MEDICAL SURGICAL NURSING/ ANSWER: Effortless respiration

FUNDAMENTALS OF NURSING 19. When the nurse conducts physical assessment of the
abdomen, auscultation should precede palpation to:
1. Purpose of small volume enema
ANSWER: Prevent altering the frequency and character of bowel
ANSWER: Used to clean the sigmoid and rectum
sounds
2. How enema function
20. Dimming lights of the room as request by the client, level of
ANSWER: Causes distention of the bowel and stimulates the
Maslow’s hierarchy of needs met
defecation reflex
ANSWER: Safety and Security
3. During enema administration, direct rectal tip of enema
21. Inadequate nutrition
solution container to
ANSWER: Emaciated and weak appearance
ANSWER: Causes distention of the bowel and stimulates the
defecation reflex
22. Desired effect of the bronchodilator in patient with severe
upper respiratory tract infection
4. Once the client is in position the nurse visualizes the anus
ANSWER: effortless respiration
and is ready to insert the rectal tip. She is doing the procedure
correctly when she directs the rectal tip to the:
23. In abdominal assessment, auscultation should precede
ANSWER: umbilicus
palpation to:
ANSWER: Prevent altering the frequency and character of bowel
5. Principle behind obtaining informed consent before invasive
sounds
procedure
ANSWER: Autonomy
24. During palpation
ANSWER: use fingertips
6. Autonomy
ANSWER: respect for an individual’s right to self-determination
25. After giving analgesic, what is the priority
and freedom to choose and implement one’s own decision
ANSWER: reassess pain level after 30 minutes to 1 hour of giving
 be sure that all patients have consented to all treatments the drug
and procedure
 explain procedures to patients properly 26. McCaffery’s guideline in pain management
ANSWER: "whatever the experiencing person says it is, existing
7. A staff nurse reports to the supervisor that a newly hired whenever and wherever the person say it does" has become the
nurse is “falsifying data in the vital signs sheet for the clients prevailing conceptualization of pain for clinicians over the past few
assigned to her.” What action should the supervisor do FIRST? decades
ANSWER: Take the client’s vital signs and compare with the data
recorded by the new nurse 27. To maintain efficacy of nitroglycerine, store drug where
ANSWER: C ANSWER: Keep sublingual tablets in amber glass bottle
8. Priority management in patient with restraint 28. Appropriate instruction to patient with Patient-Controlled
ANSWER: Release every 2 to 4 hours, Assess every 30 minutes Analgesia
or as needed ANSWER: “Push the button when you feel the pain is starting.”
9. The parents understand safety precautions on children when 29. Possible sign of ruptured appendix
they state that they: ANSWER: Pain subsides
ANSWER: Will keep plastic bags and wraps are away from reach
of children 30. An effective intervention to prevent perforation of the
ANSWER: C inflamed appendix
ANSWER: Keep patient on N PO
10. Accidental poisoning is an important concern because
poisons cause serious injuries to children and the elderly. As you 31. Short discrete bubbling sounds over the lower region of
conduct your safety awareness class for parents, you find that lungs
you need to give more detailed instructions when a parent says “I ANSWER: crackles
will:
ANSWER: induce vomiting if my child swallows kerosene.” 32. Continuous, high-pitched, squeaky musical sounds
adventitious breath sound
11. Which of the following are required measures observed by ANSWER: wheezing
health care workers when in contact with blood and body fluids?
ANSWER: Hand hygiene and gloves 33. Acromegaly, manifestation
ANSWER: Enlarged extremities due to skeletal thickness and
12. When communicating with Theresa, the nurse assumes the macroglossia (large tongue)
face to face position to:
ANSWER: Express availability and desire to communicate 34. Transphenoidal hypophysectomy, incision site
ANSWER: under the upper lip
13. Communication zone for communication between nurse and
patient 35. What to wear BEFORE scrubbing of hands in OR
ANSWER: Personal distance ANSWER: head cap, mask, goggles
14. While communicating with Theresa you use attentive 36. Skin preparation in OR, what and how to wear
listening. This requires that the nurse: ANSWER: sterile gloves – open glove technique
ANSWER: Pays attention to both the content and feeling tone of
the client 37. Most painful site of the wrist during venipuncture
ANSWER: inner aspect of the WRIST
15. The client complains of pain in the left chest down to the left
shoulder and left jaw. In your documentation for your nurses’ 38. Cause of hypospadias
notes, you will record this as: ANSWER: congenital (occurs during 3rd month of fetal
ANSWER: Radiating pain development)
16. The changes in Mrs. De Vera’s vital signs that you would 39. Surgical operation needed to be postponed for a child with
expect when she complains of pain are the following EXCEPT: hypospadias
ANSWER: Decrease in temperature ANSWER: Circumcision
17. A client with congestive heart failure is taking 40. Radioactive iodine uptake determines what
hydrochlorothiazide once a day. While the client is taking the ANSWER: Absorption of the iodine isotope
medication, the nurse should encourage the client to eat which of
the following fruits: 41. Diet for hypothyroidism
ANSWER: banana ANSWER: low calorie, high fiber

