MEDICAL SURGICAL NURSING/ 19.

When the nurse conducts physical assessment of the abdomen,

auscultation should precede palpation to:
FUNDAMENTALS OF NURSING
ANSWER: Prevent altering the frequency and character of bowel
sounds
1. Purpose of small volume enema
ANSWER: Used to clean the sigmoid and rectum
20. Dimming lights of the room as request by the client, level of
Maslows hierarchy of needs met
2. How enema function
ANSWER: Safety and Security
ANSWER: Causes distention of the bowel and stimulates the
defecation reflex
21. Inadequate nutrition
ANSWER: Emaciated and weak appearance
3. During enema administration, direct rectal tip of enema solution
container to
22. Desired effect of the bronchodilator in patient with severe upper
ANSWER: Causes distention of the bowel and stimulates the
respiratory tract infection
defecation reflex
ANSWER: effortless respiration
4. Once the client is in position the nurse visualizes the anus and is
23. In abdominal assessment, auscultation should precede palpation
ready to insert the rectal tip. She is doing the procedure correctly
to:
when she directs the rectal tip to the:
ANSWER: Prevent altering the frequency and character of bowel
ANSWER: umbilicus
sounds
5. Principle behind obtaining informed consent before invasive
24. During palpation
procedure
ANSWER: use fingertips
ANSWER: Autonomy
25. After giving analgesic, what is the priority
6. Autonomy
ANSWER: reassess pain level after 30 minutes to 1 hour of giving
ANSWER: respect for an individuals right to self-determination
the drug
and freedom to choose and implement ones own decision
be sure that all patients have consented to all treatments 26. McCafferys guideline in pain management
and procedure
ANSWER: "whatever the experiencing person says it is, existing
explain procedures to patients properly whenever and wherever the person say it does" has become the
prevailing conceptualization of pain for clinicians over the past few
7. A staff nurse reports to the supervisor that a newly hired nurse is decades
falsifying data in the vital signs sheet for the clients assigned to
her. What action should the supervisor do FIRST? 27. To maintain efficacy of nitroglycerine, store drug where
ANSWER: Take the clients vital signs and compare with the data ANSWER: Keep sublingual tablets in amber glass bottle
recorded by the new nurse
ANSWER: C 28. Appropriate instruction to patient with Patient-Controlled
Analgesia
8. Priority management in patient with restraint ANSWER: Push the button when you feel the pain is starting.
ANSWER: Release every 2 to 4 hours, Assess every 30 minutes
or as needed 29. Possible sign of ruptured appendix
ANSWER: Pain subsides
9. The parents understand safety precautions on children when they
state that they: 30. An effective intervention to prevent perforation of the inflamed
ANSWER: Will keep plastic bags and wraps are away from reach appendix
of children ANSWER: Keep patient on N PO
ANSWER: C
31. Short discrete bubbling sounds over the lower region of lungs
10. Accidental poisoning is an important concern because poisons ANSWER: crackles
cause serious injuries to children and the elderly. As you conduct
your safety awareness class for parents, you find that you need to 32. Continuous, high-pitched, squeaky musical sounds adventitious
give more detailed instructions when a parent says I will: breath sound
ANSWER: induce vomiting if my child swallows kerosene. ANSWER: wheezing
11. Which of the following are required measures observed by health 33. Acromegaly, manifestation
care workers when in contact with blood and body fluids? ANSWER: Enlarged extremities due to skeletal thickness and
ANSWER: Hand hygiene and gloves macroglossia (large tongue)
12. When communicating with Theresa, the nurse assumes the face 34. Transphenoidal hypophysectomy, incision site
to face position to: ANSWER: under the upper lip
ANSWER: Express availability and desire to communicate
35. What to wear BEFORE scrubbing of hands in OR
13. Communication zone for communication between nurse and ANSWER: head cap, mask, goggles
patient
ANSWER: Personal distance 36. Skin preparation in OR, what and how to wear
ANSWER: sterile gloves open glove technique
14. While communicating with Theresa you use attentive listening.
This requires that the nurse: 37. Most painful site of the wrist during venipuncture
ANSWER: Pays attention to both the content and feeling tone of ANSWER: inner aspect of the WRIST
the client
38. Cause of hypospadias
15. The client complains of pain in the left chest down to the left ANSWER: congenital (occurs during 3rd month of fetal
shoulder and left jaw. In your documentation for your nurses development)
notes, you will record this as:
ANSWER: Radiating pain 39. Surgical operation needed to be postponed for a child with
hypospadias
16. The changes in Mrs. De Veras vital signs that you would expect ANSWER: Circumcision
when she complains of pain are the following EXCEPT:
ANSWER: Decrease in temperature 40. Radioactive iodine uptake determines what
ANSWER: Absorption of the iodine isotope
17. A client with congestive heart failure is taking hydrochlorothiazide
once a day. While the client is taking the medication, the nurse 41. Diet for hypothyroidism
should encourage the client to eat which of the following fruits: ANSWER: low calorie, high fiber
ANSWER: banana
42. Post-thyroidectomy, assessment for possible laryngeal nerve
damage
18. The nurse is administering a bronchodilator to a client with severe ANSWER: Talk with the client and note change in voice
upper respiratory tract infection. The client is manifesting the
desired effect of the bronchodilator when the nurse assesses 43. Serum calcium level of 5.0 mg/dl, what to do
which of the following: ANSWER: Assess for signs of tetany
ANSWER: Effortless respiration

