Tiêu đề RECALLS 9 (NP3) - STUDENT COPY ✅

RECALLS EXAMINATION 9 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 SITUATION: In the emergency ward, Nurse Chaewon is currently assessing Kazuha who was admitted due to an initial attack of asthma. Nurse Chaewon must be alert to the sudden changes or improvements that Kazuha will present. 1. Nurse Chaewon knows that the mechanism and causes of asthma involves all but one: A. Inflammation B. Bronchospasm C. Aspirin use D. Acetaminophen use 2. Upon assessment, Nurse Chaewon hears wheezes throughout the bronchi of Kazuha during an asthma attack. She stays by her side and after a minute, assesses her lung sounds once more. She noticed that the wheezing has disappeared. What is Nurse Chaewon’s initial intervention? A. Document the finding B. Provide 4L/min oxygen via nasal cannula C. Notify the rapid response team D. Place Kazuha in a left side lying position 3. After the asthma attack, the blood of Kazuha is tested. The results show that the blood has a pH of 7.29, pCO2 of 56, and HCO3 of 28. Which condition describes Kazuha’s laboratory values? A. Partially compensated respiratory alkalosis B. Uncompensated respiratory acidosis C. Partially compensated respiratory acidosis D. Uncompensated respiratory alkalosis 4. When teaching Kazuha how to use the incentive spirometer, which of the following is the right statement made by Nurse Chaewon? A. “When using the spirometer, you will need to be in a semi-fowler’s to fowler’s position.” B. “You may drink coffee five minutes before using the spirometer.” C. “The spirometer is used best when you are laying down on your left side.” D. “Pursed lip breathing must be done when inhaling through the spirometer.” 5. Kazuha is prescribed with albuterol. Which vital sign must Nurse Chaewon tell Kazuha to monitor most frequently? A. Blood pressure B. Temperature C. Respiratory rate D. Heart rate SITUATION: Stella is admitted in the Richardson General Hospital. She is tended to by Nurse Will. She was diagnosed with cystic fibrosis and is currently undergoing treatments and adjustments to promote stability. 6. Stella’s condition is caused by the failure of chloride pumps to function which causes: A. Clear, viscous mucus B. Thick, sticky mucus C. Salty, watery mucus D. Lumpy, hardened mucus 7. Of the following organs, which is not affected by cystic fibrosis? A. Brain B. Lungs C. Pancreas D. Skin 8. For lung transplantation, Nurse Will must be aware that the following are criteria for a possible donor except: A. Donor is younger than 65 years old B. Donor is psychologically cleared C. Donor was not coerced into donating D. Donor has close tissue match with the recipient 9. Stella is conscious yet is having a hypoxemic spell. She is assessed to have wheezing and an O2 saturation of 93%. Which of the following must Nurse Will not do independently? A. Chest physiotherapy B. Suctioning C. Oxygen therapy D. Head of bed elevation 10. Nurse Will knows that which of the following is not possible sign and symptom of Stella? A. Steatorrhea. B. Growth retardation. C. Hemorrhoids. D. Salty urine. SITUATION: During the dry, cold season in the Philippines, cases of the common cold and other inflammatory upper respiratory tract disorders increase. 11. Jennifer is a four-year-old patient who is living in Baguio. She is constantly picking her nose which results in her having secretions all day long. One day, she was in pain and her mother noticed that Jennifer squirms when touched on her forehead. This tenderness between the eyebrows is a possible case of: A. Allergic rhinitis B. Sinusitis C. Coryza D. Rhinitis 12. To determine if Jennifer has sinusitis, a physical examination is done wherein light is shone through the sinuses in a dim room. This is called ___________. A. Phototherapy B. Positive electron transmission C. Transillumination D. Laser-assisted in situ keratomileusis 13. Kura, the mother of Jennifer, told the nurse that Jennifer was already given a six-day worth of doses of phenylephrine. The nurse’s best response is: A. “This is good to know as we will need to continue the decongestants to improve Jennifer’s breathing.” B. “We need to stop the decongestants to prevent rebound congestion.” C. “I will need to notify the physician for an increase in dosage.” 1 | Page
