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RECALLS EXAMINATION 2 NURSING PRACTICE V CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART C) 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 V” on the box provided Situation: Nurse Angela was assigned to a patient with a recent colostomy who undergoes a change in their stoma appearance and reports discomfort. Nurse Angela, who is well-versed in colostomy care, promptly assesses the stoma, identifies signs of potential complications, and takes appropriate action. 1. Nurse Angela is educating the patient on ileostomy care. She knows the teaching is effective when the patient articulates, what feeling serves as an indicator for determining the frequency of pouch drainage for individuals with an ileostomy? A. Urge to defecate B. Sensation of taste C. Sensation of smell D. Sensation of fullness 2. On the second day after undergoing abdominoperineal resection, Nurse Angela checks the colostomy stoma of her patient. She observes its appearance to anticipate any signs of complications or normal healing. She anticipates that the normal colostomy stoma will appear: A. Moist, red and raised above the skin surface B. Dry, pale pink and with flushed skin C. Dry, purple and depressed below the skin surface D. Moist, pink, with flushed skin and painful when touched 3. If the patient has stoma in ascending colon, what will be the texture of stool? A. Semi-soft B. Solid C. Mushy D. Liquid 4. During a colostomy care education session, Nurse Angela discusses dietary considerations with her patient, Mr. Smith, who wants to reduce flatulence. Mr. Smith understands the advice but seeks clarification on which foods are exceptions. What food should Mr. Smith eat to reduce flatus formation? A. Mangoes and pineapples B. Cabbage and asparagus C. Corn and peanuts D. Chewing gum and carbonated beverages 5. In a postoperative follow-up session, a patient who underwent colorectal surgery with colostomy presents with concerns about managing their stoma. The patient reports difficulty in maintaining the seal of the ostomy appliance. What are the appropriate nursing interventions to address the patient's issue with ostomy care? A. Provide education on proper stoma care, including cleaning techniques and selecting the appropriate ostomy appliance size and type. B. Refer the patient to an enterostomal therapy nurse for specialized assistance with ostomy management. C. Assess the patient's peristomal skin for irritation or damage and recommend appropriate skin protection measures. D. All of the above. Situation: In the intensive care unit, Nurse Bosi receives a bedside ABG analysis request for a critically ill patient who is experiencing respiratory distress. Meanwhile, she closely monitors the vital signs and respiratory status, knowing that the ABG results will provide crucial information about his acid-base balance, oxygenation status, and respiratory function. 6. During rounds with the doctor, Nurse Bosi was asked about the possible iatrogenic cause of respiratory acidosis. She doesn’t need further learning when she answered: A. Breathing thru paper bag B. Excessive mechanical ventilation C. Adequate ventilation - normal D. Chest tube insertion 7. A patient arrives complaining of fatigue, confusion, and nausea. The attending physician suspects a acid-base problem and orders an arterial blood gas analysis. Upon receiving the results, the pH is found to be 7.39, CO2 is 34 mmHg, and HCO3 is 21 mEq/L. Nurse Bosi interpret the result as: A. Metabolic Acidosis, Fully Compensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Acidosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 8. Nurse Bosi was ordered to draw an ABG sample to a patient. Before obtaining ABG specimens from the radial artery, the nurse should confirm which of the following tests or procedures has been conducted: A. Rinne’s Test B. Test’s Test C. Allen’s Test D. Romberg’s Test 9. Nurse Bosi is at the healthcare clinic, she analyzes the arterial blood gas results of a client: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. Based on these findings, the nurse determines that the client is experiencing which type of acid-base imbalance? A. Metabolic alkalosis, Partially Compensated B. Respiratory acidosis, Partially Compensated C. Metabolic acidosis, Uncompensated D. Respiratory alkalosis, Uncompensated 10. What is the main electrolyte imbalance can be seen in metabolic alkalosis? A. Increased potassium B. Decreased calcium C. Decreased potassium D. Increased calcium Situation: In the Philippines, mastectomy serves as a critical intervention for combating the high incidence of breast cancer among women. Despite the challenges posed by varying access to healthcare across urban and rural areas, a unique community-based approach has emerged. Grassroots initiatives, often spearheaded by local NGOs and women's health advocates, strive to bridge the gap in cancer care. 1 | Page
11. During a routine breast self-examination workshop, a participant expresses concern about changes in her breast appearance. All of the following are signs and symptoms of breast cancer, except: A. Nipple discharge without squeezing B. Swelling or lump in the breast or underarm area C. Numbness or tingling sensation in the breast or nipple area D. Presence of peau d'orange skin texture 12. Which postoperative positioning is appropriate for a patient following a mastectomy to promote comfort and prevent complications? A. Placing the patient in a prone position with the affected arm elevated. B. Elevating the affected arm on pillows to promote lymphatic drainage. C. Keeping the patient in a supine position with the affected arm extended. D. Allowing the patient to lie on the affected side to prevent shoulder stiffness. 