1
Q
SITUATION: Nurse Stunna is assigned to care for several clients admitted to the medical-surgical unit with various gastrointestinal disorders. Throughout the shift, she performs assessments, provides health teaching, and responds to changes in her clients’ conditions. She must apply
sound clinical judgment and prioritize appropriate nursing actions in managing these patients.
- A client diagnosed with appendicitis is awaiting surgery in two hours. Suddenly, the client reports worsening abdominal pain and starts vomiting. On assessment, Nurse Stunna observes abdominal distention and decreased bowel sounds. What is Nurse Stunna’s most appropriate action?
A. Administer the prescribed pain medication.
B. Request the operating room team to advance the surgical schedule immediately.
C. Notify the surgeon.
D. Reposition the client and apply a warm heating pad over the abdomen
A
A. Administer the prescribed pain medication.
B. Request the operating room team to advance the surgical schedule immediately.
C. Notify the surgeon.
D. Reposition the client and apply a warm heating pad over the abdomen
RATIO: Peritonitis-> possible rupture of appendix
2
Q
- After a client suspected of having a duodenal ulcer undergoes esophagogastroduodenoscopy, which action should Nurse Stunna prioritize in the client’s plan of care?
A. Giving warm gargles for a sore throat
B. Monitoring complaints of heartburn
C. Assessing for the return of the gag reflex
D. Monitoring the temperature
A
A. Giving warm gargles for a sore throat
B. Monitoring complaints of heartburn
C. Assessing for the return of the gag reflex
D. Monitoring the temperature
RATIO: To prevent risk for Aspiration
3
Q
- While caring for a client with bowel obstruction who recently underwent creation of a transverse colostomy, which finding should prompt Nurse Stunna to notify the primary health
care provider immediately?
A. Semiformed stool noted in the ostomy pouch
B. Stoma is beefy red and shiny
C. Skin excoriation around the stoma
D. Purple discoloration of the stoma
A
A. Semiformed stool noted in the ostomy pouch
B. Stoma is beefy red and shiny
C. Skin excoriation around the stoma
D. Purple discoloration of the stoma
RATIO: Cyanosis -> lack of circulation
4
Q
SITUATION: The following scenarios are the patients with nutritional and gastrointestinal disturbances who are under your care.
- Your patient is due for an upper gastrointestinal tract study (barium swallow), which of the following will you not expect to see in the plan of care?
A. Pre-procedure: Withhold foods and fluids for 4 to 8 hours prior to the test.
B. Post-procedure: A laxative may be prescribed
C. Pre-procedure: Explain that the client will drink barium sulfate
D. Post-procedure: Monitor stools, should appear light yellow or light green for 24-72 hours,
indicating passage of barium.
A
A. Pre-procedure: Withhold foods and fluids for 4 to 8 hours prior to the test.
B. Post-procedure: A laxative may be prescribed
C. Pre-procedure: Explain that the client will drink barium sulfate
D. Post-procedure: Monitor stools, should appear light yellow or light green for 24-72 hours, indicating passage of barium.
RATIO: Barium: Stool should be Gray or Chalky White
5
Q
- Another client for esophagogastroduodenoscopy came to the unit before the procedure. Which of the following will you not include in your nursing care plan?
A. The client must be NPO for 6 to 8 hours before the test
B. Clients are usually advised to avoid anticoagulants, unless indicated otherwise
C. Expect that a local anesthetic (spray or gargle) is administered along with medication that provides general anesthesia
D. None of the above
A
A. The client must be NPO for 6 to 8 hours before the test
B. Clients are usually advised to avoid anticoagulants, unless indicated otherwise
C. Expect that a local anesthetic (spray or gargle) is administered along with medication that provides general anesthesia
D. None of the above
6
Q
- During colonoscopy, you monitor signs of bowel perforation and peritonitis. Which of the following is not a manifestation of this complication?
A. Guarding of the abdomen
B. Diminished bowel sounds
C. Decreased BP and decreased HR
D. Rebound tenderness
A
A. Guarding of the abdomen
B. Diminished bowel sounds
C. Decreased BP and decreased HR
D. Rebound tenderness
7
Q
- During the colonoscopy procedure, you noticed outpouching or herniation of the intestinal mucosa. While differentiating diverticulosis and diverticulitis, which of the following shows confusion between the two conditions?
