NURSING PRACTICE 3B:
NURSING CARE OF CLIENT WITH PHYSIOLOGICAL
AND PSYCHOSOCIAL ALTERATIONS
DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. STRICTLY NO ERASURE!
Situation 1: It is Cancer Consciousness Week and you are participating in an Early Cancer Detection Drive of the Department of Health.
1. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breast cancer that is recommended for developing countries is:
A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)
B. an annual hormone receptor assay
C. an annual mammogram
D. a physician conduct a breast clinical examination every 2 years
2. The purpose of performing the breast self examination (BSE) regularly is to discover:
A. fibrocystic masses C. areas of thickness or fullness
B. cancerous lumps D. changes from previous BSE
3. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:
A. on the same day of each month C. on the first day of her menstruation
B. right after the menstrual period D. on the last day of her menstruation
4. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:
A. thickening of the tissue C. lumps in the breast tissue
B. axillary D. change in size and contour
5. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client’s left shoulder is to:
A. bring the breast closer to the examiner’s right hand
B. tense the pectoral muscle
C. balance the breast tissue more evenly on the chest wall
D. facilitate lateral positioning of the breast
Situation 2: Ensuring safety is one of your most important responsibilities. You will need to provide instruction and information to your clients to prevent complications.
6. LM has chest tube attached to a pleural drainage system. When caring for LM you should:
A. change the dressing daily using aseptic technique
B. empty the drainage system at the end of the shift
C. palpate the surrounding areas for crepitus
D. clamp the chest tube when suctioning
7. After pelvic surgery, the sign that would be indicative of a developing thrombophlebitis would be:
A. a tender, painful area on the leg C. a pitting edema of the ankle
B. pruritus on the calf and ankle D. a reddened area of the ankle
8. To prevent recurrent attacks on FT who has glomerulonephritis, you should instruct her to:
A. continue to take the same restrictions on fluid intake
B. seek early treatment for respiratory infections
C. avoid situations that involve physical activity
D. take showers instead of tub bath
9. GT had a laryngectomy. He is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What would you teach him FIRST?
A. reinsert another tubing immediately C. recognize that prompt closure of the tracheal opening
B. keep calm because there is no immediate D. notify the physician at once
emergency
10. When caring for TU after an exploratory chest surgery and pneumonectomy, your PRIORITY would be to maintain:
A. chest tube drainage C. ventilation exchange
B. blood replacement D. supplementary oxygen
Situation 3: Severe burn is one of the most devastating kinds of injury one can experience. It can affect any group. You have been ready to provide holistic care for patients with severe burns.
11. A burn that is white, painless, and leathery in texture describes a:
A. second degree burn C. deep partial thickness burns
B. third degree or full thickness burn D. first degree or superficial burns
12. Critically ill patients are at high risk for the following complication during the emergent phase:
A. myocardial infarction C. burn shock
B. neurogenic shock D. contractures
13. The MOST effective method of delivering pain medication during the emergent phase is:
A. intramuscularly C. orally
B. subcutaneously D. intravenously
14. Edema presents a significant problem in burn wounds because:
A. loss of protein prevents tissue repair
B. edema impedes tissue perfusion/oxygenation
C. edema provides a milieu for bacterial proliferation
D. edema can produce a tourniquet effect
15. Which of the following can be a fatal complication of upper airway burns?
A. stress ulcers C. shock
B. hemorrhage D. laryngeal spasms and swelling
Situation 4: You are assigned to take care of four patients with different conditions.
16. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine and prednisone? You recognized that KJ understood the teaching when he states, “I must take these medications:
A. until the anastomosis heals C. until the supply is over
B. during the preoperative period D. for the rest of my life
17. After the kidney transplant, you must observe KJ for signs of rejection which includes:
A. fever and weight gain C. polyuria and jaundice
B. hematuria and seizure D. moon face and muscle atrophy
18. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB tells you “I want to go off dialysis, I’d rather not live than to be in this treatment the rest of my life”. How would you respond to him?