1
44. Confirmatory diagnosis for hiatal hernia
ANSWER: barium swallow 74. Patient Marina verbalized to the nurse that she is like her mother
ANSWER: transference
45. To prevent increase in gastric acid secretion
ANSWER: avoid cigarette smoking 75. Neurotransmitters that are decrease in depression
ANSWER: serotonin and norepinephrine
46. Confirmatory test for cholelithiasis
ANSWER: UTZ 76. Therapeutic effect of Sertraline (Zoloft)
ANSWER: increases Serotonin
47. Morphine is contraindicated for cholelithaisis because:
ANSWER: Causes spasm of the Sphincter of Oddi 77. Crisis
ANSWER: Can no longer cope with usual problem-solving skills
48. Bilateral tubal ligation, ask for informed consent to whom
ANSWER: BOTH husband and wife 78. Crisis, characteristic
ANSWER: Opportunity of learning better ways of coping,
49. Role of nurse in informed consent Presence of a threatening event, Failure of usual problem-solving
ANSWER: witness mechanisms

50. Characteristic (typology) of RBC in iron deficiency anemia 79. Polyneuropathy, deficiency in vitamin
ANSWER: Microcytic and hypochromic ANSWER: B

51. Vitamin B12 deficiency, S/Sx 80. Prompt treatment of alcoholism, assess for
ANSWER: Slight jaundice, fatigue, paresthesia, glossitis ANSWER: At most eight hours from the time the patient last drank
alcohol
52. Surgeon came into the OR suite swinging her hands
ANSWER: Oblige the assistant surgeon to scrub again 81. I dont need help. Leave me alone. I am just fine.
ANSWER: denial
53. How to apply dressing after stitching of incisional site
ANSWER: Put the dressings, remove his gloves to apply the tape 82. A immediate goal of crisis intervention
ANSWER: Resolve the problem
54. Processes of absorption of nutrients by SMALL intestine
ANSWER: diffusion and active transport 83. Duration of crisis
ANSWER: 4 to 6 weeks
55. Psoriasis
ANSWER: A chronic inflammatory skin disorder, not contagious 84. Research: double blind approach
ANSWER: Neither the subject of those who administer the
56. Psoriasis skin lesions treatment know how is in the experimental and control group
ANSWER: Well demarcated regions of erythematous plaques that
shed thick silvery white flakes 85. Right to self-determination is reflected in
ANSWER: Informed consent obtained
57. Herpes Zoster (shingles), precipitating factor
ANSWER: decrease immune system 86. Blind patent, nursing diagnosis
ANSWER: Risk for injury
58. Shock, position
ANSWER: modified trendelenburg 87. Dementia, nursing diagnosis
ANSWER: Risk for injury
59. 2 characteristics of circulating blood volume in septic shock
ANSWER: (1) Vasodilation and (2) Maldistribution of circulating 88. Sodium Polystyrene Sulfonate (Kayexalate), effect
blood volume ANSWER: Excrete potassium through the intestinal tract

60. Water in the water seal bottle to fluctuate 89. Before paracentesis
ANSWER: patent chest tube ANSWER: Have patient void

61. Chest tube is dislodged 90. Increase of 1 kg in body weight is equivalent to

ANSWER: Cover insertion site with petroleum gauze ANSWER: 1 LITER of fluid retention

62. sudden increase drainage in chest tube 91. Goal of HIV management
ANSWER: Assess for signs of hemorrhage ANSWER: Improve the patients immune function

63. Corticosteroids use, nursing diagnosis 92. Juvenile Idiopathic Arthritis, cause
ANSWER: Ineffective protection (risk for infection) ANSWER: unknown

64. Hypoglycemia, manifestations 93. Plasmapharesis

ANSWER: Cool, moist skin, Slurred speech, Tremors ANSWER: Remove antibody-antigen complexes from circulation

65. Hyperresonance, determined by 94. Palliative Care

ANSWER: percussion ANSWER: Provides relief from pain and other distressing
symptoms
66. Rat bite, what to do first
ANSWER: Cleanse wound thoroughly 95. Demonstrate respect of clients autonomy
ANSWER: Facilitating and supporting clients choices regarding
67. Critical nursing intervention for a patient with status epilepticus treatment options
ANSWER: protecting airway
96. failed to attend to clients needs
68. Effect of Diazepam in seizure AMSWER: negligence
ANSWER: Relaxes peripheral muscles
97. leave me alone, I need rest, the nurse responds by saying:
69. Patient with head trauma, seizure happens when ANSWER: You sound upset.
ANSWER: Within the first few weeks postrauma
98. A client suddenly shouts Why is this taking so long? I have been
70. Chlorpromazine (Thorazine), adverse effect waiting for several hours and nobody attends to us? What should
ANSWER: Agranulocytosis and jaundice be the initial response of the nurse?
ANSWER: Talk to the client and determine her immediate needs
71. Ants are crawling all over my body. (Akathisia), problem in
ANSWER: sensorium or orientation 99. Client says to the nurse, Im nervous. Is the doctor competent in
this kind of surgery? Are there clients with similar surgery who
72. Patient with multiple sclerosis with fluctuating physical condition survived the procedure? How should the nurse best respond?
and generalized weakness, management ANSWER: You seem concerned about the surgery.
ANSWER: Space activities throughout the day
100. An order to discontinue catheterization of the client was
73. Exacerbation of multiple sclerosis implemented. She has complaints of difficulty in her first attempt
ANSWER: diplopia and nystagmus to urinate. The nurse explains that this is due to:

