Title RECALLS 13 (NP4) - STUDENT COPY ✅

RECALLS EXAMINATION 13 NURSING PRACTICE IV CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART B) NOVEMBER 2024 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE IV” on the box provided 1-5. Situation. Nurse Kim cares for a 40-year-old male with electrolyte imbalance. On assessment, the nurse observes the client to be confused, restless and lethargic. 1. Nurse Kim carries out the order for the client to have a diagnostic test. Which of the following values indicate hyponatremia? A sodium level _____ A. Below 8.5 to 10.5 mg/dL B. Between 3.5 and 5.5 mEgL C. Above 145 mEg/L D. Below 135 mEg/L 2. Nurse Kim is aware that the MOST common electrolyte abnormality in hospitalized patient is ______ A. Hyperkalemia B. Hyponatremia C. Hypernatremia D. Hypokalemia 3. Nurse Kim writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate for the client? A. Excess Fluid Volume B. Ineffective Breathing Pattern C. Deficient Fluid Volume D. Disturbed Thought Processes 4. The physician prescribes intravenous solutions for the client. Which of the following solutions is appropriate? A. 0.9 % Sodium Chloride B. Dextran 6 % in sterile water C. 0.3 % Sodium Chloride D. Dextrose 5 % in water 5. An appropriate nursing intervention for the client is for Nurse Kim to________ A. Maintain body alignment and assist with movement B. Monitor level of consciousness C. Administer oral hygiene D. Monitor laboratory findings 6-10. Situation. The nurse cares for a group of clients with allergies. 6. The nurse assesses the client who says he is highly allergic to many food items and medications. Which of the following hypersensitivity reactions would be responsible for this type of clinical manifestation? A. Type 4, delayed sensitivity B. Type 1, IgE mediated hypersensitivity C. Type 2, cytotoxic hypersensitivity D. Type 3, immune complex-mediated hypersensitivity 7. The nurse assesses an atopic client who had serious Type 1 hypersensitivity reactions. The nurse is aware that the most severe form of a Type 1 hypersensitivity reaction is which of the following conditions? A. Cell-mediated sensitivity B. Dermatitis C. Anaphylaxis D. Bronchial asthma 8. A client is experiencing anaphylaxis. Which of the following actions by the nurse takes HIGHEST priority? A. Administer epinephrine injection B. Place the client in Trendelenburg position C. Maintain an open airway D. Administer emergency oxygen 9. The nurse develops a care plan for a client with a past history of anaphylaxis. Which drug should the nurse instruct the client to always have it readily available to treat possible allergic reaction? A. Diphenhydramine B. Acetaminophen C. Epinephrine D. Acetyl Salicylic Acid 10. A client with a history of Type 1 hypersensitivity reaction is receiving immunotherapy. The nurse administers the allergen injection and asks the client to wait for how many minutes so that the immediate reactions can be treated? A. 5 – 15 minutes B. 30 – 40 minutes C. 60 minutes D. 15 – 25 minutes 11-15. Situation. Nurse Em cares for a 30 year old male who suffered a spinal cord injury sustained in a sporting accident which resulted in paraplegia. The following questions relate to the care of a client with a paraplegia. 11.The client is fortunate that the level of his injury did not affect his respiratory function. The nurse understands that the cord segments involved in maintaining respiratory function are: A. C1-2 B. C3-4 C. C5 D. C6 12. Nurse Em understands that the LEAST effective method of preventing contractures of the joints of the lower extremities would be to: A. Passively move the extremities through range of motion exercises. B. Provide the client with active exercise instructions. C. Maintain proper alignment in bed. D. Change the client’s position every two hours. 13. Nurse Em plans care for the client which includes turning the client every two hours. This nursing measure is necessary to: A. Improve circulation in the lower extremities. B. Keep the client comfortable. C. Prevent occurrence of pressure sores. D. Prevent flexion contractures in the lower extremities. 14. Nurse Em recognizes that an early major problem of the client with paraplegia is: A. Client education. B. Bladder control. C. Use of mechanical aids for ambulation. D. Quadriceps setting 15. Nurse Em is aware that a complication the client with paraplegia may experience is formation of urinary calculi. The factor that contributes to this condition is: A. High fluid intake 1 | Page
