Tiêu đề PRE INTENSIVE - NP3.pdf ✅

Prepared by: Mr. Jules Arceo Ms. Juliane Lupisan 1 | Page PRE- INTENSIVE EXAMINATION NURSING PRACTICE III CARE OF THE CLIENT WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) MAY 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: Shinobu is a staff- nurse working in medical unit with several patients suffering from cardiovascular and peripheral disorders. 1. The heart has 3 layers which has its own respective functions. Which layer is directly responsible for the cardiac output of the heart? A. Endocardium B. Myocardium C. Epicardium D. Pericardium 2. Studying the ECG, nurse Shinobu is aware of the graphic representations of the electrical impulses in the heart. Which part indicates the atrial contraction? A. QRS complex B. PR Interval C. P wave D. T wave 3. She is suspecting a patient to have myocardial infarction. Which ECG will she not expect in a case of MI? A. Presence of U wave B. Presence of pathologic Q wave C. Inverted T wave D. Elevated ST segment 4. It is expected for the nursing team to also be aware of the cardiac markers for each disease condition. Which is considered as the most definitive, important, and reliable test for MI as this can last for 3 weeks? A. CPK B. Myoglobin C. Troponin D. LDH 5. According to the American Heart Association 2020 guidelines, a high quality CPR must include which of the following? i. Minimize interruptions during chest compressions ii. “Push hard, and push fast” technique iii. Allow full chest recoil iv. Give rapid ventilations v. Compression rate of 100-120 per minute vi. Compression depth of at least 5cm A. i, ii, iii B. i, ii, iii, v C. i, ii, iii, iv, v D. i, ii, iii, v, vi Situation: On your first month as a medical unit nurse, you have encountered cases such as heart failure, valvular heart disorders, and vascular diseases. 6. The patient is exhibiting clinical manifesttaions of left-sided heart failure. Which should you not expect? A. Orthopnea B. Pulmonary edema C. Peripheral edema D. Crackles 7. He is receiving digitalis for heart failure. Which of the following nursing action should be done by you prior to the administration of the medicines? A. Take the carotid pulse rate for one full minute B. Take the heart rate for one full minute. C. Take the respiratory rate. D. Take the blood pressure. 8. You are still having trouble identifying the difference between venous and arterial insufficiency among the cases of your patients. Which sign is associated with arterial insufficiency? A. Pain with claudication B. Edema C. Warm to touch D. Venous congestion 9. The other patient is dealing with Buerger’s disease, expressing distress due to intermittent claudication in the lower extremities. What is the optimal nursing intervention to alleviate the patient's discomfort? A. Allow the patient to lie flat on bed B. Teach him foot care and leg exercises. C. Place affected extremities in a dependent position D. Apply hot water bag to the affected extremities 10. She is currently handling a patient who recently had stroke in the past 36 hours. She is giving heparin via subcutaneous route. During her rounds, her fellow nurse colleague reported to have seen her patient having an episode of hematemesis. The significant other of the patient also mentioned that she have seen blood in the patient’s stools. You will prepare to refer and administer what antidote for a suspected overdose? A. Vitamin K B. Deferoxamine C. Digibind D. Protamine sulfate Situation: Mario, a 17-year old male student, sought for medical check-up upon complaints of pain, and nasal congestion. 11. Nurse Karen identified inflammation in the lining of the sinus. What is this type of upper respiratory tract infection? A. Allergic Rhinitis B. Pharyngitis: C. Laryngitis D. Sinusitis 12. Mario engages in a conversation with the nurse about upper respiratory infection (URI) management. What statement from Mario suggests a need for further education? A. "I'll consume plenty of juices and fluids to maintain good hydration." B. "I can use nasal decongestant spray until the congestion clears up." * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
