Situation 1 : Cancer of the prostate is the leading cancer in Men other than skin cancer.

The
following questions will assess your knowledge and theoretical foundation in dealing with clients
with prostate cancer.

1. Among the following population group, who has a higher risk in the development of
prostate cancer?

A. African-American

B. Caucasian

C. Asian

D. Hispanics

2. Which among the following is NOT a risk factor for prostate cancer?

A. A family member with prostate cancer

B. Advancing age

C. High fat and diet high in red meats

D. Smoking

3. Mr. Juan Jose Rodrigo has been diagnosed with prostate cancer just a few hours ago.
Which of the following sign would alert the nurse that the cancer is already advanced?

A. “I have difficulty starting my urination”

B. “My backs and hips are painful and my right leg is slightly larger than the other”

C. “My urine is bloody”

D. “My urine is bouncing”

4. At the initial sign and symptoms of prostate cancer, before diagnosis, the physician can
perform a screening test to detect a characteristic “STONY HARD” prostate and nodules at
the prostate area using:

A. Cystoscopy

B. PSA

C. DRE
D. MRI

5. To diagnose the presence of prostate cancer, the physician will perform:

A. Transrectal needle biopsy of the prostate

B. Test to identify the PSA levels

C. Transrectal ultrasound

D. Radiolabeled monoclonal antibody capromab pendetide with indium-111

6. After the removal of the prostate tissue, the physician soaked the solution in
formaldehyde in a sterile specimen container and asked you to send the specimen
immediately. Which of the following is a correct nursing action?

A. “Dr. Ruiz, I don’t think this specimen is acceptable. Please redo the procedure and do not soak
the specimen in any medium.”

B. “Dr. Ruiz, I just want you to know that you soaked the specimen in formaldehyde wherein, it
should not be soaked in any medium at all.”

C. Accept the specimen because there is nothing wrong with the physician’s action

D. “Dr. Ruiz, it should be soaked in NSS not formaldehyde. I am going to report you to the board of
medicine for this could lead to a false result.”

7. In any biopsy, the specimen is sent to the:

A. Radiologist

B. Nearest of Kin (seriously?)

C. Pathologist

D. Medical Technologist

8. PSA is used not for the detection but to know if the cancer is responding to treatment or
advancing. The nurse knows that the abbreviation PSA stands for:

A. Prostate specific antibody

B. Prostate specific antigen

C. Prostate specific antibody

D. Prostate specified antigen

9. In testing for the PSA, the nurse will collect which specimen?

A. Blood

B. Urine

C. Feces

D. Prostatic fluid

10. Mr. Rodrigo said that he has difficulty voiding. Which of the following is the best nursing
action to encourage voiding in any clients with voiding difficulties?

A. Encourage the client to drink plenty of fluids to promote urination

B. Bring the client to the bathroom and stay with him when the sensation to void is felt by the
client

C. Catheterize the client

D. Encourage the use of bathroom or commode rather than bedpans

Situation : Care of clients with tracheotosmy is often a challenge to a beginning nurse. The
following questions will test your knowledge on Tracheostomy and its related care.

11. You know that when rendering tracheostomy care, the priority consideration is always
to keep the airway patent and also to prevent infection at the site. The nurse knows the
technique used in rendering Tracheostomy care is:

A. Clean

B. Disinfected

C. Sterile

D. Medical

12. Prior to the suctioning or removal of the inner cannula, the nurse knows that the client is
prepared and positioned in:

A. High fowlers

B. Semi fowlers position

C. Left side lying

D. Sims

13. In cleaning the inner cannula or other parts of the tracheostomy tube, The best cleansing
mediums are:

A. Hydrogen peroxide and Sterile NSS

B. Povidone Iodine and Sterile NSS

C. Alcohol and Sterile NSS

D. Alcohol and Hydrogen Peroxide

14. In contrary with Tracheostomy tubes, sizes of chest tubes are expressed in terms of:

A. French

B. Gauge

C. M2

D. Diameter

15. Which of the following is NOT true with regards to securing the Tracheostomy?

A. The cuff provides sufficient securing

B. The Tracheostomy can be sutured in place

C. The Tracheostomy can be stapled in place

D. Tie or Velcro tie are used to generally secure the Tracheostomy around the client

16. The nurse knows that in Tracheostomy creation, 1% Lidocaine and 1:100,000
Epinephrine is injected at the incision site. The purpose of Lidocaine is mainly to provide
anesthetic effect while the Epinephrine is needed to:

A. Relax the bronchus and dilate the airway for easier insertion

B. To promote faster healing

C. To prevent the Vasovagal reflex that might cause bradycardia

D. For Hemostasis
17. Which of the following is not considered as a regular part of a Tracheostomy tube?

A. The outer cannula

B. The inner cannula

C. The obturator

D. The cuff

18. Which of the following is the reason why will a surgeon select a cuffed tube over a non
cuffed Tracheostomy tube?

A. Cuffed tube offers efficient securing

B. Cuffed tube is mainly used to prevent coughing

C. Cuff tube offers excellent attachment

D. For mechanical ventilation

19. The size of the Tracheostomy tube is denoted in terms of:

A. French

B. Gauge

C. Units

D. Size / mmID

20. The function of the obturator is:

A. To direct the outer cannula to traverse the curvature of the trachea for easier insertion

B. In cases of emergency, when outer cannula accidentally dislodges

C. To facilitate dilation of the stoma for the insertion of the outer cannula

D. To prevent too much pressure on the jugular vein after the tie has been placed

Situation : Organ donation is a new form of treatment that provides multiple complication such
as rejection.

21. Organ donation to save life was initially with the first transplant done by:

A. Dr. Christian Barnard of the Union of South Africa

B. Dr. Christian of the U.S.A.

C. Dr. Christian Barnard of Soviet Union

D. Dr. Christian Barnard of U.K.

22. In 1983, The FDA approved the first anti-rejection drug by the name of:

A. Cyclosporine

B. Prednisone

C. Imuran

D. Azathioprine

23. You would expect that in cases of organ donation, you would expect that the
immunosuppressant medications such as Cyclosporine, Prednisone and Imuran are taken:

A. For 2 years

B. When the suture heals

C. When rejection is not anymore viable

D. For the rest of the client’s life

24. Which of the following is a sign that the transplanted kidney is being rejected?

A. Fever and Weight Gain

B. Fever and Weight Loss

C. Chills, Fever, Polyuria

D. Anuria, Fever, Weight Gain and Hematuria

25. Among children candidates for organ transplant, when all selected children have
appropriate tissue matches for the same donated organ, the basis for the decision as to
which child gets the organ is given to the child who:

A. will receive the most benefit from the new organ

B. is most likely to die without the transplant

C. is selected by the lottery system for available organs

D. is at the top of the list and has waited the longest time

Situation: In a client with widespread colon cancer, A colectomy is the surgical procedure of
choice instead of an Abdominal perineal resection.

26. Ileostomy is performed after a colectomy. The nurse will expect that the stool of the
client will be:

A. Mushy

B. Spicy

C. Liquid

D. Soft

27. When should the teaching about ileostomy care commence?

A. Immediately after the operation, when the anesthesia is wearing off

B. 72 hours after operation

C. When readiness and interest is observed

D. As soon as the patient is admitted

28. Which of the following indicates a need for further teaching in client’s with ileostomy?

A. “I am expecting a change in my diet.”

B. “I can remove the appliance during sleep.”

C. “I can still swim”

D. “I am prone to dehydration because of the ileostomy”

29. For the client’s stool to be more “formed” which of the following food are added to the
client’s diet?

A. Boiled rice

B. Spaghetti and macaroni

C. Cheese

D. Bran
30. An expert nurse in the field of colostomy and ileostomy is called as a/an:

A. Enterostomal Therapy Nurse

B. Ostomy nurse

C. Nurse oncologist

D. Nurse Enterostomist

Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the
basic principles in suturing as well as knowledge in selecting sutures and caring for clients with
sutures.

31. Steel has the highest tensile strength among sutures in the non absorbable category.
When you say tensile strength, it refers to:

A. The amount of weight or force necessary to break the suture

B. The cross sectional size of the suture

C. The ability of the suture to absorb fluid

D. The force necessary to cause the knot to slip

32. In suturing the internal organs such as kidneys, liver, spleen, pancreas and stomach, the
nurse knows that the type of suture material that the physician will most likely use is:

A. Steel

B. Vicryl

C. Cotton

D. Silk

33. If the suture is removed to soon, the nurse knows that it could lead to failed healing of
the wound as well as infection. If the suture is removed too late, which of the following can
occur?