D. “Maybe you can try a different drug which contains ephedrine.” 14. The physician informs Kura the possible surgical treatment if Jennifer does not improve. Which of the following is a surgical treatment to relieve sinusitis? A. Functional endoscopic sinus surgery B. Transsphenoidal hypophysectomy C. Minimally invasive sinus scoping D. Sinus rhinoplasty 15. Postoperatively, the nurse should instruct Kura to provide saline nasal sprays to Jennifer every _________. A. 1-2 hours B. 2-4 hours C. 4-6 hours D. 6-8 hours SITUATION: Various patients are at risk for blood clots which travel through the bloodstream and reach the lungs. These situations are emergency situations and nurses must be alert to the signs and symptoms caused by the clots. 16. Which of the following is the least risk factor for thromboembolisms? A. Blood hypercoagulability B. Venous stasis C. Tunica damage D. Vigorous exercise 17. Of the following, these are possible emboli which may lodge into the lung’s vascularity. 1. Fat 2. Oil 3. Air 4. Tumor cells 5. Amniotic fluid 6. IV catheters 7. Blood clots 8. Pus A. 1,2,3,4,5,7,8 B. 1,2,3,4,5,6,7,8 C. 1,3,4,5,6,7,8 D. 1,2,3,4,5,6,7 18. Lionel was diagnosed to have a venous thrombosis upon ultrasound. The physician has ordered a heparin infusion to prevent further clots. The health team will monitor the laboratory parameter __________. A. Partial thromboplastin time B. Prothrombin time C. International Normalized Ratio D. Clotting factor time 19. While having an infusion of heparin through the intravenous line, the nurse sees air bubbles travel into Lionel’s arm through the IV line. Which emergency intervention must the nurse do? A. Aspirate the IV line B. Place Lionel in a left-lateral Trendelenburg C. Provide oxygen via a venturi mask delivering 24% D. Notify the physician 20. While in heparin therapy, the nurse must instruct Lionel on proper self-care. Which of the following must Lionel do? A. Dip toothbrush in warm water before using B. Wear tight-fitting slippers and sandals C. Eat caramel, cookies, and nuts D. Trim the nails every two weeks SITUATION: Jay Y. Peace, a celebrity in the Philippines, was stabbed in the chest by a paparazzi who wanted to date him. He was then admitted to the Kwangya National Hospital for immediate treatment. 21. Which finding by the respondents does not solidify the claim that JYP is suffering from a pneumothorax? A. Reduced breath sounds on auscultation B. Hyperresonance on percussion C. PMI on the left of the left MCL D. Dull sounds on auscultation 22. In a similar case of JYP’s, if there has been another stabbing incident and the patient is seen in the streets with an open wound, what must be the first action of the responder? A. Call the emergency services B. Cover the chest wound C. Assess the pulse and responsiveness D. Determine the type of pneumothorax 23. The most fatal complication of a pneumothorax is _________________. A. Atelectasis B. Mediastinal shift C. Tracheobronchial necrosis D. Tension pneumothorax 24. For a patient undergoing thoracentesis, which position must the nurse place the patient in? A. Supine B. Semi-fowler C. Orthopneic D. Trendelenburg 25. Mark, a seven-year-old patient is brought to the emergency department. He is tachypneic and afebrile and has a respiratory rate of 36 CPM and a non-productive cough. From this history; the patient may have which condition? A. Asthma B. Bronchitis C. Emphysema D. COPD SITUATION: Nurse Nayeon is a staff nurse in the medical ward. She has patients of different conditions. Jihyo, a dancer, is admitted in the ward who is constantly urinating. 26. Nurse Nayeon has followed the physician’s orders and has deprived Jihyo of fluid intake. However, Jihyo’s urine output remains at 60mL per hour. Jihyo is suspected of having ____________. A. Syndrome of inappropriate antidiuretic hormone B. Diabetes mellitus C. Polycystic kidney disease D. Diabetes insipidus 27. The physician told Nurse Nayeon that Jihyo’s condition is caused by a defect in the pituitary gland. Which of the following pertains to this condition? A. Nephrogenic B. Primary C. Drug-related D. Oncologic 28. Upon checking Jihyo’s laboratory values, which of the following is expected? A. Urine specific gravity less than 1.005 – According to Ignatavicius (2012), urine of a diabetes insipidus patient is dilute with a low specific gravity (less than 1.005) and low osmolarity (50 to 200 mOsm/kg). B. High urine osmolarity C. Urine specific gravity more than 1.025 D. Amber urine color 29. Inhaled Desmopressin was given to Jihyo to aid in her condition. Nurse Nayeon provides health education to Jihyo regarding the administration of the drug. Which of the following indicates that teaching is effective? A. “I will take puffs of the drug while I am laying down.” B. “I will blow my nose before inhaling the drug.” C. “I will weigh myself every other day.” D. “I will take Acetaminophen for persistent headaches.” 