NURSING BOARD EXAM PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations

June 2008 Nursing Licensure Examination (NLE)
June 2008 NP3 Nursing Board Exam Answer Key

Nursing Board Exams Questions 1-20

NURSING PRACTICE III SET B

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NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part A)

GENERAL INSTRUCTIONS:

1. This test booklet contains 100 test questions.

2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.

3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.

4. AVOID ERASURES.

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INSTRUCTIONS:

1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet

Set .

2. Write the subject title “Nursing Practice I” on the box provided.

3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.

SITUATIONAL

Situation - One learns by doing especially when you practice the best methods.

1. Which action by a new nurse signifies a need for further teaching in infection control?

A. The nurse places the side rails the time to an unconscious patient.

B. The nurse elevates the head of the bed to check the BP

C. The nurse uses her bare hands to change the dressing

D. The Nurse applies oxygen catheter to the mouth.

2. You are a PM shift and about 5 patients are discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue?

A.Call the attention of the orderly in private.

B. Ignore the situation because you are busy.

C. Report this behavior to the nurse in charge.

D. Monitor the situation and note whether any other items are reported missing.

3. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient?

A. Try to explore the interaction with the nursing attendant concerned.

B. Change the attendant’s assignment.

C. Initiate a group discussion with all other nursing attendants.

D. Discuss the matter with the patient’s family.

4. Disposal of Medical Records in the Government hospital needs collaboration with which of the following department:

A. DOH

B. MMDA

C. DILG

D. RMAO

5. You saw one colleague charting medication administration that she has not yet administered. After talking to her, you also report the incident to the charge nurse. The charge nurse should:

A. Required the staff to submit an incident report.

B. Terminate the nurse

C. Charge the erring nurse with dishonesty.

D. Report to the Board of Nursing.

Situation - You are assigned at the PACU

6. Which nursing diagnosis has priority among the client in the PACU?

A. Acute Pain related to discomfort of wound and immobility

B. Body image disturbance of wound dressing and drains.

C. Ineffective airway clearance related to anesthesia.

D. Knowledge deficit related to lack of information because patients are all sedated.

7. Which of the following clients at the PACU will demonstrate the effectiveness of the nurse teaching?

A. The client demonstrates deep breathing, coughing, splintering and leg exercises.

B. The client manifests normal temperature.

C. The client sleeps well

D. The client has good balance I and O.

8. Which of the following remark indicates that the client’s relative understood the discharged instructions for would care?

A. “If the wound is painful, I will say it is normal.”

B. “It is alright to use adhesive tape over the wound to keep it intact.”

C. “It is ok for his pet to remain at his bedside to keep him company.”

D. It will report any redness or swelling of the wound.”

9. You must transfer out a post-op client to her room. What would your instructions to the family include to prevent accidents?

A. Report when the IV infusion is almost finished.

B. Test the call system if functioning.

C. Keep the room lights on for 24hrs.

D. Make sure the side rails are up.

10.One of your post-op patients has a temperature of 27.9 C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9 C. The nursing student asked you to explain the absence of shivering even if the temperature was higher.

A. The patient is no longer febrile thus he is no longer chilling.

B. Shivering normally disappears as temperature becomes higher.

C. The body has reached its new set point thus the absence of shivering.

D. The patient is feeling better.

Situation - Patients with chest tubes can be very challenging to new nurses.

11. The chest drainage of Tirso has continuous bubbling in the water seal drainage. After an hour you noticed that the bubbling stops. Which of the following condition is the possible cause of the malfunctioning sealed drainage?

A. A suction being to high

B. An air leak

C. A tube being too small

D. A tension pneumothorax

12. While you were making your endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action?

A. Assist the client back to his bed and place him on the affected side.

B. Cover the end of the chest tube with sterilize gauze

C. Reconnect the tube to the chest tube system

D. Put the end of the chest tube into a cup of sterile normal saline

13. Dr. Reyes asked you top assist him with the removal of Tirso’s chest tube. You would instruct the client to:

A. Continuously breathe normally during the chest tube

B. Take a deep breath, exhale, and bear down

C. exhale upon actual removal of the tube

D. Hold breath until the chesty tube is pulled out

14. Chest tube diameter is measured or expressed in:

A. French

B. Gauge

C. Millimeters

D. Inches

15. When transporting clients with a chest tube, the system should be:

A. Disconnected

B. Closed

C. Placed lower than the patient’s chest

D. Placed between the legs of the client to prevent breakage

Situation – The preoperative nurse collaborates with the client significant others, and healthcare providers.

16. To control environment hazards in the OR, the nurse collaborates with the following departments EXCEPT:

A. Biomedical division

B. DOH

C. Infection control committee

D. DILG

17. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated limbs) disposal should be coordinated with the following agencies EXCEPT:

A. Crematorium

B. DOH

C. MMDA

D. DILG

18. Tess, the PACU nurse discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 8 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with:

A. Nurse supervisor

B. Anesthesiologist

C. Surgeon

D. Intern on duty

19. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do?

A. Double check the doctor’s order and call the attending MD

B. Communicate with the ward nurse to verify if insulin was incorporated or not

C. Communicate with the client to verify if insulin was incorporated

D. Incorporate insulin as ordered

20. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?

A. Presence of prosthetic devices such as dentures, artificial limbs hearing aid, etc.

B. Baseline physical, emotional, and psychosocial data

C. Arguments between nurses and residents regarding treatment

D. Observed untoward signs and symptoms and interventions including contaminant intervening factors.