A. Itching

B. Swelling

C. Scarring
D. Pain

34. The nurse noticed that there are yellow and brown crustings around the area of the
suture. Which of the following is the best cleansing medium to remove such crusting?

A. Hydrogen Peroxide

B. Povidone Iodine

C. NSS

D. Alcohol

35. If the suture is performed on the client’s face. The nurse will reinforce the teaching that
the client should return when for suture removal?

A. After 7 days

B. After 3 to 4 Days

C. After 10 days

D. The next day

36. Sizes of sutures denotes the diameter. The physician will perform a corneal transplant
and will suture the eye. The nurse will prepare which of the following suture size?

A. 7

B. 5

C. 3

D. 9-0

37. Who holds the packet flaps of sutures to open it and place it in the sterile table for use?

A. Scrub nurse

B. Circulating nurse

C. Assistant surgeon

D. Surgeon
38. Non absorbable suture material such as cotton, nylon and silk are best used in suturing
which of the following abdominal layer?

A. Skin

B. Peritoneum

C. Fascia

D. Muscle

39. When least amount of trauma is desired, or when the client is prone to keloid formation,
the nurse should prepare which type of the needle?

A. Swaged

B. Round

C. Blunt

D. Taper

40. Another alternative “suture” for skin closure is the use of ____________

A. Staple

B. Therapeutic glue

C. Absorbent dressing

D. Invisible suture

Situation: The following are questions with regards to the OPERATING ROOM.

41. The operating room is divided into three areas, The unrestricted, the semi restricted and
the restricted areas. Where is the operating room?

A. Restricted

B. Unrestricted

C. Semi restricted

D. PACU

42. What OR attires are worn in the restricted area?

A. Scrub suit, OR shoes, head cap

B. Head cap, scrub suit, mask, OR shoes

C. Mask, OR shoes, scrub suit

D. Cap, mask, gloves, shoes

43. What OR attires are worn in the semi-restricted area?

A. scrub suit only

B. scrub suit, shoe cover, mask

C. scrub suit and head cap, with or without the shoe cover

D. head cap, mask, shoe cover only

44. One of the hidden dangers in the OR is missing instruments. What is the appropriate
approach to this happening?

A. correct labeling

B. “a place for everything and everything in its place”

C. install a flush sterilizer in the OR

D. increase instrument inventory

45. PACU Vital signs monitoring is performed every:

A. 5 minutes

B. 10 minutes

C. 15 minutes

D. 30 minutes

46. Mr. T.O. has undergone surgery for lyses of adhesions. He is transferred from Post
Anesthesia Care Unit (PACU) to the Surgical floor, the nurse should obtain blood pressure,
pulse and respiration every:

A. 3 minutes

B. 30 minutes
C. 15 minutes

D. 20 minutes

47. Another worthy study is the compliance to the principles of aseptic technique among the
sterile OR team. Who does NOT belong to the sterile OR team?

A. scrub nurse

B. assistant surgeon

C. x-ray technician

D. surgeon

48. The patient demonstrates knowledge of the psychological response to the operation and
other invasive procedure when she asks about:

A. Who will be with me in the OR?

B. How is the post operative pain over the site like?

C. Will I be naked during the operation?

D. Is it cold inside the?

49. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a
widespread surgical technique. What department should the nurse collaborate which is
unusual in conventional surgery?

A. engineering department

B. x-ray department

C. blood bank services

D. linen section

50. When the client is discharged from the hospital and is not capable of doing the needed
care services, the following can assume the role, EXCEPT:

A. family members

B. chaplain

C. significant others
D. responsible caregiver

Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in
the use of anesthesia enables the nurses to develop a more competitive approach in patient care.