30. Which laboratory values of Jihyo indicated to Nurse Nayeon that another dose of Desmopressin is needed? A. Urine output and specific gravity are increased B. Urine output is increased and urine specific gravity is decreased C. Urine output and specific gravity are decreased D. Urine output is decreased and urine specific gravity is increased SITUATION: Kai, a 28-year-old male, comes into the clinic with complaints regarding his body as the years go by. Nurse Victor is assessing him and is taking his health history and suspects an endocrine disorder. 31. To support Nurse Victor’s hypothesis of an endocrine disorder, which of the following statements made by Kai should be most noted of? A. “May nararamdaman po akong pagtusok-tusok sa mga daliri ko sa paa.” B. “Kapag ako ay tatakbo, mas madali na ako hingalin at parang sumasakit dibdib ko.” 2 | Page
C. “Nagtatalik kami ng Misis ko ngunit hindi na kasing ‘tikas’ tulad ng dati.” D. “Itong singsing na ito na pangkasal namin ng Misis ko, hindi ko na maisuot dahil hindi na kasya.” 32. Nurse Victor received an order to prepare Kai for an MRI scan. Nurse Victor assesses Kai and reports to the physician the following except: A. Had a hip replacement three years ago B. Took recreational drugs a year ago C. Agitation in small spaces D. Has an implanted pacemaker 33. While teaching Kai, Nurse Victor determines that the hormones secreted by the anterior pituitary gland includes: A. Prolactin B. Oxytocin C. Antidiuretic hormone D. Glucagon 34. Kai tells Nurse Victor that he noticed his voice getting deeper. Which statement made by Nurse Victor is most appropriate to tell Kai? A. “It is because of the bones in your chest which do not expand easily.” B. “You are continuing to grow.” C. “Your vocal cords have grown more than they should.” – According to Ignatavicius (2012), hypertrophy of the vocal cords are common which causes a deeper voice progressively. D. “The muscles in the throat contract lesser than normal.” 35. Kai asks Nurse Victor whether or not his bone changes are temporary. Nurse Victor tells Kai that the condition is: A. Temporary and reversible B. Permanent but curable C. Temporary with residual effects D. Permanent and irreversible SITUATION: Kai underwent surgery to address the root cause of his condition in the previous situation. Nurse Amihan is the postoperative nurse assisting him through his recovery. 36. Nurse Amihan assesses Kai and sees a clear fluid leaking out of his nose. What must Nurse Amihan do first? A. Grab a 4x4 gauze B. Notify the physician C. Tell Kai to wipe the fluid D. Assess Kai’s breathing 37. Nurse Amihan reviews Kai’s history and takes note that Kai underwent a pituitary gland removal. The endoscope was passed through the nose and nasal passages. She knows that this surgical procedure is known as ____________. A. Open lobotomy B. Transsphenoidal hypophysectomy C. Functional endoscopic pituitary surgery D. Minimally invasive adenoidectomy 38. Which of the following must Nurse Amihan tell Kai not to do to prevent complications? A. Straining on bowel movements B. Use dental floss C. Sneeze with the mouth open D. Rinse the mouth with oral mouthwash 39. Nurse Amihan notes that the mustache dressing of Kai who underwent surgery five hours ago is wet. What is Nurse Amihan’s best action? A. Check glucose in the drainage B. Notify the physician C. Reapply a dressing and document the finding D. Assess for coryza 40. Which statement made by Kai indicates lack of understanding of the health teachings provided by Nurse Amihan? A. “I will drink from a straw.” B. “I will not bend at the waist when picking up objects.” C. “I will not ride roller coasters.” D. “I will report bleeding around my ears to my physician.” SITUATION: Nurses must be constantly updating their knowledge regarding endocrine disorders involving the different glands of the body such as the adrenal glands. 