Prepared by: Mr. Jules Arceo Ms. Juliane Lupisan 2 | Page C. "I can use acetaminophen (Tylenol) to alleviate my sinus discomfort." D. "I'll monitor any alterations in nasal secretions or the sputum I cough up." 13. He often complaints of pain in the back of his head, and near the mastoid process. Nurse Karen identifies the inflammation to be at what part of the sinus? A. Frontal B. Ethmoid C. Maxillary D. Sphenoid 14. Nurse Karen provided teachings on the management for the acute condition. Which of the following statements indicate further teaching is needed? A. Increase fluid intake B. Apply warm compress over affected area C. Take antibiotics only when symptoms are present D. Use saline irrigation and heat mist 15. After teaching Mario, a patient suddenly came into the ER with blood coming out of their nose after a fight with another person. What should not be done by Nurse Karen? A. Advise patient to look up in the sky and hold nostrils B. Apply pressure over the soft tissues of the nose for at least 5 minutes-10 minutes C. Apply cold compress over the nose D. Administer topical vasoconstrictors Situation: Nurse KC is handling multiple patients in the medicine ward. All our presenting different diagnoses of respiratory tract conditions. 16. Which part of the lungs found at the end of the terminal bronchioles does gas exchange occurs? A. Alveoli B. Bronchi C. Bronchioles D. Carina 17. Francis, a patient in Bed 15, suddenly complains of restlessness, and stabbing chest pain. His breathing is fast and his skin is slowly turning blue. What is considered as the obstruction of pulmonary artery or one of its branches by a blood clot that originates somewhere in the venous system or in the right side of the heart? A. Pulmonary embolism B. Pneumothorax C. Empyema D. Acute Respiratory Distress Syndrome 18. To prevent another occurrence of the emergency in the previous number, nurse KC emphasizes its prevention.. Which among the following is not included? i.Active leg exercises ii.Early ambulation iii.Use of elastic compression stockings iv.Avoidance of leg-crossing and sitting for prolonged periods v.Maintain hydration A. i , ii & iii B. ii, iv C. All of the above D. None of the above 19. She was preparing a patient who will undergo thoracic surgery. What is the treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, and lung abscesses ?This usually involves removal of one lobe of the lung. A. Lobectomy B. Pneumonectomy C. Lobotomy D. Wedge resection 20. Picasso, a patient recently diagnosed with emphysema, asked how to manage his condition. What statement made by Picasso indicates the need to repeat the health teaching? A. Use of 3 or more pillows when laying on bed B. Practice deep breathing exercises C. Maintain high fluid intake D. Eat low calorie, low protein, and low fat diet to prevent further compression of lungs Situation: Mark, a 37 year old male patient, is admitted due to fever, painful swelling of hands, feet, joints, and in labor pain who has a diagnosis of sickle cell anemia. 21. Nurse Chandria administers oxygen to the patient Mark while taking which additional measures to prevent the occurrence of a sickling crisis. A. Maintain strict asepsis B. Maintains adequate hydration C. Monitors the temperature D. Reassures the patient 22. Nurse Sophie hooks a 1000 ml intravenous IV solution of D5Water as ordered by the physician at 9am to infuse 60 ml/hr. via macro drop infusion set (20gtts = 1ml). On the assessment of the infusion at what would be the level of the remaining amount in the IV bag at 2pm? A. 500 mL B. 300 mL C. 600 mL D. 700 mL 23. The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patient complains of difficulty of breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse? A. Recheck the unit of blood for compatibility B. Call the physician C. Check the patient’s temperature D. Stop the infusion 24. Nurse Sophie checks the gauge of the patient’s intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? A. 22-gauge B. 18-gauge C. 20-gauge D. 16-gauge 25. What are efficient ways to prevent potential complications and occurrence of sickle cell anemia crisis? A. Always provide adequate hydration B. Avoid hot temperature that may cause vasodilation C. Protect leg from trauma and contamination to prevent leg ulcer D. Aseptic technique Situation: Nurse Noelle reviews the hematologic system and disorders in preparation for the May 2024 board exam. 26. The plasma is the fluid portion of blood. It contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for clotting, as well as electrolytes, waste products, and nutrients. What is the part of the blood that contains the plasma minus the clotting factors? A. Granulocytes B. Serum C. Urea D. Hemoglobin 27. In treating patients with iron-deficiency, Nurse Noelle should be familiar as to the nature of the disease to plot out her health teaching. She aims to teach the predisposing factors of iron- deficiency anemia. Which statement indicates further health teaching is needed? A. “My pregnancy causes a permanent deficiency in anemia due to the fetus’ usage of iron. I have to take folic acid and iron supplements to combat this.” B. “The lack of green leafy vegetables in my diet led to the inadequacy of dietary iron in my body.” C. “Being an alcoholic led to decreased absorption of nutrients in my body.” D. “When I am menstruating, I have to take iron supplements since I have an increased risk for iron- deficiency anemia.” 28. Her patient, Oxford, asked what he should not avoid when taking with iron. Which among the following is correct? A. Milk B. Tea C. Coffee D. Vitamin C
