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RECALLS EXAMINATION 8 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 Situation: Taking Care of Patients with Trauma and Burns injury. 1. One of your patient’s clothes has caught on fire. Which of the following will the nurse instruct the patient to do? A. Instruct the patient to duck, cover, and hold B. Instruct the patient to stand still C. Instruct the patient to stop, drop, and roll D. Instruct the patient to start running to extinguish the flames 2. A client is rushed to the emergency room showing a pale white, leathery, and painless burned area on his skin. The nurse classifies this burn as: A. First Degree burn B. Second Degree burn C. Third Degree Burn D. Deep Partial-Thickness Burn 3. Burns that is characterized by blisters, mottled red base, and is painful is A. First Degree burn B. Second Degree burn C. Third Degree burn D. Full Thickness burn 4. During the first 48 hours of burns, dehydration occurs due to A. Increased fluid loss by evaporation from the areas of burns B. Actual fluid destruction by the burning process C. Shifting of plasma into the interstitial compartment D. Fluid loss through blister formation Situation: Linda, a 55-year-old female patient has deep partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. 5. The nurse estimates for the total body surface area burned. Using the rule of nines, how much of Linda’s body has suffered from burns? A. 54% B. 36% C. 63% D. 18% 6. Using the Parkland Burn Formula, calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 22,932 mL B. 26,208 mL C. 16,380 ML D. 12,238 mL 7. How much fluid will be given to Linda during the first 8 hours postburn? A. 11,466 ml B. 13,104 ml C. 8,190 ml D. 6,119 ml 8. The purpose of inserting an NGT Tube to patients with burns that exceeds 20% to 25% TBSA is A. For feeding or gavage B. For gastric decompression C. For aesthetic purposes D. For the rapid return of peristalsis 9. What gauge/size of the needle will be used when administering IV solutions for trauma patients? A. G18 B. G22 C. G24 D. G26 10. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient’s laboratory studies, the nurse will expect the results to indicate what? A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis 11. A client has an order for an arterial blood gas analysis. Which of the following tests should be performed first before drawing the ABG specimen? A. Weber Test B. Romberg’s test C. Allen’s test D. Rinne Test 12. The Allen’s Test checks the patency of the A. Ulnar artery B. Radial artery C. Carotid artery D. Brachial artery 13. The normal oxygen saturation is A. 80% to 85% B. 85% to 90% C. 90% to 95% D. 95% to 100% 14. All of the following results in high-pressure alarms in a ventilator, except A. The ventilator tube is obstructed because of water B. Client coughs, gags, or bites on the oral endotracheal tube C. Client is anxious or fights the ventilator D. Disconnection or leak in the ventilator 15. Where would Nurse Reyes place the call light for a male patient with a right-sided brain attack and left homonymous hemianopsia? A. On the client’s right side B. On the client’s left side C. Directly in front of the client D. Where the client likes 16. The nurse to patient ratio recommended by the Department of Health is 1 | Page
A. 1:5 B. 1:20 C. 1:12 D. 1:50 17. A client is taking an antacid for treatment of peptic ulcer disease. Which of the following, if stated by the client, indicates understanding on how to correctly take an antacid? A. “I should take my antacid together with my other medications.” B. “I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.” C. “I will wait 30 min before I can take my other medications.” D. “It is best for me to take my antacid 1 to 3 hours after meals.” 18. The nurse evaluates the client’s stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician? A. The stoma is slightly edematous B. The stoma is dark red to purple C. The stoma oozes a small amount of blood D. The stoma does not expel stool. 19. A client receiving routine preoperative fluids had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse would take which action first? A. Slow the IV infusion. B. Sit the client up in bed. C. Remove the IV catheter. D. Call the primary health care provider (PHCP). 