42. A patient is suspected of having a pheochromocytoma. To properly diagnose the disease, the nurse will perform ___________ on the patient. A. Urine dipstick test B. Fasting blood glucose test C. Midstream urine collection D. 24-hour urine collection 43. Based on Question 41, which substance is being measured by the procedure? A. Adrenocorticotropic hormone B. Vanillylmandelic acid C. Urine hemoglobin D. Bacterial culture 44. Which of the following indicates that the caregiver for a patient with pheochromocytoma is in need of further teaching? A. “I grab to the patient’s waist when I help him ambulate.” – According to Brunner and Suddarth (2016), the waist or kidney area of patients with pheochromocytoma must not be palpated to prevent further release of catecholamines. B. “I always dim the lights.” C. “I let him listen to calm white noise.” D. “I knock on his door gently before calling him.” 45. What is the hallmark sign and most common serious complication post-adrenalectomy of pheochromocytoma? A. Tachycardia B. Tachypnea C. Agitation D. Hypertension 46. Which of the following indicates that the patient needs further teaching regarding his lifestyle? A. Will not drink caffeinated beverages B. Will change position gradually C. Will attend face-to-face classes diligently – According to Ignatavicius (2012), stressors must be cut from the patient’s life to prevent further increase in catecholamines. D. Will stop smoking SITUATION: Thyroid disorders are common in the Philippines. They pose multiple risks to the patient and may even be fatal. 47. Nurse Hutao is talking to Shinobu about her health history. Nurse Hutao notices that Shinobu is sweating easily while being in an air-conditioned room. Shinobu tells Nurse Hutao that she could not stand the heat. Nurse Hutao suspects this as a case of ___________. A. Hypopituitarism B. Hyperthyroidism C. Hypothyroidism D. Hyperpituitarism 48. Which of Shinobu’s statements support Nurse Hutao’s hypothesis? A. “I noticed my scalp hair thinning already.” – According to Ignatavicius (2012), one sign of hyperthyroidism is the thinning of scalp hair. Other symptoms are for hypothyroidism. B. “My weight began increasing in the past weeks.” C. “I feel drowsy all of the time.” D. “My heart always feels like it’s about to stop.” 49. Knowing Shinobu’s possible condition, which of the following should Nurse Hutao do best? A. Place Shinobu in the room near the nurses’ station B. Illuminate the room when assessing Shinobu C. Let patients play lato-lato D. Dim the lights in Shinobu’s room when possible 50. The physician has ordered Shinobu to take Propylthiouracil. Which of the following should Shinobu immediately report to the physician? A. Tachycardia B. Jaundice C. Cyanosis D. Weight gain 51. After undergoing radioactive iodine therapy, which of the following should Nurse Hutao teach Shinobu to do? A. Flush the toilet two times after each use B. Spend time and play with her six-month-old son C. Use cloth handkerchiefs D. Buy disposable utensils 3 | Page
Situation: Martin, a newly registered nurse, is assigned in the coronary care unit of Grey-Sloan Medical Center. During his first day of work, he was ordered to handle several patients with various cardiac problems. 51. Martin reviews his patient’s electrolyte lab report and notes that the potassium level is 6.5 mEq/L. Which patterns should Nurse Martin watch out for on the ECG report of a patient with this potassium level? Select all that apply. 1. Flat P wave 2. Prolonged PR interval 3. Wide QRS complex 4. ST depression 5. Prominent U wave 6. Flat T wave A. 1, 2, 3 B. 4, 5, 6 C. 4, 5, 3 D. 2, 4, 5 52. Martin is now caring for a patient with multiple myeloma who has a calcium level of 12 mg/dL. Which patterns would Nurse Martin watch out for on the electrocardiogram? Select all that apply. 1. Wide T wave 2. Prolonged ST segment 3. Short ST segment 4. Peak T wave A. 1, 2 B. 2, 3 C. 3, 4 D. 1, 3 53. A patient with coronary artery disease is prescribed with transdermal nitroglycerin, a coronary vasodilator. Which among the following choices, if stated by the patient, indicates a need for further teaching? A. Patient applies the patch on a non-hairy area. B. Patient places the medication over his tongue. C. Patient removes the old patch before placing a new one. D. Have a 12 hour “no-nitrate” time to prevent tolerance to nitrates. 