1. Assessment of the thorax includes the palpation of the tracheal position. Mr. Tiny has been recently admitted to the unit because of chest trauma d/t a vehicular accident. Dyspnea, anxiety, tachypnea and tachycardia suddenly developed. Hyperresonance of the right lung field is observed. Tension pneumothorax of the right lung is suspected. Which of the following assessment findings if found by Nurse Bradwarden would indeed confirm the suspicion of tension pneumothorax?

Choose one answer.

a. tracheal deviation to the left  A tension pneumothorax may generate sufficient pressure inside the chest to force the trachea towards the unaffected side. In this case, the right lung is affected by tension penumothorax and the trachea is expected to deviate towards the unaffected side, which is the left. Tracheal position at midline in the suprasternal notch is a normal finding. (p. 465, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

2.Mr. Weasley, a client with nasoenteric tube feeding suddenly developed coughing, dyspnea, and cyanosis. Upon auscultation, there are crackles in the lungs. Nurse Potter’s immediate response are all but one:

d. Prepare possible initiation of antibiotics  It is a part of delayed response wherein there is already fever. All the other options are immediate responses on aspiration of stomach contents in the respiratory tract.Potter-Perry 2004

Correct

3. Caring is an aspect unique in nursing which involves a sense of harmony within the mind, body and soul of a person. Nurse Boris is taking care of Patrick, a 65 year old man, who is diagnosed as having terminal cancer of the bladder. Patrick is aware that he only has 2 weeks to live so he tells Nurse Boris his wish to be visited by the hospital chaplain. He wants his religion be changed from Protestant to Roman Catholic. Which aspects of caring will the nurse focus on in this client?

b. Spiritual aspect of care  Just as everybody has a spiritual dimension all clients have needs that reflect their spirituality. These needs are often accentuated by an illness or other health crisis. The given situation is an example of the need to take care of the spiritual aspect of a person. The person has the need to be certain there is a God or Ultimate power in the universe.

(Kozier pp. 1042-1043)

4.To auscultate correctly, the nurse needs good hearing acuity, a good stethoscope, and knowledge of how to use the stethoscope properly. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?

a. The diaphragm detects high-pitched

sounds best

The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.Potter-Perry, 2004

5.Mrs. Luna Lovegood, 30 yrs. Old, suffers from abdominal gaseous distention. Nurse Potter knows that the following may be prescribed:

b.Carminative Enema  They improve the ability to pass flatus. An example is MGW solution, which contains 30 ml of magnesium, 60 ml of glycerine, and 90 ml of water.Emollient enema or stool softeners are detergents that lower surface tension of feces, allowing water and fat to penetrate such as Docusate sodium. Saline enema agents contain salt preparation not absorbed by intestines. Osmotic effect increases pressure in bowel to act as stimulant for peristalsis such as Milk of Magnesia, sodium phosphate/fleet enema. Lubricants are agents that coat fecal contents, allowing easier passage of stool such as Mineral oil. Potter-Perry 2004

6.Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?

c. Discard the syringe to avoid a medication

error 

As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error. Potter-Perry, 2004

7.Medication absorption is the process by which a drug passes from its site of administration into the bloodstream. Which of the following are true in the absorption of medications?i. Rich blood flow promotes faster absorption of medicationsii. Liquid medications are more rapidly absorbed than solid medicationsiii. Exercise enhances absorption of oral medicationsiv. High concentration of drugs promote rapid effect

b.i, ii, iv Statements i,ii and iv are true statement in the absorption of medication.Rich blood flow promotes faster absorption of medication that is the reason why intramuscular injections promotes faster absorption that subcutaneous injection. Liquid medications are more rapidly absorbed than solid medications because it won’t undergo the process of disintegration. Drugs administered in high concentration tend to be more rapidly absorbed than drugs administered in low concentrations. Bolus dose (high concentration) is given to obtain rapid effect of the drug. Number iii statement is incorrect because exercise reduces blood supply to the stomach due to sympathetic response; therefore it slows the absorption of oral medication. (Karch, 2006)