13. In a breast cancer support group meeting, a participant expresses concern about starting hormonal therapy as part of her breast cancer treatment plan. All of the following are example of hormonal agents that is used to treat breast cancer, except: A. Tamoxifen B. Goserelin C. Fulvestrant D. Anakinra 14. During a community health lecture focused on breast cancer awareness, participants engage in a discussion about various risk factors associated with the disease. Which is not a risk factor for developing breast cancer? A. Early menarche B. Late menopause C. High fat diet D. Early menopause 15. According to American Cancer Society screening recommendations for women at high risk. Women who are at high risk for breast cancer based on certain factors should get a breast MRI and a mammogram every year, typically starting at age 30. This includes women who are: except A. Have a known BRCA1 or BRCA2 gene mutation B. Have a first-degree relative with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves C. Had radiation therapy to the chest before they were 30 years old D. Had a history of taking hormonal contraceptive pills Situation: For nurses, understanding how to manage a tracheostomy patient is crucial, as it directly impacts the patient's respiratory health and overall well-being. Effective tracheostomy care involves regular cleaning, monitoring for complications, and ensuring the patency of the airway. This specialized skill set is essential for providing comprehensive and safe care in both acute and long-term healthcare settings. 16. Nurse Theo attends to a patient who has had their tracheostomy, when the tube accidentally dislodged. The patient is experiencing difficulty breathing, and the nurse immediately springs into action to address the situation. As the nurse stabilizes the patient and prepares to reinsert the tracheostomy tube, they realize the importance of having essential equipment readily available at the bedside. Which equipment should be always available to a patient with tracheostomy? A. Suctioning device B. Ambu bag with a mask C. Spare tracheostomy tubes D. Obturator 17. Nurse Theo is caring for the patient with a newly made tracheostomy and he notices an increase in respiratory secretions and is concerned about maintaining airway patency to prevent complications. In caring for a patient with a newly or recent tracheostomy, how often should suctioning be performed to maintain airway patency and prevent secretion buildup? A. Every 1 – 2 hours B. Every 2 – 4 hours C. Every 4 – 6 hours D. Twice per shift 18. What special precaution should be taken to address the lack of filtration and humidification of air when a client breathes through a tracheostomy? All of the following are correct except: A. Provide mist collar B. Client with long term tracheostomy may wear light scarf C. A nonraveling 4x4 gauze may be held in place with cotton tie over stoma D. Use of cut sterile 4x4 gauze square to help filter air 19. Patient with tracheostomy is experiencing difficulty with crusty secretions accumulating around the tracheostomy tube. The patient is conscious and responsive but is distressed by the discomfort caused by the buildup of secretions. Given the patient's discomfort and the presence of crusty secretions around the tracheostomy tube, which solution would be most appropriate for effectively removing these secretions while minimizing irritation to the patient's airway? A. Vinegar solution B. Half strength isopropyl solution C. Half strength hydrogen peroxide D. Half strength povidone-iodine solution 20. Nurse Theo is tasked with changing the tracheostomy ties for a patient. However, the existing ties are very soiled and challenging to thread through the flange of the tracheostomy tube. The nurse recognizes the difficulty and wants to ensure a safe and effective procedure. Given the challenge of threading soiled tracheostomy ties through the flange, what is the correct action for the nurse to take? A. Proceed with the tie change independently, taking extra care to thread the ties through the flange. B. Ask the patient to hold the tracheostomy in place while replacing the ties to ensure stability. C. Refer to physician, so that he will be the one who replace the ties D. Call for assistance to put on sterile gloves and hold the tracheostomy in place while you replace the ties. Situation: Nurse Abie was assigned in the hospital's gastroenterology department. A doctor discusses test results with a patient named Sarah. The doctor explains that Sarah's need to have an fecal occult blood test, to detect the presence of blood in her stool that's not visibly apparent. 21. Which foods should Sarah avoid before her fecal occult blood test to ensure accurate results? A. Red meat B. Iron fortified cereals C. Calamansi juice D. All of the above 22. Which of the following can cause a false-negative result in a fecal occult blood test? A. Mr. Chavez consumption of fresh fruits B. Mr. Garino addiction to nonsteroidal anti-inflammatory drugs C. Mr. Robe who is diagnosed with hemorrhoids D. A luxurious dinner of ribeye steak garnished with gold flakes at Wolfgang's Steakhouse with Mr. Daclis. 23. Nurse Abie was tasked to assist a client to defecate. While assisting a client to stand, the client suddenly becomes agitated and slips on the floor. What is your initial action in this situation? A. Immediately call for assistance from other staff members B. Assess the client for any signs of injury C. Attempt to calm the client down and reassure them D. Position the patient on side lying 24. After assisting the client to defecate, Nurse Abie instructs the client to wash his hands. According to WHO guidelines, how long is the recommended duration for the entire procedure of handwashing? A. 20 – 30 secs B. 30 – 60 secs C. 40 – 60 secs D. 15 – 20 secs 2 | Page
