Title RECALLS 6 - NP3 - SC ✅

30. Andrea is teaching dietary management to a client with Addison’s disease. Which advice is appropriate? A. Eat a high-protein, high-calcium, low-calorie diet B. Avoid salt in all meals C. Increase carbohydrate intake and limit potassium-rich foods D. Consume foods rich in sodium and moderate carbohydrates Situation: Nurse Maricel is assigned to the neurology unit. She cares for clients recovering from head injuries, strokes, and spinal cord injuries. She must monitor for complications, ensure proper positioning, and teach families how to assist with daily care. 31. Maricel is transferring a client with a possible spinal injury from a stretcher to a bed. Which technique is best? A. Move the client segmentally in small parts B. Logroll the client with assistance C. Use a draw sheet and lift from behind the shoulders D. Sit the client up and transfer slowly 32. A stroke patient with right-sided hemiparesis needs to transfer from bed to wheelchair. Which is the safest approach? A. Place the wheelchair parallel to the bed on the weaker side B. Position the wheelchair 45° to the bed on the stronger side C. Ask the patient to wrap arms around the nurse’s neck D. Place the wheelchair far from the bed 33. A client with a spinal cord injury needs to be repositioned in bed. Which action will Maricel take? A. One nurse lifts the patient by the arms B. Two nurses use a draw sheet to lift the client C. One nurse rolls the patient toward the stronger side D. Ask the client to scoot up the bed 34. While caring for a patient with a head injury, which sign should Maricel report immediately? A. Complaints of mild headache B. Low-grade fever C. Mild photophobia D. Increasing drowsiness and difficulty arousing 35. A patient recovering from a stroke has mild dysphagia. Which nursing intervention is most appropriate? A. Place the patient in an upright position when eating B. Offer a clear liquid diet C. Tilt the patient’s head back while swallowing D. Provide dry finger foods like crackers Situation: Nurse Isabel is assigned to the oncology unit. She cares for patients receiving chemotherapy, radiation therapy, and palliative care. Her responsibilities include monitoring for complications, ensuring adherence to treatment protocols, and providing emotional and ethical support to patients and families. 36. A patient undergoing chemotherapy develops painful mouth ulcers. What is Isabel’s most appropriate intervention? A. Encourage frequent use of alcohol-based mouthwash B. Provide soft, bland foods and perform saline rinses C. Advise the patient to brush vigorously with a firm-bristled toothbrush D. Recommend citrus juices to promote healing 37. A cancer patient tells Isabel that a lawyer will be coming to prepare a living will and asks if she can be a witness. How should Isabel respond? A. Agree to serve as a witness to help the patient B. Refuse and avoid discussing the matter further C. Explain that nurses caring for the patient cannot serve as witnesses D. Call the attending physician to resolve the issue 38. Which of the following should Isabel include in discharge teaching for a patient who has undergone external radiation therapy? A. Apply lotion daily to the radiation site B. Avoid exposing the treated skin to direct sunlight C. Use heating pads on the treated area for comfort D. Scrub the area daily with strong soap 39. A patient with terminal cancer expresses a desire to stop aggressive treatment. Which ethical principle supports Isabel’s decision to honor the patient’s request? A. Justice B. Autonomy C. Beneficence D. Nonmaleficence 40. Isabel observes that a patient receiving chemotherapy has a temperature of 38.5°C (101.3°F). What should she do first? A. Administer acetaminophen as ordered B. Notify the physician immediately C. Encourage the patient to increase oral fluids D. Recheck the temperature in one hour Situation: Nurse Leo is assigned to a post-operative surgical ward. He is responsible for closely monitoring patients' vital signs, ensuring medications are administered correctly, and maintaining safe care practices. He must also be aware of legal and ethical implications of negligence or malpractice in nursing practice. 41. A nurse overhears a physician tell a patient derogatory remarks about the nursing staff. Which legal violation applies to the physician’s actions? A. Libel B. Slander C. Assault D. Negligence 42. Leo notices a patient’s condition deteriorates over several hours, but he does not act on the changes. The patient later requires emergency surgery. This inaction is considered: A. Tort B. Misdemeanor C. Common law D. Statutory law 43. A post-operative patient complains of severe pain despite receiving narcotics. Leo suspects the assigned LPN may be diverting narcotics. What should he do first? A. Avoid assigning the LPN to patients receiving narcotics B. Review the medication records and report the situation to the nurse supervisor C. Ask the physician to increase the narcotic dosage D. Confront the LPN directly 44. A patient is scheduled for surgery but the consent form is unsigned. What is the best action for Leo to take? A. Obtain the patient’s signature immediately B. Inform the physician that the consent is missing C. Allow the surgery because it is implied consent D. Have a family member sign the consent form 45. During the night shift, Leo discovers that a patient wants to leave the hospital against medical advice (AMA). Which statement about the AMA form is correct? A. It confirms the patient’s control over care B. It is used during readmission C. It releases the physician and hospital from liability for the patient’s health status D. It documents the patient’s refusal to pay Situation: Nurse Rafael is working in a cardiovascular step-down unit. He is caring for clients who have undergone vascular surgeries and those with chronic cardiovascular conditions. His responsibilities include assessing for complications, preventing thromboembolic events, and providing patient education about lifestyle modifications and medications. 46. Rafael is administering a fluid challenge to a client in hypovolemic shock. Which assessment finding shows the client is responding favorably? A. Urine output increases from 25 mL/hr to 40 mL/hr B. Systolic BP increases from 80 mmHg to 90 mmHg C. Central venous pressure (CVP) increases from 5 cm H2O to 7 cm H2O D. PaO2 increases to 90% saturation 47. Four hours after an aortic-femoral bypass graft, Rafael cannot palpate pulses in the operative leg, and the patient reports pain. What should he do first? A. Massage the leg and apply warm towels 3 | Page