8.Methotrexate is a folic acid analog under the anti-metabolite family. These drugs are structurally similar to nutrients like purine, pyrimidine and folic acid but when synthesizes by cells, metabolic pathways are disrupted leading to slowed growth or death. Methothrexate (Folex) PO is prescribed to Mrs. Lina, a cancer patient who is a postpartum mother. All of the following are pertinent health teachings for the patient except for one:

a. “Take the tablet with meals.”  The drug must be taken 1 hour before or 2 hours after a meal because food decreases absorption of tablets and reduces peak blood level. Methotrexate is teratogenic with a pregnancy category X. Drug therapy usually lasts for 5 days so contraception is necessary for 1 menstrual cycle. Breastfeeding is also contraindicated as the drug can be passed to the infant. Undue fatigue may be due to decreased RBC related to bone marrow suppression. Infection due to decreased WBC can also develop which is also related to bone marrow suppression. (pp. 561-563, Pharmacology for Nurses by Adams, Holland and Bostwick 2nd edition, 2007; pp. 731-735, Nursing Spectrum Drug Handbook by Schull, 2010)

9.The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. Nurse Potter is observing Mr. Weasley for signs and symptoms indicating fluid or electrolyte imbalances that may be affected by IV fluid administration. These signs and symptoms may be present except:

c. Regular pulse rhythm  Rate and rhythm change can occur with changes in intravascular volume, as well as changes in potassium, calcium, and/or magnesium. Change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. With fluid volume excess, the cardiovascular system is unable to compensate for this excess and fluids build up in the lungs, creating abnormal lung sounds and distended neck veins.

Potter-Perry, 2004

10.Mr. Charlie was dying from lymphoma. Orange-size tumors had invaded his neck, groin, chest and abdomen, and his doctors had exhausted all available treatments. Dr. Duyongco prescribed a radical approach in the management of Mr. Charlie. Nevertheless, Mr. Charlie is confident and strongly believes that a new anticancer drug called Vemurafenib would cure him, according to the latest report by pharmaceutical-research company Plexxikon and Roche/Genentech. Mr. Charlie is bedridden and fights for each breath when he received his first injection. But three days later he is cheerfully ambling around the unit, joking with the nurses. Mr. Charlie’s tumors had shrunk by half, and after 10 more days of treatment he was discharged from the hospital. And yet the other patients in the hospital who had received Vemurafenib showed no improvement. These impressive results may best be attributed to:

a. Placebo Effect  The patient’s attitude about a drug has been shown to have a real effect on how that drugs works. A drug is more likely to be effective if the patient thinks it will work than if the patient believes it will not work. (Karch, A.M., 2003, Focus on Nursing Pharmacology, 2nd ed., 23, 25). A placebo effect is a psychologic benefit from a compound that may not have a chemical structure of a drug effect. (Kee, J.L., 2006, Pharmacology: A Nursing Approach. p.11) It is one elicited by the administration of any drug, whether it is pharmacologically active or inert. The effects vary from a variety of factors, including relationship of the client with those providing treatment, belief in the ultimate success of their therapy, and the client's cultural and ethnic background, as well as many other factors. An idiosyncratic effect is one that is unexpected and may be individual to a client; the drug may have a completely different effect from the normal one or cause unpredictable and unexplainable symptoms in a particular client. Tachyphylaxis is drug tolerance to a frequently repeated administration of a certain drug.First-pass effect (hepatic first-pass effect) is the process in which the drug passes to the liver first. (Broyles, B., 2007, Pharmacological Aspects of Nursing Care, 7th ed., p.26.)

11.Nurse Potter knows that the correct length of insertion of the rectal tube for Mrs. Luna Lovegood is:

d. 7.5-10 cms 

Adult 7.5-10 cms(3-4 in)Child 5-7.5cms (2-3 in)Infant 2.5-3.75 cm (1-1.5 in)Potter-Perry 2004

12.Mr. Clinx, along with his two grandchildren, which are also his primary caregivers, is also present in the health teaching class. The 77-year old patient asks you about his problem, which is related to hearing. “I often have trouble hearing what my grandchildren are saying to me. Mary and May often shouts in front of me, but I still have trouble understanding them. Is this normal nurse? What should I do?” Nurse Raigor responds incorrectly to the patient by saying:

a. “Hard consonants like k, d and t and long vowel sounds like ay, ee are most difficult to understand, while sibilant sounds like s, th and f

are the easiest to hear for you.” 

Hard consonants (k, d and t) and long vowel sounds (ay, ee) are the easiest to understand, while sibilant sounds (s, th and f) are the hardest to understand for elderly patients with hearing problems. Sounds in low frequencies are more easily understood than higher-frequency sounds. Presbycusis is a normal change that comes with aging, and usually affects people over 65, particularly males. Impacted earwax can also contribute to hearing problem, so it must be removed. Assistive devices can be used if hearing is already diminished. (p.415, Fundamentals of Nursing by Kozier et.al. 8th edition, 2008)

13.Which of the following is an incorrect way of breaking an ampule in preparation for drug withdrawal?

c. Use a piece of sterile gauze between your thumb and the ampule neck and break off the top by bending

it away from you. 