A. leave the room and allow him to collect his thoughts
B. tell FB that “ We all have days when we don’t feel like going on”
C. tell FB that “ Treatments are only three times a week, you can live with that”
D. take a sit next to him and sit quietly
19. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which statement by DS indicates the need for further teaching before true informed consent can be obtained?
A. “a wire from the generator will be attached to my heart”
B. “the physician will make a small incision in my chest wall and place the generator there”
C. “I wonder if there is another way to protect these bad rhythms”
D. “this implanted defibrillator will protect me from those bad rhythms my heart goes into”
20. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates a lack of understanding about his rights as a research study participant?
A. “My confidentiality will not be compromised in this study”
B. “ I understand the risk associated in this study”
C. “I can withdraw from the study anytime”
D. “ I’ll have to find a new physician if I don’t complete this study”
Situation 5. You are assigned in the neurology stroke unit. To prepare for this assignment, you should be able to answer the following questions.
21. Which of the following statements can BEST describe/define stroke or brain attack?
A. it occurs when circulation to a part of the brain is disrupted
B. it is usually caused by abuse of prescribed medications
C. it is caused by a cerebral hemorrhage
D. it may be the results of a transient ischemic attack (TIA)
22. Several diagnostic tests may be ordered for proper evaluation. The purpose of each of the following diagnostic examination is correct EXCEPT:
A. Cerebral Angiography – is used to identify collateral blood circulation and may reveal site of rupture or occlusion
B. ECG – may reveal abnormal electrical activity, such as focal slowing and assess amount of brain wave
activity.
C. MRI – may reveal the site of infarction, hematoma and shift of brain structures
D. PET Scanning – may reveal information on cerebral metabolism and blood flow characteristics.
23. Which of the following is the MOST common cause of stroke or brain attack?
A. embolism C. cerebral arterial spasm
B. hemorrhage D. thrombosis
24. To guide you in your assessment, it is also important for you to remember that the clinical features of stroke vary with the following factors EXCEPT:
A. severity of damage C. artery affected
B. gender D. the extent of collateral circulation
25. It is important for you to also teach clients and their families who are at risk to observed primary prevention which includes the following EXCEPT:
A. maintain serum cholesterol level between 220 and 180 mm/dL
B. treat transient ischemic attacks (TIA) early
C. teach preventive health behaviors (consequences of smoking, obesity, alcoholism, drug abuse) to children of patients with stroke
D. screen for systolic hypertension
Situation 6:Foot care among patients with peripheral vascular problems is very important.
26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions:
A. avoid wearing canvas shoes C. avoid use of cornstarch on the foot
B. avoid using a nail clipper to cut toe nails D. avoid wearing cotton socks
27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the appropriate management, you should:
A. shave the affected leg in anticipation of surgery C. keep the affected leg level or slightly dependent
B. place a healing pad around the calf D. elevate the affected calf as high as possible
28. Peripheral neuropathies primarily affect:
A. sensory functions C. optic functions
B. vascular functions D. motor functions
29. Peripheral neuropathy can BEST be controlled by:
A. good glucose control C. vitamin supplement
B. steroid therapy D. nothing, there is no slowing the process
30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with:
A. hypertension C. liver disease
B. hyperthyroidism D. diabetes insipidus
Situation 7: You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are their common concerns. You should be able to address their concerns in a holistic manner.
31. The WHO analgesic ladder provides the health professional with:
A. specific pain management choices based on severity of pain
B. general pain management choices based on level of pain
C. pharmacologic and nonpharmacologic pain management choices
D. nonpharmacologic interventions based on level of pain
32. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT:
A. pruritus C. constipation
B. respiratory depression D. physical dependence
33. Which of the following statements about cancer pain is NOT true?
A. opioids are drugs of choice for severe pain
B. pain associated with cancer and the terminal phase of the disease occurs in majority of patients
C. under treatment of pain is often due to a clinician’s failure or inability to evaluate or appreciate the severity of the client’s problem
D. adjuvant medications such as steroids, anti convulsants, nonsteroidal anti-inflammatory drugs enhance pain perception
34. TR has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that TR is:
A. becoming psychologically dependent C. needing to have the morphine discontinued
B. developing tolerance to the morphine D. exaggerating his level of pain
35. The guidelines for choosing appropriate nonpharmacologic intervention for pain include all of the following EXPECT:
A. effectiveness for patient C. skill of the clinician health professional
B. pain problem identification D. type of opioid being used
Situation 8: To be able to provide care for patients in the critical areas, you should look into factors that will enhance your ability to provide quality nursing care.
