ILOILO DOCTORS’ COLLEGE COLLEGE OF NURSING RLE 106 – FINAL EXAM AY – 2013-2014 2013- 2014 INSTRUCTION: 1. WRITE THE LETTER OF THE CORRECT ANSWER IN THE TEST OO!LET. 2. ALL ANSWERS ANSWERS MUST E IN CA"ITAL CA"ITAL LETTERS. 3. ALL ANSWERS ANSWERS MUST E IN A LUE#LAC! IN!. 4. ERASURES AND ALTERATIONS WILL NOT E ACCE"TED
21. Hepatitis B is transmitted through parenteral transmission, except A. Blood and blood product B. Use of contaminated instruments for injection C. Use of contaminated hospital and laboratory euipment !. "exual contact #ia the #aginal and seminal secretions 22. Hepatitis B can occur during labor and deli#ery through lea$s across the placenta and can be precipitated by injury during deli#ery. %t may also also occur through through exposure of the infant to maternal secretions in the birth canal. A. &arenteral transmission C. perinatal transmission B. "exual contact !. blood transfusion 2'. (hich is not true about )etanus )etanus *eonatorum. A. An acute disease induced by toxin of tetanus bacillus gro+ing an aerobically in +ounds and at site of umbilicus among infants B. Characteried by muscular contractions C. Usually occurs through contamination of the unhealed stump of the umbilical cord !. %ncubation period is usually 2 to - days 2. (hich is not a sign or symptom of measles/ A. rashes C. bleeding B. fe#er !. 0opli$ spots 2-. A suspect cases of this disease is defined as any patient belo+ 1- years of age +ith acute flaccid paralysis for +hich no other cause can be immediately identified. A. &ertussis C. !iphtheria B. &oliomyelitis !. )uberculosis 26. A process by which the fetus and products of conception are expelled resulting from a regular , progressive, frequent and strong uterine contraction. A) Deli Deliv very ery .) !abor ") #ertili$ation D) %vulation 2. At +hat stage of labor does cro+ning be obser#ed/ A 1st stage B 2nd stage
C 'rd stage ! th stage
23. )he cardinal mo#ement that occurs immediately before expulsion. A 4xternal rotation C 5lexion B 4x 4xtension ! !escent 26. %n ne+born, an A&7A8 score of 9 signifies +hich of the follo+ing/ C "erious: critical condition A) 7ood B 7uarded ! *ormal
26. (hen is the best time to start breastfeeding/ A %mmediately after birth B (hen (hen the breat reatm mil$ il$ sta start rtss to to fl flo+
C 2 hours after deli#ery ! (hen the the mo mother ther is read ready y
';. %n performing an ideal perineal prep, ho+ many cherries are needed/ C cherries A) - cherries B 1 cherry:s+ab
! cherries
'1. %mmediately after deli#ery, +here can the uterus be palpated/ C At the le#el of the umbilicus A)
'2. (hich of the follo+ing is the least priority in assessing the lochia discharges/ 1
A) Amount
C Color ! "mell
B Clots present
''. "aturation of sanitary nap$ins during the first hour of deli#ery signifies= A Hemorrhage B A normal occurrence
C 4xpected phenomenon ! malignancy
'. (hen in the intrapartal period should the blood pressure of the mother be ta$en/ A B C !