Prepared by: Mr. Jules Arceo Ms. Juliane Lupisan 3 | Page 29. One of her patients is diagnosed to have aplastic anemia which is an autoimmune disorder characterized by hypoplastic marrow. Which clinical manifestations should nurse Noelle monitor for signs of infection? A. Ecchymoses B. Pallor C. Retinal hemorrhage D. Exudate at IV site 30. She plans her nursing management to a client with aplastic anemia. Which of the following should she not include to her nursing care plan? A. Blood transfusion as ordered B. Complete bed rest C. Give SQ, IM, and IV injections for the medications D. Reverse isolation due leukopenia 31. A client with chronic kidney disease has completed a hemodialysis treatment. Nurse Kira would use which of the following standard to evaluate client’s status after dialysis? A. Potassium & weight B. Vital signs & weight C. BUN & Creatinine D. Vital signs & BUN 32. Prior to starting another HD session, nurse Kira wants to assess the patency of an arteriovenous fistula in the left arm of the patient. Which finding indicates that the fistula is patent and can be used for HD? A. Presence of radial pulse in left wrist B. Absence of bruit upon auscultation of fistula C. Palpation of thrill over fistula D. Capillary refill time less than 3 seconds in the nail beds of the left hand 33. Nurse Kira checks the patient’s chart prior to sending her client to the HD unit. She noted that tall and peaked T waves in the ECG strip of the patient. Patient was ordered to have their laboratory values checked. What result supports the ECG tracing? A. K = 8.5 mEq/L B. Mg = 2.2 mg/dL C. Ca = 9.3 mg/dL D. Na = 3.5 mEq/L 34. Nurse Kira wants to review the ABG values of her patients to check for abnormalities. The ABG results are as follows: pH: 7.14, PaCO2: 33, HCO3-: 14 , PaO2: 90mmHg. What does this indicate? A. Partially Compensated Metabolic Alkalosis B. Fully Compensated Respiratory Acidosis C. Uncompensated Respiratory Alkalosis D. Partially Compensated Metabolic Acidosis 35. Most patients can have the chance to receive a kidney transplant. What precautions should be exercised or has the highest priority for the patient going home on maintenance drugs after kidney transplant? A. Limiting the use of table salt B. Taking weekly weights C. Monitoring for bacterial, and fungal infections D. Avoiding blood donations Situation: Nurse Megumi is reassigned to help out in the medical-surgical unit for the week. He review the patients’ charts and plans out his NCPs accordingly. 36. To determine possible causes, nurse Megumi will ask a patient admitted with acute glomerulonephritis about: A. Recent bladder infection B. History of kidney stones C. Recent sore throat or fever D. History of high blood pressure 37. A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? A. Poor skin turgor B. Recent weight gain C. Elevated urine ketones D. Decreased blood pressure 38. He will plan to teach a 31-yr-old woman who smokes two packs of cigarettes daily about the increased risk for? A. Kidney stones B. Bladder cancer C. Bladder infection D. Syphilis 39. Identifying the cause of acute renal failure will help nurse Megumi formulate his treatment. He determined that the 73- year old male patient was previously diagnosed with untreated benign prostatic hyperplasia. What is the cause of his acute renal failure? A. Prerenal B. Anterenal C. Intrarenal D. Postrenal 40. Renal failure has two types: acute and chronic. Which characteristic differentiates the acute renal failure from chronic renal failure? A. Acute renal failure can undergo kidney transplant B. Acute renal failure is caused by sudden loss of function C. Acute renal failure is the progressive loss of kidney function D. Acute renal failure has to undergo hemodialysis for a lifetime Situation: Efficient nursing management is anchored to proficient nursing assessment. 