2
 ANSWER: Attempt of the body to adjust to normal reflex
mechanism. 120. a toddler loves to play at the park, and the nurse encourages the
mother to continue physical activities for what reason
101. removal of the inner cannula when he/she: ANSWER: allowing the toddler to walk, run and hop enhances the
ANSWER: Unlocks inner cannula by turning counter-clockwise childs kinaesthesia
and gently withdrawing in line with its curvature
121. how to prevent early-childhood dental cavities
102. clear liquid diet for a post-surgery client ANSWER: Make sure your childs diet is nutritious, and limit
ANSWER: Tea, cola drinks, gelatin snacks high in sugar.

103. assists the client to identify and cope with stressful emotional 122. In caring for a 3-year-old Nurse Sarah knows that she needs to
problems obtain the height of the child as part of routine health screening.
ANSWER: Counselor To obtain an accurate measurement, the child must:
ANSWER: Remove his shoes and stand upright, with head level
104. hospital director gives the nurse a position of authority within a
formal organization, she assumes the role of: 123. The 12 month old child with birth weight 8 lbs. Upon assessment
ANSWER: Manager the child now weighs 18 lbs. in documenting this result, the nurse
knows that this weight is:
105. The nurse who uses his interpersonal skills to guide the client in ANSWER: Below the expected weight
making decisions about his health care is acting the role of:
ANSWER: Leader 124. radiation safety
ANSWER: Shielding, distance, time
106. Part of your teaching plan that helps address nutrition problems in
the community include all 125. LEAST protection from radiation
ANSWER: ANSWER: Rubber gloves
Aiming for ideal body weight in all age brackets
Building health nutrition related practices 126. On auscultation, Mitral Stenosis?
Choosing food wisely focusing on food pyramid guide ANSWER: Low pitched, rumbling murmur occurring during
diastole
107. The nurse observes that childhood obesity is more common now.
The frequent cause of this is the Filipino parents belief that: 127. On auscultation, Aortic Stenosis?
ANSWER: A fat child is healthy, a thin child is sickly ANSWER: Cresendo-decresendo systolic murmur

108. plan to do first for a client who is experiencing depression? 128. On auscultation, Mitral regurgitation?
ANSWER: Assist the patient to express feelings, beliefs, and ANSWER: Blowing high pitched systolic murmur
values
129. Which of the following chemotherapeutic agents effects will be
109. While the nurse is assisting the client in her care, the client starts interfered by vitamin folic acid?
to cry and strikes her. The behavior that the client is manifesting ANSWER: methotrexate
best describes which of the following stages of death and dying?
ANSWER: Anger 130. Chronic Hepatitis B can transmitted by
ANSWER: Contaminated needle
110. A client with injured left leg is sitting on the bed preparing to
transfer to a wheel chair. The nurse is assisting the client and 131. therapeutic range of lithium
positions the wheelchair on the: ANSWER: 0.5 to 1.5 mEq/L
ANSWER: Clients right side
132. When the body responds to stress, epinephrine is released
111. A client has difficulty walking and needs a wheel chair to facilitate producing which physiological response?
performance of daily activities. Anticipating the needs of the client, ANSWER: A more forceful heart beat
the nurse should have the wheel chair ready by placing it at:
ANSWER: 45-degree angle to the bed 133. terminate SVT through stimulation of which of the following cranial
nerves?
112. You noticed that a clients temperature has widely fluctuated ANSWER: Cranial nerve X
above the normal temperature. You will record this type of fever in
the clients chart as: 134. Stevens-Johnson Syndrome?
ANSWER: Remittent ANSWER: Hypersensitivity reaction

113. temperature readings indicate that he has been having fever but 135. Which of the following symbols are used to document arterial
his body temperature would return to normal only to recur the next oxygen saturation as measured by pulse oximeter?
day ANSWER: SpO2 (SaO2)
ANSWER: Relapsing
136. The ICU nurse orientee observed the following arterial blood
114. While conducting rounds, the nurse notices a fire in a clients gases results in one of the patients record: ph-7.46; paO2-
room. Which of the following should be the appropriate action of 97mmHg; paCO2-40mmHg and HCO3-30meq/L. Which of the
the nurse? following is the interpretation of these results?
ANSWER: Evacuate the client from the room ANSWER: Metabolic alkalosis

115. To confirm pregnancy, the doctor will most likely: 137. Epinephrine
ANSWER: Order an ultrasound examination ANSWER: Bronchodilating effects

116. Madelaine complains that her early morning nausea and vomiting 138. Based on the suspected diagnosis, the nurse would expect that
really bothers her and prevents her from completing her work. To the gnawing epigastric pain will DECREASE with which of the
decrease the discomfort and keep her nourished, you advise her following activities of the client?
to: ANSWER: Eating a bland diet
ANSWER: Eat dry crackers or toast before getting up in the
morning 139. The stool examination result of clients with peptic ulcer is
POSITIVE for:
117. Last menstrual period (LMP) was March 15, 2010. Using Nagels ANSWER: blood
rule, her expected date of delivery (EDD) is:
ANSWER: December 22, 2010 140. Intussusception, manifestation
ANSWER: Crampy and intermittent severe abdominal pain

