Title PRE-INTENSIVE - NP3 - SC ✅

rate increases to improve oxygenation. Nurse Froilan expects the patient’s ABG to present: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 28. The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis 29. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings? A. pH 7.25, PCO2 50 mm Hg B. pH 7.35, PCO2 40 mm Hg C. pH 7.50, PCO2 52 mm Hg D. pH 7.52, PCO2 28 mm Hg 30. The nurse is caring for a client with an IV who is experiencing dyspnea, hypotension, a weak, rapid pulse, a decreased level of consciousness, and who is becoming cyanotic. The priority nursing intervention is to: A. Notify the physician B. Place the client in Trendelenburg position C. Administer oxygen D. Discontinue the IV 31. Mr. Antonio Sanchez, 47 y.o., was diagnosed with chronic renal failure. Which of the following ABG findings would be expected? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 32. A 60-year-old client is admitted to the hospital presenting shortness of breath, fever, and productive cough. Which ABG finding is most related to the diagnosis of COPD? A. pH 7.33, PaCO2: 48mmHg; HCO3: 24mEq/L B. pH 7.48; PaCO2: 30mmHg; HCO3: 23mEq/L C. pH 7.30; PaCO2: 40mmHg; HCO3: 20mEq/L D. pH 7.49; PaCO2: 38mmHg; HCO3: 29mEq/L 33. A patient is taking furosemide, a potassium-wasting diuretic. Which among these ABG findings would you expect in his long-term use of the diuretic? A. pH 7.48, PaCO2: 46mmHg; HCO3: 28mEq/L B. pH 7.26; PaCO2: 32mmHg; HCO3: 21mEq/L C. pH 7.35; PaCO2: 40mmHg; HCO3: 25mEq/L D. pH 7.30; PaCO2: 33mmHg; HCO3: 20mEq/L 34. A clinical instructor observes SN Tina as she performs ET suctioning to an unconscious client. Which of these indicates that Tina needs further teaching on carrying out the procedure? A. Tina suctioned for 20 seconds on the last suctioning to ensure that the airway is clear. B. Tina pressed the silent button of the mechanical ventilator momentarily prior to suctioning. C. Tina suctioned a small amount of NSS after each suctioning. D. Tina applied suction on the catheter while it was being withdrawn. 35. The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care? A. Percussion and postural drainage should be done before lunch. B. The order should be coughing, percussion, positioning, and then suctioning. C. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested. D. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen. Situation: In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. 36. Which of the following should be given highest priority when receiving patient in the OR? A. Assess level of consciousness B. Verify patient identification and informed consent C. Assess vital signs D. Check for jewelry, gown, manicure and dentures 37. Surgeries like I and D (Incision and Drainage) and debridement are relatively short procedures but considered “dirty cases.” When are these procedures best scheduled? A. Last case B. In between cases C. According to the availability of the anesthesiologist D. According to the surgeon’s preference 38. Katarina, an active cheerleader, complains of flashes of lights appearing and a shadow covering the upper vision of her left eye. You suspect that Katarina sustained a: A. Retinal Detachment B. Glaucoma C. Cataract D. Macular degeneration 39. Based on the situation, you plan to position the client on: * A. Side-lying on the affected eye B. Lateral on the affected eye C. Dependent position on the area affected D. Independent position on the side affected 40. As you prepare the patient for surgery, you noticed that the patient is fidgeting, going in and out of his bed and frequently asks about the procedure. These behaviors of the patient most likely suggest? A. The patient does not have enough sleep last night. B. Client is pressed between financial burden and family responsibilities. C. She drank too much coffee during breakfast D. She is anxious about the surgery. 41.The nurse should expect a patient who has chronic renal failure to be given epoetin alfa (Epogen) to A. elevate the white blood cell count B. enhances the maturation of thrombocytes. C. increases the production of platelets. D. stimulates the synthesis of red blood cells. 42. To which of the following nursing diagnoses would a nurse give priority when caring for a patient who has syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? A. Decreased cardiac output B. Altered nutrition C. Urinary incontinence D. Fluid volume excess 43. A 48- year- old woman, who does not have a family history of breast cancer, asks a nurse in the ambulatory care center whether she should have a mammogram. Which of the following responses by the nurse would be accurate? A. “At your age, a mammogram is recommended every one to two years.” B. “You do not need to begin to get mammograms until you are 50 years old.” C. “A mammogram is not indicated unless you have a family history of breast cancer.” D. “A mammogram would be necessary only if you feel a change in breast tissue.” 44. When planning care for a 14- year- old female who is pregnant, a nurse should recognize that the adolescent is at risk for A. glucose intolerance B. fetal chromosomal abnormalities C. incompetent cervix D. iron deficiency anemia 45. Which of the following statements made by a patient who is scheduled for a mammogram indicates a need for further teaching? A. “I will not use underarm antiperspirant before the procedure.” B. “A dye will be injected into my vein prior to the procedure.” C. ‘I may experience discomfort during the procedure.” D. “My breasts will be compressed while the x –rays are taken.” 46. Which of the following findings in a 13- year- old girl who 3 | Page
has Crohn’s disease would indicate that corticosteroid therapy has been effective? A. Expansion of muscle mass B. Increase in the number of stools C. Moon- like appearance of the face D. Decreased complaints of abdominal pain 47. The teaching plan for a child who is taking long- term corticosteroid therapy would include which of the following instructions? A. Dental check- ups every three months to assess for gingival hyperplasia B. Regular physical therapy sessions to prevent muscular hypertrophy C. Eye examinations yearly to assess for cataract formation D. Regular appointments with a registered dietician to prevent malnutrition 48. A six- year- old child has a short arm cast placed on the right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings? A. Mild edema B. Pain on movement C. Slight coolness of the cast when touched D. Capillary refill greater than three seconds 49. A patient who is undergoing detoxification from heroin complains to the nurse of severe muscle cramps and headache and demands additional Methadone. Which of the following actions should the nurse take first? A. Measure vital signs. B. Administer p. r. n. medication. C. Provide support and reassurance. D. Contact the physician. 50. Which of the following measures should a nurse include in the care plan of a patient who has a diagnosis of bipolar disorder, manic type? A. Decrease environmental stimuli B. Involve the patient in competitive activities C. Limit the verbalization of feelings D. Foster independent decision- making 51. A nurse should instruct a pre- menopausal woman to examine her breasts according to which of the following schedules? A. During the week prior to the onset of the monthly period B. During every shower C. Seven days after the menstrual period D. On the same day every month 52. A nurse is taking the history from a patient who is suspected of having Hodgkin’s disease. Which of the following questions should the nurse ask to support the diagnosis? A. “Do you wake up sweating during the night?” B. “Do you urinate more frequently?” C. “Have you noticed recent memory lapses?” D. “Have you experienced visual changes lately?” 53. A nurse is observed taking all of the following actions when suctioning a patient who has a newly- placed tracheostomy tube. Which of the following actions require intervention? A. Applying suction for less than 15 seconds at one time B. Administering 100% oxygen prior to starting suctioning C. Utilizing negative pressure of 120 mm Hg during suctioning D. Deflating the tracheostomy cuff for three minutes before initiating suction 54. Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa? A. Electrolyte balance B. Energy level C. Fluid intake D. Desire to eat 55. A nurse evaluates a three- month- old, developmentally- delayed infant for manifestations of cerebral palsy. Which of the following findings would a nurse report? A. Exaggerated arching of the back B. Absence of the extrusion reflex when fed from a spoon C. Head circumference measurement less than the 50th percentile D. Slight head lag when pulled to a sitting position 56. To which of the following nursing diagnoses should a nurse give priority in the care of a patient who is receiving chemotherapy for treatment of breast cancer? A. Risk for infection B. Stress incontinence C. Altered sexuality patterns D. Impaired physical mobility 57. Which of the following conditions, reported to a nurse by a 20- year- old male patient, would indicate a risk for development of testicular cancer? A. Genital herpes B. Undescended testicle C. Measles D. Hydrocele 58. Which of the following criteria would indicate improvement in an outpatient who has anorexia nervosa? A. The patient identifies the relationship between emotions and eating behaviors. B. The patient develops a plan to control negative feelings. C. The patient reports putting “thin” clothes on display in her room as a reminder to maintain proper weight. D. The patient avoids contact with her dysfunctional family. 59. A 10- year- old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. When evaluating for a major complication of this disease, a nurse would give priority to assessing which of the following body systems? A. Integumentary B. Neurological C. Respiratory D. Gastrointestinal 60. The parent of a 12- year- old child, who is on acetylsalicylic acid (Aspirin) therapy for juvenile rheumatoid arthritis, tells a nurse, “I just read an article that said Aspirin should not be given to children.” Which of the following responses by the nurse is most appropriate? A. “Stop the Aspirin only if your child is diagnosed with a viral illness.” B. “Your child can take a different anti- inflammatory instead of aspirin.” C. “Because the Aspirin dose your child receives is so small, the risk is minimal.” D. “The benefits of Aspirin for your child outweigh the risks.” Situation: As a community health nurse, you are now in the entry phase of community organizing process, after establishing rapport with the people in Barangay PutingBuhangin. The following questions apply. 61. In the entry phase of community organizing, all but one are the activities a community health nurse shall implement: A. Information campaign on health programs B. Project Management C. Core group formation D. Conduct of deepening social investigation 62. Identification of potential leaders is crucial during the entry phase, this will facilitate the core group formation and start community mobilization. Which of these characteristics may not be necessary to an efficient and effective community leader? A. Responsive and willing to work for change B. Must have relatively good communication skills C. A respected member of the community D. A college graduate who has good management and leadership skills 63. The best way in identifying potential community leader which is proven to be effective is: A. Do a house-to-house survey among the people on who they see as a leader in the community B. During group meetings and other small mobilization, observe people who actively motivates other residents C. Ask volunteers who are willing to become community leaders D. Conduct a review of the family background and wealth as a basis for the community leader’s capacity 4 | Page