20. Which of the following findings are to be seen in a patient with Addison’s disease? A. Hypokalemia B. Hypernatremia C. Hypoglycemia D. Hypertension 21. A prescription reads 1000 ml of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/ 1 ml. The nurse gets the flow rate at how many drops per minute? A. 30 gtts/min B. 31 gtts/min C. 32 gtts/min D. 33 gtts/min 22. A prescription reads 1000 mL D5W to infuse at a rate of 125 mL/hr. The nurse determines that it will take how many hours for 1 L to infuse? A. 6 hours B. 7 hours C. 8 hours D. 9 hours 23. A prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? A. 0.5 tablet B. 1 tablet C. 1.5 tablets D. 2 tablets 24. A prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters (mL) of potassium chloride to administer the correct dose of medication? A. 5 ml B. 10 ml C. 15 ml D. 20 ml 25. Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes to a client with an infection. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? A. 30 gtts/min B. 31 gtts/min C. 32 gtts/min D. 33 gtts/min 26. Which of the following medications is an example of an Angiotensin-Converting Enzyme (ACE) Inhibitor? A. Telmisartan B. Amlodipine C. Enalapril D. Prazosin 27. The nurse is reviewing the client’s record with a diagnosis of cirrhosis and noted that there is a presence of asterixis. How would the nurse assess for its presence? A. Dorsiflex the client’s foot B. Measure the abdominal girth C. Ask the client to extend the arms D. Instruct the client to lean forward 28. In obtaining specimen for a sputum culture and sensitivity, which of the following instruction is the best. A. Upon waking up, cough deeply and expectorate into a sterile container B. Cough after pursed lip breathing C. Save sputum for two days in a covered container D. After a few breaths, spit into a clean container. 29. Which clinical manifestation in a client does the nurse assess as a typical reaction to long-term phenytoin (Dilatin) therapy? A. Weight gain B. Insomnia C. Excessive growth of gum tissue D. Deteriorating eyesight 30. The nurse determines that Baclofen is given for a client with Multiple Sclerosis to achieve what? A. Induces sleep B. Stimulate the client’s appetite C. Relives muscular spasticity D. Reduces the urine bacterial count 31. The client who is very anxious and is experiencing deep, rapid respiration is admitted in the emergency department. Which of the following acid-base imbalances may occur? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis 32. Which of the following diet is recommended for a client with Meniere’s disease? A. Low salt B. Low potassium C. Low fiber D. Low fat 33. Which of the following actions of a new RN when performing tracheostomy suctioning needs intervention by the charge nurse? A. Hyperoxygenating the patient before suctioning B. Applying suction while withdrawing the catheter C. Using non-sterile gloves D. Applying suction for 5 to 10 seconds at a time 34. The most characteristic sign and symptoms of Kawasaki Disease is A. Koplik’s spot B. Slapped face appearance C. Cervical lymph node enlargement and fever D. Linear burrows in the skin. 35. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretics. Which of the following is the most appropriate method to assess the urine output? A. Weighing the diapers B. Inserting a urinary catheter C. Comparing intake with output D. Measuring the amount of water added to formula 36. Which of the following foods is most appropriate to be given to a manic patient? A. Pasta B. Beef Stew C. Yogurt and banana D. Raisins, carrots, peanut butter cookies 37. A client with peptic ulcer disease has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the intended effect of the medication if the client reports the absence of which symptom? A. Diarrhea B. Heartburn 2 | Page
C. Flatulence D. Constipation 38. The nurse is instructing a client on how to perform a testicular self-examination (TSE). The nurse would explain that which is the best time to perform this exam? A. After a shower or bath B. While standing to void C. After having a bowel movement D. While lying in bed before arising 39. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A. A defect in the cochlea B. A defect in cranial nerve VIII C. A physical obstruction to the transmission of sound waves D. A defect in the sensory fibers that lead to the cerebral cortex 40. The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client became restless and tried to get out of bed. 41. Which of the following oxygen delivery systems delivers a precise and consistent FiO2? A. Venturi Mask B. Simple Face Mask C. Partial Rebreather Mask D. Nonrebreather Mask 42. When administering eye medications, the nurse should instruct the client to A. Look to the left B. Look to the right C. Look up to the ceiling D. Look at the nurse 43. Proper administration of an otic medication to a 2-year-old client includes which of the following? A. Pull the ear straight back B. Pull the ear down and back C. Pull the ear up and back D. Pull the ear straight upward 44. A client has an AV-fistula on the right arm. The nurse would intervene if the student nurse performs which of the following? A. Listens for bruits B. Palpates for thrill C. Takes the blood pressure on the right arm D. Takes the blood pressure on the left arm 45. The client has been diagnosed to have SIADH. Which of the following signs and symptoms of the client should be given highest priority by the nurse? A. Serum Na is 120 mEq/L B. Serum K is 4.5 mEq/L C. Serum Mg is 1.8 mEq/L D. Serum Ca is 10 mEq/L 46. After gastrojejunostomy, which of the following instructions should be included in the health teachings of the patients? A. “Limit carbohydrate in your diet.” B. “Increase your fluid intake during meals.” C. “Avoid lying down after eating.” D. “Limit proteins in your diet.” 47. Which of the following is an important nursing consideration when administering Garamycin? A. Monitor blood pressure B. Monitor intake and output C. Monitor body temperature D. Monitor pulse rate 48. The patient is receiving Heparin. Which of the following should the nurse keep readily available? A. Calcium Gluconate B. Naloxone C. Deferoxamine D. Protamine Sulfate 49. A client’s vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement based on this finding? A. Provide the client with materials on legal blindness. B. Instruct the client that glasses may be needed when driving. C. Inform the client of where to purchase a white cane with a red tip. D. Inform the client that it is best to sit near the back of the room when attending lectures 50. Which of the following laboratory results should be checked by the nurse before giving potassium? A. Blood glucose levels B. Serum creatinine C. Complete blood count D. Serum amylase 51. Which of the following foods is best included in a high calcium diet? A. Canned soup and vegetables B. Cheese C. Beef D. Liver 52. Despite the client refusing the procedure, the nurse inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? A. An unintentional tort B. Assault C. Invasion of privacy D. Battery 53. Which test is the best resource for determining the preoperative status of a client’s liver function? A. Serum electrolytes B. Blood urea nitrogen (BUN), creatinine C. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin D. Serum albumin 54. A client was informed of a cancer diagnosis and assures the nurse he is fine. Which of the following is the most indicative physical evidence that the client is experiencing stress? A. Constricted pupils B. Dilated peripheral blood vessels C. Hyperventilation D. Decreased heart rate 55. The nurse is preparing a client after a tonsillectomy. The nurse documents on the plan of care and places the client in which position? A. Supine B. Side-lying C. High-Fowler’s D. Trendelenburg’s 56. The nurse is instructing a client with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse tell the client? A. Administer the iron at mealtimes. B. Administer the iron through a straw. C. Mix the iron with cereal to administer. D. Add the iron to apple juice for easy administration. 57. A client has undergone spinal anesthetic. It will be important that the nurse immediately position the client in: A. On the side, to prevent obstruction of airway by tongue B. Flat on back C. Prone D. Flat on the stomach, with the head turned to the side 58. A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? A. Clear CSF, decreased pressure, and elevated protein level B. Clear CSF, elevated protein, and decreased glucose levels C. Cloudy CSF, elevated protein, and decreased glucose levels 3 | Page