118. A pregnant she was diagnosed with gestational diabetes. She 141. intussusception
asks, what are my chances of becoming a real diabetic later in ANSWER: Telescoping of bowel into the adjacent segment
life? The best reply by the nurse would be:
ANSWER: Women diagnosed with gestational diabetes have an 142. primary indication of the NGT in intussusception
increased risk of developing diabetes later in life. ANSWER: decompresssion

119. A 17 weeks gestation a type 1 diabetic undergoes an ultrasound 143. Which of the following food enhance absorption of iron?
examination. What information about the fetus at this time in ANSWER: Citrus fruits
pregnancy will the results of this examination provide?
ANSWER: Placental Maturity
3
144. The client was prescribed ferrous Sulfate as iron supplement. For
better absorption, the nurse would instruct the client to take this 164. High in purine
supplement. ANSWER: Organ meats, wine and mussels
ANSWER: 1 hour before
165. Shooting in ER, first to do by the nurse
145. The scrub nurse aids the assistant surgeon apply the sterile ANSWER: hide
drape. The scrub nurse understands that once the drapes are
positioned over the prepped incision site, the drapes must not be: 166. Hypotension, compensatory mechanism of the body
ANSWER: Moved ANSWER: Activation of Renin-Angiotensin

146. During the interview, nurse found out that the client takes 167. Scrub nurse, role played for patient under anesthesia
Prophythiouracil (Prophyl-Thracil) daily. Which of the following is ANSWER: Client advocate (the nurse fights for the rights of the
the specific action of this drug? patient)
ANSWER: Blocks thyroid hormone production
168. Scrub nurse
147. Along with other treatments. Metformin HCL (Glucophage) was ANSWER: Guardian of asepsis
prescribed. The nurse should monitor for which potential serious
side effect of the drug? 169. Surgeon
ANSWER: Lactic acidosis ANSWER: Captain of the ship (makes major decision)

148. Colchicine is prescribed during the acute attack phase. Nurse 170. Circulating nurse, function
Karmela is aware that the action of the drug is to: ANSWER: Validates informed consent
ANSWER: Interfere with the inflammation response of uric acid
crystals in the joints. 171. Circulating nurse, first thing to be done upon entrance of patient in
OR
149. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once daily has ANSWER: Greet the patient and CHECK the IDENTITY
been prescribed for the client. The specific action of this thiazide
diuretic is to: 172. Surgery done without consent
ANSWER: Promote excretion of sodium and chloride be ANSWER: Battery
decreasing absorption in the distal tubule.
173. Role of nurse in obtaining informed consent
150. From the results of the laboratory test prescribed by the ANSWER: Witness
physician, which of the following will the nurse consider as an
indication of impaired renal function? Elevated levels of: 174. Role of head nurse in OR
ANSWER: Creatinine ANSWER: Scheduling of patients for surgery

151. Which of the following examination would the nurse expect to be 175. Anterior Pituitary Gland, hormones
ordered? ANSWER:
ANSWER: Synovial fluid analysis Prolactin/ Lactotropic
TSH
152. The client is 24-hour urine collection for uric acid determination. Growth Hormone (Somatostatin)
To have a reliable result, the nurse anticipates which diet GnRH: FSH and LH
prescribed prior to the examination? MSH
ANSWER: Low-purine diet ACTH

153. Which activity indicates that a client is fully aware of his/her 176. Posterior Pituitary Gland
impending surgery? ANSWER: Oxytocin
ANSWER: Voluntarily signs the consent for surgery ADH

154. For client who cannot totally give up smoking, nurses should 177. Hypophysectomy, post-op position
instruct client to cease smoking at least how many weeks before ANSWER: Fowlers
surgery?
ANSWER: 1 178. Transphenoidal Hypophysectomy, watch out for bleeding
ANSWER: Nose
155. Health instructions like encourage the client to move after surgery
should also be understood and reinforced to the significant others. 179. Potassium, acceptable rate
The goal of the instruction includes the following EXCEPT: ANSWER: 10 to 15 mEq/ hr
ANSWER: Comply with Institutional policy Give with NSS

156. The purpose of pre-anesthetic medication is one vital information 180. Maximum drug given subcutaneously
given by the nurse prior to any surgery. Clients should be made to ANSWER:
understand that this medication will: 1 ml pedia
ANSWER: Facilitate induction of anesthesia 2 ml adult

157. Virgilio has been taking Atenolol (Tenormin) 50 mg orally once 181. Maximum drug given intramuscularly
daily. The nurse understands thatr the specific action is to block: ANSWER: 3 ml
ANSWER: Beta receptor stimulation of the heart
182. SQ, drug administration, obese
158. Stools of breastfed babies ANSWER: 90 degrees and taut the skin
ANSWER: Breastfed infants usually have soft stools the bottle-fed
infants. 183. SQ, drug administration, skinny
ANSWER: 45 degrees and pinch the skin
159. The nurse is inserting a nasogastric tube on a toddler. Which of
the following restraints would be most appropriate for the nurse to 184. ID, drug administration
use with this child during the procedure? ANSWER:
ANSWER: elbow Parallel to skin, 10 to 15 degree
Bevel up
160. When assessing a client with Menieres disease, the nurse
expects the client to experience: 185. 1L NSS to be given in 24 hours, rate per hour
ANSWER: ringing of the ears ANSWER: 41 ml/ hr