A. Diverticulosis is an outpouching of the intestinal mucosa while diverticulitis is the herniation of the intestinal wall.
B. Diverticulitis is the inflammation of one or more diverticula that occurs from penetration of fecal matter through the thin-walled diverticula while diverticulosis is most common in the sigmoid colon, but can occur in any part of the intestine.
C. Diverticulitis can lead to perforation which can progress to intra-abdominal perforation with generalized peritonitis.
D. None of the above
A
A. Diverticulosis is an outpouching of the intestinal mucosa while diverticulitis is the herniation of the intestinal wall.
B. Diverticulitis is the inflammation of one or more diverticula that occurs from penetration of fecal matter through the thin-walled diverticula while diverticulosis is most common in the sigmoid colon, but can occur in any part of the intestine.
C. Diverticulitis can lead to perforation which can progress to intra-abdominal perforation with generalized peritonitis.
D. None of the above
8
Q
- When diverticulitis is active, which of the following will you instruct the patient to do?
A. Provide bed rest
B. Provide a high fiber diet
C. Instruct the client to refrain from lifting
D. Instruct the client to increase fluid intake to 2500 to 3000 mL daily
A
A. Provide bed rest
B. Provide a high fiber diet
C. Instruct the client to refrain from lifting
D. Instruct the client to increase fluid intake to 2500 to 3000 mL daily
9
Q
- Which of the following refers to dilated and tortuous veins in the submucosa of the esophagus?
A. Portal hypertension
B. Portacaval shunting
C. Esophageal varices
D. Barrett’s esophagus
A
A. Portal hypertension
B. Portacaval shunting
C. Esophageal varices
D. Barrett’s esophagus
10
Q
- You are assigned to care for a client prescribed with a Sengstaken-Blakemore tube, which is unlikely to be done by the nurse?
A. Label each lumen.
B. Place the client in the left-side lying position for insertion.
C. Double-clamp the balloon ports
D. Keep scissors at the bedside at all times
A
A. Label each lumen.
B. Place the client in the left-side lying position for insertion.
C. Double-clamp the balloon ports
D. Keep scissors at the bedside at all times
RATIO: Upright or fowlers position=insertion of SBT
11
Q
- Which of the following will you NOT typically expect to assess in a patient with a working diagnosis of cholecystitis?
A. Tachycardia
B. Hypogastric pain that radiates to the right shoulder or scapula
C. Pain localized in the right upper quadrant and triggered by a high-fat or high-volume meal
D. Guarding, rigidity, and rebound tenderness
A
A. Tachycardia
B. Hypogastric pain that radiates to the right shoulder or scapula
C. Pain localized in the right upper quadrant and triggered by a high-fat or high-volume meal
D. Guarding, rigidity, and rebound tenderness
RATIO: Wrong yung Hypogastric Pain -> Hypergastric dapat
12
Q
- After the patient underwent laparoscopy cholecystectomy, which of the following will you least likely include in the nursing care plan?
A. Encourage coughing and deep breathing and incentive spirometer use every 2 hours
B. Encourage bed rest for the day
C. Instruct the client about splinting the abdomen
D. Maintain NPO status and NG tube suction as prescribed.
A
A. Encourage coughing and deep breathing and incentive spirometer use every 2 hours
B. Encourage bed rest for the day
C. Instruct the client about splinting the abdomen
D. Maintain NPO status and NG tube suction as prescribed.
RATIO: After Cholecystectomy encourage ambulation
13
Q
- A T-tube is placed after surgical exploration of the common bile duct.
Which of the following is UNTRUE about the placement of T-tube?
A. Place the client in semi-Fowler’s position to facilitate drainage
B. Report sudden increases in bile output to the primary health care provider
C. Keep the drainage system below the level of the umbilicus
D. None of the above
A
A. Place the client in semi-Fowler’s position to facilitate drainage
B. Report sudden increases in bile output to the primary health care provider
C. Keep the drainage system below the level of the umbilicus
D. None of the above
RATIO: Should be below the level of gallbladder
14
Q
- A client is admitted with hypoparathyroidism. Which physiological finding should Nurse pHercule expect to assess based on the function of the parathyroid hormone (PTH)?
