NUR 163

1. The nurse is preparing a client for surgery. What is the most effective method for obtaining an accurate blood pressure reading from the client? a. Obtain a cuff that covers the upper one third of the client’s arm. b. Position the cuff approximately 4 inches above the antecubital arm. c. Use a cough that is wide enough to cover the upper two thirds of the client’s arm. d. Identify the Korotkoff sounds, and take a systolic reading. 2. Which of the following items on a client’s pre-surgery laboratory results would indicate a need to contact the surgeon? a. Platelet count of 250,000/cumm b. Total cholesterol of 325nmg/dL c. Blood urea nitrogen (BUN) 17 mg/dL d. Hemoglobin 9.5 mg/dL 3. To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection? a. Turn, cough, and deep breathe every 30 minutes. around the clock b. Get the client out of bed and ambulate to a bedside chair. c. Provide passive ROM three times a day. d. It is not necessary to worry about complications of immobility on the first operative day? 4. In the recovery room, the post-operative client suddenly becomes cyanotic. What is the most appropriate nursing action? a. Start administration of oxygen through nasal cannula. b. Call for assistance c. Reposition the head and determine patency of the airway. d. Insert an oral airway and suction the nasopharynx 5. A client is scheduled for surgery in the morning. Preoperative orders have been written. What is the most important to do before surgery. a. Remove all jewelries or tape wedding ring. b. Verify that all laboratory work is complete. c. Inform family or next of kin d. Have all consent forms signed. 6. The nurse is caring for a first-day post-operative surgical client. What is the first type of the client’s diet? a. Full liquid c. Clear liquid b. NPO d. Soft 7. A post-operative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client’s tray, what would the nurse anticipate the client’s current diet order to be? a. Bland diet c. Full liquid diet b. Soft diet d. Regular diet 8. The nurse is preparing the post-operative client for surgery. Select the statement that indicates that the client is not knowledgeable about his impending surgery. a. After surgery, I will need to wear the pneumatic compression device while sitting on the chair. b. The skin prep area is going to be longer and wider than anticipated incision. c. I cannot have anything to drink or eat after midnight on the night before the surgery. d. To ensure my safety a “time out “will be conducted in the operating room. 9. Which of the following is the primary purpose of maintaining NPO for 6-8 hours before surgery? a. To prevent malnutrition c. To prevent aspiration pneumonia b. To prevent electrolyte imbalance d. To prevent intestinal obstruction 10. The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the operative teachings? a. Before administration of operative medications b. The afternoon or evening prior to surgery c. Several days prior to surgery d. Upon admission of the client in the recovery room 11. Which of the following factors ensure validity of informed written consent except? a. The patient is off legal of age with proper mental disposition b. The consent has been secured within 24 hours before the surgery. c. If the patient is a child, secure consent from the parents or legal guardian. d. The consent is secure just after the administration of preoperative medication. 12.Which of the following drugs is administered to minimize respiratory secretions preoperatively? a. Valium (diazepham) b. Phenergan (promethazine) c. Atropine Sulfate d. Demerol (meperidine) 13. Which of the following is experienced by the patient who is under the third phase of general anesthesia? a. The patient is unconscious b. The patient is awake c. The patient experience slight pain d. The patient experience loss of sensation in the lower half of the body. 14.Which of the following is most dangerous complication during the induction of spinal anesthesia? a. Cardiac arrest b. Hypotention c. Hyperthermia d. Respiratory paralysis 15. Which of the following postoperative patients is at risk for respiratory complications a. The obese patient with long history of smoking who had undergone upper abdominal surgery. b. The patient with normal pulmonary function who had undergone upper abdominal surgery. c. An adolescent patient with diabetes mellitus who has under gone cholecystectomy. d. A football player who had undergone knee replacement surgery. 16. The patient had undergone spinal anesthesia for appendectomy? To prevent spinal headache, the nurse should place the patient in which of the following positions? a. Semi-Fowler’s b. Flat on bed for 6-8 hours c. Prone position d. Modified Trendelenburge position. 