Title RECALLS 11 (NP3) - STUDENT COPY ✅

RECALLS EXAMINATION 11 NURSING PRACTICE III CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) 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 III” on the box provided 1. Nurse Kaye is trying to communicate with a client with brain attack and aphasia. Which of the following actions by the nurse would be least helpful to the client? A. Speaking to the client at a slower rate B. Allowing plenty of time for the client to respond. C. Completing the sentences that the client cannot finish. D. Looking directly at the client during attempts at speech. 2. The nurse is caring for a patient diagnosed with hepatic encephalopathy. Which of the following interventions is inappropriate for this patient? A. Encourage high protein diet B. Administer lactulose as ordered C. Administer Neomycin sulfate as ordered D. Monitor neurologic status and motor disturbances 3. The nurse receives a report on a client with an advanced brainstem tumor causing central neurogenic hyperventilation. The ABG results shows as follows: pH 7.45 PaCO2 30 HCO3 20 The nurse knows that this client is experiencing which of the following? A. Uncompensated respiratory alkalosis B. Compensated respiratory acidosis C. Compensated respiratory alkalosis D. Uncompensated respiratory acidosis 4. nurse is caring for a client who requires a mechanical ventilator for breathing assistance. The nurse checks the client’s routine ABG values: pH 7.51 PaCO2 32 HCO3 24 These laboratory values best represent which of the following? A. respiratory alkalosis B. respiratory acidosis C. metabolic alkalosis D. metabolic acidosis 5. A client presents to the emergency room with CNS depression due to narcotic overdose. The ABG results are as follows: pH 7.35 PaCO2 48 HCO3 35 The nurse knows that the client is experiencing which of the following? A. Fully compensated respiratory acidosis B. Partially respiratory acidosis C. Fully compensated metabolic acidosis D. Partially compensated metabolic acidosis 6. A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets these findings as indicative of which condition? A. Metabolic acidosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic alkalosis 7. A client's ABG values reflect respiratory alkalosis. Which action by the nurse is most appropriate? A. Help the client raise their breathing rate by utilizing a sternal rub B. Give oxygen as ordered and look for an underlying cause such as an opioid overdose C. Increase environmental stimulation by turning up the lights and engaging the client in conversation D. Help the client lower their breathing rate by breathing slowly into a paper bag 8. A client is in respiratory alkalosis. The nurse knows that which of the following is a potential cause? Select all that apply. A. Hyperventilation B. Antacid overdose C. Mechanical ventilation D. Dehydration 9. The nurse is caring for a patient with metabolic alkalosis. which of the following is less likely the cause of this condition? A. Excessive vomiting B. NG Tube Suctioning C. Diuretics D. Diarrhea 10. client is brought to the emergency department (ED) after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis 11. Which risk factors exhibited by the client presenting in the emergency department (ED) would place the client at risk for metabolic acidosis? Select all that apply. A. Abdominal fistulas B. Chronic obstructive pulmonary disease C. Pneumonia D. Acute renal failure E. Hypovolemic shock 12. The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A. pH 7.32 B. PaCO2 18 mmHg C. HCO3 8 mEq/L D. PaCO2 48 mmHg 13. nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? A. Weight gain B. Enlarged liver C. Distended abdomen D. Cool extremities 14. The nurse is caring for a client who is recovering from a stroke. The nurse notes the client has developed neglect syndrome. Which of the following signs does the nurse observe to come to this conclusion? Select all that apply. A. The client exclusively uses the unaffected side of the body B. The client turns their head to scan the room rather than moving their eyes C. The client refuses to utilize adaptive equipment for transfers 1 | Page
D. The client verbalizes a decreased sensation to heat and cold E. The client's affected upper limb remains motionless during a meal 15. A nurse is caring for a client who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed. Which best describes the purpose of this test? A. To assess the amount of dysphagia present B. To determine the nutrients needed to put in TPN C. To determine the type of feeding tube that is most appropriate D. To check whether the client has a medical condition that causes swallowing problems 16. A client who had a stroke has been diagnosed as having self-care deficit and is unable to feed or groom independently. Which of the following therapeutic interventions would be most appropriate in this situation? A. Give the client privacy when getting dressed before helping with other activities B. Encourage independence and do not intervene until the client demonstrates that he or she cannot complete a task C. Note partial achievements and provide positive reinforcement D. Ask the client about feelings related to the self-care deficit 17. The nurse just received report on an assigned client who is on the ventilator. The nurse should check the client if which of the following alarms sounds? A. When an alarm sounds more than once, the nurse should assess B. High pressure alarm C. Every ventilator alarm should be assessed D. Low pressure alarm 18. The nurse observes a ventilated client biting on their endotracheal tube. Which of the following ventilator alarm sounds does the nurse anticipate? A. Pressure support alarm B. Low oxygen alarm C. High pressure alarm D. Low pressure alarm 19. You are assigned to care for Bell, a 28-year-old engineer. She has been admitted for elective colon removal secondary to a 10-year history of ulcerative colitis. She is scheduled for an ileal pouch anal anastomosis with J-pouch construction and will have a temporary ileostomy. When Bell returns from surgery, the nurse assesses the stoma. How should the stoma look immediately after surgery? A. Red and moist B. Appear just below the skin level C. Have stents protruding from it D. Pink and dry 20. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urinary output of 20 mL/hr B. Temperature of 37.6° C (99.6° F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the surgical dressing 21. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? A. “Use of an incentive spirometer will help prevent pneumonia.” B. “Close monitoring of your oxygen saturation will detect hypoxemia.” C. “Administration of intravenous fluids will prevent or treat fluid imbalance.” D. “Early ambulation and administration of blood thinners will prevent pulmonary embolism.” 22. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A. “If it’s any help, everyone is nervous before surgery.” B. “I will be happy to explain the entire surgical procedure to you.” C. “Can you share with me what you’ve been told about your surgery?” D. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.” 23. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees 24. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats per minute C. Blood pressure of 110/70 mm Hg D. Hypoactive bowel sounds in all 4 quadrants 25. A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. A. Contact the surgeon. B. Instruct the client to remain quiet. C. Prepare the client for wound closure. D. Document the findings and actions taken. E. Place a sterile saline dressing and ice packs over the wound. F. Place the client in a supine position without a pillow under the head 26. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed? A. Hemoglobin, 8.0 g/dL (80 mmol/L) B. Sodium, 145 mEq/L (145 mmol/L) C. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) D. Platelets, 210,000 cells/mm3 (210 × 109/L) 27. 487A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider’s prescription? A. Endotracheal intubation B. 100 units of NPH insulin C. Intravenous infusion of normal saline D. Intravenous infusion of sodium bicarbonate 28. The nurse is assigned to care for a patient diagnosed with DKA. Which findings support this diagnosis? Select all that apply. A. Increase in pH B. Comatose state C. Deep, rapid breathing D. Decreased urine output E. Elevated blood glucose level 29. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. A. Polyuria B. Shakiness C. Palpitations D. Blurred vision E. Lightheadedness F. Fruity breath odor 30. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). 2 | Page
Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply. A. Initiate an infusion of 3% NaCl. B. Administer intravenous furosemide. C. Restrict fluids to 800 mL over 24 hours. D. Elevate the head of the bed to high-Fowler’s. E. Administer a vasopressin antagonist as prescribed. 31. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A. A urinary output of 50 mL/hr B. A coagulation time of 5 minutes C. A heart rate that is 90 beats per minute and irregular D. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) 32. A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? A. Glipizide B. Metformin C. Repaglinide D. Regular insulin 33. client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? A. Administer digoxin. B. Defibrillate the client. C. Continue to monitor the client. D. Prepare for transcutaneous pacing 34. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A. Muffled heart sounds B. Client reports dyspnea C. A rise in blood pressure D. Jugular venous distention 35. The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client’s chest and before discharging the device, which intervention is a priority? A. Ensure that the client has been intubated. B. Set the defibrillator to the “synchronize” mode. C. Administer an amiodarone bolus intravenously. D. Confirm that the rhythm is ventricular fibrillation 36. A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. A. Place the client on a cardiac monitor. B. Notify the primary health care provider (PHCP). C. Put the client on NPO (nothing by mouth) status except for ice chips. D. Review the client’s medications to determine whether any contain or retain potassium. E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration 37. The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client’s peripheral response to pain? A. Sternal rub B. Nailbed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle 38. The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure 39. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A. “We need to discourage him from wearing eyeglasses.” B. “We need to place objects in his impaired field of vision.” C. “We need to approach him from the impaired field of vision.” D. “We need to remind him to turn his head to scan the lost visual field.” 40. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? A. Meningitis or encephalitis during the last 5 years B. Seizures or trauma to the brain within the last year C. Back injury or trauma to the spinal cord during the last 2 years D. Respiratory or gastrointestinal infection during the previous month 41. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active range of motion C. Providing information, giving positive feedback, and encouraging relaxation D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors 42. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig’s sign B. Absence of nuchal rigidity C. A positive Brudzinski’s sign D. A Glasgow Coma Scale score of 15 43. Carbidopa-levodopa is prescribed for a client with Parkinson’s disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? A. Pruritus B. Tachycardia C. Hypertension D. Impaired voluntary movements 44. The nurse is caring for a client in the emergency department who has been diagnosed with Bell’s palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed? A. Pentostatin B. Auranofin C. Fludarabine D. Acetylcysteine 45. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? A. Hypotension B. Tachycardia C. Slurred speech D. No abnormal finding 46. A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition 47. client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 3 | Page
