NURSING PRACTICE IV – CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS – PART B
Situation 1: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponges and instrument count.
1. Counting is performed thrice: during the pre-incision phase, the operative phase and closing phase. Who counts the sponges, needle
and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating nurse
2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer.
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/fat
5. Skin
a. 5,4,3,2,1
b. 5,4,2,1,3
c. 5,4,1,3,2
d. 5,4,1,2,3
3. When is the first sponge instrument count reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
4. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that
immediate and appropriate action is instituted?
a. Anesthesiologist
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse
5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
a. MRI and incidence report
b. CT Scan, MRI, Incidence report
c. XRAY and incidence report
d. CT Scan and incidence report
Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.
6. A client 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. Clamp 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 insert a sterile needle into the self sealing port
7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
a. Upon waking up, cough deeply and expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate into a container
8. The best time for collecting the sputum specimen for culture is
a. Before retiring at night
b. Upon waking up in the morning
c. Anytime of the day
d. Before meals
9. When suctioning the endotracheal tube, the nurse should
a. Explain procedure to patient. Insert catheter gently applying suction. Withdraw using twisting motion
b. Insert catheter until resistance is met then withdraw slightly, applying suction
c. Hyperoxygenate client. Insert catheter using back and forth motion
d. Insert suction catheter four inches into the tube. Suction 30 seconds using twisting motion as catheter is withdrawn.
10. The purpose of NGT IMMEDIATELY after an operation is:
, a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of stomach content
d. For the rapid return of peristalsis
Situation 3: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems liles scantly urination, hematuria and dysuria.
11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as
follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral opening
c. Bladder wall, uterine wall, and urethral opening
d. Urethral opening, ureteral opening bladder
12. In the OR, you will position Mr. Santos who is undergoing cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him?
a. “Cystoscopy is direct visualization and examination by urologist.”
b. “cystoscopy is done by x-ray visualization of the urinary tract.”
c. “Cystoscopy is done by using lasers on the urinary tract.”
d. “Cystoscopy is an endoscopic procedure of the urinary tract.”
14. Withing 24-48 hours post cystoscopy, it is normal to observe one of the following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
15. Leg cramps are NOT uncommon post-cystoscopy. Nursing intervention includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath
Situation 4: Mang Felix, a 79 year old man who is brought to the surgical unit form PACU after a transurethral resection. You are assigned to receive
him. You noted that he has a 3 way indwelling urinary catheter for continuous fast drip bladder irritation which is connected to a straight drainage.
16. Immediately after surgery, what would you expect his urine to be?
a. Light yellow
b. Amber
c. Bright red
d. Pinkish to red
17. The purpose of the continuous bladder 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 and fluid
d. Ensure accurate monitoring of intake and output
18. 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 on his own
b. Irrigate his catheter
c. Tell him to “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
19. You decided to check on Mang Felix’s IV fluid infusion. You noticed a change in flow rae, pallor and coldness around the insertion site.
What is your assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic rection
d. Air embolism
20. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post
operative day, which of the following is the LEAST relevant to document in the case of Mang Felix?
a. Chest pain and vital signs
Situation 1: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponges and instrument count.
1. Counting is performed thrice: during the pre-incision phase, the operative phase and closing phase. Who counts the sponges, needle
and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating nurse
2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer.
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/fat
5. Skin
a. 5,4,3,2,1
b. 5,4,2,1,3
c. 5,4,1,3,2
d. 5,4,1,2,3
3. When is the first sponge instrument count reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
4. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that
immediate and appropriate action is instituted?
a. Anesthesiologist
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse
5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
a. MRI and incidence report
b. CT Scan, MRI, Incidence report
c. XRAY and incidence report
d. CT Scan and incidence report
Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.
6. A client 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. Clamp 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 insert a sterile needle into the self sealing port
7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
a. Upon waking up, cough deeply and expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate into a container
8. The best time for collecting the sputum specimen for culture is
a. Before retiring at night
b. Upon waking up in the morning
c. Anytime of the day
d. Before meals
9. When suctioning the endotracheal tube, the nurse should
a. Explain procedure to patient. Insert catheter gently applying suction. Withdraw using twisting motion
b. Insert catheter until resistance is met then withdraw slightly, applying suction
c. Hyperoxygenate client. Insert catheter using back and forth motion
d. Insert suction catheter four inches into the tube. Suction 30 seconds using twisting motion as catheter is withdrawn.
10. The purpose of NGT IMMEDIATELY after an operation is:
, a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of stomach content
d. For the rapid return of peristalsis
Situation 3: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems liles scantly urination, hematuria and dysuria.
11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as
follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral opening
c. Bladder wall, uterine wall, and urethral opening
d. Urethral opening, ureteral opening bladder
12. In the OR, you will position Mr. Santos who is undergoing cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him?
a. “Cystoscopy is direct visualization and examination by urologist.”
b. “cystoscopy is done by x-ray visualization of the urinary tract.”
c. “Cystoscopy is done by using lasers on the urinary tract.”
d. “Cystoscopy is an endoscopic procedure of the urinary tract.”
14. Withing 24-48 hours post cystoscopy, it is normal to observe one of the following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
15. Leg cramps are NOT uncommon post-cystoscopy. Nursing intervention includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath
Situation 4: Mang Felix, a 79 year old man who is brought to the surgical unit form PACU after a transurethral resection. You are assigned to receive
him. You noted that he has a 3 way indwelling urinary catheter for continuous fast drip bladder irritation which is connected to a straight drainage.
16. Immediately after surgery, what would you expect his urine to be?
a. Light yellow
b. Amber
c. Bright red
d. Pinkish to red
17. The purpose of the continuous bladder 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 and fluid
d. Ensure accurate monitoring of intake and output
18. 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 on his own
b. Irrigate his catheter
c. Tell him to “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
19. You decided to check on Mang Felix’s IV fluid infusion. You noticed a change in flow rae, pallor and coldness around the insertion site.
What is your assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic rection
d. Air embolism
20. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post
operative day, which of the following is the LEAST relevant to document in the case of Mang Felix?
a. Chest pain and vital signs