%mmediately after the expulsion of the baby After the separation of the placenta %mmediately after the expulsion of the placenta Anytime
>rs. )aba Chiu a 7&2 ?@2@;@1@2 in acti#e labor is admitted in the labor room. Her cer#ix is 2 cm. open , 3; effaced , in cephalic presentation +ith B( intact, station 1. Her labor started at 3=- +hich is moderate in intensity and lasted for 2; seconds. At 3=-- another contraction occurs for 2; seconds. 4arlier in the 48, an intra#enous infusion +ith !-<8 1< 1; DuE oxytocin x 1;; cc:H +as started using a Baxter macroset. %n reference to the situation mentioned, ans+er the follo+ing uestions= '-. Ho+ many children does >rs. Chiu ha#e at present/ A) & ) 2 ") ' D) ( '9. (hat type of solution is !-<8/ A Hypertonic solution B %sotonic solution
C Hypotonic solution ! *one of the abo#e
'. xytocin is indicated in all conditions belo+, except= A %nduce labor C %ncomplete abortion B &re#ent post partum bleeding ! &lacenta pre#ia
'3. (hat complication of pregnancy does >rs. Chiu has experienced/ A &reterm deli#ery ") Abortion
C )hreatened abortion ! 4clampsia
'6. %f you are to regulate the %F infusion of >rs. Chiu, +hat +ould be the rate of flo+ in gtts.:min./ A '' gtts.:min B '; gtts.:min
C ; gtts.:min ! '3 gtts.:min
;. "tation 1 means= A )he presenting part of the fetus is engaged. B )he presenting part is at the perineum C )he head of the fetus is floating D) )he presenting part of the fetus is just belo+ the ischial spine . 1. )his term refers to the time period from the beginning of one contraction to the start of the next contraction. A 5reuency C duration B %nter#al ! puerperium
2. )he follo+ing are characteristics of amniotic fluid, except= A Gello+ish green in color C &ro#ides the fetus a cushion from injury B &ro#ides the fetus +ith optimum temp ! Has fetal, urine, lanugo and epithelial cells '. After suctioning a term neonate +ho appears in good condition after birth, +hich of the follo+ing +ould the nurse do next/ A &lace the fetus in a radiant +armer C %nstill erythromycin ophthalmic B btain the ne+born +eight ! &ut %! bracelet in the +rist . All of the follo+ing are contained in an B pac$, except= A Cord clamp C 5orceps B "terile go+n ! 8eceptacle for placenta
-. 8abies #irus can be transmitted through= a. &enetration of bro$en s$in b. contact +ith a pre@existing +ound or scratch c. penetration of intact mucosa d. any of these modes of transmission 9. )he nursing inter#ention that %s most important in a patient on %F >orphine/ a. >onitor for hypertension 2
b. Monitor for decreased respiration c. >onitor for cardiac rates d. >onitor for hyperglycemia . A client +ith tuberculosis is gi#en the drug pyrainamide ?&yrainamide. (hich one of the follo+ing diagnostic tests +ould be inaccurate if the client is recei#ing the drug/ a.
o#ement of the head 6. )he nurse is counseling a client +ith the diagnosis of glaucoma. "he explains that if left untreated, this condition leads to a. Blindness b. >yopia c. 8etrolental fibroplasia d. U#eitis -;. )he physician has ordered a 2@hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. )his specimen is then a. !iscarded, then the collection begins b. "a#ed as part of the 2@hour collection c. )ested, then discarded d. &laced in a separate container and later added to the collection -1. 5ollo+ing an accident, a client is admitted +ith a head injury and concurrent cer#ical spine injury. )he physician +ill use Crutchfield tongs. )he purpose of these tongs is to a. Hypoextend the #ertebral column b. Hyperextend the #ertebral column c. !ecompress the spinal ner#es d. Allo+ the client to sit up and mo#e +ithout t+isting his spine -2.)he most appropriate nursing inter#ention for a client reuiring a finger probe pulse oximeter is to a. Apply the sensor probe o#er a finger and co#er lightly +ith gaue to pre#ent s$in brea$do+n b. "et alarms on the oximeter to at least 1;; percent c. %dentify if the client has had a recent diagnostic test using intra#enous dye d. 8emo#e the sensor bet+een oxygen saturation readings -'. A client admitted to a surgical unit for possible bleeding in the cerebrum has #ital signs ta$en e#ery hour to monitor to neurological status. (hich of the follo+ing neurological chec$s +ill gi#e the nurse the best information abou t the extent of bleeding/ a. &upillary