161. The nurses focus of care on clients with hearing and balance 186. D5W, classification
problems is: ANSWER: Isotonic fluid but hypotonic in function
ANSWER: safety and promotion of independence
187. Heparin lock
162. The onset of crisis is triggered by a: ANSWER:
ANSWER: sudden precipitating event S.A.S.H. method (Saline, Antibiotic, Saline, Heparin)

163. A client is in a skeletal traction, the nurse understands that this 188. Infiltration
procedure involves pulling force: ANSWER: Stop and warm compress
ANSWER: Directly through pins inserted into the bone

4
189. Dehiscence ANSWER: 5 minutes
ANSWER: Stop and cold compress
215. Suctioning, per attempt
190. Billroth 1 ANSWER: 5 to 10 seconds
ANSWER: Gastroduodenostomy
216. Withdrawal of NGT
191. Billroth 2 ANSWER: Inhale hold breath pinch the catheter
ANSWER: Gastrojejunostomy withdraw

192. Complication of Billroth 1 and 2 217. During liver biopsy, instruction

ANSWER: dumping syndrome and pernicious anemia ANSWER: Inhale exhale hold breath

193. Confirmatory test for cancer 218. Sleep disturbance

ANSWER: Biopsy ANSWER: Quality of sleep > Quantity of sleep

194. Preferred treatment of cancer for pedia 219. Kidney transplant patient taking immunosuppressant may still
ANSWER: Chemotherapy experience rejection, what is the possible sign
ANSWER: Increase serum creatinine
195. Preferred treatment of cancer for adult
ANSWER: Surgery 220. Dialysis, not affected by the treatment
ANSWER: Hemoglobin
196. Cruciferous vegetables (anti-cancer)
ANSWER: 221. Iron deficiency anemia
Cabbage, broccoli, cauliflower, Brussels sprouts, Kohlrabi ANSWER: Spoon shaped fingernail (koilonychia)

197. Prostate cancer, risk factors 222. Post-pneumonectomy, position

ANSWER: Age above 40 ANSWER: Supine or to the affected side

198. Bladder cancer, risk factors 223. Post-mastectomy, position

ANSWER: Smoking, hair dye ANSWER: Elevate arms (liberty position)

199. Lung cancer, risk factors 224. Post-laminectomy, position

ANSWER: Smoking, asbestosis, radon gas ANSWER: Supine position

200. Cervical cancer, risk factors 225. Post-laryngectomy, expect

ANSWER: ANSWER: Absence of voice
Multiple sex partners, early sexual experience, HPV
226. Rich in iron
201. Breast cancer, risk factors ANSWER: Clams, leafy greens, enriched cereals, and liver
ANSWER:
Nulliparity, high fat diet/obesity, 227. Rich in calcium
early menarche, late menopause ANSWER: Orange, yogurt, spinach

202. Breast cancer, S/Sx 228. Hepatitis A and E

ANSWER: ANSWER: Fecal-oral
Dimple or mass at RUQ o the breast (tail of Spence)
229. Hepatitis B, C and D
203. Stage III Breast Cancer ANSWER: Blood, sexual intercourse, needle prick
ANSWER: Surgery and Chemotherapy
230. Hepatic encephalopathy, diet
204. Korotkoff sounds ANSWER: Low protein diet (protein increases ammonia)
ANSWER:
1- loud tapping 231. Hepatic encephalopathy, laboratory findings:
2- whoosing sound ANSWER:
3- crisp tapping a. Increase serum ammonia
4- muffled sound b. Increase bilirubin level in blood
5- silence
232. Non absorbable suture (silk, nylon, vicryl, cotton, daron)
205. BP of 104/100/90 ANSWER: Commonly used in SKIN
ANSWER: Korotkoff sound phases I/IV/V
(systolic/ muffling/ disappearance) 233. Absorbable sutures (chromic gut, plain gut)
ANSWER: Commonly used in internal organs
206. Auscultate pulse, use
ANSWER: Bell of stethoscope 234. 1st successful heart transplant
(diaphragm for obese patients) ANSWER: Cape Town, South Africa

207. Inflate cuff more after palpable systolic BP around 235. 1st successful bone marrow and kidney transplant
ANSWER: 30 mmHg ANSWER: USA

208. Deflate cuff, rate 236. Coumadin (Warfarin), foods to avoid

ANSWER: 2 to 3 mmHg/ beat ANSWER: Green leafy vegetables (contains Vitamin K)

209. Correct about VS taking 237. Anticoagulants (Coumadin, Heparin), how does it work
ANSWER: wait at last 30 minutes after exercise, eating or ANSWER: It inhibit synthesis of Vitamin K dependent clotting
smoking factors

210. Sequence of chest physiotherapy (CPT) 238. Heparin-induced side effect

ANSWER: ANSWER: Thrombocytopenia
1 postural drainage
2 percuss 239. Burn in chest, arms, face
3 vibrate ANSWER: Priority patient because it may cause inhalation burn
4 let the patient cough and airway edema
211. Death certificate, signing 240. Electrical burn, immediate management
ANSWER: physician/ municipal health officer ANSWER: Turn off the electrical source