Use an ampule opener or place a piece of sterile gauze or alcohol wipe between your thumb and ampule neck or around the ampule neck, and break it off the top by bending it toward you to ensure the ampule is broken away from yourself and away from others. The sterile gauze protects the fingers from the broken glass, and any glass fragments will spray away from the nurse. Place antiseptic wipe packet over the top of the ampule before breaking off the top. This method ensures that all glass fragments fall into the packet and reduces the risk of cuts. (Berman, A. (2008). Fundamentals of Nursing New Jersey: Pearson)

14.The concepts of man forms the first foundational component of nursing. To be able to provide individualized, holistic, humane, ethical and quality nursing care, it is primary consideration to understand MAN. The theory on man as a Biopsychosocial and Spiritual Human being by Sister Callista Roy conceptualizes the following except:

c. Man, is a spiritual being only when he professes that he believes in

God. 

According to the theory on Man as a Biopsychosocial and Spiritual being, all men are spiritual in nature. Man, as a biologic being is like all other men because all men have the same basic human needs. Man, as a psychologic being is like no other man because man is a unique, irreplaceable, one time being. Man, as a psychologic being has the following characteristics: rational but at times irrational, mature with core of immaturity, with limited and unlimited nature, and a being who is usually at the crossroads of indecisiveness. Man, as a social being is like some other men because a group of people have common attributes that make them different from other groups. (Udan, 2009)

15.Mrs. Lich, an elder woman, asks Nurse Raigor about changes in the body with regards to sexual function. “Why is there pain when we have sex with my husband? Is there something wrong with me or is it just normal?” she asked. The nurse’s best answer is:

b. “Painful intercourse in an elderly woman is usually caused by changes in vaginal secretion production. I recommend using lubricating jellies and if the pain is still present, address it to me or to your

doctor.” 

Women experience different changes related to intercourse. One of these changes is related to vaginal secretions. It takes longer for a woman to produce vaginal secretions during intercourse and also the production is decreased, which can be the cause of painful intercourse. Lubricating jellies can be recommended. These changes are only normal. Going to a gynecologist is unnecessary since the problem can be addressed by using artificial lubricants. The husband has nothing to do with the problem. (pp. 415-416, Fundamentals of Nursing by Kozier et.al. 8th edition)

16.Airborne precaution are used for microorganisms transmitted by small-particle that can remain suspended and widely disperesed by air currents. Nurse Ron enters the room of the client on airborne precautions due to tuberculosis. Which of the following are appropriate actions by Nurse Ron?i. He wears mask covering, covering the mouth and nose.ii. He washes his hands before and after removing gloves, after suctioning the client’s secretions.iii. He removes gloves and mask before leaving the client’s room.iv. He discards contaminated suction catheter tip in a trash can found in the client’s room

c. i, ii, iii and iv The mask should cover the nose and mouth snugly. The hands should be washed befcre and after removing the gloves . Gloves and mask should be removed before leaving the client’s room, to contain the microorganisms within the client’s unit. Contaminated articles like suction catheter should be discarded in a trash found in the client’s room to prevent contamination of the outside

environment. (De Laune,2006)

17.A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

d.Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor. Potter-Perry, 2004

Correct

18.A female patient with a terminal illness is in denial. Indicators of denial include:

d. Shock dismay  Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief. Anger-resists the loss, may strike out at everyone and everything.Potter-Perry, 2004

19.Communication is essential in establishing the helping-healing relationship between the nurse and the patient. Important aspects of health education are information, communication and education. Which of the following statements is most likely to promote a client’s compliance in performing post-operative deep breathing, coughing and turning exercises?

c. “Deep breathing, coughing and turning exercises will promote good breathing , body

circulation. This will prevent complications.” 