chec$s b. "pinal tap c. !eep tendon reflexes d. 4#aluation of extrapyramidal motor system -. Using the principles of standard precautions, the nurse +ould +ear glo#es in +hat nursing inter#entions/ A. &ro#iding a bac$ massage B. 5eeding a client C. &ro#iding hair care !. &ro#iding oral hygiene --. )he nurse is preparing to ta$e #ital sign in an alert client admitted to the hospital +ith deh ydration secondary to #omiting and diarrhea. (hat is the best method used to assess the clientIs temperature/ A. ral B. Axillary C. 8adial !. Heat sensiti#e tape -9. A nurse obtained a clientIs pulse and found the rate to be abo#e normal. )he nurse document this findings as= A. )achypnea B. Hyper pyrexia '
C. Arrythmia !. )achycardia -. (hich of the follo+ing actions should the nurse ta$e to use a +ide base support +hen assisting a client to get up in a chair/ A. Bend at the +aist and place arms under the clientIs arms and lift B. 5ace the client, bend $nees and place hands on clientIs forearm and lift C. "pread his or her feet apart !. )ighten his or her pel#ic muscles -3. A client had oral surgery follo+ing a motor #ehicle accident. )he nurse assessing the client finds the s$in flushed and +arm. (hich of the follo+ing +ould be the best method to ta$e the clientIs body temperature/ A. ral B. Axillary C. Arterial line !. 8ectal -6. A client +ho is unconscious needs freuent mouth care. (hen performing a mouth care, the best position of a client is= A. 5o+lerIs position B. "ide lying C. "upine !. )rendelenburg 9;. A client is hospitalied for the first time, +hich of the follo+ing actions ensure the safety of the client/ A. 0eep unnecessary furniture out of the +ay B. 0eep the lights on at all time C. 0eep side rails up at all time !. 0eep all euipment out of #ie+ 91. A +al$@in client enters into the clinic +ith a chief complaint of abdominal pain and diarrhea. )he nurse ta$es the clientIs #ital sign hereafter. (hat phrase of nursing process is being implemented here by the nurse/ A. Assessment B. !iagnosis C. &lanning !. %mplementation 92. %t is best describe as a systematic, rational method of planning and pro#iding nursing care for indi#idual, families, group and community A. Assessment B. *ursing &rocess C. !iagnosis !. %mplementation
9'. 4xchange of gases ta$es place in +hich of the follo+ing organ/ A. 0idney B.
9. !uring +hat specific part ot the 4C7 tracing that a nurse should defibrilate the patient/ A. ") +a#e B. K8" +a#e C. & +a#e !. ) +a#e 93. %t is used in balanced combination to produce #arying le#els of loss of consciousness, pain control and:or s$eletal muscle relaxationJ A. general anaesthesia B. local anaesthesia C. tranuiliers !. sedati#es 96. Used to produce pain control +ithout rendering the client unconsciousJ A. general anaesthesia B. local anaesthesia C. tranuiliers !. sedati#es ;. )he stage of anaesthesia +here the patient is in complete respiratory depressionJ A. stage 1 B. stage 2 C. stage ' !. stage 1. )he stage of anaesthesia +here the operation beginsJ A. stage 1 B. stage 2 C. stage ' !. stage 2.)he stage of anaesthesia +here the client becomes dro+sy and losses consciousnessJ A. stage 1 B. stage 2 C. stage ' !. stage '. %t is also $no+n as the stage of excitementJ A. stage 1 B. stage 2 C. stage ' !. stage . )o pre#ent air+ay obstruction in the postoperati#e patient +ho is unconscious or semiconscious, the nurse A. encourages deep breathing. B. ele#ates the head of the bed. C. administers oxygen per mas$. !. positions the patient in a side@lying position.-. (hich of the follo+ing should be included in the plan of care for a patient +ho had spinal anesthesia/ A. 4le#ating the head of the bed to decrease nausea B. 4le#ating the patients feet to increase blood pressure C. %nstructing the patient to remain flat in bed for 9 hours !. Administering oxygen to reduce hypoxia produced by spinal anesthesia -. (hich of the follo+ing may be left in place +hen a patient is sent to the operating room/ A. (ig B. Hearing aid C. 4ngagement ring !. (ell@fitting dentures 9. (hich of the follo+ing nursing inter#entions should recei#e highest priority +hen a patient is admitted to the postanesthesia care unit/ A. &ositioning the patient B. bser#ing the operati#e site C. Chec$ing the postoperati#e orders !. 8ecei#ing report from operating room personnel.