212. Suctioning, oropharyngeal/ nasopharyngeal 241. Patient is burning, priority management

ANSWER: Interval: 20 to 30 seconds ANSWER: STOP, DROP and ROLL

213. Suctioning, tracheal 242. Burns, 2 parameters to measure

ANSWER: Interval: 2 to 3 minutes ANSWER:
1 extent percentage
214. Suctioning, entire procedure 2 severity degree

5
 ANSWER: RA pain occurs during immobility whereas OA pain
243. Fire in hospital, management (in sequence) happens because of mobility
ANSWER:
1 protect client 268. Patient prone to chocking or aspiration, priority management
2 activate the alarm ANSWER: Position the patient in upright
3 confine the fire
4 extinguish the fire 269. Otic medication administration
ANSWER:
244. Burns, 2nd degree (superficial partial thickness burn) Up and back (out) adults
ANSWER: Blisters (vesicles), painful Down and back (out) pedia

245. Burns, 3rd degree (deep partial thickness burn) 270. Patient prone to infection
ANSWER: Red to gray, local edema, wet, painless ANSWER:
Removal of spleen
246. Burns, 4th degree (full thickness burn) ICU patients
ANSWER: Charred, dry, leathery, painless Steroids (Kidney transplant patient, Cushings disease)
HIV
247. MRI, avoid
ANSWER: Pacemaker, jewelry, metallic objects 271. Phytochemicals, examples
ANSWER: lycopene in tomatoes, isoflavones in soy and
248. CT scan, before flavanoids in fruits.
ANSWER: check for allergy to iodine
272. Antioxidants and phytochemicals, benefits
249. Cardiac catheterization, after ANSWER: Anti-cancer
ANSWER: Check for distal pulses and possible bleeding
273. Total Parenteral Nutrition (TPN), most appropriate
250. Ventricular tachycardia, characteristic ANSWER: Sterile technique
ANSWER: Bizarre QRS complex, regular rhythm
274. Total Parenteral Nutrition (TPN), type of dressing to be use
251. Ventricular fibrillation, characteristic ANSWER: Air occlusive and transparent dressing
ANSWER: Chaotic pattern, no rhythm, no P wave, no QRS
complex 275. TPN solution is emptied but no follow up doctors order, what will
you give
252. Parkinson disease, S/Sx: ANSWER: hypertonic solution
ANSWER: D10 W pedia
Tremors (resting and pill rolling) D50W adult
Rigidity (cogwheel)
Akinesia or Bradykinesia 276. Liver cirrhosis, health teaching
Mask like appearance ANSWER: Good nutrition, avoid infection and abstain from
alcohol
253. Menieres disease, S/Sx:
ANSWER: Vertigo, Hearing loss (sensorineural), Tinnitus 277. Bronchoconstriction, appropriate nursing diagnosis
ANSWER: Ineffective airway clearance
254. Menieres disease, priority
ANSWER: Safety (Nursing Diagnosis: Risk for Injury) 278. Crackles, appropriate nursing diagnosis
ANSWER: Impaired breathing pattern
255. Menieres disease, diet
ANSWER: Low sodium, restrict fluid 279. Respiratory acidosis, appropriate nursing diagnosis
ANSWER: Impaired gas exchange
256. Legal Blind, visual acuity
ANSWER: 20/ 200 280. Infusion pump, alarm on when
ANSWER:
257. DM patient, before extraneous activity, AVOID Empty/ near empty IV fluid
ANSWER: Insulin injection Sudden twisting or movement
Tension on the tubing/ occlusion
258. Insulin, when to decrease dose Sudden change on the solution
ANSWER: During breastfeeding
281. Pulse oximeter, purpose
259. 100ml of NSS to be given at 10ml/ hour starting at 10 am, when ANSWER: measures oxygen saturation and pulse
will it end
ANSWER: 8pm 282. To reduce tenacity of secretions
ANSWER: Increase fluid intake
260. Cholecystitis, pain location
ANSWER: RUQ radiating to midsternal, shoulders and back 283. Stimulant of breathing
ANSWER: Carbon dioxide
261. Cholecystitis, laboratory data
ANSWER: 284. Metered dose inhaler, correct teaching
Increase bilirubin ANSWER:
Increase alkaline phosphatase Disperse drug with inhalation
Increase WBC Do not place inside the mouth the tip of the inhaler, provide 1 to 2
inches apart from the lips
262. Obstructed bile flow Provide mouthwash after drug administration
ANSWER: increase bilirubin
285. Evaluation of Tissue perfusion
263. Pericarditis, characteristic of breathing ANSWER: Monitor hourly urine output
ANSWER: Rapid and shallow
286. Foods that retain fluids in the body
264. Pericarditis, pain location ANSWER: Salty foods (dried fish), cola, pickles
ANSWER: Substernal
287. Foods that causes diuresis
ANSWER: Tea, coffee

265. pH 7.30
CO2 28 288. To prevent atelectasis:
HCO3 12 ANSWER: Ambulate as soon as possible
ANSWER: Metabolic acidosis, Partially compensated
289. Fifth vital sign:
266. Long bone fracture, check ANSWER: Pain
ANSWER: RR (possible fat embolism)
290. SEVERE pain medication:
267. Rheumatoid arthritis and Osteoarthritis ANSWER: Morphine