D. Cloudy CSF, decreased protein, and decreased glucose levels 59. The nurse is assigned to care for a client with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician’s prescriptions and would contact the pediatrician to question which prescription? A. Obtain daily weight. B. Provide clear liquid intake. C. Nasotracheal suction as needed. D. Maintain a patent intravenous line. 60. You are assigned to take care of a client with a suspected diagnosis of cataract. Which assessment finding would the nurse expect to see in the early stages of cataract formation? A. Diplopia B. Absence of the red reflex C. Presence of a white pupil D. Blurred vision 61. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? A. “I should consume less than 1 liter of fluid per day.” B. “I should use my treadmill or go for walks daily.” C. “I should follow a moderate-calcium, high-fiber diet.” D. “My alendronate helps keep calcium from coming out of my bones.” 62. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? A. Warm the client. B. Maintain a patent airway. C. Administer thyroid hormone. D. Administer fluid replacement 63. 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 primary health care provider. D. Document the lack of complexes. 64. Which medication, if prescribed for the client with glaucoma, would the nurse question? A. Betaxolol B. Pilocarpine C. Erythromycin D. Atropine sulfate 65. The nurse provides instructions to a client who is taking levothyroxine. The nurse would tell the client to take the medication in which way? A. With food B. At lunchtime C. On an empty stomach D. At bedtime with a snack 66. A client has been diagnosed with gastroesophageal reflux disease. To decrease incidences of heartburn, the nurse should instruct the client to eliminate which of the following items from his diet? A. Lean beef B. Air-popped popcorn C. Hot chocolate D. Raw vegetables 67. Gray was scheduled for craniotomy after being diagnosed with brain tumor. In order to prevent the development of cerebral edema after surgery, the nurse expects the doctor to use: A. Antihistamine B. Antihypertensive C. Steroids D. Anticonvulsants 68. When administering a unit of packed red blood cells, the nurse should know that the maximum transfusion time is A. 6 hours B. 4 hours C. 3 hours D. 2 hours 69. What is the best indication of proper placement of a nasogastric tube in the stomach? A. Client is unable to speak B. Client gags during insertion C. pH of the aspirate is less than 5 D. Fluid is easily instilled into the tube 70. A client is receiving a unit of packed red blood cells and complains of lumbar pain. After stopping the infusion, Nurse John should A. Keep the IV line open with normal saline B. Assess the patient’s vital signs C. Notify the blood bank D. Notify the physician 71. Which of the following are modifiable risk factors of Coronary Artery Disease I. Family history II. Age III. Hypertension IV. Obesity V. Race VI. Hyperlipidemia A. I, II, V B. II, III, VI C. III, IV, VI D. III, V 72. The nurse is conducting health screening for clients who are at risk for developing osteoporosis. Which client is at the greatest risk for developing this problem? A. A 25-year-old client who runs B. A 36-year-old client who has asthma C. A 70-year-old client who consumes excess alcohol D. A sedentary 65-year-old client who smokes cigarettes 73. Which of the following is the antidote for Cholinergic Overdose? A. Calcium gluconate B. Acetylcysteine C. Vitamin K D. Atropine Sulfate 74. The nurse is evaluating a client who is in skeletal traction. When assessing the pin sites, the nurse would be most concerned with which finding? A. Redness around the pin sites B. Pain on palpation at the pin sites C. Thick, yellow drainage from the pin sites D. Clear, watery drainage from the pin sites 75. What is the correct sequence for donning personal protective equipment (PPE)? A. Goggles, Mask, Gown, Gloves B. Gloves, Mask, Goggles, Gown C. Gown, Mask, Goggles, Gloves D. Gloves, Goggles, Mask, Gown 76. A client with tuberculosis is prescribed with the drug Rifampicin. He notices that his urine turned red orange in color. As a knowledgeable nurse, you instruct him to A. Go to the emergency room as this is an adverse reaction B. Increase fluid intake to dilute the drug C. Stay calm as this is a normal side effect of the medication D. Contact his HCP and ask to change his TB medication 77. All of the following errors when taking a patient’s blood pressure will result to an erroneously high blood pressure reading, except: A. Bladder cuff too narrow B. Arm unsupported C. Insufficient rest before the assessment D. Bladder cuff too wide 78. What type of knot will be used when applying restrains to a client? A. Restraints knot B. Binding knots C. Half-bow knot D. Knot knot 79. The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? A. Placing a safety knot in the safety device straps B. Safely securing the safety device straps to the side rails C. Applying safety device straps that do not tighten when force is applied against them 4 | Page