. (hat +ould be the most effecti#e +ay for a nurse to #alidate Linformed consentL/ A. As$ the family +hether the patient understands the procedure. B. Chec$ the chart for a completed and signed consent form. C. As$ the patient +hat he or she understands regarding the procedure. !. !etermine from the physician +hat +as discussed +ith the patient. 3. )he reason pts are sent to a &ACU after surgery is= A. to be monitored +hile reco#ering from anesthesia. B. to remain near the surgeon immediately after surgery. C. to allo+ the medical@surgical unit time to prepare for transfer. !. to pro#ide time for the pt to cope +ith the effects of surgery. 6. &atients may experience +hich problem 2@3 hrs post@op as a result of anesthetics/ A. colitis B. "tomatitis C. &aralytic ileus !. 7astrocolic reflux 3;. A nurse is assessing a pt +ith a closed chest tube drainage s ystem connected to suction. (hich finding +ould reuire additional e#aluation in the post@operati#e period/ -
A. -ml of bright red drainage in the system. B.Column of +ater 2;cm high in the suction control chamber. C. Constant bubbling in the +ater seal chamber !.*one of the abo#e. 31. )he nurse is pro#iding teaching to a patient regarding pain control after surgery. )he nurse informs the patient that the best time to reuest pain medication is= A. Before the pain becomes se#ere. B. (hen the patient experiences a pain rating of 1; on a 1@to@1; pain scale. C. After the pain becomes se#ere and relaxation techniues ha#e failed. !. (hen there is no pain, but it is time for the medication to be administered. 32. )he &ACU has recei#ed a semiconscious patient from the operating room and re#ie+s the chart for orders related to positioning of the patient. )here are no specific orders on the chart related to specific orders for the patients position. %n this situation, in +hat position +ill the nurse place the patient/ A. )rendelenburg position B. &rone position C. "ide@lying position !. "upine position 3'. "igns of il$y +hite anesthetic use in sedating patients A. Uro#ison C. Allopurinol B. &ropofol !. )racrium 3. !r. Mohnson is ligating the bleeders, 7ray the scrubber +ould offer A. "il$ C. Chromic B. &lain !. Ficryl 3-. Another term for cigarette drain A. ':2 penrose drain C. 1 inch penrose drain B. N penrose drain !. none of these 39. >easures the 2 saturation of the body A. >anometer C. Cardiac monitor B. &ulse oximeter !. &ulse probe 3. 7i#en as &re@& medication to inhibit secretions A. 4pinephrine C. )racrium B. A)" !. &lasil
33. >rs. "anders is going to prep her patient, she +ill prepare the follo+ing= A. Cidex C. &o#idone@iodine B. )riiodine HC< !. Chlorhexidine gluconate 36. 5acilitates insertion of endotracheal tube= A. )racheostomy tube C. )horacic Catheter B. easure inta$e O output B. Chech )emperature !. none of these 61. )he purpose of pre@op s$in prep is to= A. 8educe the nimber of microorganism C. All of the abo#e B. 8ender s$in sterile 62. )he primary goal of *& before surgery is to pre#ent= A. Aspiration C. %nfection B. !istention !. bstruction 6'. (hich is not correct in the follo+ing statements about the principles o f surgical asepsis/ A. Al+ays face the sterile area B. )able are sterile only at table le#el C. "terile persons touch only sterile items !. )ying the go+n of the surgeon at the bac$ 9
6. &hase of preoperati#e nursing +hich begins +hen the client is transferred to the r table and ends +ith the admission of the clients to the reco#ery room= A. %ntra@op C. &re@op B. &ost@op !. none of these 6-. Another term for round nose= A. 8ing forcep C. >ayo forcep B. 0elly 5orcep !. Allis forcep 69. "ponge Bob is explaining some of the common term used in 8, sterile field means = A. 5ree of microorganism B. )he area around the incision site, mayo table , sterile drapes and instruments, surgical field C. "terile instruments !. none of these 6. "urgery that must be performed ")A) to preser#e life, maintain an organ or limb function and to stop bleeding= A. %mperati#e nursing C. 8euired surgery B. 4lecti#e surgery !. 4mergency surgery 63. 7i#e meaning of adhesion= A. Union of t+o normally separate surfaces C. !e#iation from the normal B. Hypertrophy of an organ !. none of these 66. Anastomosis means= A. Adjoining parts C. !estruction of tissue B. Connection bet+een t+o organs of parts !. 5olds into lumen 1;;. 8rhaphy is to repairJ otomy is to= A. "urgical remo#al C. "urgical attachment B. "craping of body ca#ity !. none of these GOOD LUC!$$$
&repared by= >rs. Macueline 7. 8ios 8.*., >.A.* Ad#iser B"* %F@5 *oted by= >rs. >a. Mosephine B. &ro#ido 8.*., >.A.*. !ean, College of *ursing
