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REFRESHER PHASE DIAGNOSTIC EXAMINATION NURSING PRACTICE 5 (NP5) NOVEMBER 2024 Philippine Nurse Licensure Examination Review Situation: Nurse Chona Mae is handling patients in Ward 11. The following questions apply. 1. When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain? A. Client's ethnic background B. Client's report of symptoms C. Client's vital signs D. Extent of client's injury 2. The mother of an infant asks the nurse what a communicating hydrocephalus is. What is the nurse’s best response? A. There is obstruction in the passageway of CSF in the brain. B. It is caused by impaired CSF reabsorption even without obstruction. C. There is increased absorption of CSF in the brain. D. The ventricles produce more CSF than the normal rate of production. 3. The nurse just hung the packed RBC to be transfused to the patient for 20 drops per minute. After how long must the nurse observe the patient for any adverse reaction? A. 30 minutes B. 20 minutes C. 15 minutes D. 10 minutes 4. A pregnant mother in the health center complains to leg cramps especially during the night. Which of the following is an appropriate teaching by the nurse? A. Stretch your foot towards your knees. B. Apply cold compress for 15 minutes. C. Apply warm compress for 20 minutes. D. Have a bed rest whenever leg cramps begin. 5. A client needs surgery to relieve an intestinal obstruction. The nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing? A. Tap water enemas until clear. B. Out of bed as tolerated. C. Neomycin sulfate 1 g P.O. every 4 hours. D. Betadine scrub to abdomen. SITUATION: A 50-year old male is brought to the emergency room by two policemen for stab wound at the left thorax. He is bleeding and has difficulty breathing. You are the ER nurse. 6. You would position the patient: A. On his left side with head elevated B. On his right side in bed with a pillow supporting his left arm C. On his back with feet elevated D. In High-fowler's position with left side supported 7. You place a large pressure dressing over the stab wound. The purpose of this action is to: A. seal off major vessels B. protect the pleura C. prevent additional contamination D. maintain negative intrathoracic pressure 8. You encourage the patient to perform deep breathing exercises. This is to: A. Counteract respiratory acidosis B. Increased blood volume C. Expand the residual volume D. Decrease partial pressure of oxygen 9. The patient complains of severe pain following surgical repair of the wound. You should do which of the following: A. Administer analgesic B. Take the vital signs C. Assure the patient that pain is normal in his situation D. Tell the patient to rest 10. You assess the patient. You should be primarily concerned with the: A. amount of serosanguinous drainage B. blood pressure and papillary response C. quality and depth of respirations D. degree and level of pain SITUATION: Mang Kanoris a 58-year old with a long-standing history of alcoholism. He started binge drinking when he was 22 years old. On Friday the 13th , he was admitted to the hospital with ascites and difficulty of breathing. The doctor’s tentative medical diagnosis was liver cirrhosis. 11.The nurse performs which intervention as a priority measure to assist Mang Kanor with breathing? A. Repositions side to side every 2 hours B. Elevates the head of the bed 60 degrees C. Auscultates the lung fields every 4 hours D. Encourages deep breathing exercises every 2 hours 12.To confirm the doctor’s tentative diagnosis, he scheduled Mang Kanor to have a liver biopsy. Before the procedure, it is most important for the nurse to assess Mang Kanor’: A. Tolerance for pain B. Allergy to iodine or shellfish C. History of nausea and vomiting D. Ability to lie still and hold the breath 13.Since liver biopsy may pose a risk to the patient, the nurse is aware that what additional precautions must she observe prior to the procedure? Check liver function test result A. Check coagulation test result B. Check BUN & serum Creatinine levels C. Check patient’s lipid profile Situation: Care of the aging individual presents one of the greatest challenges for nurses. Julia is aware that aging individuals experience many losses and are vulnerable to depression and feelings of low self-worth. Lolo Teryo was seen by a nurse in the ER who was reported to be becoming increasingly withdrawn. He eats little food and has lost some weight. His wife died 6 years ago and attended the funeral of his best friend a month ago and after which behavioral changes began. 14.In her admission, the nurse observes an open sore on Lolo Teryo’s arm. When asked about it he says he scraped it on the fence 2 weeks ago and the lesion was smaller than it was. The nurse may analyze the data as A. He might be trying to commit suicide B. Delay in healing might indicate super imposed skin cancer C. Diminished inflammatory response in elderly D. Age related changes on the skin and maldistribution of fats 15.Lolo Teryo is deaf on his right side. Which is the most appropriate nursing intervention for communicating with Lolo Teryo? A. Speak loudly to his ear B. Speak to him from a position on his left side C. Speak face-to face in a low pitched voice D. Speak face-to-face in a high pitched voice 16.Why is it important to have the nurse check the temperature of water before Lolo Teryo takes a shower? TOP RANK REVIEW ACADEMY, INC. Page 1 | 6