6
291. Pain assessment used in pediatric clients
ANSWER: Faces scale 317. Shock
ANSWER:
292. Colonic Cancer Decreased BP, Decreased MAP
ANSWER: CEA- Carcino Embryonic Antigen Increased RR, Increased PR
Narrowing pulse pressure
293. Ascites, measure
ANSWER: abdominal girth 318. Digoxin (Lanoxin), effects
ANSWER:
294. Eye pain after cataract surgery Increased force of contraction,
ANSWER: Call the MD increased cardiac output, increased tissue perfusion
increased urine output
295. Myasthenia Gravis, initial manifestation decreased electrical impulse
ANSWER: Ptosis (drooping, sinking or falling down of an organ or decreased heart rate, decreased workload
part, particularly the drooping of the upper eyelid) increased myocardial oxygenation

296. AV fistula how long does it mature? 319. Decreased tissue perfusion in kidney, effect
ANSWER: 3-4 weeks ANSWER: Stimulates erythropoietin causing bone marrow
stimulation leading to polycythemia
297. AV fistula with no bruit/thrill
ANSWER: Obstruction/clot 320. Most common nosocomial infection:
ANSWER: UTI
298. Purpose of neomycin in peri-ops
ANSWER: To kill bacteria in the gut 321. Best management for UTI
ANSWER: increased water intake
299. Heparin/Insulin is measured as
ANSWER: Units/ml 322. Stridor and wheezing, first drug to be given
ANSWER: bronchodilator
300. 1 grain is equal to
ANSWER: 60 mg 323. Pruritus
ANSWER: oatmeal bath colloidal bath
301. 1 tsp is equal to
ANSWER: 5 ml 324. Tinea Capitis hair loss is:
ANSWER: temporary
302. Appendicitis report ASAP
ANSWER: Rigid abdomen, indicates peritonitis 325. Pediculosis Capitis:
ANSWER:
303. Colorectal cancer, screening: Treat all household members
ANSWER: Lindane is not given in children (can cause seizure in children)
a. Rectal exam (DRE) correct answer
b. Biopsy confirmatory test 326. Gastric Cancer s/sx:
ANSWER: Weight Loss
304. Best way to measure fluid retention
ANSWER: Weight 327. Lung Cancer s/sx:
ANSWER: dry hacking cough
305. Best way to measure body fat
ANSWER: Skin fold thickness 328. Herpes zoster:
ANSWER: give antiviral
306. Nursing audit
ANSWER: Review of records 329. Patient with Luccid (clear thoughts) then unarousable:
ANSWER: hematoma cerebral
307. Quality assurance
ANSWER: ensuring and evaluating that the nursing care rendered 330. Most reliable sign of cardiac arrest:
is within the minimum standards of care (REACTIVE) ANSWER: absence of pulse

308. Structure evaluation 331. High Risk for bleeding:

ANSWER: physical setting ANSWER: Patient with thrombocytopenia

309. Process evaluation 332. Non-plaster cast a.k.a. synthetic cast gets wet:
ANSWER: how the nursing care is given ANSWER: Hair blower on a cool setting for itchiness

310. Outcome evaluation 333. Assessing brachial plexus injury in Newborn

ANSWER: output of nursing care given (demonstrable changes) ANSWER: Assess moro reflex

311. Total quality management 334. Collecting urine specimen for C&S sterile procedure
ANSWER: focus on identifying real and potential problem ANSWER: 5 to 10ml
(PROACTIVE)
335. Routine urinalysis
312. Hyperparathyroidism, main problem ANSWER: 30 to 50 ml
ANSWER:
Increased serum calcium 336. Abdominal: post-op: sleeping intestines:
Decreased serum phosphate ANSWER: paralytic ileus

313. Hypoparathyroidism, main problem 337. Residual volume of urine

ANSWER: ANSWER: 50-100 ml
Decreased serum calcium
Increased serum phosphate 338. Spina Bifida lack of:
ANSWER: folic acid
314. Increased ICP, position
ANSWER: Fowlers position 339. Arthralgia is
ANSWER: with pain and no swelling

315. Increased ICP (Cushings response) 340. Arthritis is

ANSWER: ANSWER: with pain and swelling
Increased BP, Increased MAP
Decreased RR, Decreased PR 341. PRESBYOPIA
Widening pulse pressure ANSWER: Decrease accommodative ability of the lens that
occurs with aging
316. Reason for elevating patient with increase ICP
ANSWER: 342. HYPEROPIA
To promote venous drainage ANSWER: Farsightedness

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 372. Discharges
343. MYOPIA Serous Clear
ANSWER: Nearsightedness Sanguineous Red (open wounds)
Seroanguineous Pinkish (surgical incision)
344. SIADH s/s: Purulent Pus
ANSWER: (dilutional) hyponatremia Purosanguineous Pus and blood (new infected wound)

345. Meningeal irritation s/s:

ANSWER: nuchal rigidity, photophobia, 373. OSTEOMYELITIS
kernings sign, brudzinskis sign ANSWER: Immobilize

346. Breast exams 374. Milwaukee brace

ANSWER: 5-7 days after onset of mens ANSWER: wear it for 23 hours and 1 hour intended for bathing

347. GCS score of a patient who is moaning and mumbling 375. Plaster of Paris
ANSWER: 2 ANSWER: 24 to 72 hours

348. GCS score, highest 376. synthetic/ fiber glass

ANSWER: 15 ANSWER: 20 minutes

349. GCS score, coma 377. Patient has weak side, where to place the wheelchair during
ANSWER: 7 and below transfer?
a. Unaffected/ STRONG SIDE
350. GCS, the higher the score b. Affected
ANSWER: the deeper the level of consciousness
378. Transfer from surgical bed to wheelchair, position of the
351. Manifestation of ICP wheelchair?
ANSWER: Bradycardia a. Foot of the bed
b. Facing the client
352. Pernicious anemia CORRECT UNDERSTANDING: c. Middle of the bed
ANSWER: Vitamin B12 for life IM d. Parallel to the bed