Giving information is a therapeutic technique of communication,like giving explanation on the benifits that a client will experience from deep breathing,coughing and turning exercises during post-operative period. Mentioning that the exercises will cause pain would not promote compliance. Enumerating the possible complications and benifits using medical terms would not promote compliance because the patient may not understand the meaning of the terms. The nurse should not give a vague explanation and give the patient false reassurance.(De Laune, 2006)

20.Inspection of the uvula is done by making the patient “Ah”. During the assessment, Nurse Lich notices that the uvula is positioned at the midline of the soft palate and did not rise when the patient says “Ah.” Which of the following actions should the nurse most appropriately do?

b.document the findings and report to the

physician

The uvula is normally found at the midline of the soft palate. The soft palate and uvula should rise symmetrically when the patient says “Ah”, which indicates an intact CN X. An immobile uvula or a uvula that does not rise may indicate damage to the CN X and impairment of gag reflex. Having the patient eat and drink might be dangerous. This finding must be documented and reported to the physician. (p. 604, Fundamentals of Nursing by Kozier et. al. 8th edition, 2008; p. 405, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

21.Laxatives stimulate peristalsis and promote defecation. It is administered as ordered because overuse of laxatives inhibits natural defecation reflexes,rebound constipation occurs. You are taking care of a patient who is to undergo Barium enema. In preparation for this, he was ordered to take Castor oil. You know that castor oil is what type of laxative?

b. a. Chemical stimulant Castor oil provides chemical stimulation to the intestinal mucosa, to increase peristalsis and promote defecation. It is classified as a chemical stimulant together with Bisacodyl (Dulcolax) and Senna (Senekot). It may be misleading to consider it as an oil for one might classify it as a lubricant. Lubricants lubricates the intestinal contents, example of it is mineral oil.Stool softeners attract water into the intestinal contents, example of it is Decosate (colace). Bulk- forming laxative attracts water into the lumen. Example of it are Lactulose, Psyllium (Metamucil) and Milk of magnesia (Karch, 2006)

22.Atelectasis is defined as the lack of gas exchange within alveoli, due to alveolar collapse or fluid consolidation. Banehollow, a 4-year old child, was rushed to the ER after swallowing several pieces of clay. After undergoing x-ray, the child is diagnosed with atelectasis of the right lung d/t to complete obstruction in the right bronchus. Stat surgery is to be done. Which of the following assessment findings would Nurse Bradwarden most likely find?

c. tracheal shift to the right, breath sounds absent in the right lung, present in the left, dull

percussion on the right lung 

In atelectasis, fewer aerating alveoli are present and therefore have a lower pressure. Therefore, the trachea is slightly pushed by the healthy lung to the affected side, which contains less air and lesser pressure. Breath sounds are absent in the right lung because alveoli are not ventilated because air does not reach them. Breath sounds are present in the left lung because the alveoli are still ventilated as the bronchus is

unobstructed. Dull percussion is elicited because the alveoli are collapsed and air is not present in the affected lung. (p. 473, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

23.. In caring for a client receiving oxygen via nasal cannula which step takes precedence?

b. Attach the flow meter to the wall

outlet or tank.

Attach the flow meter to the wall outlet or tank. Attach the humidifier bottle to the base of the flow meter. Attach the prescribed oxygen tubing and delivery device to the humidifier. Put the cannula over the client’s face, with the outlet prongs fitting into the nares and the elastic band around the head. (Berman, A. (2008). Fundamentals of Nursing, (8th ed., p.1377) New Jersey: Pearson.)

24.Mrs. Rylai asked the nurse regarding urinary incontinence. She mentioned that she had been experiencing incontinence for about a week now. She complains that she sometimes wets her underwear without her noticing it. “Is incontinence a part of getting old? What should I do about it?” she asked. All of the following are suitable responses to Mrs. Rylai except for one:

d. “Incontinence is a typical part of aging so you

need not be so anxious about it.”

It should be explained by the nurse that Urinary incontinence (UI) is not a normal change related to aging. The nurse must promptly investigate UI, particularly of new onset, because of its ill effects on the patient, like social isolation, falls and skin breakdown. Pelvic muscle exercises and avoiding bladder irritants such as chocolates, oranges, lemons, and tomatoes help prevent or control UI. (p.415, Fundamentals of Nursing by Kozier et.al. 8th edition)

25.Cyclophosphamide (Cytoxan) is an alkylating agent which binds to the DNA and disrupts replication of cells. Mrs. Mirana has been prescribed with cyclophosphamide (Cytoxan) PO for her cancer and has been taking the drug for about a week. Which of the following assessment findings should immediately prompt Nurse Pudge to report to the physician?