41. The nurse wants to check the patient’s oxygen saturation. Which nursing consideration is incorrect? A. Remove nail polish B. Hold finger dependent and motionless to improve quality of signal C. Keep the finger sensor exposed to ambient light D. Assess site of oximetry monitoring for perfusion because pressure ulcer may develop 42. Prior to retrieving blood for ABG, patency of the arteries must be checked using the what test? A. Allen’s Test B. ABG Test C. Capillary refill test D. Skin turgor test 43. Which of the following steps in performing the Allen’s test would indicate the need for the head nurse to intervene? A. Apply direct pressure over the radial and ulnar artery simultaneously B. While applying pressure, nurse asks patient to keep palm open C. Release pressure over ulnar artery while maintain pressure over radial artery D. Assess the color of extremity distal to the point 44. Upon analyzing the blood gas specimen, its findings was Metabolic alkalosis. Which of the following is the possible cause of the abg imbalance? A. COPD B. Excessive mechanical ventilation C. Diarrhea D. Vomiting 45. The nurse checks the tonicity of each IV solution. Which is not classified as hypertonic? A. 0.33 NaCl B. D5LR C. D5NSS D. D10W Situation: The nurse should also be competent in executing medical and nursing interventions to achieve quality patient care. 46. During blood transfusion, patient suddenly exhibits flank pain, vomiting, hypotension, tachycardia, tachypnea, and hemoglobinuria in his catheter bag. What transfusion reaction is happening? A. Hemolytic B. Anaphylactic C. Febrile D. Circulatory overload 47. With the previous number, what is the first action of the nurse? A. Flush the line with NSS
Prepared by: Mr. Jules Arceo Ms. Juliane Lupisan 4 | Page B. Take vital signs C. Report to physician D. Stop infusion 48. A patient with thalassemia major is seen to experience iron overload. What is the antidote for the event? A. Deferoxamine B. Warfarin C. Vitamin K D. Glucagon 49. Which is not a component of chest physiotherapy? A. Postural drainage B. Percussion C. Vibration D. Suction 50. When is the worst time to conduct chest physiotherapy? A. After meals B. Bedtime C. Early morning D. After Nebulization Situation: As part of the requirements for applying to the hospital as a staff nurse, nurse Jake attends the hospital’s in- service training regarding advanced cardiac life support and disaster nurse competencies, especially triage and first-aid. 51. Which among the following criteria is not used to prioritize patients under START triage? A. Mental status B. Movement C. Blood flow D. Breathing 52. You are on-response to a patient who was reported to be suffering from multiple leg fractures in a highway after having been a victim of a car collision. What is your immediate nursing action upon arrival to the scene? A. Immobilize the fracture B. Open the airway and secure breathing C. Attach electrodes for the AED D. Move the patient away 53. As a disaster nurse, part of your interventions is to conduct fire and earthquake drills to the community to augment their knowledge and skills should a disaster come. What phase of disaster nursing are you acting upon? A. Prevention B. Mitigation C. Preparedness D. Response 54. What ethical principle is at use by the nurse who prioritizes those who are tagged as color green compared to those who are tagged as color red during disasters? A. Justice B. Utilitarianism C. Beneficence D. None. The nurse should prioritize those tagged as red compared to green according to acuity 55. In an emergency situation, the nurse will approach this patient the last: A. A 15-year old infant who has a sucking chest wound B. A 70-year old male who has agonal breaths and penetrating head injury C. A 25-year old pregnant woman who has leg fracture D. A 35-year old male who is frantically crying looking for his family members 56. While talking to a patient in the hallway, they suddenly became unconscious. Upon assessment, the nurse determines the patient has no breathing and has no pulse rate. What immediate nursing intervention should they administer? A. Activate the code and get the E-cart B. Perform chest compressions C. Open the airway and provide bag-valve mask ventilation D. Administer epinephrine 57. Which of the following is an appropriate action by the nurse to the same patient who is 25 years old? A. Compress at a rate of 15 compressions and 2 ventilations B. The depth of compressions should be 1.5 inches C. Assessment of pulse and breaths should be less than 15 seconds D. Compressions should be done at the lower half of the sternum 58. Upon hooking the patient to the ECG, the nurse knows that defibrillation