51. An anesthesia delivered directly to the spinal canal is known as:

A. Epidural

B. Intrathecal

C. General

D. Local

52. After spinal anesthesia, 30% of the patient develops spinal headache. This is due to:

A. Severe hypotension associated with Vasodilation due to the anaesthetics.

B. Increase volume of the cerebrospinal fluid due to anesthesia induction.

C. Cerebral edema due to rapid absorption of the anaesthetics.

D. CSF leakage due to the puncture created by the spinal needle in the membrane that surrounds
the spinal cord.

53. Before the induction of spinal anesthesia, the client is placed in which of the following
preferred position to widen the vertebral space:

A. Quasi fetal position

B. Prone position

C. Flat on bed supine position

D. Side Lying position affected side

54. After spinal anesthesia, to prevent spinal headache, the client is placed on which of the
following position?

A. Sitting position

B. Side Lying position affected side

C. Flat on bed, supine

D. Flat on bed, prone

55. Another way to prevent spinal headache is by the use of the correct needle gauge. If the
client is an adult client, the anaesthesiologist might order a pink spinal set. The nurse knows
that the pink spinal set has a gauge of:

A. 12

B. 16

C. 22

D. 26

56. In medical and nursing practice, code means a call for:

A. DNR state

B. call to order

C. clinical case

D. cardiopulmonary resuscitation

57. The OR team collaborates from the first to the last surgical procedure. Who monitors the
activities of each OR suite?

A. scrub nurse

B. anesthesiologist

C. circulating nurse

D. surgeon

58. In patients with acute pancreatitis, the administration of the analgesic morphine may
cause:

A. addiction

B. urinary retention

C. paralytic ileus

D. spasms of the sphincter of Oddi

59. Who is responsible in daily monitoring the standards of safe, nursing practice in the
operating suite?

A. surgeon

B. perioperative nurse

C. OR nurse supervisor

D. chief nurse

60. During surgery, movement of personnel should be:

A. kept to a minimum

B. restricted

C. monitored

D. eliminated when possible

61. The patient has a right to information regarding the operation or other invasive
procedure and potential effects. This right is achieved through:

A. Enlightened Consent

B. preoperative visit

C. charting

D. doctor’s rounds

62. Which statement about a person’s character is evident in the OR team?

A. it assists in the control of feelings, thoughts and emotions in the face of difficulty

B. it reflects the moral values and beliefs that are used as guides to personal behavior and actions

C. it encourages the constructive use of the pleasure of the senses

D. it refers to the quality of being righteous, correct, fair and impartial

63. You continuously evaluate the client’s adaptation to pain. Which of the following
behaviors indicate appropriate adaptation?

A. The client reports pain reduction and decreased activity

B. The client denies existence of pain

C. The client can distract himself during pain episodes

D. The client reports independence from watchers

64. Pain in orthopedic cases may not be mainly due to the surgery. There might be other
factors such as cultural or psychological that influence pain. How can you alter these factors
as the nurse?

A. Explain all the possible interventions that may cause the client to worry

B. Establish trusting relationship by giving his medication on time

C. Stay with the client during pain episodes

D. Promote client’s sense of control and participation in control by listening to his concerns

65. In some hip surgeries, Fentanyl analgesia is given. What is your nursing priority care in
such a case?

A. Instruct client to observe strict bed rest

B. Check for epidural catheter drainage

C. Administer analgesia through epidural catheter as prescribed

D. Assess respiratory rate carefully

Situation: Mrs. Diaz is assigned in the female surgical ward. While on duty, an 15 year old client,
married, was admitted for CS. The informed consent for the operation has to be obtained.

66. The person legally responsible for taking the informed consent is:

A. The OR nurse who is going to assist with the operation

B. Any doctor assigned with the team

C. The doctor who is going to perform the procedure

D. The ward nurse where the patient stayed before the operation

67. Mr. Diaz has to remember the following with regard to the Informed Consent:

A. Because the patient is a minor, the parents should be asked to sign the consent.
B. The informed consent should be signed either by the patient or her 20 year old husband if
patient is unconscious

C. Nurses has the responsibility to obtain the informed consent prior to surgery

D. Legal guardian should sign the consent since the client is 15 year old

68. The medical intern who assisted in the operation gave post operative orders. In this
case, Mrs.Diaz should:

A. Validate the order from the surgeon and request him to counter sign

B. Follow the order as long as they are within the scope of nursing practice

C. Clarify from the medical intern those that are ambiguous

D. Refuse to follow the order because it is not legal

69. After one year, Mrs. Diaz was rotated to the delivery room. As a DR Nurse, the
Obstetrician ordered her to administer spinal anesthesia because the anaesthesiologist did
not arrive at the scene. The nurse would:

A. Give the anesthesia if the supervising nurse approves it

B. Give the anesthesia if the OB supervises her

C. Give the anesthesia if the doctor writes the order

D. Do not follow

70. Which of the following should the nurse remember when a doctor requests them to
administer anesthesia?

A. The nurse has the right to refuse it, if the doctor’s order is unlawful

B. Doctor’s order should always be written

C. The nurse may render medical procedure if the doctor supervises him

D. The staff nurse can be accused of insubordination if she does not follow the doctor’s order

Situation: Miss Matias, found out that Mr. Carding, newly admitted patient, has terminal cancer
and that his nurse has not yet informed him of the diagnosis.