36. Research study show that nurses who work with critically patients as opposed to nurses who work with less acute patient:
A. are more satisfied with their role C. are most acceptable to burn out
B. move a greater support system D. experience greater stress
37. Which of the components of HARDINESS has been linked to burnout?
A. less commitment to work C. a sense of control over the patient
B. perception of change D. sense of control to life
38. Nurses who work with critically ill patients should base their practice on all of the following EXCEPT:
A. recognition and appreciation of a person’s unique and social environmental relationships
B. delegated responsibility
C. thorough knowledge of the interrelatedness of body system
D. appreciation of the collaborative role of all health team members
39. Common aspects of the critical care nursing role include:
A. disaster management C. direct care provider
B. staff liaison D. community referral
40. Which of the following interventions would support your patient’s circadian rhythm cycle?
A. putting a wall clock up on your patient’s room
B. decreasing environmental noise
C. encouraging normal bowel movement
D. dimming light during normal sleeping time
Situation 9: To ensure continuity of care and for legal purposes, you have important responsibilities to accurately document all nursing activities.
41. For the past 24 hours, TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluid intake of 800 ml. TD’s urine is dark amber. These assessments indicate which nursing diagnosis?
A. Impaired urinary elimination C. Excessive fluid volume
B. Deficient fluid volume D. Imbalanced nutrition: less than body requirement
42. Which document addresses the patient’s right to information, informed consent and treatment refusal?
A. Code for Nurses C. Patient’s Bill of Rights
B. Nursing Practice Act D. Standard of Nursing Practice
43. You are caring for GG with a history of falls. The FIRST PRIORITY when caring for GG who is at risk for falls is:
A. instruct GG not to get out of bed unassisted
B. keep the bedpan available so she does not have to get out of bed
C. placing the call light for easy access
D. keep the bed at the lowest position ever
44. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm. You notice that JJ is restless, slightly diaphoretic, and has a temperature of 37.8 deg C, heart rate of 10 beats/min.; regular, slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY?
A. decreased cardiac output C. acute pain
B. anxiety D. risk for imbalanced body temperature
45. FF, has a nursing diagnosis of “Risk for injury related to adverse effects of potassium-wasting diuretics”. What’s the correct written client outcome for this diagnosis?
A. FF states the importance of eating potassium rich foods daily
B. Upon discharge, FF knows which food sources are rich in potassium
C. Upon discharge, FF correctly identifies three potassium rich foods
D. FF knows all the complications of the disease process
Situation 10: You are taking care of LC who develops acute respiratory distress. An endotracheal tube had to be inserted to correct the hypoxia.
46. The primary purpose of the endotracheal tube cuff is to:
A. seal off the oropharynx from the nasopharynx C. seal off the oropharynx from the esophagus
B. seal off the lower airway from the esophagus D. seal off the lower airway from the upper airway
47. Endotracheal tube size indicated on the tube reflects what measurements:
A. the circumference size of the tube C. the internal diameter of the tube
B. the length of the tube D. the length of the person’s airway
48. In adults, an inflated E-T tube cuff is necessary for mechanical ventilation primarily because:
A. it seals off the lower airway from the upper airway
B. it prevents air from getting into the stomach
C. it seals off the nasopharynx from the oropharynx
D. it prevents stomach contents from getting into the lungs
49. Endotracheal tube size indicated on the tube reflects what measurements:
A. the internal diameter of the tube C. the circumference size of the tube
B. the length of the person’s airway D. the length of the tube
50. Which of the following statements is TRUE about securing the artificial airway?
A. artificial airways must be secured directly to the patient
B. the airway is generally sutured in place
C. a nasotracheal tube does not require securing
D. the inflated cuff provides sufficient securing
Situation 11: Because of the serious effects of severe burns, management requires a multidisciplinary approach. You have important responsibilities as a nurse.