42. Post-thyroidectomy, assessment for possible laryngeal nerve

18. The nurse is administering a bronchodilator to a client with damage
severe upper respiratory tract infection. The client is manifesting ANSWER: Talk with the client and note change in voice
the desired effect of the bronchodilator when the nurse assesses
which of the following:
1
43. Serum calcium level of 5.0 mg/dl, what to do ANSWER: Space activities throughout the day
ANSWER: Assess for signs of tetany
73. Exacerbation of multiple sclerosis
44. Confirmatory diagnosis for hiatal hernia ANSWER: diplopia and nystagmus
ANSWER: barium swallow
74. Patient Marina verbalized to the nurse that she is like her
45. To prevent increase in gastric acid secretion mother
ANSWER: avoid cigarette smoking ANSWER: transference

46. Confirmatory test for cholelithiasis 75. Neurotransmitters that are decrease in depression
ANSWER: UTZ ANSWER: serotonin and norepinephrine

47. Morphine is contraindicated for cholelithaisis because: 76. Therapeutic effect of Sertraline (Zoloft)
ANSWER: Causes spasm of the Sphincter of Oddi ANSWER: increases Serotonin

48. Bilateral tubal ligation, ask for informed consent to whom 77. Crisis
ANSWER: BOTH husband and wife ANSWER: Can no longer cope with usual problem-solving skills

49. Role of nurse in informed consent 78. Crisis, characteristic

ANSWER: witness ANSWER: Opportunity of learning better ways of coping,
Presence of a threatening event, Failure of usual problem-solving
50. Characteristic (typology) of RBC in iron deficiency anemia mechanisms
ANSWER: Microcytic and hypochromic
79. Polyneuropathy, deficiency in vitamin
51. Vitamin B12 deficiency, S/Sx ANSWER: B
ANSWER: Slight jaundice, fatigue, paresthesia, glossitis
80. Prompt treatment of alcoholism, assess for
52. Surgeon came into the OR suite swinging her hands ANSWER: At most eight hours from the time the patient last drank
ANSWER: Oblige the assistant surgeon to scrub again alcohol

81. “I don’t need help. Leave me alone. I am just fine.”