B. Increases loss of calcium for the skeletal system. C. Inadequate kidney functioning. D. Increased calcium intake. 16-20. Situation. A 63-year-old male arrives at the Out-Patient Department complaining of numbness and tingling sensation of the lower extremities and pain in the legs upon exercising. The nurse suspects the client may have Peripheral Arterial Disease (PAD). 16. The nurse asks the client the following questions. Which of the questions would determine the risk factors of PAD? 1. “Do you smoke cigarettes?” 2. “Are you diabetic?” 3. “Are you hypertensive?” 4. “Do you exercise?” 5. “Do you drink alcohol?” A. 2, 3, & 4 B. 1, 2, 3, 4, & 5 C. 1, 4, & 5 D. 1, 2, & 3 17. The client asks the nurse what the doctor meant when he heard him say that the client has intermittent claudication. The nurses’ BEST response is, Intermittent claudication is_______ A. Pain that can occur in the body with exercise B. Pain in the leg when exercising C. Pain in the leg that occurs when at rest D. A tingling feeling of sensation in the hands 18. The nurse writes a nursing diagnosis of Ineffective Tissue Perfusion for the client. Which of the following interventions is MOST appropriate for this nursing diagnosis? A. Keep his legs in dependent position B. Elevate his legs C. Take hot bath D. Limit his daily activities. 19. The nurse writes another nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is MOST appropriate for the nurse to instruct the client? A. Monitor the extremities for color, motion and sensation, and pulses. B. Maintain an appropriate level of activity to promote circulation. C. Avoid risk factors that may increase problems with Peripheral Arterial Disease. D. Protect the legs from injury because the tissues are fragile. 20. Which of the following outcomes indicate that there is increased arterial blood supply to the extremity of the client with peripheral arterial disease? A. Reduced sensation to touch B. Reduced muscle pain C. Increased rubor D. Decreased hair on the extremity 21-25. Situation. Nurse Rose is a newly registered nurse. She is assigned to the surgical unit of X hospital. She is aware of the legal responsibilities when performing patient care. The following are situations she encountered in the surgical unit with legal significance. 22. A patient is scheduled for abdominal surgery. Which of the following statements is a responsibility of Nurse Rose in obtaining a consent form? 1. Ensure that the consent form has been signed and is attached to the chart of the patient before the operation. 2. Witness the signing of the consent before the operation is performed. 3. Provide a detailed description of the operation before asking the patient to sign the consent form 4. Answer questions that the patient may ask before the patient signs the consent form. A. 3 & 4 B. 1, 2 & 3 C. 1, 2 & 4 D. 1 & 3 21. Which of the following health care professionals is legally responsible for obtaining informed consent for an invasive procedure? The ____ A. Surgeon B. Nurse Supervisor of the unit C. Medical director D. Registered nurse on duty 23. Nurse Rose documents her observation on a patient for abdominal surgery. Which of the following statements is legally appropriate notation? A. “The charge nurse spoke with the patient about the surgery” B. “The surgeon committed an error in the medication dose to be given” C. “Patient says he will sue the surgeon and the hospital if the operation turns out to be a failure.” D. “Patient says he feels sharp and stabbing pain in the abdominal area.” 24. The attending physician writes an order of Do Not Resuscitate (DNR) on a patient who is seriously ill. Which of the following is a responsibility of Nurse Rose? Nurse Rose should ________ 1) Carry out the order in the event the patient experiences sudden need for CPR 2) Determine if there is a living will on the medical record of the patient 3) Consult the policies and procedures of the Institution if she feels such DNR order is contrary to the patient’s or family’s wishes. 