17. The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse? a. Assessing the patient’s level of consciousness. b. Checking the patient’s vital signs c. Checking the patient’s identification and correct operative permit. d. Positioning and performing skin preparation to the patient. 18. Which of the following assessment data nis most important to determine when caring for a client who has received spinal anesthesia? a. The time of return of motion and sensation in the patient’s legs and toes. b. The character of the clients respiration c. Patients level of consciousness d. The amount of wound drainage. 19. The nurse is transferring the patient from post anesthesia care unit to the surgical unit. Which of the following. Which of the following is the primary reason for gradual change of position of the patient? a. To prevent muscle injury b. To prevent sudden drop of blood pressure. c. To prevent respiratory distress d. To promote comfort. 20. The nurse is caring for a client who had undergone exploratory laparotomy. Which of the following postop findings should the nurse report to the physician? a. The patient pushes out the oral airway with his tongue. b. The patient’s urine output is 20 ml/hr. for the past two hours. c. The patients’ vital signs are as follows: BP= 110/70 mmHg; PR 95 bpm; RR=9/min; Temperature=36.8 C. d. The patient’s wound drainage. 21. The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function? a. Cyanosis, lethargy b. Fast, thready pulse ,bradypnea c. Apprehension and restlessness d. Faintness, pallor. 22. The diabetic patient who had undergone abdominal surgery experiences wound evisceration.Which of the following is the most appropriate immediate nursing action. a. Cover the wound with sterile gauze moistened with sterile normal saline. b. Cover the wound with sterile gauze. c. Cover the wound with water-soaked gauze. d. Leave the wound uncovered and pull the skin edges together. 23. The patient had undergone total hip replacement. He complains of pain in the operative site. Which of the following is the appropriate initial nursing action? a. Administer the ordered analgesic b. Instruct the patient to deep breathing and coughing exercises. c. Assess the patients pain level and vital signs d. Change the patient’s position. 24. Which among the following are not members of the sterile team in the operating room? a. The surgeon b. The anesthesiologist c. The scrub nurse d. The second assist 25. The best position for kidney, chest or hip surgery is? a. Supine b. Trendelenburg c. Lithothomy d. Lateral 26.Appendectomy is classified as: a. Ablative surgery b. Constructive Surgery c. Reconstructive surgery d. Palliative surgery 27. The worst of all fears among clients undergoing surgery is a. Fear of financial burden b. Fear of death c. Fear of the unknown d. Fear of loss of job 28. The patient has been pacing along the hallways, goes to the bathroom frequently and asks questions repeatedly during preoperative assessment. The most likely cause of the behavior is: a. She is anxious about the surgical procedure. b. She is worried about separation from the family. c. She has urinary tract infection d. She has underlying emotional problem. 29. Which of the following nursing actions would help the patient decrease anxiety during the preoperative period? a. Explaining all procedures thoroughly in chronological order b. Spending time listening to the patient and answering questions c. Encouraging sleep and limiting interruptions d. Reassuring the patient that the surgical staffs are competent professionals. 30.Which of the following characterizes excitement stage of anesthesia a. Occurs from the administration of anesthesia to the loss of consciousness b. Extends from the loss of consciousness to the loss of lid reflex, characterized by struggling and talking. c. From the loss lid reflex to the loss of most reflexes. d. From the loss of most reflexes of most reflexes to respiratory and circulatory failure. 31.The patient who has undergone TAH-BSO (total abdominal hysterectomy and bilateral salpingo-oophorectomy) complains of pain. Which of the following is an initial nursing action? a. Administer the PRN Analgesic b. Instruct to do deep breathing exercises c. Assess VS and position and wound dressing of the patient d. Change the patients position 32. How frequent should the nurse monitor the VS of the patient in the recovery room? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 60 minutes 33. Which of the following drugs is given to relieve nausea and vomiting? a. Mepevacaine b. Aquamephyton c. Nubain d. Plasis 34. The most important factor in the prevention of post op infection is a. Proper administration of antibiotics b. Fluid intake of 2-3 L/day c. Practice strict aseptic technique d. Frequent change of wound dressing 35. Which of the following measures primarily prevents postop complications: a. Adequate fluid intake b. Early ambulation c. Well-balance diet d. Administration of antimicrobials. 36. Regarding the surgical patient, which of the following terms refers to the period of time that constitute the surgical experience? a. Pre-operative phase b. Intraoperative phase c. Postoperative phase d. Perioperative phase 37. When the indication for surgery is without delay the nurse recognizes the surgery will be classified as: a. Emergency b. Urgent c. Required d. Elective 38. Mr. Allan is receiving Total Parenteral Nutrition (TPN).If you will evaluate her nutritional status which of the following indicators would tell you that TPN was effective? a. Laboratory tests b. Adequate hydration c. Weight gain d. Diminish episode of nausea and vomiting 39. A client with liver cirrhosis vomits bright red blood and the physician suspects bleeding esophageal varices. The physician decodes to insert a Sengstaken Blackmore tube. The Nurse should explain to the client that the tube acts? a. To providing a smaller diameter for effective gastric lavage b. Applying direct pressure to the gastric bleeding sites. c. Blocking blood flow to the stomach and esophagus. d. Applying pressure directly to the entire esophagus. 40. When a client developes steatorrhea, the nurse should describe this stool? a. Sterile, greenish-black colored stool. b. Greasy, bulky and foul smelling stool c. Black and blood-streak stool d. Clay colored and pasty stool. 41. The nurse should assess for the development of pernicious anemia when a client has a history? a. Severe bleeding b. Diabetes Insipidus c. Having had a gastrectomy d. Increases intake of water soluble vitamins 42. Rene was diagnosed of Liver Cirrhosis secondary to alcoholism and develops ascites. The following are pathological basis of ascites except? a. Portal hypertension b. Decrease synthesis of Vitamin K c. Hypoalbuminia d. Increase hydrostatic pressure 43. Menopausal women are more prone in developing osteoporosis due to estrogen. Aside from being menopausal which of the following clients are greatest risk of developing osteoporosis? a. A 20 y/o with asthma b. A 28 y/o woman who do regular exercise c. A person with sedentary lifestyle and a long time smoker d. A person that has a well-balanced diet. 44. Which of the following laboratory values would the nurse expect to note in a client with Gouty Arthritis? a. Calcium level of 8.5 mg/dl b. Sodium of 140 meQ/L c. Uric acid level of 9.5 mg/dl d. Phosphorous level of 3 mg/dl 45. A nurse is preparing a list of cast care instructions for a client who had plaster cast applied to his left leg. All instructions that the nurse would include in the list except? a. Leave cast uncovered and should be exposed to air to promote dryness b. Use fans to promote dryness of cast c. Use of stick that will fit under the cast to scratch the skin under the cast. d. Autographing the cast with pen can be allowed. 46. A female client was diagnosed with osteoarthritis and was admitted in the health care facility due to pain. Which of the following clinical manifestation associated with the disorder? a. Morning stiffness that last less than 30 munites b. A decrease sedimentation rate c. Joint pain that increase with rest d. Presence of tophi formation in the pinna of the ear 47. The nurse explains to the client with fracture of lower leg that one of the complications of his condition is pulmonary embolism. All of the following are manifestations of pulmonary embolism secondary to fracture except? a. Sudden dyspnea b. Restlessness c. Oxygen saturation of 93% d. Elevated blood pressure 48. The most common clinical manifestation or feature of Systemic Lupus Erythematosus would be? a. Choasma on the face b. Malar rash on the face c. Mongilian spots d. Petechiae on the face 49. The purpose of applying a dressing over a bleeding wound is to? a. Prevent infection b. Promote hemostatis c. Increase proliferation of puss d. Promote immobilization 50. During emergency situations it is very important for a nurse to know how to do correct bandaging. Which of the following is correct in bandaging? a. Start bandaging from proximal to distal to promote circulation b. Cover the end part of the extremity to be bandage to prevent infection. c. Slightly flex the joints during bandaging d. The bandage should be too tight to immobilize the extremity. 