25. Nurse Abie performs a guaiac test on a stool sample from a patient. Upon inspecting the test result, she notices a color change on the test card. What color change is typically observed on the guaiac test card to indicate a positive result? A. Black B. Yellow C. Brown D. Blue Situation: Nurse Gail is preparing to conduct a patient education session on hypertension. As she explains the basics of hypertension, she emphasizes the importance of understanding blood pressure readings, risk factors, and lifestyle modifications. 26. During a nursing conference on hypertension management, Nurse Gail presents a case study involving a patient with longstanding hypertension. She discusses the various complications associated with hypertension and its impact on different organs. Considering the systemic effects of hypertension on various organs, which one tends to be LEAST affected by the condition in most cases? A. Brain B. Eyes C. Liver D. Heart 27. According to American Heart Association, when a patient has a BP reading of 139 mmHg in systolic and 80 mmHg in diastolic. What blood pressure category do they belong? A. Prehypertension Stage B. Hypertension Stage 1 C. Hypertension Stage 2 D. Hypertension Stage 3 28. On the other hand, according to the JNC-7 classification of hypertension, when a patient has a blood pressure reading of 159 mmHg systolic and 99 mmHg diastolic, to which category do they belong? A. Prehypertension Stage B. Hypertension Stage 1 C. Hypertension Stage 2 D. Hypertension Stage 3 29. Which of the following lifestyle modifications is not typically recommended for managing hypertension? A. Increased intake of processed foods B. Regular aerobic exercise C. Reduction in sodium consumption D. Maintaining a healthy weight 30. Which of the following is a key component of the Renin-Angiotensin-Aldosterone System involved in the increasing the blood pressure and often targeted for pharmaceutical interventions in hypertension? A. Aldosterone B. Renin C. Angiotensin II D. Angiotensin I Situation: Nurse Raiven emphasizes the importance of efficient record management. He explains that organized documentation ensures timely access to crucial patient information, enhances patient safety, and minimizes legal risks. Recognizing the significance, Nurse Raiven and his colleagues commit to improving their record-keeping practices to deliver better care. 31. In the midst of administering medication, Nurse Raiven notices a patient experiencing severe nausea and dizziness. Upon stabilizing the patient, Nurse Raiven recognizes the importance of accurate documentation. Without delay, she completes an incident report, ensuring all vital details are recorded for review and analysis. What following information should Nurse Raiven include in incident report, except? A. Date, time and place of incident B. Facts about incident C. Client’s account about the incident D. Nurse’s conclusion about the incident 32. Nurse Raiven is discussing how to ensure the confidentiality of patient data. Which scenario is she emphasizing as the correct approach? A. One password for all computers in the ward B. Nurse Raiven his password to himself C. The nurse manager knows Nurse Raiven password for emergency purposes D. Nurse Raiven storing patient data on an easy access computer 33. Nurse Raiven is tasked with managing patient records. He comes across a medico-legal case involving a serious medical incident. In the context of healthcare practice in the Philippines, for how long should medico-legal cases be stored to ensure compliance with legal and regulatory requirements? A. 20 years B. 25 years C. 50 years D. Indefinitely 34. According to RA 9173, a person occupying supervisory or managerial positions requiring knowledge of nursing must possess a Bachelor of Science in Nursing degree, with at least how many units in management and administration courses at the graduate level? A. 4 units B. 5 units C. 9 units D. 10 units 35. Nurse Raiven mistakenly administers the wrong medication to a patient. Following an investigation, it is revealed that Nurse Raiven failed to adhere to proper medication administration protocols. Due to the severity of the error and its potential consequences for patient safety, Nurse Raiven’s nursing license is revoked by the licensing board. What is the maximum duration of license revocation for Nurse Raiven according to Republic Act 9173? A. 5 years B. 4 years C. 3 years D. 2 years Situation: In a malaria-endemic tropical region, a local clinic sees many patients with fever, chills, and body aches. Suspecting malaria due to prevalent symptoms, the physician orders a blood test. Nurse Al promptly carries out the order. 36. What characteristic would you expect to find in a blood smear of a patient diagnosed with malaria? A. Eggs in the blood B. Elevated white blood cell count C. Decreased platelet count D. Plasmodium parasite in the blood smear 37. Nurse Al is conducting health teaching about malaria. Nurse Al is correct when he states that malarial infection can be transmitted through various means. Which of the following options is NOT a correct transmission route for malaria? A. Close proximity contact with an infected individual B. Blood Transfusion C. Needle prick injury of contaminated needle D. Mosquito bites 38. During a health education session about malaria prevention, Nurse Al discusses various preventive measures with the community. Which is NOT a recommended malaria preventive measure? A. Application of insect repellant lotion B. Carabao and cattle rearing near house C. Destruction of breeding places D. Wearing of long sleeves in the morning 39. Which medication was historically considered the drug of choice for treating malaria? A. Doxycycline B. Quinine C. Tetracycline D. Chloroquine 40. What is the primary vector responsible for transmitting malaria? A. Aedes mosquito B. Culex mosquito C. Anopheles mosquito D. Tsetse fly Situation: Nurse Trisha responds to a Code Red alert in her assigned ward. Thick smoke fills the unit as patients are hurriedly evacuated. Though chaotic, Nurse Trisha’s swift 3 | Page