4) Refer to the Ethics Committee of the Institution the DNR order to determine appropriateness of the order. A. 2 & 3 B. 1 & 3 C. 3 & 4 D. 1 & 2 25. The physician orders a dose of medication to be given to a patient before undergoing surgery. Nurse Rose is aware that the dose is too high for the patient. She tries to locate the physician to check the order but the physician is not available. Which of the following is the MOST appropriate action Nurse Rose will take to ensure the safety of the patient? A. Notify the nurse supervisor immediately B. Administer half of the dose of the medication ordered. C. Administer the medication as ordered. D. Withhold the medication. 26-30. Situation. The charge nurse in the Emergency Department calls for a crisis meeting to review principles in mass casualty to enhance preparedness and improve emergency quality care. 26. Which of the following statements is NOT TRUE about emergency preparedness? A. Hospitals should have an emergency preparedness plan that is tested through drills or actual participation. B. Generally, hospital employees participate seriously in emergency drills. C. Emergency preparedness training and drills are standard functions of emergency departments of hospitals. D. Drills must involve the participation and collaboration of the community. 27. The charge nurse explains that mass casualty incidents are due to events such as the following EXCEPT: A. Earthquakes B. Severe weather phenomena. C. Lightning strikes. D. Transportation disasters. 28. The charge nurse reiterates the importance of using a disaster triage tag system. Clients that have been “green-tagged” are those ________. A. With injuries of closed fracture, sprains, contusions and abrasions. B. Who are expected to die or are dead already. C. With major injuries such as open fractures and large wounds. D. Experiencing hemorrhagic shock that requires immediate treatment. 29. The term NBC means nuclear, biological and chemical weapons of mass destruction. Which of the following is an example of biologic terrorism agents? A. Vaccine B. Nerve agent antidotes C. Anthrax D. Neoplastic agents 2 | Page
30. The charge nurse emphasizes the overall goal in a disaster situation which is ___. A. Saving as many lives as possible B. Using a disaster triage system that categorizes triage priority by color and number. C. Calling all emergency medical service providers from the hospital to attend the needs of the victims. D. Doing the greatest good for the greatest number of people. 31-35. Situation. The nurse in the emergency department performs initial assessment on clients brought to the department. The following questions pertain to assessment and nursing interventions. 31. The nurse assesses a trauma client in pain who refuses pain medication. Which of the following alternative methods to manage pain can the nurse use or recommend? 1) Positioning/Splinting 2) Application of heat and cold 3) Non-therapeutic touch 4) Guided imagery 5) Humor A. 1, 2, 3 & 5 B. 2, 4 & 5 C. 1, 2, 3, 4 & 5 D. 1, 2 & 5 32. The nurse assesses circulation of an adult trauma victim by palpating a central pulse. Which of the arteries will the nurse palpate? A. Apical artery B. Brachial artery C. Femoral artery D. Popliteal artery 33. The nurse performs complete spinal immobilization. The procedure includes the following actions EXCEPT _____. A. Placing the client on the backboard B. Placing a small pillow on the head. C. Application of a rigid cervical collar. D. Immobilization of the head and neck. 34. In inspecting a client’s airway, the nurse should observe the following, EXCEPT: A. Tongue obstructing the airway B. Foreign objects that may have been lodged. C. Loose teeth or dentures. D. Condition of the tonsils. 35. The correct sequence of the primary assessment of trauma clients is ____. 1) Open and inspect the client's airway while initiating or maintaining cervical spine protection. 2) Palpate a central pulse for strength and rate. 3) Conduct a brief neurologic assessment to determine the degree of disability as measured by the client’s level of consciousness. 4) Remove clothing so that all injuries can be quickly identified. 5) Assess for spontaneous breathing. A. 2, 5, 1, 3 & 4 B. 1, 2, 3, 4 & 5 C. 1, 3, 2 & 5 D. 1, 5, 2, 3 & 4 36-40. Situation. A 38 year old female trauma victim is brought to the emergency department of X hospital. 36. The trauma client has a blood type of AB+. Which type of blood will the client need? A. AB- B. AB+ C. Any type D. O+ only 37. Nurse Pau continues to monitor the condition of the trauma client. The client is in hypovolemic shock. Which of the following types of blood products should Nurse Pau prepare? A. Platelets B. Packed red blood cells C. Plasma D. Whole blood 38. Nurse Pau admits the client. What factors will assist the nurse in determining the classification of a trauma client? 