B. Elevate the leg and recheck the pulse C. Call the physician immediately D. Assist the patient to ambulate 48. A client with peripheral vascular disease is being discharged. Which modifiable risk factor is most important for Rafael to address? A. Orthostatic hypotension B. Age C. Smoking D. Hypoglycemia 49. Rafael is caring for a client 6 hours postpartum and wants to prevent thrombophlebitis. What is the best nursing action? A. Encourage early ambulation and increased fluid intake B. Restrict bathroom privileges and elevate legs C. Administer anticoagulants to all postpartum clients D. Initiate breastfeeding as soon as possible 50. Ms. H. is admitted to the coronary care unit to rule out a myocardial infarction. She tells the nurse she is sure it is just angina and cannot understand what the difference is between angina and infarct pain. Which response is most appropriate for the nurse to make? A. Anginal pain usually only lasts 3–5 minutes B. Anginal pain produces clenching of the fists over the chest while acute MI pain does not C. Anginal pain requires morphine for relief D. Anginal pain radiates to the left arm while acute MI pain does not Situation: Kiera has felt constipated and bloated for quite a while now. Two days ago, she was complaining of moderate cramping in her abdomen. Upon assessment, she is febrile with two episodes of vomiting before arriving to the emergency department. Nurse Eliza suspects that she has diverticulitis. The following questions apply. 51. Nurse Eliza is aware that, most commonly, the location of diverticulitis is found in which area of the abdomen? A. Right upper quadrant B. Right lower quadrant C. Left upper quadrant D. Left lower quadrant 52. Nurse Eliza differentiates diverticulitis from diverticulosis. She in incorrect when she states which of the following statement to describe the disorders? A. Diverticulosis develops as a result of high intake of fiber and fast colonic transit time B. Diverticulitis develops when one or more diverticula is inflamed C. Diverticulosis forms when the mucosal layers of the colon herniate through the muscular wall 53. Which of the following dietary recommendation can Nurse Eliza provide Kiera to manage her condition? A. Fluid intake of 2 liters a day B. Foods low in fiber C. High fat diet D. Regular diet 54. The diagnostic procedure of choice to confirm diverticulitis and reveal any perforation or abscess is done through? A. Abdominal CT scan with contrast B. Abdominal X-ray C. CBC with elevated WBC count D. Prescence of frank blood in the stool 55. A few hours later, Kiera reports sdden severe abdominal pain that radiates to the back and shoulder, upon assessment the abdomen appears rigid and board like with absent bowel sounds. Kiera has a weak and thready pulse and nauseated. Which of the following priority intervention should nurse eliza perform immediately? A. Administer fleet enema as ordered B. Insert an NG tube C. Notify the Physician D. Administer Psyllium as ordered Situation: Critically ill patients with prolonged pressure due to immobility poses great risk for pressure injury. As an ICU nurse. Nurse Llyana initiates intervention to prevent the occurences of these injuries. 56. In order to assess for risk for pressure injury. Nurse llyana can perform all of the following nursing actions, except. (-) A. Evaluate the level of mobility B. Assess the neurovascular status C. Determine the presence of incontinence D. Evaluate the use of skin care products 57. The most common site or area susceptible to pressure injuries are. A. Scapula and elbows B. Sacrum and heels C. Occiput and ears D. All of the above 58. Nurse Llyana stages the pressure injury of one of the patients who was admitted to the ICU with existing community acquired pressure injury. She is aware that partial thickness skin loss with exposed epidermis is considered as A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury 59. To minize moisture on the skin, the most inappropriate measure for Nurse Llyana to apply would be? (-) A. Wash soiled skin with mild soap and water B. Lubricate the skin with a bland lotion C. Put absorbent pads in the skin D. Apply drying agents and powders 60. Which nursing intervention is most crucial for the prevention of pressure injuries A. Frequent position changes B. Elevate the head of bed to more than 30 degrees C. Eliminate protein from the diet D. Ignore skin folds when performing hygiene measures Situation: Elmer has been diagnosed with ESRD and si set to go undergo hemodialysis while awaiting for availability of functioning kidney transplant. Nurse Mocha assist him during his stay in the Hospital 61. Nurse Moca knows that the most sensitive indicator of renal function is A. Blood urea nitrogen B. Serum Creatinine C. Glomerular Filtration Rate D. ABG 62. Nurse Mocha interprets the Arterial Blood Gas of the patient. Result shows a ph 7.28 HCo3 10 and Paco2 55 A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis 63. Nephrologist require strict monitoring of intake and output among patients with renal disorders. Nurse Mocha can effectively assess for fluid status by doing all of the following except.? A. Assess skin turgor and presence of edema B. Assess patient’s food preferences C. Weight the patient daily D. Check for neck distention 64. Elmer is scheduled for surgical AVF creation on his right forearm. Nurse Mocha will interpret the following as abnormal when it comes to the vascular access for dialysis except. A. Distal Pain of the right extremity B. Poor capillary refill C. Numbness and Tingling D. Presence of a thrill and bruit 65. Nurse Mocha understands that all but one are inappropriate intervention when it comes to the patient with an arteriovenous fistula? A. Check the BP in the right and left extremities B. Perform blood culture and sensitivity on two sites C. Insert a large bore access in the right arm for blood transfusion D. Place an arm precaution sign on the bedside. Situation: Patients approaching the end of life experience can benefit from palliative care. As a nurse, Nurse Regine is knowledge about palliative and end of life principles of care and the ability to recoignize the unique response of each 4 | Page