d. hematuria  Hematuria is a sign of hemorrhagic cyctitis, which is an adverse effect of the drug. Several metabolites of cyclophosphamide may cause hemorrhagic cystitis if urine becomes concentrated; therefore a high-fluid intake is maintained during the course of chemotherapy. Alopecia, N&V, as well as thrompocytopenia are expected. Alopecia is expected to subside and hair growth to return once chemotherapy is over. Severe N&V however, is an adverse reaction which requires referral to physician. Platelet counts as well as other blood cell counts are

expected to decrease, reaching a nadir at 6-10 days, but eventually rises back to normal. A persistent low platelet count beyond the expected nadir however is abnormal. (pp. 558-559, Pharmacology for Nurses by Adams, Holland and Bostwick 2nd edition, 2007; pp. 291-293, Nursing Spectrum Drug Handbook by Schull, 2010)

26.Tactile or vocal fremitus is the palpable vibration of the chest wall that is produced by spoken words. Which of the following assessment findings would be most likely found when Nurse Bradwarden assesses a health individual’s fremitus?

b. the fremitus created by the voices of male patients are more readily palpated

than female voices

The low-pitched voices of males generate more vibration and therefore are more readily palpated than the high-pitched voices of females. The fremitus are normally more pronounced in the apex, over the trachea and major bronchi than in the periphery and base of the lungs. There should be bilateral symmetry of the fremitus. A decreased or increased fremitus in either the left or right indicates a disease or abnormality. (p. 615, Fundamentals of Nursing by Kozier et. al. 8th edition, 2008; pp. 463-464, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

27.Tamoxifen (Nolvadex) is an antiestrogen drug which exerts its therapeutic effect by blocking estrogen receptors in breast cancer cells and activates estrogen receptors in other parts of the body. Nurse Pudge is caring for 4 patients with breast cancer who are all taking tamoxifen. Who among the four patients would Nurse Pudge report to the physician immediately?

c. Patient Drow, who complains of

swelling and tenderness in the leg

Tamoxifen is associated with an increased risk of endometrial cancer and thromboembolic disease. Calf pain or tenderness indicates DVT, which is a form of thromboembolic disease. “Tumor flare” or an idiosyncratic increase in tumor size, is an expected therapeutic event in the initial stage of tamoxifen use. Nausea and vomiting are expected of the drug. Tamoxifen can also be used as a prophylaxis for patients who are high-risk candidates for developing breast cancers (older than 35 and have at least 1.67% chance of developing breast cancer in the next 5 years. (pp. 569, Pharmacology for Nurses by Adams, Holland and Bostwick 2nd edition, 2007; pp. 1122-1123, Nursing Spectrum Drug Handbook by Schull, 2010)

28.The overall goal of bladder retraining is to restore a normal pattern of voiding. Nurse Snape tells the incontinent client the different measures to gain control over urination which are all but one of the following:

c. None of the above  All are part of the restorative and rehabilitative care. Other measures are: initiating a toileting schedule on awakening, at least every 2 hrs during the day and evening, before getting into bed, and every 4 hrs at night.Using methods to relax and aid complete bladder emptying (reading and deep breathing)Minimizing tea, coffee, other caffeine drinks, and alcoholTaking prescribed diuretic medication or fluids that increase diuresis early in the morningSampselle 2003s

29.Air rushing through the respiratory tract during inspiration and expiration generates different breath sounds. Considering that he is a healthy male adult, when Nurse Bradwarden auscultates the area above his own trachea, all but one of the following statements correctly describes the expected assessment finding?

Choose one answer.

a. vesicular breath sounds are

expected 

Bronchial or tubular breath sounds is expected over the trachea. Vesicular breath sounds are heard over the peripheral or bases of the lungs. All other options correctly describe bronchial or tubular breath sounds. It has a high pitch with a loud, “harsh” quality. It is heard longer during expiration than inspiration (1:2). (p. 613, Fundamentals of Nursing by Kozier et. al. 8th edition, 2008; pp. 469-470, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

30. “Off-label” drug use occurs when a drug is approved by the FDA; the therapeutic indications for which the drug approved are stated. Once a drug becomes available, it is sometimes used for indications that are not part of the approved indications. Which of the following best shows the risks of “off-label” use of drugs?