51. When caring for DS, who sustained 40% severe flame burn yesterday, which among these interventions should be your PRIORITY?
A. provide a calm, efficient and safe environment
B. keep the body parts in good alignment to prevent contractures
C. assess for airway, breathing and circulation problems
D. assess the injury for signs of sepsis
52. Your primary therapeutic goal for DS during the ACUTE PHASE is:
a. wound healing c. emotional support
b. reconstructive surgery d. fluid resuscitation
53. CV who sustained upper torso and neck burns. Which action is MOST likely to cause a functional contracture?
a. hourly hyperextension neck exercises
b. helping the patient to a position of comfort
c. encouraging self-care
d. discouraging pillows behind the head
54. AW, 3 year old boy just sustained full thickness burns of the face, chest and neck. What will be your PRIORITY nursing action?
a. Risk for infection related to epidermal disruption
b. Impaired urinary elimination related to fluid loss
c. Ineffective airway clearance related to edema
d. Impaired body image related to physical appearance
55. FG, with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascular checks to detect:
a. hypothermia c. arteriosclerotic changes
b. ischemia d. adequate wound healing
Situation 12: Infection can cause debilitating consequences when host’s resistance is compromised and environmental factors are favorable. As a nurse you have important roles and responsibilities in infection control.
56. EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. To assess her risk factors, what question should you ask?
a. “Have you taken any analgesic recently?”
b. “Do you have pain at your back?”
c. “Do you hold your urine for a long time before voiding?”
d. “Have you had any sore throat lately?”
57. While caring for a patient with an infected surgical incision, you observe for signs of systemic response. These include all of the following EXCEPT:
a. a febrile state due to release of pyrogens
b. anorexia, malaise, and weakness
c. loss of appetite and pain
d. leukopenia due to increased WBC production
58. One of the MOST effective nursing procedures for reducing nosocomial infection is:
a. proper handwashing technique
b. aseptic wound care
c. control of upper respiratory tract infection
d. administration of prophylactic antibiotic
59. A wound that has hemorrhaged has increased risk for infection because:
a. dead space and dead cells provide a culture medium
b. retrograde bacterial contamination may occur
c. the tissue becomes less resilient
d. of reduced amounts of oxygen and nutrients are available
60. You are instructing EP regarding skin tests for hypersensitivity reactions. You should teach her to:
a. stay out of the sun until the skin tests are read
b. come back on the specified date to have the skin tests read
c. wash skin test areas with soap and water daily
d. keep skin test areas moist with mild lotion.
Situation 13: TR attends a Health Education Class on colostomy care. The following are taken up: types of ostomies, indications and care.
61. A colostomy can BEST be defined as:
a. cutting the colon and bringing the proximal end through the abdominal wall
b. creating a stomal orifice from the ileum
c. excising a section of the colon and doing an end-to-end anastomosis
d. removing the rectum and suturing the colon to the anus.
62. When an abdominoperineal resection is done, the patient should be informed he/she will have a;
a. temporary colostomy c. transverse loop colostomy
b. permanent colostomy d. double-barreled
63. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT:
a. corn and peanuts c. mangoes and pineapples
b. cabbage and asparagus d. chewing gum and carbonated beverages
64. During the first post operative week, the nurse can BEST help the patient with a colostomy to accept the change in body image by:
a. changing the dressing just prior to meals
b. encouraging the patient to observe the stoma and its care
c. deodorizing the room periodically with a spray can
d. applying a large bulky dressing over the stoma to decrease odors
Situation 14: These are gastrointestinal disease that can compromise life and that would necessitate extensive surgical management. You are assigned to take care of a patient with such a condition.
66. BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery, a low residue diet is ordered. You explain to BC that this is necessary to:
a. prevent irritation of the intestinal mucosa
b. reduce the amount of stool in the large bowel
c. limit production of flatus in the intestines
d. lower the bacterial count in the GI tract
67. Several days prior to bowel surgery, the patient may be given sulfasuxidine and neomycin, primarily to:
a. soften the stool by retaining water in the colon
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. promote rest of the bowel by minimizing peristalsis
68. To promote perineal wound healing after an abdominoperineal resection, you should encourage BC to assume:
a. dorsal recumbent position
b. left or right Sim’s position
c. left or right side lying position
d. knee-chest position
69. BC returns from surgery with a permanent colostomy. During the 24 hours, the colostomy does not drain. You, as the nurse should realize that this is a result of:
a. the absence of intestinal motility
b. a presurgical decrease in fluid intake
c. proper functioning of the nasogastric tube
d. intestinal edema following surgery
70. On the second day following abdominoperineal resection, you anticipate that the colostomy stoma will appear:
a. moist, pink, with flushed skin and painful when touched
b. moist, red and raised above the skin surface
c. dry, pale pink and with flushed skin
d. dry, purple and depressed below the skin surface
Situation 15: Specific surgical interventions may be done when lung cancer is detected early. You have important peri-operative responsibilities in caring for patients with lung cancer.
71. GM is scheduled to have lobectomy. The purpose of closed chest drainage following a lobectomy is:
a. expansion of the remaining lung
b. facilitation of coughing
c. prevention of mediastinal shift
d. promotion of wound healing
72. Following thoracic surgery, you can BEST help GM to reduce pian during the deep breathing and coughing exercises by:
a. splinting the patient’s chest with both hands during the exercises
b. administering the prescribed analgesic immediately prior to exercises
c. providing rest for 6 hours before exercises
d. placing the patient on his/her operative side during exercises
73. During the immediate post operative period following a pneumonectomy, deep tracheal suction should be done with extreme caution because:
a. the remaining normal lung needs minimal stimulation
b. the patient will not be able to tolerate coughing
c. the tracheobronchial tree are dry
d. the bronchial suture line maybe traumatized
74. What should you do as a nurse when the chest tubing is accidentally disconnected?
a. reconnect the tube c. notify the physician
b. change the tubing d. clamp the tubing
75. Which of the following observations indicates that the closed chest drainage system is functioning properly?
a. less than 25 ml drainage in the drainage bottle
b. absence of bubbling in the suction-control bottle
c. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
d. intermittent bubbling through the long tube of the suction control bottle.
Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. As a nurse of BL which of the following nursing diagnosis will be your PRIORITY?
76. BL was brought to the Emergency Room for severe left flunk pain, nausea and vomiting. The physician gave a tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your PRIORITY?
a. imbalance nutrition: less than body requirements
b. impaired urinary elimination
c. acute pain
d. risk for infection
77. Which of the following is the appropriate intervention for BL who has ureterolithiasis?
a. inserting an indwelling urinary catheter
b. administering opioid analgesics preferably intravenously
c. administering intravenous solution at a keep vein open rate
d. inserting a nasogastric tube (low suction)
78. You are caring for YA, 30 year old business woman, with renal stones. Her skin and mucous membranes are dry and her 24 hour intake and output record reveal an oral intake of 900 ml and a urinary output of 700 ml. Her urine is dark amber. Based on the above data, your nursing diagnosis is:
a. imbalance nutrition, less than body requirements
b. fluid volume deficit
c. impaired urinary elimination
d. knowledge deficit regarding health
79. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity?
a. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine
b. drain urine from the drainage bag into the sterile container
c. disconnect the tubing from the urinary catheter and let urine flow into a sterile container
d. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle
80. You are caring for WE, a 56 year old man who is dehydrated and with urinary incontinent. Upon physical examination, you noted perineal excoriation. What will be your PRIORITY intervention?
a. orient him to time, person and place
b. offer the bed pan every 4 hours
c. encourage oral fluid intake
d. keep the perineal area clean, and dry
Situation 17: You are caring for several patients with various disease problems.