71. Initially, Miss Matias should:

A. Tell the doctor the Mang Carding hinted that he feels he has Cancer

B. Be available to listen when the patient decides to discuss his illness

C. Call in the family and the team to prepare Mr. Carding about his impending death

D. Inform Mr. Carding about his Diagnosis

72. On the second day, the wife of Mr. Carding shows signs of grieving, The stages of
Grieving identified by Elisabeth Kubler-Ross Are:

A. Numbness, Anger, Resolution and Reorganization

B. Denial, Anger, Bargaining, Disorganization, Acceptance

C. Denial, Anger, Bargaining, Depression, Resolution

D. Denial, Anger, Bargaining, Depression, Detachment

73. Which of the following will be the most helpful therapy for the Grieving family?

A. Watching the video of the dying client over and over to encourage moving on

B. A course on death and dying

C. Psychotherapy

D. Group meeting with other grieving families

74. The nurse, when dealing with the relatives of a dying patients must be sensitive to their
emotional reactions. A family member who blames herself for the condition of the dying
patient indicates that she:

A. Has major issues

B. is oversensitive

C. Has neurotic tendencies

D. Is potentially risk for suicide

75. In caring of a dying client during post mortem, the most important thing that the nurse
should remember is:

A. Treat the body with utmost dignity

B. Close the eyes immediately before the onset of rigor mortis

C. Verify that the client is really dead by checking the ABC and double checking the death notice

D. Close the mouth, straighten the body, elbows and knees before the onset of rigor mortis

Situation : The patients chart is a legal documentation the is admissible in the court. In working
with the client, The protection of the information on the chart and patient’s privacy is one of the
priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the
daughters of Maria, A 38 year old mother of 12.

76. Who cannot access the client’s chart?

A. Maria

B. The patient

C. Member of the health care team

D. The nurse from the nearby hospital

77. Who owns the patient chart?

A. The patient

B. The doctor in charge

C. The hospital

D. The government

78. If the court issues an investigation necessitating the utilization of Ana’s chart, you know
that the chart will not be admissible IF:

A. Maria refuses

B. Ana refuses

C. The chart is not legible

D. The chart is missing

79. The research teams from other countries are interested in investigating Ana’s case. They
want to read and gather information about Ana and the manifestation of her condition. For
the sake of improving knowledge and the development of a cure, the nurse knows that
research is very important. Permission in this case will be taken from:

A. Ana

B. Maria

C. The hospital management

D. The doctor in charge

80. If Ana reaches the age of majority, 18 years of age, and Maria asks for her chart, which of
the following is the best nursing action?

A. Ignore Maria’s request

B. Decline Maria’s request

C. Give the chart to the Mother of Ana

D. Tell Maria to ask permission from Ana

Situation 6 – Infection can cause debilitating consequences when host resistance is compromised
and virulence of microorganisms and environmental factors are favorable. Infection control is one
important responsibility of the nurse to ensure quality of care.

81. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice,
after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma
globulin for herself and her household help. Your most appropriate response would be:

A. “Don’t worry your husband’s type of hepatitis is no longer communicable”

B. “Gamma globulin provides passive immunity for hepatitis B”

C. “You should contact your physician immediately about getting gammaglobulin.”

D. “A vaccine has been developed for this type of hepatitis”

82. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means?
Your best response would be:

A. “You acquired the infection after you have been admitted to the hospital.”

B. “This is a highly contagious infection requiring complete isolation.”

C. “The infection you had prior to hospitalization flared up.”

D. “As a result of medical treatment, you have acquired a secondary infection.’

83. As a nurse you know that one of the complications that you have to watch out for when
caring for Omar who is receiving total parenteral nutrition is:

A. stomatitis

B. hepatitis

C. dysrhythmia

D. infection

84. A solution used to treat Pseudomonas wound infection is:

A. Dakin’s solution

B. Half-strength hydrogen peroxide

C. Acetic acid

D. Betadine

85. Which of the following is the most reliable in diagnosing a wound infection?

A. Culture and sensitivity

B. Purulent drainage from a wound

C. WBC count of 20,000/μL

D. Gram stain testing

Situation : Respiration is one of the most important vital sign. This is usually the first Vital sign to
be assessed more than anything for it is easily altered by the patient’s consciousness. The nurse
should be aware of the different changes and alteration in respiration.