1) Site the injury 2) Speed of the vehicle 3) Height of fall 4) Mechanism of injury A. 2 & 4 B. 1, 2, 3, & 4 C. 1 & 3 D. 1, 2 & 4 39. The trauma client manifests a deviated trachea, jugular vein distention, and cyanosis. Nurse Pau realizes that the trauma client is MOST likely demonstrating? A. Tension pneumothorax B. Cervical spine injury C. Blunt trauma to the chest D. Acceleration-deceleration injury 40. The physician assesses the trauma client using the Champion Revised Scoring System. Nurse Pau understands that the elements of this scoring system are which of the following: 1) Diastolic Blood Pressure 2) Systolic Blood Pressure 3) Heart Rate 4) Glasgow Coma Scale 5) Respiratory Rate A. 2, 4 & 5 B. 2, 3, 4 & 5 C. 1, 3 & 5 D. 1, 2, 3, 4 & 5 41-50. Situation. The nurse assists in the care of a 20-year old male client needing blood transfusion. The attending physician writes an order of blood transfusion of 250 cc of packed red cells after blood cross matching. 41. Before infusing the blood, the nurse assesses the client’s ________. A. Vital signs B. Mental state C. Skin color D. Hemoglobin and hematocrit levels 42. The nurse takes the temperature of the client. The temperature registers 390C. Based on this finding, the nurse should: A. Administer an antihistamine and transfuse the blood. B. Start the blood transfusion as ordered. C. Withhold the blood transfusion and notify the physician. D. Give tepid sponge bath and wait for the temperature to go down then transfuse the blood. 43. Which of the following nursing interventions should have the HIGHEST priority when caring for a client receiving blood transfusion? A. Regulate the drops accurately. B. Instruct the client to notify the nurse if the client experiences itchiness, headache or difficulty of breathing. C. Document the blood type, time transfusion started, and vital signs taken. D. Inform the client that the transfusion may last for one and a half to two hours. 44. The nurse administers the blood and starts the transfusion at 20 – 25 drops per minute. The nurse observes for a transfusion reaction which usually occurs during the _____ minutes after transfusion. A. 15 minutes B. 45 minutes C. 5 minutes D. 30 minutes 45. The client receiving blood transfusion begins to wheeze on respiration, itch and observes that his skin becomes flushed with hives. The nurse recognizes these signs as characteristic of what type of reaction? A. Bacterial B. Hemolytic C. Allergic D. Systemic 46-50. Situation. Nurse Olan works the day shift in the female medical unit. Nurse Olan is aware that when caring for clients, the nursing process can be an effective tool for communication. 3 | Page
48. Nurse Olan understands that the MOST important aspect of communication is to_____ A. Observe the facial expressions of your patients. B. Clarify the statements made. C. Listen to what is being said. D. Restate the words you hear from the client. 49. Which of the following activities will Olan consider to validate effectiveness of a nurse-client communication? A. Assessment of the physician. B. Feedback from the client. C. Adaptation of the client to physiologic changes. D. Conference with the members of the health team. 46. Nurse Olan formulates nursing diagnoses for her clients. She knows that a nursing diagnosis represents the: A. Prepared plan of care. B. Actual nursing interventions carried out. C. Nursing judgments about the health of her patients. D. Actual or potential health problems of her patients. 47. Nurse Olan collects data and begins to develop a trust relationship with her clients. This activity is what aspect of the nursing process? A. Evaluation B. Implementation C. Planning D. Assessment 50. Nurse Olan understands that the nursing process is a scientific method and a proven form for: A. Problem solving B. Health education C. Oral communication D. Cost containment 51-55. Situation. The nurse assists in the care of female clients. Jaira is a 35 year old woman with hyponatremia. According to the client she is taking diuretic medications. 51. Which of the following statements is TRUE about hyponatremia? A. Hyponatremia from diuretic use may produce small quantities of urine. B. Hyponatremia occurs because of excess fluid volume diluting the potassium. C. A serum sodium level determined above 135 mEq/L indicates hyponatremia. D. Hyponatremia from diuretic use may produce large quantities of urine. 