June 2008 Nursing Licensure Examination (NLE)
June 2008 NP4 Nursing Board Exam Answer Key
Nursing Board Exams Questions 61-80
Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.
61. As Andrea’s nurse, what will be your priority interventions?
A. Insert and intravenous catheter
B. Insert an oral or nasopharyngeal airway
C. Obtain arterial blood gases
D. Give 100% oxygen
62. Andrea’s arterial blood gases respiratory acidosis. This most likely related to:
A. Partially obstructed airway
B. Ineffective breathing pattern
C. Head injury
D. Pain
63. Andrea loses consciousness. You should prepare for which of the following FIRST?
A. Placement of nasogastric tube
B. Placement of a second IV line
C. Endotracheal intubation or surgical airway placement
D. CT scan of head
64. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to:
A. Promote cerebral-tissue fluid movement
B. Promote renal perfusion
C. Correct acid-base imbalances
D. Enhance renal-excretion of drugs
65. As Andrea’s nurse your goal is to prevent increased Intracranial Pressure (ICP). Which of the following independent nursing interventions is NOT suited for her?
A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration?
B. Keep ahead of bed 30-35 degrees elevated
C. Maintain Andrea’s head in straight alignment and prevent hip flexion
D. Prevent constipation and increases in intra-abdominal pressure
66. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:
A. Biot’s
B. Kussmaul’s
C. Cheyne Stokes
D. Eupnca
67. What do you call the triad of sign and symptoms seen in a client with increasing ICP?
A. Virchow’s Triad
B. The Chinese triad
C. Cusching’s Triad
D. Charcot’s Triad
68. Which of the following is true with the Cushing’s Triad seen in head injuries?
A. Narrowing of Pulse Pressure, Cheyne strokes respiration, Tachycardia
B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmaul’s respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia
69. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?
A. Ineffective airway clearance
B. Ineffective breathing pattern
C. Impaired gas exchange
D. Activity Intolerance
70. You know the apnea is seen in client’s with cheyne stoke respiration, APNEA is defined as:
A. Inability to breath in a supine position so the patient sits up in bed to breathe.
B. The patient is dead, the breathing stops
C. There is an absence of breathing for a period of time usually 15 seconds or more
D. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of normal respiratory functioning
Situation - 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. Horace underwent lobectomy. Which of following is the purpose of Horace’s closed chest drainage post lobectomy:
a. expansion of the remaining lung
b. facilitation of coughing
c. prevention of mediastinal shift
d. promotion of wound healing
72. Which of the following observations indicates that the closed chest drainage system is functioning properly?
A. absence of bubbling in the suction-control bottle
B. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
C. intermittent bubbling through the long tube of the suction control bottle.
D. less than 25 ml drainage in the drainage bottle
73. Following lobectomy, you can BEST help Horace to reduce pain during the deep breathing and coughing exercises by:
A. placing the patient on his/her operative side during exercises
B. splinting the patient’s chest with both hands during the exercises
C. administering the prescribed analgesic immediately prior to exercises
D. providing rest for 6 hours before exercises
74. Peter underwent pneumonectomy. During the immediate post operative period, deep tracheal suction should be done with extreme caution because:
A. Peter will not be able to tolerate coughing
B. the tracheobronchial trees are dry
C. the remaining normal lung needs minimal stimulation
D. the bronchial suture line maybe traumatized
75. On which of the following positions should you place Peter who just underwent pneumonectomy?
A. Prone position
B. On his abdomen or on the side opposite the surgery
C. On his back or on the side of surgery
D. Any position is acceptable
Situation – Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling catheter for continuous fast dip bladder irrigation which is connected to a straight drainage.
76. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
B. Amber
C. Bright red
D. Pinkish to red
77. The purpose of the continuous bladders irrigation is to:
A. Allow continuous monitoring of the fluid output status
B. Provide continuous flushing of clots and debris from the bladder
C. Allow for proper exchange of electrolytes
D. Ensure accurate monitoring of intake and output
78. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action?
A. Remove his catheter then allow him to void his own
B. Irrigate his catheter
C. Tell him “Go ahead and void. You have an indwelling catheter”
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation
79. You decided to check on Mang Felix’s IV fluid infusion. You noted in flow rate, pallor and coldness around the insertion site. What is your assessment finding?
A. Phlebitis
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism
80. Knowing that proper documentation of assessment findings and interventions share important responsibilities of the nurse during first post operative days, which of the following is the LEAST relevant to document in the case of Mang Felix?
A. Chest pain and vital signs
B. Intravenous infusion rate
C. Amount, color and consistency of bladder irrigation drainage
D. Activities of daily living started
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