86. Another name for an abnormal breath sound is:

A. Adventurous breath sound

B. Excursion

C. Adventitious breath sound

D. Dyspnea

87. In a client with diabetic ketoacidosis, Kussmauls respiration is exhibited. This is

evidence that there is the presence of:

A. Respiratory acidosis

B. Metabolic acidosis

C. Respiratory alkalosis

D. Metabolic alkalosis

88. If the nurse will auscultate the base of the lungs, it is expected that she will hear:

A. Bronchovesicular

B. Tubular

C. Vesicular

D. Crackles

89. The respiratory center is found in the:

A. Pons B. Hypothalamus C. Medulla D. Lungs

90. Initially in asthma, you are expecting that the client’s acid base disturbance is:

A. Respiratory acidosis

B. Metabolic acidosis

C. Respiratory alkalosis

D. Metabolic alkalosis

Situation: Carbon Monoxide poisoning is said to be the 2nd leading cause of poison death. It is
said to be the leading cause of inhalation poisoning. Mr. Edgardo was rushed to the hospital after
being unconscious inside an enclosed parking lot. Carbon monoxide poisoning is suspected.

91. The pulse oximetry reading of Mr. Edgardo is 100%. This suggests that:

A. There is no danger of hypoxia

B. There is no carbon monoxide poisoning, it should be ruled out

C. This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is
required

D. That the client has an improved chance of surviving, since the client is well oxygenated

92. Which of the following is a sign the nurse will expect to see on Mr. Edgardo?

A. Cherry-red skin

B. Pale skin

C. Cyanotic

D. Restlessness

93. Initially, in patient with suspected inhalation poisoning, the most important
intervention at the scene of poisoning is:

A. Assess the patient’s airway breathing and circulation

B. Conduct a head to toe physical assessment

C. Administer oxygen and loosen the client’s clothing

D. Carry the client on the fresh air immediately opening all windows and doors if this is enclosed

94. Which of the following laboratory result is constantly checked in clients undergoing
treatment for carbon monoxide poisoning?

A. Oxygen saturation

B. RBC count

C. Skin color

D. Carboxyhemoglobin level

95. If a client demonstrates psychoses, visual disturbance, ataxia, amnesia and confusion
even after completion of resuscitation and the return of normal oxygenation, this will
indicate that:

A. The client suffered from an irreversible brain damage

B. That the client still needs to be evaluated for this is evidence that resuscitation is not yet
complete
C. That the client will need a longer rehabilitation to go back to the previous functioning

D. That the client is exhibiting secondary gains

Situation: The physician has ordered 3 units of whole blood to be transfused to Wally following a
repair of a dissecting aneurysm of the aorta.

96. You are preparing the first unit of whole blood for transfusion. From the time you obtain
it from the blood bank, how long should you infuse it?

A. 6 hours

B. 1 hour

C. 4 hours

D. 2 hours

97. What should you do FIRST before you administer blood transfusion?

A. verify client identity and blood product, serial number, blood type, cross matching results,
expiration date

B. verify client identity and blood product serial number, blood type, cross matching results,
expiration date with another nurse

C. check IV site and use appropriate BT set and needle

D. verify physician’s order

98. As Wally’s nurse, what will you do AFTER the transfusion has started?

A. add the total amount of blood to be transfused to the intake and output

B. discontinue the primary IV of Dextrose 5% Water

C. check the vital signs every 15 minutes

D. stay with Wally for 15 minutes to note for any possible BT reactions

99. Wally is undergoing blood transfusions of the first unit. The EARLIEST signs of
transfusion reactions are:

A. oliguria and jaundice C. hypertension and flushing

B. urticaria and wheezing D. headache, chills, fever

100. In case Wally will experience an acute hemolytic reaction, what will be your PRIORITY
intervention?

A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician

B. stop the blood transfusion and monitor the patient closely

C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank

D. immediately stop the BT, notify the blood bank and administer antihistamines

Answers

1.A. African-American

2.D. Smoking

3.B. “My backs and hips are painful and my right leg is slightly larger than the other”

4.B. PSA

5.A. Transrectal needle biopsy of the prostate

6.B. “Dr. Ruiz, I just want you to know that you soaked the specimen in formaldehyde wherein, it
should not be soaked in any medium at all.”