A. He may catch cold if the water temperature is too low B. He may burn himself because of a lower pain sensitivity C. Has difficulty of discriminating between hot and cold D. He might have lower pain threshold 17. The nurse encouraged Lolo Teryo to attend early morning exercise. He becomes tired and short of breath. The nurse interprets this as A. Changes in the cardiovascular system B. Attributed to his sedentary lifestyle C. Effects of his depression on his stamina D. Medication the doctor might give him 18.According to studies and literature, which of the following is most important for Lolo Teryo to maintain a healthy, adaptive old age? A. To remain socially interactive B. To disengage slowly in preparation to last stage of life C. To move in with his son and family D. To maintain total independence and accept help Situation: Danny a 46 year old patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has doctor orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. She is taken care of by Leona, a newly graduate nurse. 19.Because of Danny’s premature ventricular contraction, the nurse should monitor its effects on which of the following parameters? A. Electrolyte levels B. Apical radial heart rate C. Oxygen saturation D. Medications 20.In analyzing a patient’s electrocardiographic (ECG) rhythm strip, Leona uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by A. PR interval B. QT interval C. QRS complex D. P wave 21.A considerable difference between the apical and radial pulse rate of Danny would indicate A. Stronger left than right ventricular muscles B. Numerous weak ineffectual cardiac contractions C. Thickened myocardium and large heart chambers D. Increased pressure in systemic arteries 22.As Danny is assessed he complains of being nauseated and very weak. The nurse should A. Perform nutritional assessment B. Alert staff for potential help C. Explore and discuss possible effect of stress D. Provide reassurance while focusing on pleasant topics 23.The Physician scheduled for an exercise electrocardiogram (stress test). What information should the nurse include when explaining the value of this test? Exercise stress testing is a: A. definitive method to diagnose the cause of chest pain B. diagnostic modality of minimal value in planning treatment of angina C. noninvasive means of assessing cardiovascular conduction and function D. minimally invasive manner of assessing a body’s reaction to increase in exercise SITUATION: You are caring for a married woman who underwent modified radical left mastectomy 24.On admission to Post-anesthesia Care Unit, you read the OR report which indicates that estimated blood loss during surgery was 1000mL. From the list below, select the MOST objective indicator for the nurse to monitor closely. A. Changes in vital signs B. Altered level of consciousness C. Soaked dressing D. Pupillary reaction to light 25.You assisted positioning the client. Her left arm should be placed in which of the following manner? A. Placed above the level of the heart B. Hyperextended away from the chest C. Placed at the level of the heart and the hand below the heart D. Adducted and flexed 26.When the patient woke up from anesthesia, she refuses to see her husband. She remarks that she is “not the same person, no longer a woman; much, much less a wife.” Which psychosocial nursing diagnosis would best describe this situation? A. Altered role performance r/t impaired physical function B. Anxiety r/t surgical removal of the breast C. Altered body image r/t perception of disfigurement and incapacity D. Self-esteem disturbance r/t changing ability to perform basic wife function 27. The client was obviously withdrawn although her recovery from the surgery was uneventful. How can the nurse be of best help during this period of recovery? A. Allowing the client to have more time to herself B. Encouraging the client to have more time to verbalize concerns with her family C. Allowing the client to talk with other clients in the ward who had the same kind of surgery D. Allowing the patient more time to reflect about the effects of surgery 28.During the first 8 hours postoperative, the total drainage from the Jackson-Pratt drain attached to the wound totaled to 25 mL. What is your next best action? A. Do nothing as the drainage is expected B. Empty the Jackson-Pratt device C. Notify the surgeon stat D. Inform the client that her wound is draining well. Situation: Gerard 56 years old underwent partial gastrectomy with gastrojejunostomy. 29.The nurse identified iron deficiency anemia as a potential problem. Which of the following specifically would predispose the patient to this problem? A. Rapid gastric emptying due to gastrojejunostomy B. Inadequate intake of food rich in iron C. Excessive loss of blood during surgery D. Inability to eat large meals 30.The nurse understands that iron deficiency anemia results in decreased RBC which are: A. Abnormally crescent shaped B. Large and immature C. Microcytic and hypochromic D. Fragile and megaloblastic 31.The physician emphasized that Vitamin B12 levels will be routinely monitored. Which of the following mechanism correctly explains the possibility of the patient developing Vitamin B12 deficiency? A. Vitamin B12 is primarily absorbed in the duodenum B. Fast emptying of food from the stomach interfere with Vitamin B12 absorption C. Intrinsic factor is necessary for absorption of Vitamin B12 is inadequate D. Inadequate liver storage of Vitamin b12 due to decreased stomach size 32.Which of the following group of manifestations will the nurse expect in case Vitamin B12 deficiency develops in the patient? A. Pallor, weakness, spoon shaped nails, smooth sore tongue B. Progressive weakness, shortness of breath, palpitations, cheilosis C. Fatigue, irritability, pallor, painful swelling of hands D. Slight jaundice, fatigue, paresthesia, glossitis 33.Priority nursing diagnosis is identified by the nurse for Gerard is “Imbalanced nutrition related to patients’ inadequate intake of food.” Which of the following is an appropriate intervention? A. Based on list of patients choice of food, prepare diet plan B. Plan diet with family members in consultation with dietician C. Prepare a diet plan taking into consideration the patient's preferred eating pattern TOP RANK REVIEW ACADEMY, INC. Page 2 | 6