353. Urine output per hour 379. First to check if patient has 1000 mL blood loss:
ANSWER: 30 60 ml a. VS
b. Soaked dressing
354. What substance is produced by the kidneys that assists in blood c. Pain
pressure control
ANSWER: Renin 380. Patient on NPO complains of thirst, how to alleviate?
a. Wet cotton put on lips
355. A patient has had a sudden 5-kg weight gain. How much fluid has b. Gargle but dont swallow
been retained? c. Sip water
ANSWER: 5L
381. Promote safety to a patient in a bed without siderails
356. The functional unit of the kidney is called a(n) ANSWER:
ANSWER: Nephron lower the bed

357. What is oliguria? 382. Most common type of goiter is related to deficiency of
ANSWER: ANSWER: Iodine
c. Oliguria is a urine output less than 400 mL in 24 hours.
383. Earliest sign of skin reaction to radiation therapy is
358. Anuria is a urine output of ANSWER: Erythema
ANSWER: 50 to 100 mL/24 hours
384. Waste disposal like biological wastes disposal should be
359. most reliable pain indicator coordinated to
ANSWER: Subjective complaint of patient; DIAPHORESIS ANSWER: DILG, MMDA

360. Analgesics 385. 3 TYPES OF JAUNDICE

ANSWER: Before formation of prostaglandin ANSWER:
1. Hepatic jaundice inability of the liver to conjugated
361. Position cord prolapse unconjugated bilirubin to conjugated bilirubin)
ANSWER: Trendelenurg/ knee chest 2. Obstructive jaundice due to cholelithiasis
3. Hepatic jaundice due to RBC hemolysis
362. Acute Renal Failure:
ANSWER: decrease urine output 386. Last step in research process
ANSWER: utilization of the research into practice
363. Creatinine clearance
ANSWER: 24 hour urine collection 387. Incident report, not included
ANSWER: derogatory comments of patient
364. Most common post op complication
ANSWER: Hemorrhage 388. Final step in nursing process
ANSWER: putting research evidence into nursing practice
365. Most common triggering factor of asthma
ANSWER: Dust mites 389. Correct understanding about sampling technique
ANSWER: the greater the sample size, the more accurate will be
366. Most common type of liver cirrhosis the estimate of the true population mean
ANSWER: Laennecs (due to alcohol)
390. Client with hearing impairment
367. The worst of all fears among clients undergoing surgery is: ANSWER: speak slowly in front of the patient
ANSWER: Fear of unknown
391. Patient is teary eyed and stops talking
368. HYPERCALCEMIA,S/SX: ANSWER: remain silent, sit with the client
ANSWER: muscle weakness

369. Theophylline toxicity 392. fight free radicals

ANSWER: Tachycardia and nausea and vomiting ANSWER: antioxidants and phytochemicals

370. In OR, who validates/verifies consent: 393. Signs of dysphagia

ANSWER: Ciculator ANSWER:
Coughing while eating
371. Sellick maneuver Delayed swallowing
ANSWER: application of pressure in the cricoid cartilage Abnormal movements of tongue and mouth
Uncoordinated speech

8
394. Positioning patient into lithotomy position
ANSWER: place both legs slowly and simultaneously on well-
padded stirrups

395. Document outlining selected medical treatment to be done to a

patient when he/ she losses his/ her ability to decide
ANSWER: advance directives

396. Chest pain in patient with pneumonia is due to

ANSWER: pleuritic friction rub

397. Peptic ulcer disease, cause

ANSWER: H. pylori, NSAIDs smoking, alcohol

398. Sign of gastric ulcer perforation

ANSWER: rigid, board-like abdomen

399. Grafts used in CABG

ANSWER:
Saphaneous vein
Internal mammary artery
Radial artery

400. Pain during coughing exercises

ANSWER: splint using cough pillow

401. Antacids
ANSWER: neutralize gastric acidity

402. Ezomeprazole magnesium (Nexium)

ANSWER: Proton pump inhibitor

403. Cushing syndrome

ANSWER: OVERSECRETION of glucocorticoids

404. 3 elements of fire

ANSWER:
Oxygen (open windows
Combustible material (leaking gas stove)
Friction (disposable drapes)

405. Furosemide, excrete what electrolytes in urine

ANSWER: sodium, potassium and calcium

406. Renal stones

ANSWER:
Flank pain/ costovertebral pain
Strain urine

407. Swelling of leg due to congestion

ANSWER: elevate leg

408. Phatom limb pain caused by

ANSWER: severing peripheral nerves

409. Laboratory result in patient with pericarditis

ANSWER: Erythrocyte sedimentation rate

410. OHA (Metformin) and NSAIDS or ASA

ANSWER: hypoglycemia

411. Insertion of foley catheter

ANSWER: sterile technique

412. White pulp of spleen

ANSWER: lymphocyte production

413. Kidney function, indicator

ANSWER: creatinine clearance

414. increased hematocrit

ANSWER: polycythemia, dehydration