53. How to apply dressing after stitching of incisional site
ANSWER: denial
ANSWER: Put the dressings, remove his gloves to apply the tape
82. A immediate goal of crisis intervention
54. Processes of absorption of nutrients by SMALL intestine
ANSWER: Resolve the problem
ANSWER: diffusion and active transport
83. Duration of crisis
55. Psoriasis
ANSWER: 4 to 6 weeks
ANSWER: A chronic inflammatory skin disorder, not contagious
84. Research: double blind approach
56. Psoriasis skin lesions
ANSWER: Neither the subject of those who administer the
ANSWER: Well demarcated regions of erythematous plaques that
treatment know how is in the experimental and control group
shed thick silvery white flakes
85. Right to self-determination is reflected in
57. Herpes Zoster (shingles), precipitating factor
ANSWER: Informed consent obtained
ANSWER: decrease immune system
86. Blind patent, nursing diagnosis
58. Shock, position
ANSWER: Risk for injury
ANSWER: modified trendelenburg
87. Dementia, nursing diagnosis
59. 2 characteristics of circulating blood volume in septic shock
ANSWER: Risk for injury
ANSWER: (1) Vasodilation and (2) Maldistribution of circulating
blood volume
88. Sodium Polystyrene Sulfonate (Kayexalate), effect
ANSWER: Excrete potassium through the intestinal tract
60. Water in the water seal bottle to fluctuate
ANSWER: patent chest tube
89. Before paracentesis
ANSWER: Have patient void
61. Chest tube is dislodged
ANSWER: Cover insertion site with petroleum gauze
90. Increase of 1 kg in body weight is equivalent to
ANSWER: 1 LITER of fluid retention
62. sudden increase drainage in chest tube
ANSWER: Assess for signs of hemorrhage
91. Goal of HIV management
ANSWER: Improve the patient’s immune function
63. Corticosteroids use, nursing diagnosis
ANSWER: Ineffective protection (risk for infection)
92. Juvenile Idiopathic Arthritis, cause
ANSWER: unknown
64. Hypoglycemia, manifestations
ANSWER: Cool, moist skin, Slurred speech, Tremors
93. Plasmapharesis
ANSWER: Remove antibody-antigen complexes from circulation
65. Hyperresonance, determined by
ANSWER: percussion
94. Palliative Care
ANSWER: Provides relief from pain and other distressing
66. Rat bite, what to do first
symptoms
ANSWER: Cleanse wound thoroughly
95. Demonstrate respect of client’s autonomy
67. Critical nursing intervention for a patient with status
ANSWER: Facilitating and supporting client’s choices regarding
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
70. Chlorpromazine (Thorazine), adverse effect
been waiting for several hours and nobody attends to us?” What
ANSWER: Agranulocytosis and jaundice
should 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, “I’m nervous. Is the doctor
competent in this kind of surgery? Are there clients with similar
72. Patient with multiple sclerosis with fluctuating physical
condition and generalized weakness, management
2
 surgery who survived the procedure?” How should the nurse best
respond?
ANSWER: “You seem concerned about the surgery.”
100. An order to discontinue catheterization of the client was
implemented. She has complaints of difficulty in her first attempt
to urinate. The nurse explains that this is due to:
ANSWER: Attempt of the body to adjust to normal reflex
mechanism.
101. removal of the inner cannula when he/she:
ANSWER: Unlocks inner cannula by turning counter-clockwise
and gently withdrawing in line with its curvature
102. clear liquid diet for a post-surgery client
ANSWER: Tea, cola drinks, gelatin
103. assists the client to identify and cope with stressful emotional
problems
ANSWER: Counselor
104. hospital director gives the nurse a position of authority within
a formal organization, she assumes the role of:
ANSWER: Manager
118. A pregnant she was diagnosed with gestational diabetes.
She asks, ‘what are my chances of becoming a real diabetic later
in life?” The best reply by the nurse would be:
ANSWER: “Women diagnosed with gestational diabetes have an
increased risk of developing diabetes later in life.”
119. A 17 weeks gestation a type 1 diabetic undergoes an
ultrasound examination. What information about the fetus at this
time in pregnancy will the results of this examination provide?
ANSWER: Placental Maturity
120. a toddler loves to play at the park, and the nurse encourages
the mother to continue physical activities for what reason
ANSWER: allowing the toddler to walk, run and hop enhances the
child’s kinaesthesia
121. how to prevent early-childhood dental cavities
ANSWER: “Make sure your child’s diet is nutritious, and limit
snacks high in sugar.”
122. In caring for a 3-year-old Nurse Sarah knows that she needs
to obtain the height of the child as part of routine health
screening. To obtain an accurate measurement, the child must:
ANSWER: Remove his shoes and stand upright, with head level

105. The nurse who uses his interpersonal skills to guide the 123. The 12 month old child with birth weight 8 lbs. Upon
client in making decisions about his health care is acting the role assessment the child now weighs 18 lbs. in documenting this
of: result, the nurse knows that this weight is:
ANSWER: Leader ANSWER: Below the expected weight

106. Part of your teaching plan that helps address nutrition 124. radiation safety
problems in the community include all ANSWER: Shielding, distance, time
ANSWER:
 Aiming for ideal body weight in all age brackets 125. LEAST protection from radiation
 Building health nutrition related practices ANSWER: Rubber gloves
 Choosing food wisely focusing on food pyramid guide
126. On auscultation, Mitral Stenosis?
107. The nurse observes that childhood obesity is more common ANSWER: Low pitched, rumbling murmur occurring during
now. The frequent cause of this is the Filipino parents’ belief that: diastole
ANSWER: A fat child is healthy, a thin child is sickly
127. On auscultation, Aortic Stenosis?
108. plan to do first for a client who is experiencing depression? ANSWER: Cresendo-decresendo systolic murmur
ANSWER: Assist the patient to express feelings, beliefs, and
values 128. On auscultation, Mitral regurgitation?
ANSWER: Blowing high pitched systolic murmur
109. While the nurse is assisting the client in her care, the client
starts to cry and strikes her. The behavior that the client is 129. Which of the following chemotherapeutic agent’s effects will
manifesting best describes which of the following stages of death be interfered by vitamin folic acid?
and dying? ANSWER: methotrexate
ANSWER: Anger
130. Chronic Hepatitis B can transmitted by
110. A client with injured left leg is sitting on the bed preparing to ANSWER: Contaminated needle
transfer to a wheel chair. The nurse is assisting the client and
positions the wheelchair on the: 131. therapeutic range of lithium
ANSWER: Client’s right side ANSWER: 0.5 to 1.5 mEq/L

111. A client has difficulty walking and needs a wheel chair to 132. When the body responds to stress, epinephrine is released
facilitate performance of daily activities. Anticipating the needs of producing which physiological response?
the client, the nurse should have the wheel chair ready by placing ANSWER: A more forceful heart beat
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 client’s temperature has widely fluctuated ANSWER: Cranial nerve X
above the normal temperature. You will record this type of fever in
the client’s chart as: 134. Stevens-Johnson Syndrome?
ANSWER: Remittent ANSWER: Hypersensitivity reaction

113. temperature readings indicate that he has been having fever 135. Which of the following symbols are used to document arterial
but his body temperature would return to normal only to recur the oxygen saturation as measured by pulse oximeter?
next 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 client’s gases results in one of the patient’s 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 138. Based on the suspected diagnosis, the nurse would expect
vomiting really bothers her and prevents her from completing her that the gnawing epigastric pain will DECREASE with which of the
work. To decrease the discomfort and keep her nourished, you following activities of the client?
advise her 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 ANSWER: blood
Nagel’s rule, her expected date of delivery (EDD) is:
ANSWER: December 22, 2010 140. Intussusception, manifestation
ANSWER: Crampy and intermittent severe abdominal pain

3
141. intussusception
ANSWER: Telescoping of bowel into the adjacent segment 161. The nurse’s focus of care on clients with hearing and
balance problems is:
142. primary indication of the NGT in intussusception ANSWER: safety and promotion of independence
ANSWER: decompresssion
162. The onset of crisis is triggered by a:
143. Which of the following food enhance absorption of iron? ANSWER: sudden precipitating event
ANSWER: Citrus fruits
163. A client is in a skeletal traction, the nurse understands that
144. The client was prescribed ferrous Sulfate as iron this procedure involves pulling force:
supplement. For better absorption, the nurse would instruct the ANSWER: Directly through pins inserted into the bone
client to take this supplement.
ANSWER: 1 hour before 164. High in purine
ANSWER: Organ meats, wine and mussels
145. The scrub nurse aids the assistant surgeon apply the sterile
drape. The scrub nurse understands that once the drapes are 165. Shooting in ER, first to do by the nurse
positioned over the prepped incision site, the drapes must not be: ANSWER: hide
ANSWER: Moved
166. Hypotension, compensatory mechanism of the body
146. During the interview, nurse found out that the client takes ANSWER: Activation of Renin-Angiotensin
Prophythiouracil (Prophyl-Thracil) daily. Which of the following is
the specific action of this drug? 167. Scrub nurse, role played for patient under anesthesia
ANSWER: Blocks thyroid hormone production ANSWER: Client advocate (the nurse fights for the rights of the
patient)
147. Along with other treatments. Metformin HCL (Glucophage)
was prescribed. The nurse should monitor for which potential 168. Scrub nurse
serious side effect of the drug? ANSWER: “Guardian of asepsis”
ANSWER: Lactic acidosis
169. Surgeon
148. Colchicine is prescribed during the acute attack phase. ANSWER: Captain of the ship (makes major decision)
Nurse Karmela is aware that the action of the drug is to:
ANSWER: Interfere with the inflammation response of uric acid 170. Circulating nurse, function
crystals in the joints. ANSWER: Validates informed consent

149. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once daily 171. Circulating nurse, first thing to be done upon entrance of
has been prescribed for the client. The specific action of this patient in OR
thiazide diuretic is to: ANSWER: Greet the patient and CHECK the IDENTITY
ANSWER: Promote excretion of sodium and chloride be
decreasing absorption in the distal tubule. 172. Surgery done without consent
ANSWER: Battery
150. From the results of the laboratory test prescribed by the
physician, which of the following will the nurse consider as an 173. Role of nurse in obtaining informed consent
indication of impaired renal function? Elevated levels of: ANSWER: Witness
ANSWER: Creatinine
174. Role of head nurse in OR
151. Which of the following examination would the nurse expect ANSWER: Scheduling of patients for surgery
to be ordered?
ANSWER: Synovial fluid analysis 175. Anterior Pituitary Gland, hormones
ANSWER:
152. The client is 24-hour urine collection for uric acid Prolactin/ Lactotropic
determination. To have a reliable result, the nurse anticipates TSH
which diet prescribed prior to the examination? Growth Hormone (Somatostatin)
ANSWER: Low-purine diet GnRH: FSH and LH
MSH
153. Which activity indicates that a client is fully aware of his/her ACTH
impending surgery?
ANSWER: Voluntarily signs the consent for surgery 176. Posterior Pituitary Gland
ANSWER: Oxytocin
154. For client who cannot totally give up smoking, nurses should ADH
instruct client to cease smoking at least how many weeks before
surgery? 177. Hypophysectomy, post-op position
ANSWER: 1 ANSWER: Fowlers

155. Health instructions like encourage the client to move after 178. Transphenoidal Hypophysectomy, watch out for bleeding
surgery should also be understood and reinforced to the ANSWER: Nose
significant others. The goal of the instruction includes the
following EXCEPT: 179. Potassium, acceptable rate
ANSWER: Comply with Institutional policy ANSWER: 10 to 15 mEq/ hr
Give with NSS
156. The purpose of pre-anesthetic medication is one vital
information given by the nurse prior to any surgery. Clients should 180. Maximum drug given subcutaneously
be made to understand that this medication will: ANSWER:
ANSWER: Facilitate induction of anesthesia 1 ml – pedia
2 ml – adult
157. Virgilio has been taking Atenolol (Tenormin) 50 mg orally
once daily. The nurse understands thatr the specific action is to 181. Maximum drug given intramuscularly
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 184. ID, drug administration
to 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 Meniere’s 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

4
 4 – let the patient cough
186. D5W, classification 211. Death certificate, signing
ANSWER: Isotonic fluid but hypotonic in function ANSWER: physician/ municipal health officer

187. Heparin lock 212. Suctioning, oropharyngeal/ nasopharyngeal

ANSWER: ANSWER: Interval: 20 to 30 seconds
S.A.S.H. method (Saline, Antibiotic, Saline, Heparin)
213. Suctioning, tracheal
188. Infiltration ANSWER: Interval: 2 to 3 minutes
ANSWER: Stop and warm compress
214. Suctioning, entire procedure
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
ANSWER: Chemotherapy still 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

5
 ANSWER: Priority patient because it may cause inhalation burn
and airway edema
240. Electrical burn, immediate management 265. pH – 7.30
ANSWER: Turn off the electrical source CO2 – 28
HCO3 – 12
241. Patient is burning, priority management ANSWER: Metabolic acidosis, Partially compensated
ANSWER: “STOP, DROP and ROLL”
266. Long bone fracture, check
242. Burns, 2 parameters to measure ANSWER: RR (possible fat embolism)
ANSWER:
1 – extent  percentage 267. Rheumatoid arthritis and Osteoarthritis
2 – severity  degree ANSWER: RA pain occurs during immobility whereas OA pain
happens because of mobility
243. Fire in hospital, management (in sequence)
ANSWER: 268. Patient prone to chocking or aspiration, priority management
1 – protect client ANSWER: Position the patient in upright
2 – activate the alarm
3 – confine the fire 269. Otic medication administration
4 – extinguish the fire ANSWER:
Up and back (out) – adults
244. Burns, 2nd degree (superficial partial thickness burn) Down and back (out) – pedia
ANSWER: Blisters (vesicles), painful
270. Patient prone to infection
245. Burns, 3rd degree (deep partial thickness burn) ANSWER:
ANSWER: Red to gray, local edema, wet, painless Removal of spleen
ICU patients
246. Burns, 4th degree (full thickness burn) Steroids (Kidney transplant patient, Cushing’s disease)
ANSWER: Charred, dry, leathery, painless HIV

247. MRI, avoid 271. Phytochemicals, examples

ANSWER: Pacemaker, jewelry, metallic objects ANSWER: lycopene in tomatoes, isoflavones in soy and
flavanoids in fruits.
248. CT scan, before
ANSWER: check for allergy to iodine 272. Antioxidants and phytochemicals, benefits
ANSWER: Anti-cancer
249. Cardiac catheterization, after
ANSWER: Check for distal pulses and possible bleeding 273. Total Parenteral Nutrition (TPN), most appropriate
ANSWER: Sterile technique
250. Ventricular tachycardia, characteristic
ANSWER: Bizarre QRS complex, regular rhythm 274. Total Parenteral Nutrition (TPN), type of dressing to be use
ANSWER: Air occlusive and transparent dressing
251. Ventricular fibrillation, characteristic
ANSWER: Chaotic pattern, no rhythm, no P wave, no QRS 275. TPN solution is emptied but no follow up doctors order, what
complex will you give
ANSWER: hypertonic solution
252. Parkinson disease, S/Sx: D10 W– pedia
ANSWER: D50W – adult
Tremors (resting and pill rolling)
Rigidity (cogwheel) 276. Liver cirrhosis, health teaching
Akinesia or Bradykinesia ANSWER: Good nutrition, avoid infection and abstain from
Mask like appearance alcohol

253. Meniere’s disease, S/Sx: 277. Bronchoconstriction, appropriate nursing diagnosis

ANSWER: Vertigo, Hearing loss (sensorineural), Tinnitus ANSWER: Ineffective airway clearance

254. Meniere’s disease, priority 278. Crackles, appropriate nursing diagnosis

ANSWER: Safety (Nursing Diagnosis: Risk for Injury) ANSWER: Impaired breathing pattern

255. Meniere’s disease, diet 279. Respiratory acidosis, appropriate nursing diagnosis
ANSWER: Low sodium, restrict fluid ANSWER: Impaired gas exchange

256. Legal Blind, visual acuity 280. Infusion pump, alarm on when
ANSWER: 20/ 200 ANSWER:
Empty/ near empty IV fluid
257. DM patient, before extraneous activity, AVOID Sudden twisting or movement
ANSWER: Insulin injection Tension on the tubing/ occlusion
Sudden change on the solution
258. Insulin, when to decrease dose
ANSWER: During breastfeeding 281. Pulse oximeter, purpose
ANSWER: measures oxygen saturation and pulse
259. 100ml of NSS to be given at 10ml/ hour starting at 10 am,
when will it end 282. To reduce tenacity of secretions
ANSWER: 8pm ANSWER: Increase fluid intake

260. Cholecystitis, pain location 283. Stimulant of breathing

ANSWER: RUQ radiating to midsternal, shoulders and back ANSWER: Carbon dioxide

261. Cholecystitis, laboratory data 284. Metered dose inhaler, correct teaching
ANSWER: ANSWER:
Increase bilirubin Disperse drug with inhalation
Increase alkaline phosphatase Do not place inside the mouth the tip of the inhaler, provide 1 to 2
Increase WBC inches apart from the lips
Provide mouthwash after drug administration
262. Obstructed bile flow
ANSWER: increase bilirubin 285. Evaluation of Tissue perfusion
ANSWER: Monitor hourly urine output
263. Pericarditis, characteristic of breathing
ANSWER: Rapid and shallow 286. Foods that retain fluids in the body
ANSWER: Salty foods (dried fish), cola, pickles
264. Pericarditis, pain location
ANSWER: Substernal 287. Foods that causes diuresis
ANSWER: Tea, coffee

6
288. To prevent atelectasis: 315. Increased ICP (Cushing’s response)
ANSWER: Ambulate as soon as possible ANSWER:
Increased BP, Increased MAP
289. Fifth vital sign: Decreased RR, Decreased PR
ANSWER: Pain Widening pulse pressure

290. SEVERE pain medication: 316. Reason for elevating patient with increase ICP
ANSWER: Morphine ANSWER:
To promote venous drainage
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: Fowler’s position 339. Arthralgia is
ANSWER: with pain and no swelling

7
 ANSWER: muscle weakness

340. Arthritis is 369. Theophylline toxicity

ANSWER: with pain and swelling ANSWER: Tachycardia and nausea and vomiting

341. PRESBYOPIA 370. In OR, who validates/verifies consent:

ANSWER: Decrease accommodative ability of the lens that ANSWER: Ciculator
occurs with aging
371. Sellick maneuver
342. HYPEROPIA ANSWER: application of pressure in the cricoid cartilage
ANSWER: Farsightedness
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
kerning’s sign, brudzinski’s 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
c. Pain
blood 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
b. Gargle but don’t swallow
fluid has 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: Laennec’s (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
8
392. fight free radicals
ANSWER: antioxidants and phytochemicals

393. Signs of dysphagia

ANSWER:
Coughing while eating
Delayed swallowing
Abnormal movements of tongue and mouth
Uncoordinated speech

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