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 41-60

Situation – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient

safety goals and requirements include the care and efficient use of technology in the OR and

elsewhere in the healthcare facility.

41. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm

systems?

A. Limit suppliers to a few so that quality is maintained

B. Implement a regular inventory of supplies and equipment

C. Adherence to manufacturer’s recommendation

D. Implement a regular maintenance and testing of alarm systems

42. Overdosage of medication or anesthetic can happen even with the aid of technology like

infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you

improve the safety of using infusion pumps?

A. Check the functionality of the pump before use

B. Select your brand of infusion pump like you do with your cellphone

C. Allow the technician to set the infusion pump before use

D. Verify the flow rate against your computation

43. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site,

wrong person, and wrong procedure/surgery includes the following, EXCEPT:

A. Mark the operative site if possible

B. Conduct pre-procedure verification process

C. Take a video of the entire intra-operative procedure

D. Conduct ‘time out’ immediately before starting the procedure

44. You identified a potential risk of pre-and postoperative clients. To reduce the risk of

patient harm resulting from fall, you can implement the following, EXCEPT:

A. Assess potential risk of fall associated with the patient’s medication regimen

B. Take action to address any identified risks through Incident Report (IR)

C. Allow client to walk with relative to the OR

D. Assess and periodically reassess individual client’s risk for falling

45. As a nurse, you know you can improve on accuracy of patient’s identification by 2

patient identifiers, EXCEPT:

A. identify the client by his/her wrist tag and verify with family members

B. identify client by his/her wrist tag and call his/her by name

C. call the client by his/her case and bed number

D. call the patient by his/her name and bed number

Situation – Team efforts is best demonstrated in the OR.

46. If you are the nurse in charge for scheduling surgical cases, what important information

do you need to ask the surgeon?

A. Who is your internist

B. Who is your assistant and anesthesiologist, and what is your preferred

time and type of surgery?

C. Who are your anesthesiologist, internist, and assistant

D. Who is your anesthesiologist

47. In the OR, the nursing tandem for every surgery is:

A. Instrument technician and circulating nurse

B. Nurse anesthetist, nurse assistant, and instrument technician

C. Scrub nurse and nurse anesthetist

D. Scrub and circulating nurses

48. While team effort is needed in the OR for efficient and quality patient care delivery, we

should limit the number of people in the room for infection control. Who comprise this

team?

A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly

B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist

C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist

D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

49. When surgery is on-going, who coordinates the activities outside, including the family?

A. Orderly/clerk

B. Nurse Supervisor

C. Circulating Nurse

D. Anesthesiologist

50. The breakdown in teamwork is often times a failure in:

A. Electricity

B. Inadequate supply

C. Leg work

D. Communication

Situation – Colostomy is a surgically created anus. It can be temporary or permanent,

depending on the disease condition.\

51. Skin care around the stoma is critical. Which of the following is not indicated as a skin

care barriers?

A. Apply liberal amount of mineral oil to the area

B. Use karaya paste and rings around the stoma

C. Clean the area daily with soap and water before applying bag

D. Apply talcum powder twice a day

52. What health instruction will enhance regulation of a colostomy (defecation) of clients?

A. Irrigate after lunch everyday

B. Eat fruits and vegetables in all three meals

C. Eat balanced meals at regular intervals

D. Restrict exercise to walking only

53. After ileostomy, which of the following condition is NOT expected?

A. Increased weight

B. Irritation of skin around the stoma

C. Liquid stool

D. Establishment of regular bowel movement

54. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

A. Increase the irrigating solution flow rate when abdominal cramps is felt

B. Insert 2-4 inches of an adequately lubricated catheter to the stoma

C. Position client in semi-Fowler

D. Hang the solution 18 inches above the stoma

55. What sensation is used as a gauge so that patients with ileostomy can determine how

often their pouch should be drained?

A. Sensation of taste

B. Sensation of pressure

C. Sensation of smell

D. Urge to defecate

Situation – As a nurse, you should be aware and prepared of the different roles you play.

56. What role do you play when you hold all client’s information entrusted to you in the

strictest confidence?

A. Patient’s advocate

B. Educator

C. Patient’s Liaison

D. Patient’s arbiter

57. As a nurse, you can help improve the effectiveness of communication among healthcare

givers by:

A. Use of reminders of ‘what to do’

B. Using standardized list of abbreviations, acronyms, and symbols

C. One-on-one oral endorsement

D. Text messaging and e-mail

58. As a nurse, your primary focus in the workplace is the client’s safety. However, personal

safety is also a concern. You can communicate hazards to your co-workers through the use

of the following EXCEPT:

A. Formal training

B. Posters

C. Posting IR in the bulletin board

D. Use of labels and signs

59. As a nurse, what is one of the best way to reconcile medications across the continuum

of care?

A. Endorse on a case-to-case basis

B. Communicate a complete list of the patient’s medication to the next provider of

service

C. Endorse in writing

D. Endorse the routine and ‘stat’ medications every shift

60. As a nurse, you protect yourself and co-workers from misinformation and

misrepresentations through the following EXCEPT:

A. Provide information to clients about a variety of services that can help alleviate

the client’s pain and other conditions

B. Advising the client, by virtue of your expertise, that which can contribute to the

client’s well-being

C. Health education among clients and significant others regarding the use of

chemical disinfectant

D. Endorsement thru trimedia to advertise your favourite disinfectant

solution