can be given to this patient if the rhythm is: A. Torsades de pointes B. Ventricular tachycardia with pulse C. Asystole D. Ventricular fibrillation 59. If the patient presents with supraventricular tachycardia, the nurse knows that the defibrillator should be set to cardioversion. Before administering the shock, it is vital that the shock should be synchronized to which part of the ECG? A. P wave B. PR interval C. QRS complex D. T wave 60. Which of the following manifestations of the patient dictate that they have recovered? A. Conscious, HR of 60 bpm, and conversant B. Conscious, bradycardic, and pale C. Unconscious, and HR of 145 bpm D. Conversant at times, HR of 90 bpm Situation: Nurse Krane decided to specialize in geriatric nursing care after passing the board exams. This requires them to be knowledgeable about the different theories and principles that are specific to geriatric patients as these patients require a different type of care compared to adult patients. 61. Nurse Jane is planning to make an education program for her older aged clients. She knows that the cut-off for defining older people in the Philippines is what age? A. 60 years old B. 65 years old C. 70 years old D. 75 years old 62. In coming up with the contents of the program, nurse Jane knows that she should initially assess which of the following? A. The budget for the event B. Where the event will take place C. What the audience knows and needs to know 63. In considering care for older adults, which statement of nurse Jane indicate that they do not need to refresh their knowledge on facts about the elderly? A. More older aged Filipinos are concentrated in the urban areas B. More than half of older aged Filipinos are single C. Older women are found to be associated with a higher level of experiencing functional difficulties D. The educational profile of older Filipinos has worsened where more older Filipinos have not had finished secondary education 64. Which of the following is not included in the common difficulties of Filipino older aged people? A. Vision B. Hearing C. Walking or climbing stairs D. Cooking food 65. Elder abuse is the term for knowing, intentional, or negligent act by a caregiver or any other person to an older adult. What type of elder abuse involves not providing food, housing, or medical care to older adults? A. Financial abuse B. Psychological abuse C. Physical abuse D. Neglect or abandonment 66. Which of the following facts are false in terms of elder abuse? A. Only 4% of cases of elder abuse are reported B. 90% of all abusers belong to the home of the elderly C. There are adequate systems in place to address elder abuse D. People who commit elder abuse commonly belong to the group of healthcare workers
Prepared by: Mr. Jules Arceo Ms. Juliane Lupisan 5 | Page 67. Which of the following is not an expected physiologic change in the aging process? A. Higher risk for burns or frostbites B. Having dementia C. Experiencing constipation D. Acquiring left ventricular hypertrophy 68. This biologic theory of aging indicates that due to continued use of cells of the body, tissues wear out to the point that they cannot regenerate itself. As a result, organs cannot repair themselves and this leads to death. A. Wear and tear theory B. Cross-linkage theory C. Radical theory D. Somatic mutation theory 69. In consideration of the psychosocial theory of development, which intervention by nurse Jane indicate that they need to revise their care plan accordingly? A. Distract older adults from talking about retirement and focus on how functional they have been in their work B. Encourage older adults to look back over their accomplishments and failures C. Allow an older adult to verbalize feelings over physical effects of aging and assist them in revising their lifestyle accordingly D. Assist an older adult and their family to plan their funerals ahead of time 70. Which among the following should a geriatric nurse recognize as true regarding health promotion and disease prevention in ageing? A. Older adults have a healthier diet as compared to the younger population B. Aerobic exercises such as zumba dance classes is the main mode of exercise among older adults C. Older adults should be given assistance against falls as they often become nearsighted D. Environmental adjustments should be done as older adults tend to have difficulty hearing higher frequency sounds Situation: As the number of reported HIV cases gradually rose, the Philippines faced the growing realization that HIV was not merely a health issue, but also a social, economic, and human rights concern. The government and various organizations, including nurses in the Philippines, began to intensify efforts to address the multifaceted challenges posed by HIV, seeking to implement strategies that encompassed prevention, care, treatment, and support for those affected. 71. Which among the following can most likely cause transmission of HIV from one person to another? A. Having sex with a condom B. Exposure of mucous membranes to sweat or saliva of a patient with HIV C. Being tattooed with a reused needle D. Performing oral sex only and not insertive/receptive sex 72. Which of the following statements of a patient with HIV regarding the stages of HIV infection necessitate further education? A. There are three stages of HIV infection B. HIV stage I is where a person is exposed to HIV but is not contagious C. HIV stage II is when HIV is latent. There are no symptoms but the person can transmit HIV D. Persons who are in HIV stage III have a life expectancy of about three years 73. What is the considered count of CD4+ T cells which is considered to be at the stage of AIDS? A. Less than 1200 cells/mm3 B. Less than 500 cells/mm3 C. Less than 300 cells/mm3 D. Less than 200 cells/mm3 74. Which of the following is true regarding the protocol for HIV testing? A. Enzyme immunosorbent assay detects HIV antigens and is the confirmatory test for HIV B. Enzyme immunosorbent assay detects HIV antibodies and is the initial test for HIV C. Western blot detects HIV antibody proteins and is the initial test for HIV D. Western blot detects HIV antibody proteins and is the confirmatory test for HIV 75. A patient comes to you and mentions that they believe they have been exposed to HIV last night when they had sex. Backed up with your knowledge in HIV transmission, what is your most appropriate advice regarding testing? A. They should get tested immediately so they can be sure they do not HIV B. They should go to a treatment hub to acquire pre- exposure prophylaxis C. They will only be able to confirm their HIV status at most three months from now D. They should consult a physician to acquire antiviral medications immediately Situation: Nurse Theresa is assigned to the care of patients with immunological disorders. The following are vital information they should know to provide proper care for these patients. 76. Which of the following claims of a patient most likely indicates that they have rheumatoid arthritis? A. The first symptom I felt is extreme pain in the great toe of my left foot B. Both my left and right elbows hurt in the morning C. I can hear scratchy, grating sounds when I move my joints D. My joints hurt when I wake up but it goes away after 10 minutes 77. Which of the following is not considered a deformity associated with rheumatoid arthritis? A. Palpable joint hypertrophy in the distal and proximal interphalangeal joints B. Metacarpophalangeal joints become swollen and bend abnormally towards the 5th or 6th digits C. Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint D. Flexion of the base of the finger, extension of the proximal interphalangeal joint, and flexion of the distal interphalangeal joint 78. Which of the following interventions for a patient with RA indicates that a nurse has adequate understanding of their care? A. Provide a diet high in protein B. Group together activities to promote longer and continuous rest C. Make sure the beddings and mattress of the patient is soft to increase comfort D. Schedule vigorous activities to enhance the physical health of the patient 79. Upon assessment of a patient with SLE, the nurse knows that which medication increased their risk of getting the disease? A. Diazepam B. Digoxin C. Isoniazid 80. Your patient with systemic lupus erythematosus is scheduled for their daily walking session at 8:00 AM. As you go to the patient’s bedside, you assess that they have 8/10 joint pain, temperature of 38 C, and warm to touch joints. What is your appropriate intervention? A. Continue with the planned walking session as it will relieve the patient’s symptoms B. Allow the patient to rest and provide tepid sponge bath C. Administer scheduled medications before the activity D. Contact the physician in-charge as this indicates a complication Situation: Mia has been assigned to conduct a study assessing the satisfaction levels of patients regarding the care they received at the hospital. Her plan is to include all adult patients admitted between June and October, on their first admission, with an average hospital stay duration of 4-5 days and no complications.