ss C. Exa Examin mine e the client client for for any extern external al bleedi bleeding ng D. Observe/ Observe/ assess assess client’ client’ss breathing breathing or res respirat piratory ory eo eort rt 89. A 45 year-old male cl client ient was brought in the ED with head and neck trauma sus sustained tained in a motorcycle accident. The FIRST acon of Nurse Rolly is to ________ . A. Sucon Sucon of the the mout mouth h and and or oroph ophary arynx nx B. Obta Obtain in venou venouss ac acces cesss C. Imm Immobi obiliz lize e tthe he cervic cervical al spi spine ne D. Admini Administe sterr suppl supplemen emental tal oxygen oxygen 90. Jerome , 65 years old wh who o work as carpenter fell o o from a ladder while while xing the roof of of neighbor. He was brought to the ED by family members. He is unconscious. Nurse Rolly does a orimary assessment on client Jerome which is to : A. Ask tthe he family family about about Jero Jerome’s me’s medical medical co condio ndions ns
B. As Asse sess ss the the vit vital al si sign gns. s. C. A Aach ach a car cardi diac ac E ECG CG m mon onit itor or.. D. Obtain Obtain a Glasg Glasgow ow C Coma oma Sca Scale le Sc Score ore.. Situaon 19 – A 30 year-old female is admied for fever, fague, lymphadenopathy, thrush, diarrhea and muscle and joint pains. She also has a rash in in her torso and arms. 91. The nurse assesses th the e client. What queson should she ask to determine the client’s possible possible exposure to HIV? A. “ Do you used used publi publicc toile toilett sea seats? ts?”” B. “Did you shake shake hands with a pers person on infected infected with HIV?” C. “Di “Did d you receiv receive e bloo blood d transfu transfusio sion n recently recently?” ?” D. “Do “Do you you prac pracce ce safe safe ssex? ex?”” 92. The nurse writes a care p plan lan for the client. Included in the care plan plan is to provide provide health teachings. Before the nurses performs any teaching, what should the nurse do FIRST? A. Eval Evaluate uate the cl client’ ient’ss exisng exisng level of of knowledge knowledge about about HIV infecon infecon.. B. Assess the client’s client’s immed immediate iate clini clinical cal statu status. s. C. Ass Assess ess the the emoo emoonal nal sstat tatus us of the the client client.. D. Focus on on potenal potenal pro problems blems tthe he client client may enco encounter unter during during the the illness. illness. 93. To determine whether the clien clientt is infected with H HIV, IV, the physician writes an order for HIV anbody tesng. What test would conrm a posive ELISA test? A. CD4 CD4 ccel elll cou coun nt B. East Easter ern n Blo Blott ttes estt C. HI HIV V an ang gen en te test st D. We West ster ern n Blo Blott tes testt 94. The client is bein being g treated for thrush. The The paent ask if there are any side eects of the medicaon she is receiving for thrush. Which of the following should the nurse include in her teaching? A. “Ther “There e are few side side eects associ associated ated with with the medicao medicaons ns to trea treatt thrush.” thrush.” B. “Hepa “Hepas s can can devel develop op a ass a sside ide ee eect.” ct.” C. “Naus “Nausea, ea, v vomin oming, g, and diarrhea diarrhea are common common side side eects eects.. “ D. “Skin disc discolora oloraon on is common common side eect.” 95. The client complains of increasing pain pain in her feet and legs. legs. The nurse realizes that the client is demonstrang a/an _______ : A. Nervou Nervouss sys system tem manif manifest estao aon n of the diseas disease e B. Re Reac aco on n tto o a medi medica cao on n C. Op Oppo port rtun unis isc c infe infeco con n D. Seco Second ndar ary y ca canc ncer er Situaon 20 – An adult male is wheeled in the emergency department with complaints of nausea and voming, abdominal pain and lower back pain. The physician writes a medical diagnosis of abdominal aorc aneurism (AAA). 96. The nurse assesses th the e paent with AAA. Whi Which ch of the following following assessment ndings is related to the aneurism? 1. Puls Pulsa ale le abd abdom omin inal al ma mass ss
2. Hype Hypera rac cve ve bo bowe well ssou ound ndss 3. Systol Systolic ic brui bruitt ov over er the the area area of of th the e mass mass 4. Subjecve Subjecve sensa sensaon on o off “heart “heart beang beang”in ”in the abdomen abdomen A. 1, 3, 4 B. 1, 2, 3, 4, C. 2, 3, 4 D. 1, 2, 3 97. The nurse auscultates th the e abdominal area of of the paent with AAA. Which of the fo following llowing sounds can be DISTINCTLY heard over the area? A. Dullness B. Bruit C. Fri Fricon ru rubs D. Crackles 98. The nurse recalls specic anatomic sites for aneurism. aneurism. The most common common sites are the aorc arch, thoracic aorta and abdominal aorta. Which of the following areas is an AAA most commonly located? A. Proxim Proximal al to the rental rental arteri arteries es B. Dist Distal al to to the the ilia iliacc art arter erie iess C. Dist Distal al to to the the renal renal art arteri eries es D. Ad Adja jacen centt to tthe he aor aorc c arc arch h 99. The paent complains of sever lower back p pain. ain. Which of the following is the the PRIORITY acon by the nurses? A. Take Take the vital vital ssign ignss and d docu ocumen mentt results results B. Admini Administe sterr pain pain medicao medicaon n as prescr prescribe ibed d C. No Nof fy y the the phys physic icia ian n D. Observ Observe e for sign sign of abdom abdomina inall dis disten tenon on 100.. 100 Th The e nur nurse se is awar aware e ttha hatt rrup uptu ture re of an aneu eury rysm sm is a lif lifee- threa threate teni ning ng emer emergen gency cy.. Whi Which ch of the following groups of symptoms indicates a ruptured AAA? A. Interm Intermient ient lower lower back back pain, pain, decreas decreased ed blood blood pressure, pressure, decreased decreased RBC RBC count count,, increase WBC count B. Severe llower ower back back pain pain , decreased decreased blood blood pressur pressure e , decreased decreased RBC RBC coun count, t, decreased WBC count C. Lower ba back ck pain, pain, increased increased blood blood pressure, pressure, de decreased creased R RBC BC count count,, increased increased WBC count D. Severe lower lower back pain, pain, decreas decreased ed blood pressur pressure, e, decreased decreased RBC count count,, increased increased WBC count.
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