7.C. Pathologist

8.B. Prostate specific antigen

9.A. Blood

10.D. Encourage the use of bathroom or commode rather than bedpans

11.C. Sterile

12.B. Semi fowlers position

13.A. Hydrogen peroxide and Sterile NSS

14.A. French

15.A. The cuff provides sufficient securing

16.D. For Hemostasis

17.D. The cuff

18.D. For mechanical ventilation

19.D. Size / mmID

20.A. To direct the outer cannula to traverse the curvature of the trachea for easier insertion

21.A. Dr. Christian Barnard of the Union of South Africa

22.A. Cyclosporine

23.D. For the rest of the client’s life

24.A. Fever and Weight Gain

25.D. Is at the top of the list and has waited the longest time

26.C. Liquid

27.C. When readiness and interest is observed

28.B. “I can remove the appliance during sleep.”

29.A. Boiled rice

30.A. Enterostomal Therapy Nurse

31.A. The amount of weight or force necessary to break the suture

32.D. Silk

33.C. Scarring

34.A. Hydrogen Peroxide

35.B. After 3 to 4 Days

36.D. 9-0

37.B. Circulating nurse

38.A. Skin

39.A. Swaged

40.A. Staple
41.A. Restricted

42.B. Head cap, scrub suit, mask, OR shoes

43.C. scrub suit and head cap, with or without the shoe cover

44.B. “a place for everything and everything in its place”

45.C. 15 minutes

46.B. 30 minutes

47.C. x-ray technician

48.B. How is the post operative pain over the site like?

49.B. x-ray department

50. B. chaplain

51.B. Intrathecal

52.D. CSF leakage due to the puncture created by the spinal needle in the membrane that
surrounds the spinal cord.

53.A. Quasi fetal position

54.D. Flat on bed, prone

55.B. 16

56.D. cardiopulmonary resuscitation

57.C. circulating nurse

58.D. spasms of the sphincter of Oddi

59.C. OR nurse supervisor

60.A. kept to a minimum

61.A. Enlightened Consent

62.B. it reflects the moral values and beliefs that are used as guides to personal behavior and
actions

63.C. The client can distract himself during pain episodes

64.D. Promote client’s sense of control and participation in control by listening to his concerns

65.D. Assess respiratory rate carefully

66.C. The doctor who is going to perform the procedure

67.B. The informed consent should be signed either by the patient or her 20 year old husband if
patient is unconscious

68.D. Refuse to follow the order because it is not legal

69.D. Do not follow

70.A. The nurse has the right to refuse it, if the doctor’s order is unlawful

71. B. Be available to listen when the patient decides to discuss his illness

72.C. Denial, Anger, Bargaining, Depression, Resolution

73.D. Group meeting with other grieving families

74.D. Is potentially risk for suicide

75.A. Treat the body with utmost dignity

76.D. The nurse from the nearby hospital

77.C. The hospital

78.A. Maria refuses

79.B. Maria

80.D. Tell Maria to ask permission from Ana

81.C. “You should contact your physician immediately about getting gammaglobulin.”

82.A. “You acquired the infection after you have been admitted to the hospital.”

83.D. infection

84.A. Dakin’s solution

85.A. Culture and sensitivity

86.C. Adventitious breath sound

87.B. Metabolic acidosis

88.C. Vesicular

89.C. Medulla

90.C. Respiratory alkalosis

91.C. This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is
required

92.D. Restlessness

93.D. Carry the client on the fresh air immediately opening all windows and doors if this is
enclosed

94.D. Carboxyhemoglobin level

95.A. The client suffered from an irreversible brain damage

96.C. 4 hours

97.D. verify physician’s order

98.D. stay with WQ for 15 minutes to note for any possible BT reactions

99.D. headache, chills, fever

100.C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank