Title RECALLS 1 - NP3 - SC ✅

3. Hyperglycemia 4. Glycosuria A. 1 and 3 B. 2 and 3 C. 1 and 2 D. 3 and 4 13. Which nursing action is critical in monitoring Mara’s condition? A. Measuring intake and output B. Assessing vital signs C. Monitoring sleeping pattern D. Analyzing blood glucose 14. The physician orders “weigh daily”. When instructing the nursing aide to weigh the client, what essential instruction is MOST important to obtain an accurate data? A. Weight the client on the same scale time of the day wearing the similar amount of clothing B. Ask the client to state her weight before the disorder manifested C. Instruct the client to weigh before breakfast daily D. Have the client remove her footwear 15. The client was prescribed with intranasal Lypressin (Diapid) 2 spray 4x a day and as needed. Which is the CORRECT way to administer the spray? A. Siting in an upright position, insert the spray into the nostril then inhale while compressing the container B. Shaking the spray vigorously before inhaling in both nostrils C. Tilting the head to the side, and inhale the spray 2 times D. Inhaling with each spray 2 times Situation: Documentation is one of the topics for discussion among the nurse - orientees. 16. In the hospital, narrative documentation is used. From the guidelines below the nurse orientees were made to select which are the CORRECT guidelines related to narrative documentation. Select all that apply: 1. Use blue colored ink ball pen all the time 2. Date and time all entries 3. Completely document subjective and judgmental information gathered 4. Sign and affix appropriate title 5. Avoid evaluative statement 6. Do not leave blank spaces on documentation forms A. 3, 4, 5, and 6 B. 1, 2, 4, and 6 C. 2, 3, 4, and 6 D. 2, 4, 5, and 6 17. Nurse Jell made an error in documenting an assessment finding on her client’s chart. She must CORRECT the error by: A. Over the wrong entry, write ERROR in red, then write the correct data B. Draw one line over the wrong entry, write the correct data, sign and put the date C. Erase neatly the wrong entry and write on the same place the correct data D. Delete the wrong entry and write the correct data 18. Another nurse -orientee administered an inaccurate dose of Ampicillin to her client. Following the assessment, reporting to the doctor and the head nurse, she accomplishes an incident report. The orientee understand that the report: A. Will form part of her 201 file B. Will result to her suspension from the hospital C. Will be reported to the Regulatory Board of Nursing D. Is a method of promoting quality care and risk management 19. The nurse-orientee was charting while waiting for the result of the cross-matching result of her client. When the fax machine activated, the nurse saw a result of the cross– matching of her client’s name but with another hospital – bed – number. The MOST appropriate action of the nurse would be to: A. Return the result of cross - matching and send another request B. Consider the result as that of her client C. Refer the matter to the head nurse D. Call the laboratory to confirm result of cross – matching 20. The nurse-orientee is to present a case in the meeting with the staff nurses. She Xeroxed the chart of her client to study at home. While she was dressing up to go home, a staff nurse saw the folder of Xeroxed copies of the patient’s record. The staff nurse would call the attention of the nurse-orientee that: A. This is a violation of hospital policy B. The owner of the record should be consulted C. Her action is against the client’s right to privacy D. A prior permission from the Medical Record Section should be obtained Situation: Nurses should demonstrate management skills while on duty to promote safe and quality health care delivery. 21. Nurse Kell was waiting for her turn to use the Comfort room (CR) of the Nurses Station, when a nursing attendant Millie came out drying her face with sterile gauze dressing. Nurse Kell immediately called her attention to: A. Bring their own personal toiletries B. Use hospital supplies like dressings, judiciously C. Conserve water as there is not enough for everyone D. Limit the use of the nurse’s station comfort room for the staff on duty 22. A nurse is preparing to start an intravenous infusion of D5% Lactated Ringer’s solution with 40 mEq Kcl on a postoperative client with an infusion pump. When she attempted to plug the pump cord into the wall socket, the pump did not seem to work. Which of the following is MOST appropriate nursing action? A. Initiate the intravenous line without using the pump B. Use an extension cord from the corridor to plug the pump C. Contact the electrical maintenance for assistance D. Plug the pump cord in the available plug above the room sink 23. A nurse is going to change the soiled beddings of the client with ulcerative colitis. When personal protective equipment (PPE) should be worn by the nurse? A. Gown and gloves B. Gloves C. Goggles and gloves D. Gloves and mask 24. Nurse Kell has four clients. After the endorsement rounds, she plans to do assessment of her four clients. Which client would she attend FIRST? A. Client on oxygen inhalation who bad difficulty of breathing last night B. Client for chest x-ray C. A preoperative client for cardio pulmonary clearance D. The post vagotomy client who is for discharged 25. Nurse Kell observed that during meal hours, there are no orderlies present in the unit. Which nursing management strategy must be done? A. Plan a schedule of meal so that every staff will have a fix time to take lunch for 30 minutes. B. Any orderly who leaves the unit should ask permission from the head nurse C. When the orderly leaves for lunch, she/he should log in and out D. Allow a mid A.M. break of 15 minutes Situation: A 45-year-old female was admitted because of acute pancreatitis. Nurse Delly was assigned to take care of the client. 26. While nurse Delly was making her rounds before endorsement to the next shift, her client asks her which would be a comfortable position to assume. The nurse would recommend the following positions EXCEPT: A. Flexing the left leg B. Leaning forward C. Lying in supine position D. Sitting up 27. There has been an increasing rate of acute pancreatitis in the Philippines. She is aware that the most common cause of acute pancreatitis is? A. Alcohol Use 2 | Page
B. Trauma C. Infections D. Gallstones 28. Nurse Delly is aware that the treatment of acute pancreatitis consist of pain relief and “putting the pancreas to rest”. This is BEST accomplished by which of the following? A. Serving clear liquid diet B. Following a frequent but small feeding C. Feeding by nasogastric tube D. Parenteral nutrition administration as prescribed 29. The client has a standing order of Meperidine HCL (Demerol) 100mg intramuscularly (IM) every 4 hours. At 8am, nurse Delly administered Demerol as prescribed. At 10am, the client asked for the next dose. The nurse verified the intensity of pain and the client said, it is not so painful. I just don’t want to feel any sort of pain”. What would be the MOST appropriate action of the nurse? A. Apply warm compress over the painful area B. Inject the prescribed dose and the other half at 12 noon C. Change patient’s position and implement diversional activity D. Administer the full dose of Demerol now. 30. When the client said, “it is not so painful”. What is the client trying to describe? A. Unrelieved pain B. Location of pain C. Pain tolerance D. Quality of pain Situation: Communication is one of the best tools in patient -nurse interaction towards safe delivery cure. 31. Mrs. Gomez told the nurse that she was concerned about her husband. Which of the following responses of the nurse would encourage Mrs. Gomez to open the discussion A. “Would you like to talk about the reason for your visit?” B. “Would it help to discuss your feelings? C. “What brought you to the hospital?” D. “Does it concern you on what happen to your husband?” 32. While Listening to your patient about his near death experience during his last surgery, you crossed your arms on your chest. What message is the nurse conveying to the client? A. Trying to end the conversation with your client B. Conveying that you have ample time to listen to the client C. Pretending to listen to what the client is narrating D. Uninterested to hear what the client has to say 33. Another client told you that he was not looking forward to having this hemorrhoids removed. Which statement of the nurse would MOST likely stir up an expression of fear to the client? A. “are you implying that surgery is frightening?” B. “why don’t you just look forward to your surgery to relieve you of the present discomfort?” C. “don’t you think your surgeon is competent enough?” D. “have you ever bad surgery before?” 34. You are assessing a 60 year old client who lives alone by herself and with permanent colostomy. Which of the following statements of the client indicate that she has fully accepted her-present condition? A. “My children no longer visit me. I’m just waiting for my Creator to take me” B. “My life is slowly deteriorating each day” C. “I was a good O.R. nurse when I was younger. Now I’m just client” D. “I had a good life and I intend to enjoy it” 35. Mrs. Orchard, a post hysterectomy client with 7 children, made no comment about the recent death of her 13 year old daughter in a tragic car accident. She shifted topics quickly when asked about how her other children were adjusting to the loss of their sister. Which of the following interpretation of her actuation should receive your PRIORITY nursing intervention for Mrs. Orchard? A. Need of support system B. Changing life roles C. Avoiding a painful subject D. Resolved grief SITUATION: Peptic Ulcer Disease prevalence in urban-based hospitals is 15-30%. The following questions are related to PUD. 36. Ciara presents to the hospital stating she is having gastric ulcer. Which of the following assessment data supports the diagnosis? A. The client is experiencing blood in his stool for the past month B. After eating a heavy fatty meal, the patient experiences upper abdominal pain. C. The patient reports wave-like burning sensation D. After ingesting food, the patient complains epigastric pain 30 to 60 minutes. 37. The nurses performs physical examination to the client. The nurse is knowledgeable when she implements which among the following first? A. Examine the abdominal area for tenderness using fingertips B. Listening to each of the quadrants using a stethoscope C. Use plexor and pleximeter in assessing the abdominal borders to identify organs D. Assess the tender area from progressing to nontender 38. Ciara was referred to a gastrointestinal doctor and was informed that she should undergo diagnostic test. What tests confirms the diagnosis? A. MRI B. CTSCAN C. FOBT D. EGD 39. Which physiological complications is expected for the nurse to consider in creating plan of care for patient diagnosed with PUD? A. Knowledge deficit in the causes of ulcers B. Inability to cope in bowel elimination C. Potential for alteration in gastric emptying D. Alteration in bowel elimination patterns. 40. Ciara was discharged and was given home instructions. Which among the following statements means that Ciara learned the expected outcome? A. She should not present any signs and symptoms of hemoptysis B. She should take antacids with each meal to prevent excessive gastric acid. C. She controls her pain by taking NSAIDs D. She maintains modifications in her lifestyle Situation: A G4 P5 client who is in labor pains is transferred from the delivery room to the Operating Room for emergency Cesarean section (CS). 41. As you reviewed the client’s chart, you found out that the reason for the emergency CS is “fetal distress”. Which of the following assessment findings would confirm the indication of emergency CS? A. Fetal heart rate of 180 beats per minute B. Multiple pregnancy C. Non-progressing labor D. A 6 to 6.7 lbs baby 42. The circulation nurse prepares the client to which of the following positions? A. Supine with wedge support under the right hip B. Supine with pillows for head support C. Lithotomy with padded stirrups D. Semi -Fowler’s position with one pillow under the knees 43. As soon as the baby is out, the scrub nurse must focus FIRST on which of the following nursing action? A. Slap the newborn to induce crying B. Wipe the mouth, nose and eyes with a sterile operating sponge (OS) C. Attach the name tag D. Suction the mouth and nose of the newborn 44. Prior to the closure of the endometrium, the scrub and circulating nurses should perform which of the MOST critical 3 | Page
nursing intervention? A. Change drapes B. Have a large basin to contain the placenta C. Report sponge count status to the surgeon D. Prepare chronic cut gut suture for the endometrium 45. One week after surgery, the mother developed high fever and was found out that the cause of infection was a sponge left inside her body. The health care professional most liable for this case is: A. Anesthesiologist B. Surgeon C. Scrub Nurse D. Circulating Nurse Situation: A nurse admitted a 6 year old boy who is dyspneic, tachypneic with respiratory rate of 40 breaths/minute, afebrile, and with paroxysmal, irritative non – productive cough. Physician’s diagnosis is asthma. 46. Which of the following correctly describes asthma? A. Often irreversible B. Inflammatory disorder of the airways C. Characterized by hypoventilation D. Dyspnea with respiratory rate of 40/minute 47. When the nurse examines the patient’s chest on auscultation, which of the following assessment findings would indicated that the obstruction progresses? A. Productive cough B. Audible wheeze C. Silent chest D. Prominent sweating 48. The nurse administered aminophylline as ordered. Which of the following assessment indicates effectiveness of the drug? A. Thinning of the tenacious purulent sputum B. Normal breath sounds C. Normal body temperature D. Decreasing bronchial secretions 49. The client was prescribed with a short term corticosteroid therapy, The nurse knows that the preferred route of administration is through metered-dose inhalation because it: A. Is well tolerated B. Minimizes mucous secretions C. Reduces cushingoid effects D. Enhances absorption of drug 50. Throat irritation is associated with nebulizer use. What nursing intervention is BEST to decrease irritation? A. Taking lozenges B. Drinking ice cold fruit juices C. Sipping or gargling water D. Chewing gum Situation: A woman who underwent hysterectomy 2 days ago is under your care. 51. Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity? A. Drinking coffee at least 3 to 5 cups in a day B. Refusing to get out of bed C. Taking soft diet only D. Requesting for analgesics frequently 52. The following are true regarding antiemboli stockings except: A. Too small stockings may cause skin breakdown. B. Apply stockings in the morning. C. The patient who has been ambulating should wait for 1 hour before applying the stockings. D. Antiemboli stockings can prevent edema of the legs and feet. 53. The nurse assesses the client for Homan’s sign. Which of the following is the CORRECT instruction of the nurse? A. Have the client push each foot hard against the mattress B. Tell the client to sit on bed and point to her toes C. Ask the client to contract her tight muscles D. Instruct the client to extent her legs and flex each foot toward the head 54. Which client’s response suggest a positive Homan’s sign? A. Inability of the client to bend her knees B. Sudden numbness while extending the foot C. Tingling sensation throughout the affected leg D. Sharp, immediate calf pain in the legs 55. Based on the findings, the client has been diagnosed with deep vein thrombophlebitis. Which of the following nursing action must be AVOIDED? A. Elevating the client’s leg B. Massaging the affected leg C. Applying warm compress to the affected leg D. Crossing the legs when seated SITUATION: Anemia in the Philippines is prevalent and needs an intervention. There are different types of anemia and the following questions are about it. 56. The nurse is admitting Cloyd, a 26-year-old male. In gathering his past medical history, he stated that he undergone a gastric bypass surgery for his obesity 3 years ago. The following assessment findings includes height 5’7’’, weight 81kg, P112, R26, BP110/70, pale mucous membranes and dyspnea on exertion. Upon assessment, the nurse suspects that the client is having what type of anemia? A. Folic Acid Deficiency B. Vitamin B12 Deficiency C. Sickle cell anemia D. Iron deficiency Anemia 57. The client with a diagnosis of IDA is prescribe FeSO4 orally. The patient should be educated about: A. Taking laxative for diarrhea B. Exercise being limited until tolerance to the supplement is achieved C. Red meats and organ meats are the only foods that should be consumed to increase the level of iron in the body D. The stools may appear dark green-black which may mask blood 58. The anemia of the patient diagnosed with CHF became so severe that requires the HCP to order two units of PRBCs to transfuse. The unit has 250 mL of RBC plus 45mL of additive. The nurse set the IV pump at what rate to infuse each unit of PRBC? A. 74ml/hr B. 62-63ml/hr C. 147ml/hr D. 125ml/hr 59. You are the charge nurse assigned in the ward. Patients with different types of anemia was admitted. As a charge nurse, you assigned which among the patient to the most experienced nurse? A. client with IDA taking supplements B. client with Vitamin B12 deficiency requiring intramuscular administration C. client with Renal problem with deficiency of erythropoietin D. client with aplastic anemia which developed pancytopenia. 60. The client diagnosed with anemia was discharged. Which among the health education given by the nurse is correct? A. Take the prescribed iron until it is consumed B. Checking the vital signs specially pulse and BP at botika weekly C. Performing exercises at least three times a week D. Have a regular blood workup for CBC at HCP’s office. Situation: Many times clients would ask to be admitted to their room of choice. The hospital is not always ready to give client their preferred room but consider other parameters that would nonetheless enhance safe environment while confined in the hospital. 61. The nursing aide is asked to prepare a room for a child with post-operative fever. The room should be equipped with the following EXCEPT: A. Game board B. Bedside rails C. Air conditioning unit D. Call system 4 | Page