A. Monitor for kidney failure. B. Monitor psychosocial status. C. Monitor for signs of bleeding. D. Have heparin sodium available. 48. The nurse administered intravenous bumetanide to a client being treated for heart failure. Which outcome indicates that the medication has achieved the expected effect? A. Cough becomes productive of frothy pink sputum. B. Urine output increases from 10 mL/hr to greater than 50 mL hourly. C. The serum potassium level changes from 3.8 to 3.1 mEq/L (3.8 to 3.1 mmol/L). D. B-type natriuretic peptide (BNP) factor increases from 200 to 262 ng/mL (200 to 262 mcg/L). 49. A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse’s best response to the client’s question? A. “It will boost the cells in your pancreas if you have insufficient insulin.” B. “It will help promote insulin absorption when your glucose levels are high.” C. “It is for the times when your blood glucose is too low from too much insulin.” D. “It will help prevent lipoatrophy from the multiple insulin injections over the years.” 50. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? A. “Your hair will need to be shaved.” B. “You will receive spinal anesthesia.” C. “You will need to ambulate after surgery.” D. “Brushing your teeth needs to be avoided for at least 2 weeks after surgery.” Situation: Cardiovascular diseases (CVDs) – or diseases of the heart and blood vessels – are responsible for a third of death in the Philippines. According to the Philippine Statistics Office (PSA), CVDs are part of the larger group of noncommunicable diseases (NCDs), which account for 72% of deaths in the country in 2021 (WHO, 2022) 51. Who among the following clients is MOST LIKELY to develop a cardiovascular disorder? A. A 23-year old staff nurse who is a smoker and has a stressful life B. A white woman, age 75, with a BP of 170/110 mmHg who is physically inactive C. An Asian woman, age 45,with a cholesterol level of 240 mg/dl and a BP of 130/74 mmHg D. An obese Hispanic man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm Hg 52. The nurse is caring for a hospitalized client with angina pectoris who begins to experience chest pain. The nurse administers a nitroglycerin tablet sublingually as prescribed, but the pain is unrelieved. The nurse should take which action next? A. Reposition the client B. Call the client’s family C. Contact the health care provider D. Administer another nitroglycerin tablet 53. Cardiac enzymes and biomarkers are used to diagnose an acute Myocardial Infarction. What should the nurse do prior to blood extraction for the said test? A. NPO 24 hours prior B. Check for the latest CBG result C. Ask the client when was his last meal D. Ensure that there is no physical exertion for 24 hours. 54. A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? A. Monitor for kidney failure. B. Monitor psychosocial status C. Monitor for signs of bleeding. D. Have heparin sodium available 55. A 70-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: A. Administer the morphine B. Obtain a 12-lead ECG C. Obtain the blood work D. Prescribe the chest radiograph 56. What describes Janeway's lesions that are manifestations of infective endocarditis? A. Hemorrhagic retinal lesions B. Black longitudinal streaks in nail beds C. Painful red or purple lesions on fingers or toes D. Flat, red, painless spots on the palm of hands and soles of feet 57. Which initial physical assessment finding would the nurse expect to be present in a patient with acute left-sided heart failure? A. Bubbling crackles and tachycardia B. Hepatosplenomegaly and tachypnea C. Peripheral edema and cool, diaphoretic skin D. Frothy, blood-tinged sputum and distended jugular veins 58. A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A. Obesity and high intake of sodium and saturated fat B. Diabetes and use of oral contraceptives C. Metabolic syndrome and smoking D. Renal disease and coarctation of the aorta 59. As a nurse, you are aware that cardiac surgery is a source of stress to the patient. Which of the following strategies should the nurse implement FIRST to overcome stress? A. Identify coping mechanisms helpful to the patient and family B. Recognize fears and concerns regarding surgery and future health status C. Explore support system available D. Reinforce understanding on the surgical procedure 60. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code. B. Check the client’s status. C. Call the health care provider. D. Document the lack of complexes Situation: Nurse Coleen is assigned to Medical-Surgical Ward and caters to cases of various Respiratory Disorders 61. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? A. Undergo weekly immunotherapy. B. Identify and avoid triggers of the allergic reaction C. Use cromolyn nasal spray prophylactically year round. D. Use over-the-counter antihistamines and decongestants during an acute attack 62. The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A. Anxiety related to diagnosis of cancer B. Altered nutrition related to swallowing difficulties C. Ineffective airway clearance related to airway alterations D. Impaired verbal communication related to removal of the larynx 63. A nurse is caring for a young adult patient whose medical history includes an alpha1 -antitrypsin deficiency. This deficiency predisposes the patient to what health problem? A. Pulmonary edema B. Lobular emphysema C. Cystic fibrosis (CF) D. Empyema 64. A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? A. Gradually increase levels of physical exertion. 4 | Page