52. In assessing the client, the nurse should focus on which part of the following? The ______: A. Spiritual state of the client B. Physical signs and symptoms C. Diagnostic to be done on the client D. Mental status of the client 53. The nurse writes a nursing diagnosis. Which of the following is appropriate? A. Disturbed thought processes B. Decreased cardiac output C. Activity intolerance D. Ineffective breathing pattern 54. The client has a serum sodium level of 115 mEq/L. a priority nursing intervention is for the nurse to: A. Give frequent oral care B. Take precautions for occurrence of seizures C. Monitor cardiac rhythm D. Take the vital signs every two hours 55. The nurse is much aware that a client receiving D5W at 100 ml/hr. is MOST at risk for developing which of the following conditions? A. Hyponatremia B. Fluid volume excess C. Hypernatremia D. Fluid volume deficit 56-60. Situation. Nurse Frances assists in the care of female patients with coronary artery disease (CAD). She schedules time to educate these groups of women about CAD. 56. A correct statement about CAD in women is that _____: A. Hormone Replacement Therapy is recommended for prevention of coronary artery disease. B. Women develop CAD earlier than men. C. The genetic component for CAD is weak. D. The rate of women having CAD is steadily rising while it is declining in men. 57. Research indicates that a woman with CAD needs to exercise to decrease the risk of having CAD. Which of the following exercises is recommended? A. Light to moderate exercise for 30 minutes 5x a week. B. Light exercises (walking) 20 minutes 3x a week. C. Aggressive exercise for 30 minutes 3x a week D. Moderate exercise for 20 minutes 5x a week. 58. Nurse Frances gives information about blood pressure in women. Which of the following statements is correct? A. Hypertension doesn’t affect CAD risk as women age. B. Low blood pressure is twice as common as oral contraceptive users. C. Twenty percent of women have hypertension before menopause. D. Weight, age, and oral contraceptive use affect blood pressure. 59. Nurse Frances explains that stress can be managed by which of the following: A. An individual has low and constant stress B. An individual has high stress level and low control C. An individual has high control and low stress level D. Stress is controlled over short periods. 60. Nurse Frances explains that stress can be managed by which of the following: A. Socializing with other patients with similar disease B. Taking in prescribed medications to relieve you of stress. C. Finding spiritual meaning in what you are experiencing D. Reflecting on your condition and accepting it. 61-65. Situation. The nurse assists in the care of a female client, 45 years old admitted for severe pain related to cancer. 61. In relieving pain related to cancer, which of the following nursing actions is MOST appropriate? A. Keep the room well-lighted so that the nurse can assess the client thoroughly. B. Allow the client to stay in one position to prevent the occurrence of pain. C. Apply heat or cold in the areas that are painful as prescribed by the physician. D. Place a hand bedroll behind the client’s back. 62. The client has a tunneled epidural catheter to control pain. The catheter site should be assessed every shift by the nurse on duty. Which of the following signs indicate catheter migration or tissue trauma? A. Bright red bleeding under the dressing. B. Catheter insertion site is red, swollen with purulent discharges. C. Bright red bleeding and fluid collecting under the dressing with loss of pain control. D. Bright red bleeding and fluid collecting under the dressing. 63. If catheter becomes disconnected from the tubing, the nurse should use which of the following solutions to clean the tubing or connectors: A. Alcohol B. Povidone-iodine solution C. Sterile water D. Saline 64. The nurse instructs the client to report if she experiences signs and symptoms of local anesthetic toxicity which includes the following: 1. Perioral numbness 2. Palpitations 3. Ringing in the ears 4. Seizures A. 2 & 3 B. All of the options C. 1, 2, 3 D. 3 & 4 65. The client describes the pain as knifelike chest pains that increase in intensity on respiration. Which of the following systems is most likely its origin? A. Pulmonary B. Gastrointestinal C. Cardiac 4 | Page