81. You are obtaining a history of MR. who is admitted with acute chest pain. Which question will be MOST HELPFUL for you to ask?
a. Why do you think you had a heart attack?
b. Do you need anything now?
c. What seem you doing when the pain started?
d. Has anyone in your family been sick lately?
82. BO who received general anesthesia returns from surgery. Post-operatively, which nursing diagnosis takes HIGHEST PRIORITY for BO?
A. impaired physical mobility related to surgery
B. decrease fluid volume related to blood and fluid loss from surgery
C. risk for infection related to anesthesia
D. acute pain related to surgery
83. WW is blind. She is admitted for treatment of gastroenteritis. Which nursing diagnosis takes HIGHEST PRIORITY for WW?
A. anxiety C. activity intolerance
B. risk for injury D. impaired physical mobility
84. You are documenting your care for CC who has iron deficiency anemia. Which nursing diagnosis is MOST appropriate?
A. ineffective breathing pattern C. deficient fluid volume
B. impaired gas exchange D. ineffective airway clearance
85. RR, age 89, has terminal cancer, he demonstrates signs of dementia. You should give HIGHEST PRIORITY to which nursing diagnosis:
A. risk for injury C. ineffective cerebral tissue perfusion
B. bathing or hygiene self care deficit D. dysfunctional grieving
Situation 18: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.
86. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?
A. 6 hours C. 4 hours
B. 1 hour D. 2 hours
87. What should you do FIRST before you administer blood transfusion?
A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date
B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with
another nurse
C. check IV site and use appropriate BT set and needle
D. verify physician’s order
88. As WQ’s nurse, what will you do AFTER the transfusion has started?
A. add the total amount of blood to be transfused to the intake and output
B. discontinue the primary IV of Dextrose 5% Water
C. check the vital signs every 15 minutes
D. stay with WQ for 15 minutes to note for any possible BT reactions
89. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:
A. oliguria and jaundice C. hypertension and flushing
B. urticaria and wheezing D. headache, chills, fever
90. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?
A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician
B. stop the blood transfusion and monitor the patient closely
C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank
D. immediately stop the BT, notify the blood bank and administer antihistamines
Situation 19. The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the kidney’s functions can cause disease. As a nurse it is important that you understand the rationale behind the treatment regimen used.
91. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase?
A. urine output directly related to the amount of IV fluid infused
B. urine output is less than 400 ml/24 hours
C. urine output of 30-60 ml/hour
D. no urine output, kidneys in a state of suspension
92. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?
A. increased urine output, increased absorption of sodium and water
B. decreased urine output, decreased absorption of sodium and water
C. increased urine output, decreased absorption of sodium and water
D. decreased urine output, increased absorption of sodium and water
93. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:
A. hyperkalemia C. hypokalemia
B. hypercalcemia D. hypernatremia
94. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge?
A. drink plenty of water C. monitor your fruit intake and eat plenty of bananas
B. restrict your salt intake D. be sure to eat meat every meal
95. BN, is also advised not to use salt substitute in the diet because:
A. salt substitute contain potassium which must be limited to prevent arrhythmias
B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood
C. fluid retention is enhanced when salt substitutes are included in the diet
D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane
Situation 20. You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are common concerns experienced by them. You should be able to address the concerns in a holistic manner.
96. Pain in the elder persons require careful assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold
97. Administration of analgesics to the older persons requires careful patient assessment because older people:
A. are more sensitive to drugs
B. have increased hepatic, renal and gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
98. The elderly patient is at higher risk for urinary incontinence because of:
A. increased glomerular filtration C. decreased bladder capacity
B. diuretic use D. dilated urethra
99. Which of the following is the MOST COMMON sign of infection among the elderly?
A. decreased breath sounds with crackles C. pain
B. fever D. change in mental status
100. Priorities when caring for the elderly trauma patient:
A. circulation, airway, breathing C. airway, breathing, disability (neurologic)
B. disability (neurologic), airway, breathing D. airway, breathing, circulation