A. Hypercalcemia and decreased bone density
B. Hypocalcemia and increased neuromuscular irritability
C. Hyperkalemia and cardiac dysrhythmias
D. Hypoglycemia and increased sensitivity to insulin
A
A. Hypercalcemia and decreased bone density
B. Hypocalcemia and increased neuromuscular irritability
C. Hyperkalemia and cardiac dysrhythmias
D. Hypoglycemia and increased sensitivity to insulin
15
Q
- Nurse Hercule is caring for a client with Liver Cirrhosis who has developed advanced Hepatic
Encephalopathy. The client is increasingly lethargic and exhibits asterixis. The physician orders
Lactulose 30 mL orally four times a day. Which finding would indicate that the treatment is most
effective?
A. The client has 2 to 3 soft stools per day and improved mental status.
B. The client’s serum ammonia levels remain unchanged, but the abdominal girth has decreased.
C. The client’s skin appears less jaundiced and the urine color has lightened.
D. The client reports a decrease in right upper quadrant pain and improved appetite.
A
A. The client has 2 to 3 soft stools per day and improved mental status.
B. The client’s serum ammonia levels remain unchanged, but the abdominal girth has decreased.
C. The client’s skin appears less jaundiced and the urine color has lightened.
D. The client reports a decrease in right upper quadrant pain and improved appetite.
RATIO: Asterixis: liver flap
16
Q
- You are explaining why patients with liver cirrhosis usually develop jaundice, you are correct
when you say which of the following?
A. Occurs because the liver is unable to metabolize bilirubin and because scarring of the
hepatic bile ducts interfere with normal bile and bilirubin secretion
B. Occurs because the liver cannot metabolize the byproducts of an incorrect dietary intake
C. Jaundice is always from heavy drinking or an increase in intake of junk food.
D. All of the above
A
A. Occurs because the liver is unable to metabolize bilirubin and because scarring of the
hepatic bile ducts interfere with normal bile and bilirubin secretion
B. Occurs because the liver cannot metabolize the byproducts of an incorrect dietary intake
C. Jaundice is always from heavy drinking or an increase in intake of junk food.
D. All of the above
17
Q
- How can you elicit asterixis in a patient with cirrhosis?
A. Have the client extend the arm, extend the wrist and fingers
B. Have the client flex the arm, extend the wrist and make a fist
C. Have the client extend the leg, dorsiflex the foot, and extend the toes
D. Have the client extend the arm, dorsiflex the wrist, and extend the fingers
A
A. Have the client extend the arm, extend the wrist and fingers
B. Have the client flex the arm, extend the wrist and make a fist
C. Have the client extend the leg, dorsiflex the foot, and extend the toes
D. Have the client extend the arm, dorsiflex the wrist, and extend the fingers
18
Q
- As part of the care plan for a patient with Diabetes Mellitus, you conduct health teaching
about dietary modifications and exercise. Which of the following will prompt further teaching if
said by the patient?
A. The client should try to exercise at the same time each day and should exercise when glucose
from the meal is peaking
B. Jogging as a form of exercise can still be done even after insulin is injected in the thighs
C. Instruct the client with diabetes mellitus to monitor the blood glucose level before, during,
and after exercising.
D. If the client requires extra food during exercise to prevent hypoglycemia, it need not be
deducted from the regular meal plan.
A
A. The client should try to exercise at the same time each day and should exercise when glucose
from the meal is peaking
B. Jogging as a form of exercise can still be done even after insulin is injected in the thighs
C. Instruct the client with diabetes mellitus to monitor the blood glucose level before, during,
and after exercising.
D. If the client requires extra food during exercise to prevent hypoglycemia, it need not be
deducted from the regular meal plan.
RATIO: Will cause Hypoglycemia
19
Q
- Which of the following refers to the phenomenon characterized by hyperglycemia upon
morning awakening that results from excessive early morning release of GH and cortisol?
A. This is a normal response
B. GH-DM phenomenon
C. Somogyi phenomenon
D. Dawn phenomenon
A
A. This is a normal response
B. GH-DM phenomenon
C. Somogyi phenomenon
D. Dawn phenomenon
20
Q
- Referring to the phenomenon from the previous item, which of the following will you expect
to be done?