54. Nurse Martin is teaching a new patient named Jo about nitroglycerin and what are the signs to look out for to assess if the drug is working effectively. Nurse Martin is correct is he tells patient Jo the following statements except? A. Pulse rate increases B. Pain subsides C. BP lowers D. Activity tolerance increases 55. Chai, a 2 nd year student nurse, asked Nurse Martin about the clinical manifestations of arterial insufficiency. The following are manifestations of the said disorder except: A. Leg pain relieved by rest B. Reddish skin in the leg C. Cold skin in the lower extremities D. Diminished pulse in the leg 56. Sheena is a hypertensive patient who is currently taking an ACE inhibitor (Captopril). As a knowledgeable nurse, which of the following diuretics is contraindicated to Sheena? A. Lasix B. Penicillin C. Spironolactone D. Bumex 57. Karina was admitted to the ER department due to suspected abdominal aortic aneurysm. Which among the following should be done during the physical assessment? A. Percussing the chest B. Inspecting the abdomen C. Palpating the abdomen D. Pressing the abdomen firmly to reduce pain 58. Sean, a 50-year-old male diagnosed with hypertension was prescribed with Bumex, to be taken daily. Which among the following assessment should alert the nurse to immediately intervene and notify the HCP? A. BP of 160/90 B. ECG findings reveal NSR C. Serum potassium level of 2.7 mEq/L D. UO of 30 ml/hr. 59. Mina, a patient diagnosed with chronic heart failure has been placed on a low sodium diet. Mina demonstrates adequate knowledge if she avoids which of the following food sets? A. Baked potatoes, egg yolks, and nuts B. Orange, sardines, tofu C. Cereal, bacon, and canned tomato soup D. Dark chocolate, dark green leafy vegetables, tuna 60. Mr. Shepherd is admitted to the hospital with a diagnosis of right-sided CHF. Upon assessment, the nurse should expect to find the following manifestations except: A. Extensive peripheral edema B. Jugular vein distention C. Dyspnea on exertion D. Weight gain 61. Aya, a 55-year-old female, has been admitted with a diagnosis of left-sided CHF. Which assessment finding would most likely be present? A. Hepatomegaly B. Weight gain C. Peripheral edema D. Crackles 62. Luisa has been prescribed with Lanoxin by her physician. Right after her consultation, Luisa went to you and ask about the toxic effects that she should be looking out for while taking this drug. Which among the following manifestations would you tell Luisa? A. Halos around lights B. Constipation C. Increase appetite D. Tachycardia 63. Shana is on heparin therapy. Which among the following statements should not cause for a concern on the nurse? A. I use an electric razor when shaving. B. I switched my mouthwash from the commercial one to chlorhexidine wash. C. I use a soft-bristled toothbrush when I brush my teeth. D. I love playing basketball every afternoon. 64. Mr. Taylor, a 54-year-old obese, went to the emergency room with presenting signs and symptoms of chest pain. The resident on duty ordered an ECG for thorough assessment and detected cardiac abnormalities. As an aspiring registered nurse, which among the following ECG patterns would tell that the Mr. Taylor already had a previous MI? A. Pathologic Q wave B. Elevated ST segment C. Inverted T wave D. ST depression 65. Cloud is a 54-year-old male patient diagnosed with arterial insufficiency. Which of the following set of signs and symptoms characterize this condition? A. swelling of legs, calf pain B. dull and crampy pain C. redness along the course of the vein D. absence of distal pulse, pale skin on legs 66. Laboratory studies are ordered for Karen, a patient receiving Digoxin and Furosemide. As a competent registered nurse, you should immediately notify the healthcare provider if you see which of the following results? A. K = 3.9 mEq/L; digoxin level 1.5 ng/mL B. K = 5.0 mEq/L; digoxin level 1.0 ng/mL C. K = 3.0 mEq/L; digoxin level 2.3 ng/mL D. K = 3.8 mEq/L; digoxin level 0.5 ng/mL 67. Referring from the situation on the previous item, which of the following food sets will you give to Karen? A. Baked potatoes, oranges, and raisins B. Sardines, anchovies, and milk C. Liver, shellfish, and alcohol D. Peanut butter, peas, and cauliflower Situation: Hazel, a nurse manager at Grey-Shepherd Medical Center just completed her seminar on standards and criteria development as part of her management training. The following questions apply. 67. Nurse Hazel, as the nurse manager in her respective unit, evaluated her staff nurses on how they perform a step-by-step procedure of NGT insertion and removal. This evaluation is called: A. Structure B. Process C. Input 4 | Page