Choose one answer.

a. Glutathione IV injection for purposes of

skin whitening

Glutathione IV, according to MIMS Philippines, is prescribed for Adjunct treatment to minimize the occurrence of toxicity associated w/ cisplatin chemotherapy. The Department of Health issued DOH-FDA Advisory No. 2011-004 dwelling on safety issues of the off-label use of glutathione solution for injection, namely: (1) Stevens Johnsons Syndrome/TENS; (2) Derangements in the thyroid function; (3) Suspected kidney dysfunction potentially resulting in kidney failure; (4) Severe abdominal pain in a patient receiving twice-weekly; (5) sepsis; (6) air embolus; (7) transmission of Hepa B and HIV; (8) use of non-sterile preparation, leading to serious infections. Clinical trials have shown that Gabapentin, which is oft-marketed as an anti-seizure medication, works effectively in the treatment of phantom

limb pain. Tricyclic Antidepresant are approved and labeled to be used for clinical depression. Today these drugs are seldom used for depression because safer drugs are now available to treat it. But doctors have found that the tricyclics often work very well in treating certain types of pain. Misoprostol is actually labeled as being used for “Termination of pregnancy (?49 days of duration)”. Hence, this is not an “off-label use”.

31.Inspection of the tonsils requires taking note of the color, discharge and size. Nurse Lich documents “kissing tonsils” after inspecting Mr. Purist’s oral cavity. The best description for this would be:

b. Grade 4 or +4 – one or both tonsils extend to the midline of the oropharynx

Kissing tonsils means that the tonsils are already touching each other, meaning that they are already Grade 4 or +4. This indicates that both tonsils have already extended up to the midline of the oropharynx. Grade 1 is when the tonsils are behind the tonsillar pillars. Grade 2 is when the tonsils are between the pillars and uvula, Grade 3 is when the tonsils touches the uvula. Grades 3 – 4 already indicate tonsillitis while normal tonsillar size is Grade 1 and 2. (p. 604, Fundamentals of Nursing by Kozier et. al. 8th edition, 2008; p. 406, Health Assessment and Physical Examination by Estes 3rd edition, 2006)

32.Doxorubicin is an antitumor antibiotic which attaches to DNA, distorting its double helical structure and preventing normal DNA and RNA synthesis. It is used for a variety of solid tumors. Mr. Gondar, a patient with lung cancer, has been prescribed with doxorubicin (Adriamycin). During drug preparation and administration, which of the following should Nurse Pudge not follow?

d. back pain, chest tightness and flushing are expected but stay alert for erythematous streaking along vein next to injection site, which may indicate too-rapid

infusion

Back pains, chest tightness, flushing, as well as erythematous streaking along the vein next to the injection site are all acute infusion-related reactions due to rapid administrations. These are not expected effects of the drug. The drug is easily absorbed in the skin and by inhalation so protective equipment is worn during preparation. Administer the drug using a large vein slowly for 3-5 minutes into tubing of free-flowing IV infusion of either NSS or D5W. Extravasation from an injection site can cause severe pain and extensive tissue damage. The most serious adverse effect is cadiotoxicity. Acute effects include arrhythmias, and delayed effects include irreversible heart failure, that is why cardiac monitoring is essential. (pp. 563-565, Pharmacology for Nurses by Adams, Holland and Bostwick 2nd edition, 2007; pp. 378-381, Nursing Spectrum Drug Handbook by Schull, 2010)

33.Mr. Balanar, another patient in his late 50’s also asked questions regarding sexuality and aging. “My older friends here in the nursing home told me that by the time I reach 60 or 70 I would lose my libido and my ability to produce sperm cells, and it would take longer for me to become sexually aroused and achieve ejaculation.” “Are these all true?” he asked. All but one of the following responses made by Nurse Raigor are correct:

Choose one answer.

a. “Yes, interest in sex-related activities is

lost by the time you reach 60 or 70.” 

Interest in sex or libido is not lost with aging. The elder man’s libido may decrease, but it should not disappear. Sperm cell production still continues well into old age, but it gradually decreases with aging. Sexual arousal as well as ejaculation may take longer than when the patient was still younger. (pp. 415-416, Fundamentals of Nursing by Kozier et.al. 8th edition)

34. Mrs. Villavicencio had been paralyzed for six months. Due to immobility she has acquired Stage IV pressure ulcer at her scapula. After cleaning her wound, a hydrocolloid dressing will be applied. Which of the following is not an advantage of using hydrocolloid dressing?

b. They are occlusive, are opaque,

and obscure wound visibility.

Hydrocolloid dressings are waterproof adhesive wafers, pastes, or powders. The inner adhesive layer has particles that absorb exudates and form a hydrated gel over the wound; the outer film provides an occlusive seal. Its purpose is to absorb exudates; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; to protect the wound form bacterial contamination, foreign debris, and urine or feces; and to prevent shearing. (Berman, A. (2008). Fundamentals of Nursing New Jersey: Pearson.)