A. Nothing, continue the prescribed insulin schedule and dose
B. Decrease in the client’s insulin dose
C. Change in the time of insulin administration
D. Increase in the bedtime snack
A
A. Nothing, continue the prescribed insulin schedule and dose
B. Decrease in the client’s insulin dose
C. Change in the time of insulin administration
D. Increase in the bedtime snack
21
Q
- A hospitalized client with diabetes mellitus complains of sweating and hunger, and the nurse
notes that the client is pale and shaking. The nurse recognizes these cues as a hypoglycemic
reaction, which of the following is the initial action to be done by the nurse?
A. Alarm the healthcare team
B. Checks the client’s blood glucose level
C. Administer 15 g of a simple carbohydrate such as ½ cup of fruit juice
D. Glucagon is administered subcutaneously, intramuscularly, or intravenously
A
A. Alarm the healthcare team
B. Checks the client’s blood glucose level
C. Administer 15 g of a simple carbohydrate such as ½ cup of fruit juice
D. Glucagon is administered subcutaneously, intramuscularly, or intravenously
RATIO: To confirmed if they having hypoglycemic
22
Q
- Which of the following refers to the metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of ACTH secreted
by the pituitary gland?
A. Cushing’s disease
B. Addison’s disease
C. Conn’s syndrome
D. Pheochromocytoma
A
A. Cushing’s disease
B. Addison’s disease
C. Conn’s syndrome
D. Pheochromocytoma
RATIO: increase SSS
Sugar: Glucoccorticoid
Salt: Mineralocorticoid
Sex Hormone: Androgen
23
Q
- You are processing the admission of a patient from the previous item, which is not a key characteristic of this disease?
A. Moon face
B. Truncal obesity with thin extremities
C. Hypotension
D. Hyperglycemia
A
A. Moon face
B. Truncal obesity with thin extremities
C. Hypotension
D. Hyperglycemia
24
Q
- A patient who underwent transsphenoidal hypophysectomy, which of the following will you
need to refer to the physician?
A. Postnasal drip or clear nasal drainage
B. Nasal stuffiness/congestion
C. Headache
D. All of the above
A
A. Postnasal drip or clear nasal drainage
B. Nasal stuffiness/congestion
C. Headache
D. All of the above
25
25. How come a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is in seizure precaution?
A. Because all patients with endocrine problems are on seizure precautions
B. Because of the possible cerebral malignancies related to SIADH
C. Because it may cause cerebral edema
D. Because of the possible trauma to the head
A. Because all patients with endocrine problems are on seizure precautions
B. Because of the possible cerebral malignancies related to SIADH
**C. Because it may cause cerebral edema**
D. Because of the possible trauma to the head
RATIO: Fluid retention->cerebral edema->risk for seizures
26
27. A patient with glaucoma is scheduled to have trabeculectomy surgery next week. While waiting for the surgery, which of the following will prompt you further teaching if done by the patient?
A. "I will report eye pain, halos around the eyes, and changes in vision"
B. "I will stop my glaucoma medications 3 days before the procedure"
C. "I will avoid anticholinergic medications as much as possible"
D. None of the above
A. "I will report eye pain, halos around the eyes, and changes in vision"
**B. "I will stop my glaucoma medications 3 days before the procedure"**
C. "I will avoid anticholinergic medications as much as possible"
D. None of the above
RATIO: Continue the medication up to the day of surgery
27
26. A patient with cataracts underwent phacoemulsification with intraocular lens implantation,
which of the following nursing interventions will you not include?
A. Elevate the head of the bed 30 to 45 degrees
B. Use an eye shield during day time and remove when sleeping only
C. Avoid bending or lifting objects heavier than 5 lbs
D. None of the above
A. Elevate the head of the bed 30 to 45 degrees
**B. Use an eye shield during day time and remove when sleeping only**
C. Avoid bending or lifting objects heavier than 5 lbs
D. None of the above
RATIO: Should be bedtime
28
28. Which of the following is characterized by demyelination of the neurons?
A. Multiple sclerosis
B. Myasthenia Gravis
C. Parkinson's Disease
D. Guillain-Barré Syndrome
**A. Multiple sclerosis**
B. Myasthenia Gravis
C. Parkinson's Disease
D. Guillain-Barré Syndrome
RATIO: MS: Charcot's Triad
-Scanning speech
-Intentional tremors
-Nystagmus
29
SITUATION: Nurse Maye, a newly registered nurse, is assigned to a medical ward caring for patients with neurologic disorders. She is assisting in the care of a patient admitted due to a cerebrovascular accident.
29. A 68-year-old client with a history of atrial fibrillation suddenly develops right-sided weakness and slurred speech. Brain imaging reveals an occlusion in a cerebral artery with no evidence of hemorrhage. Based on these findings, which statement best explains the underlying mechanism of the client's condition?
A. Sudden interruption of blood flow to the brain due to a blood clot
B. Bleeding in the brain caused by rupture of a blood vessel
C. Temporary decrease in blood flow to the brain that fully resolves
D. Long-term damage to brain cells due to aging
**A. Sudden interruption of blood flow to the brain due to a blood clot**
B. Bleeding in the brain caused by rupture of a blood vessel
C. Temporary decrease in blood flow to the brain that fully resolves
D. Long-term damage to brain cells due to aging
30
30. Nurse Maye is assigned in the medical ward to care for several clients admitted with
cerebrovascular risk factors. To reduce the likelihood of stroke during hospitalization and after
discharge, which condition should the nurse prioritize managing because it is the most common
modifiable cause of stroke?
A. Family history of stroke
B. Increasing age
C. Uncontrolled hypertension
D. Male sex
A. Family history of stroke
B. Increasing age
**C. Uncontrolled hypertension**
D. Male sex
31
31. A patient admitted with acute ischemic stroke is scheduled to receive thrombolytic therapy
within the therapeutic window. The patient asks what is its primary purpose? Nurse Julian is
correct when he replies that the primary purpose of thrombolytic therapy is:
A. To dissolve the blood clot
B. To prevent future clot formation
C. To reduce brain swelling
D. To lower blood pressure
**A. To dissolve the blood clot**
B. To prevent future clot formation
C. To reduce brain swelling
D. To lower blood pressure
32
32. Another patient with hemorrhagic stroke has a history of hypertension and diabetes
mellitus. Among which nursing intervention is MOST important to prevent complications in the
future?
A. Allow the patient to stop medication once blood pressure is normal
B. Instruct the patient to take medication only when symptoms occur
C. Ensure the patient adheres to the prescribed regimen
D. Rely solely on lifestyle modifications to control blood pressure
A. Allow the patient to stop medication once blood pressure is normal
B. Instruct the patient to take medication only when symptoms occur
**C. Ensure the patient adheres to the prescribed regimen**
D. Rely solely on lifestyle modifications to control blood pressure
33
SITUATION: Nurse Jirah, a newly-licensed RN is caring for patients diagnosed with multiple sclerosis in a SPH's neurology ward.
33. A patient with multiple sclerosis reports sudden worsening weakness, blurred vision, and fatigue. Which treatment is MOST appropriate for managing this acute exacerbation?
A. High-dose corticosteroids
B. Plasmapheresis
C.Interferon beta therapy
D. DMARDS
**A. High-dose corticosteroids**
B. Plasmapheresis
C.Interferon beta therapy
D. DMARDS
RATIO: To decrease inflammation in the Myelin Sheath
34
34. Another patient recently diagnosed with MS reports difficulty walking and maintaining balance. Which nursing intervention is MOST appropriate?
A, Provide assistance with ambulation and encourage safety measures
B. Restrict movement to prevent falls
C. Encourage long periods of walking without rest
D. Suggest the patient avoid physical therapy
**A, Provide assistance with ambulation and encourage safety measures**
B. Restrict movement to prevent falls
C. Encourage long periods of walking without rest
D. Suggest the patient avoid physical therapy
35
35. A client reports increasing muscle weakness that worsens with activity and improves with
rest. On assessment, the nurse notes descending paralysis affecting the eyelids and facial
muscles. This condition is primarily caused by which underlying mechanism?
A. Autoimmune destruction of acetylcholine receptors at the neuromuscular junction
B. Degeneration of motor neurons in the spinal cord
C. Demyelination of peripheral nerves
D. Direct damage to skeletal muscle fibers
**A. Autoimmune destruction of acetylcholine receptors at the neuromuscular junction**
B. Degeneration of motor neurons in the spinal cord
C. Demyelination of peripheral nerves
D. Direct damage to skeletal muscle fibers
36
36. Patients with myasthenia gravis are at risk for aspiration and severe fatigue. To prevent
these complications, which nursing intervention should be prioritized?
A. Scheduling meals during periods of maximum muscle strength
B. Encouraging rapid food intake to reduce fatigue
C. Restricting oral intake during daytime hours
D. Providing continuous physical activity without rest
**A. Scheduling meals during periods of maximum muscle strength**
B. Encouraging rapid food intake to reduce fatigue
C. Restricting oral intake during daytime hours
D. Providing continuous physical activity without rest
37
37. An elderly patient diagnosed with osteoporosis is at high risk for fractures. Which nursing intervention is MOST effective in preventing further bone loss?
A. Encourage a diet high in calcium only
B. Encourage a diet high in calcium with adequate vitamin D intake
C. Promote to exposure to present reduce bone stress
D. Limit sun exposure to prevent fatigue
A. Encourage a diet high in calcium only
**B. Encourage a diet high in calcium with adequate vitamin D intake**
C. Promote to exposure to present reduce bone stress
D. Limit sun exposure to prevent fatigue
RATIO: It strengthen the bone structure
38
38. Interventions for managing osteoporosis focus on reducing fracture risk and promoting bone
health. Which action is considered the most foundational in managing this condition?
A. Taking calcium supplements only when bone pain occurs
B. Using pain medication routinely without activity modifications
C. Engaging in regular weight-bearing and resistance exercises
D. Restricting all physical activity to avoid falls
A. Taking calcium supplements only when bone pain occurs
B. Using pain medication routinely without activity modifications
**C. Engaging in regular weight-bearing and resistance exercises**
D. Restricting all physical activity to avoid falls
39
39. During rounds, the patient reports painful blurring of vision and seeing halos around lights. Medications have been prescribed to control eye pressure. Long-term management of this condition is essential to prevent irreversible vision loss. Which instruction should the Nurse
Sarah emphasize?
A. Eye medications may be stopped once vision improves
B. Eye drops are taken only during periods of eye pain
C. Lifelong adherence to prescribed eye medications is required
D. Eye medications may be alternated with over-the-counter drops
A. Eye medications may be stopped once vision improves
B. Eye drops are taken only during periods of eye pain
**C. Lifelong adherence to prescribed eye medications is required**
D. Eye medications may be alternated with over-the-counter drops
RATIO: “CHOP”
-Close
-Halos around light
-Open
-Peripheral vision loss
40
40. Another nurse is providing postoperative care to a cataract patient who recently underwent eye surgery for blurred vision. The patient suddenly reports seeing new floaters and flashes of light. What should the nurse do FIRST?
A. Reassure the patient that floaters are expected after surgery
B. Instruct the patient to rest and avoid eye strain
C. Notify the surgeon immediately
D. Administer prescribed analgesics and reassess later
A. Reassure the patient that floaters are expected after surgery
B. Instruct the patient to rest and avoid eye strain
**C. Notify the surgeon immediately**
D. Administer prescribed analgesics and reassess later
RATIO: Indicates Retinal D
41
41. In caring for a patient with hearing impairment, effective communication is essential to
ensure safety and understanding. Which nursing intervention should be given the highest
priority?
A. Speak loudly and rapidly to ensure the patient hears the message
B. Provide written instructions and position oneself facing the patient when speaking
C. Minimize verbal interaction to reduce patient frustration
D. Encourage the patient to rely solely on family members for communication
A. Speak loudly and rapidly to ensure the patient hears the message
**B. Provide written instructions and position oneself facing the patient when speaking**
C. Minimize verbal interaction to reduce patient frustration
D. Encourage the patient to rely solely on family members for communication
41
42.A patient newly prescribed chlorpropamide asks how to safely monitor the effects of the medication at home. Proper self-management is necessary to prevent complications. Which instruction should Nurse Alex emphasize to ensure safe use of this medication?
A. Monitor blood glucose levels regularly
B. Check serum potassium levels routinely
C. Increase food intake whenever dizziness is experienced
D. Discontinue the medication once blood sugar normalizes
**A. Monitor blood glucose levels regularly**
B. Check serum potassium levels routinely
C. Increase food intake whenever dizziness is experienced
D. Discontinue the medication once blood sugar normalizes
42
43. A patient is being taught a breathing technique to improve lung expansion and reduce shortness of breath. The nurse demonstrates the steps and asks the patient to return-
demonstrate the procedure. Which action indicates correct understanding of diaphragmatic
breathing?