51.It is Excess of isotonic fluid in the extra cellular compartments. a. Water intoxication b. Hypovolemia c. Dehydration d. Hypervolemia 52. The following are TRUE regarding the cause of hypervolemia EXCEPT? a. Excessive fluid and Na intake b. Fluid and Na retention c. Fluids shift into the intravascular spaces d. Diabetes insipidus 53. Occurs when excess fluid moves from the ECS to the ICS. a. Hypovolemia b. Dehydration 54. Causes of Water Intoxication EXCEPT? a. Hyper secretion of the ADH b. Rapid infusion of hypotonic solution c. Rapid infusion of hypertonic solution d. Enema in some cases c. Hypervolemia d. Water intoxication 55. Which of the following is late a manifestation of cerebral edema a. Thirst b. Weight loss c. Dilated pupils d. Headache 56. A nurse directed to administer a hypotonic IV solution. Which of the following solutions should she choose? a. 0.45% NaC l b. 0.9% NaCl c. D5LRS d. 5% dextrose in NSS 57. When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? a. Hypotonic b. Hypertonic c. Isotonic d. Osmosis 58. You’re teaching a group of athletes how to prevent excessive fluid loss. you should tell them to consume fluids when they: a. Experience dry mouth b. Feel light-headed or dizzy c. Are thirsty d. Sweaty 59. Is a fluid movement where solutes move from a higher concentration to areas of lower concentration a. Diffusion b. Osmosis c. Active transport d. None of the above 60. A hormone that is responsible for reabsorbing water a. Aldosterone b. Vasopressin c. ANP d. RAAS 61. These hormone is responsible in increasing calcium level in the blood a. Antidiuretic hormone b. Aldosterone c. Calcitonin d. Parathyroid hormone 62. Hypernatremia can lead to dehydration? a. Yes b. Not 63. Which of the following is major extracellular compartment electrolyte c. Potassium d. Phosphates e. Calcium f. Magnesium 64. Which of the following is major intracellular compartment electrolyte a. Calcium b. Bicarbonate c. Chlorine d. Magnesium 65. Which of the following is the most important indicator of fluid volume deficit a. Thirst b. Dry mouth c. Urine output d. Cyanosis 66. Mr. Rham is a 60 years old with chronic obstructive pulmonary disease. He is admitted to the hospital for pneumonia with a chief complaint of shortness of breath and congestion. Using Maslow’s Hierarchy of Needs, the most basic need of Mr. Rham at this point in time would be: a. Safety c. Self-esteem b. Air d. Food 67. During the assessment phase of the nursing process, the nurse would a. Propose hypotheses c. Validate data b. Generate desired outcomes d. Document care 68. The phase of the nursing process known as nursing diagnosis or diagnosing may also be referred to as: a. Analysis c. interpreting b. Defining d. determination 69. An important problem at this point in Mr. Rham’s care would be: a. Altered nutritional status related to inability to swallow b. Potential for depression related to chronic illness c. Inadequate oxygenation related to chronic lung disease d. Impaired circulation related to congestive heart failure 70. His wife reports that he usually sleeps on two or three pillows at home. Which of the following nursing interventions is most appropriate based on this information? a. Have him assume the semi-fowler’s position for sleep b. Allow him to sit in a chair to sleep c. Ambulate three times a day with breathing exercises d. Apply oxygen as needed for dyspnea 71. Which of the following is true about suppositories? a. Are always administered rectally c. Have a base that melts at body temperature b. Produce bowel evacuation d. Are soothing to mucous membranes 72. A medication that consists of a suspension of fat globules and water is classified as a (an): a. Emulsion c. Tincture b. Ointment d. Elixir 73. Pills that are enteric coated are: a. Absorbed through the skin c. Dissolve by gastric acid b. Dissolved by intestinal juices d. Held in the mouth until dissolved 74. When administering a troche or lozenge, the nurse should instruct the patient to: a. Always take it dissolved in water to protect the teeth b. Follow the medication with a full glass of water c. Hold it in the mouth until dissolved d. Take it on an empty stomach 75. A full liquid diet is termed as one that contains: a. Clear liquids at body temperature c. Only liquids that have residue b. Liquids at body temperature d. Only liquids that have no residue 76. When reviewing a patient’s dietary intake, the nurse would identify which nutrient as providing the most concentrated source of energy in the body? a. Protein c. Fats b. Carbohydrates d. Macrominerals