35.Nurse Snape is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?

d. Sensory deficits  Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.Potter and Perry, 2004

36.Physiologic aging can be considered as a phenomenon, because no two individuals age in the same way. That is why a number of theories have been created in order to explain such phenomenon. Nurse Raigor most accurately refers to the free-radical theory when he states that:

Choose one answer.

a. “Organic materials like proteins and carbohydrates which undergo oxidation in our body produce unstable groups of atoms, which in turn cause changes in the cells in our body, and

the cells cannot regenerate themselves.” 

“Our immune system becomes less effective with age, resulting in reduced resistance to infectious disease and viruses and an increase in autoimmune responses, causing the body to attack itself.” refers to immunological theory, “Our bodies become run down with time, like cars. Our cells become worn out through exposure to internal and external stressors.” refers to wear-and-tear theory, and “Our hypothalamus and pituitary glands which chiefly regulate hormone production are responsible for changes in hormone production that result in the decline of our body.” refers to endocrine theory. Other theories which explains physiologic aging includes genetic and cross-linking theories. (p.411, Fundamentals of Nursing by Kozier et.al. 8th edition)

37.An enema is the instillation of a solution into the rectum and sigmoid colon. The physician ordered a cleansing enema for Mr. Weasley, 45 yrs. Old scheduled for colonoscopy. Nurse Potter shows competence in administering the enema if he does all but one of the following:

Choose one answer.

a. Prepares a rectal tube French size

12 

Appropriate sizes:Adult 22-30 FrChild 12-18 FrAssessment determines the factors indicating need for enema and the type of enema use. Applying gloves reduces transmission of microorganism. Assisting the client into a left side-lying position allows enema solution to flow downward by gravity along natural curve of sigmoid colon and rectum, thus improving retention of solution.Potter-Perry 2004

38.A medication error should be documented at the:

b. medication administration record  To prevent other caregivers from giving the client additional doses of similar drugs or

doses of drugs that may be contraindicated it should be documented on the medication administration record or at the nurses’ notes. Lois White. Documentation & the Nursing Process pp. 102-103

39.To improve quality of care and prevent legal accountability, Nurse Czar plans to implement a standard protocol on documenting nursing care. Which of the following should not be included in the protocol?

c. Accurate, factual, time-sequenced, non-

descriptive notations 

Documenting nursing care should be accurate, factual, time-sequenced and DESCRIPTIVE. All other options are correc.. Lois White. Documentation & the Nursing Process p.80

40.Enteral Nutrition refers to nutrients given via the GI tract. It is the preferred method if the client’s GI tract is functioning. All of these are indications for enteral nutrition except:

c. Paralytic Ileus  Enteral nutrition is only used if there is a functional GI Tract. In the case of Paralytic Ileus, Parenteral Nutritin may be used.Potter-Perry 2004

41.Drug prescription should be written clearly and legibly. A prescription was given by the physician. The part where the drug name, strength and dose are written is called:

b.Superscription Inscription contains the drug name, strength and dose. Superscription includes the client’s name, address and age. Subscription contains directions about the number of tablets or amount to be dispersed that is given to the pharmacist. (De Laune, 2006)

42.Administering medications to pediatric patients should be given extra caution as they are more prone to toxicity and over or under dose. You are caring for an 11-month old infant who has a PRN order of Paracetamol if temperature exceeds 380C. Your paracetamol at hand has a stock dose of 500mg/15ml. You know that the

average adult dose of paracetamol is 1000 mg. Using the appropriate formula in calculating pediatric dosage, you would administer the correct pediatric dose of paracetamol to the infant which is?