A. Expanding the chest while keeping the abdomen still during inspiration
B. Placing one hand on the belly and one on the chest, allowing the belly to rise during inhalation
C. Inhaling deeply and holding the breath for 5 seconds before exhaling
D. Breathing rapidly through the mouth while tightening the abdominal muscles
A. Expanding the chest while keeping the abdomen still during inspiration
**B. Placing one hand on the belly and one on the chest, allowing the belly to rise during inhalation**
C. Inhaling deeply and holding the breath for 5 seconds before exhaling
D. Breathing rapidly through the mouth while tightening the abdominal muscles
43
44. Nurse Rose was assigned to a patient with laryngeal cancer scheduled for laryngectomy. In
providing holistic care, which professional team member will be excluded in the patient's
management post-laryngectomy?
A. Physical Therapist
B. Psychologist
C. Speech therapist
D. Dentist
A. Physical Therapist
B. Psychologist
C. Speech therapist
D. Dentist
44
45. Another nurse in the ward is managing a diabetic patient with persistent high blood sugar
despite proper insulin therapy. Which professional should the nurse involve to optimize
medication and overall diabetes management?
A. Endocrinologist
B. Cardiologist
C. Nutritionist
D. Physical Therapist
**A. Endocrinologist**
B. Cardiologist
C. Nutritionist
D. Physical Therapist
45
46. A patient was prescribed several stat medications to prevent potential complications. Nurse
Rose closely coordinates with which professional to facilitate the immediate release of the
necessary medicine and supplies?
A. Attending Physician
B. Nurse Supervisor
C. Pharmacist
D. Head Nurse
A. Attending Physician
B. Nurse Supervisor
**C. Pharmacist**
D. Head Nurse
46
47. Accurate and professional documentation is essential for patient safety, legal compliance,
and effective teamwork. Which is the appropriate way to correct an error in the nurse's notes?
A. Take the whole page out and replace it with a fresh one.
B. Draw a single line through the error, write the correct information if needed, and initial it
C. Use the sticky side of plastic tape to erase the error
D. Use a rubber eraser to erase the error
A. Take the whole page out and replace it with a fresh one.
**B. Draw a single line through the error, write the correct information if needed, and initial it**
C. Use the sticky side of plastic tape to erase the error
D. Use a rubber eraser to erase the error
47
48. Right after endorsement and during rounds, the incoming nurse notices that the IV fluid is at
800 mL instead of 400 mL, as indicated in the endorsement. Knowing that accurate
documentation is essential for patient safety, continuity of care, and legal accountability, what is
the correct information that the nurse should chart?
A. Record any amount, since no one reads the chart anyway.
B. Record the endorsed 400 mL
C. Chart that the IV fluid is at 800 mL
D. Refer to the head nurse before charting.
A. Record any amount, since no one reads the chart anyway.
B. Record the endorsed 400 mL
**C. Chart that the IV fluid is at 800 mL**
D. Refer to the head nurse before charting.
48
SITUATION: Nurses must reflect on decisions that affect their personal and professional growth. The nurse must decide how to act ethically and responsibly in a professional setting.
49. Len, a registered nurse, has signed a contract for two years in a medical center. A recruitment agency has offered her a "fat" salary for foreign employment. What is the appropriate course of action in this situation?
A. Discuss your plans with your parents.
B. Accept the recruitment offer and go on absence without official leave.
C. Write a letter of resignation to your employer 30 days before leaving.
D. Accept recruitment's offer and give an excuse to employer on behalf of her "sick" mother.
A. Discuss your plans with your parents.
B. Accept the recruitment offer and go on absence without official leave.
**C. Write a letter of resignation to your employer 30 days before leaving.**
D. Accept recruitment's offer and give an excuse to employer on behalf of her "sick" mother.
49
50. A nurse is learning about different leadership styles in the healthcare setting and how they influence team collaboration and professional growth. Some leaders are considered transactional leaders. Which of the following traits is NOT characteristic of a transactional
leader?
A. Focuses on management tasks
B. Inspires others with vision
C. Acts as a caretaker
D. Uses bargaining to meet goals
A. Focuses on management tasks
**B. Inspires others with vision**
C. Acts as a caretaker
D. Uses bargaining to meet goals
Closed Door
flashcards
Decks in class (6)
# Cards