Choose one answer.

a. 2.2 ml  Fried’s rule applies to a child younger than 1 year of age. The rule assumes that an adult dose would be appropriate for a child who is 150 months old. Child’s dose= infant’s age in months x average adult dosee. 150 months

b. = 11 months x 1000mga. 150 months

c. = 73.33 mg

Desired dose x diluentStock dose= 73.33 mg x 15 ml500 mg=2.2 ml

43.Vincristine is a vinca alkaloid antineplastic which kills cancer cells by preventing their ability to complete mitosis. It is a cell-cycle specific drug, which specifically targets the M-phase. Pugna, a patient with leukemia has been prescribed with vincristine (Oncovin). Nurse Pudge is correct when he follows which of the following guidelines with the use of vincristine:

d. regularly monitor neurologic and mental status, as well as feelings of despair, verbalized suicide plan or

suicidal attempt

The most serious adverse effect of vincristine is related to nervous system toxicity. Numbness and tingling of the limbs and muscular weakness should be assessed, as well as difficulty in walking and talking. Visual disturbances can also occur. Convulsions and feelings of despair or suicidal plan or attempt can also happen. Intrathecal administration is fatal. Bone marrow suppression is minimal with vincristine. Severe constipation is common, as well as reversible alopecia. (pp. 566-567, Pharmacology for Nurses by Adams, Holland and Bostwick 2nd edition, 2007; pp. 1232-1234, Nursing Spectrum Drug Handbook by Schull, 2010)

44.The ten rights of medication administration are: right medication, dose, client, route, time, documentation, assessment, right to refuse, education and evaluation. A nurse is carrying out the doctor’s order. Which of the following drugs should the nurse question if the doctor prescribed it to a client on Methotrexate therapy, who has been observed with bleeding gums, blood in stools, urine and vomitus?

b. a. Naproxen Methotrexate overdose can result to hematologic toxicity (platelet levels are decreased). In order to prevent this salicylates, NSAIDs, phenytoin, tetracycline and chlorampenicol should be avoided. Examples of NSAIDs are aspirin, indomethacin (Indocin), ibuprofen (Motrin), naproxen (Naprosyn), piroxicam (Feldene), and nabumetone (Relafen). The breakdown of methotrexate produces uric acid. Allopurinol is used to decrease uric acid in Methotrexate therapy. Leucovorin is given for Methotrexate overdose. Vincristine is an anti-cancer drug used alone or with other antineoplastics (e.g. Methotrexate) in treating cancer/leukemia.(Karch, 2006)

45.During an assessment, the nurse learns that the client has a history of liver disease. Which of the following diagnostic tests is least indicated for this client.

b. Myoglobin  ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. Alkaline Phosphatase is found in the liver, bone, intestine, and placenta. It is used as an index of liver and bone disease when correlated with other clinical findings. The liver contributes to the metabolism which results in the production of ammonia. If the liver is damaged, the ammonia level will increase. Myoglobin is a marker for muscle damage. (Berman, A. (2008). Fundamentals of Nursing (8th ed., p. 803 -804) New Jersey: Pearson)

46.When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?

d. Aging-related physiological changes  Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.

Correct

47.Jo, a postoperative client has not been able to void. The physician has ordered the client to have a urinary catheter inserted. After explaining the procedure to the client, the nurse can facilitate the insertion by asking the client to:

b.Breathe deeply When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn’t recommended during catheter insertion. Holding the penis or the labia won’t ease insertion, and doing so may contaminate the sterile field.

48.Nursing theory guides knowledge development and directs education, research and practice. Health is a fundamental right of every human being. The theorist who advocates that health is the ability to maintain dynamic equilibrium is:

c.Walter Cannon Walter Canon advocates that health is the ability to maintain dynamic equilibrium (homeostasis) It is regulated by the negative feedback mechanism. Bernard advocates that health is the ability to maintain internal milieu and that illness is the result of failure to maintain the internal environment. Hans Selye is the father of modern stress theory. Betty neuman believes that health is a condition in which all parts and subparts of an individual are in harmony with the whole system.(Udan, 2009)

49.To prevent documentation discrepancies, Nurse Czar plans to implement a standard protocol on documenting nursing care. In planning the protocol, she should know that documentation of the nursing care the client receives must:

Choose one answer.

a. never have an error  Error is not allowed in documentation as much as possible. It should not have spaces between entries. Entries should be signed every after documenting it not at the end of the shift. Finally documentation must reflect the nursing process. Lois White. Documentation & the Nursing Process p.80

50.Assessment of the eyes includes the performance of the corneal reflex test. Nurse Lich is about to perform corneal reflex test as part of the physical assessment of Mr. Purist. Which of the following statements should he least likely consider?

b. ask the patient to look towards the right if right-handed, and look towards

the left if left-handed 

The patient is asked to keep both eyes open and to look straight away so that he/she will not see the gauze while it approaches the outer canthus of the eye. This avoids making the patient unnecessarily blink before the gauze touches the cornea. All other options are correct. (p. 589, Fundamentals of Nursing by Kozier et. al. 8th edition, 2008)