Saint Marys University SCHOOL OF HEALTH SCIENCES Bayombong, Nueva Vizcaya (Medicine Ward: Evaluation Examination)

Multiple Choices: Choose the best answer. Answer each question before the number. 1. A 45 year old client diagnosed with fluid volume overload due to acute kidney dysfunction is placed on a 1,000 ml fluid restriction per 24 hour period. The client ask the nurse why there is such a severe fluid restriction when I already have dry lips and mouth? which response by the nurse is best? a. The doctor ordered the fluid restriction, so u must comply with those orders b. Your kidneys are not able to eliminate extra fluid right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid c. You probably drunk too much fluid before you got sick, so u cant compare your usual intake to your limitations now that your kidneys are not working d. Too much fluid will cause your heart to fail and your lungs to fill with water, which could be fatal 2. The nurse is helping a client who was recently placed on a low-sodium diet to choose food for lunch. What lunch menu would be best for this client? a. Grilled chicken sandwich on white bread, apple, salad and ice tea b. Bologna sandwich on wheat bread, canned fruit cocktail, salad and a soda c. Canned hum and bean soap, fresh fruit salad, pickles and a diet soda d. Fast food cheese burger , grapes, pineapples and tomato juice 3. A 28 year old client was admitted with severe bleeding from a fractured femur. Which intravenous fluid does the nurse anticipate using as the most appropriate to replace potential fluid loss? A. Normal saline C. 5% dextrose in water B. 3% saline D. 5% dextrose in 0.0225 () saline 4. The nurse making rounds discovers D5W infusing at 75 ml/hour. The order for the client states, NSS at 75ml/hour. What is the best action should the nurse take first? A. Complete the infusion of D5W to avoid waste and then ensure that the next bag is correct B. Slow the infusion and contact the physician for current order C. Immediately change the infusion too the ordered solution D. Complete an unusual occurrence report and submit it to the supervisor 5. The nurse is monitoring intravenous fluid therapy for a client with hyponatremia. The nurse knows that which of the following types of solutions exerts the same osmotic pressure as the fluid on the other side of the cell membrane and thus maintains equilibrium and minimizes fluid shift? A. Hypertonic C. Hypotonic B. Hyperosmolar D. Isotonic 6. An indwelling Foley catheter has been inserted in an adult patient who was dehydrated from vomiting. Which urine output indicates that the patient received adequate fluid replacement? A. 5ml/hour C. 25ml/hour B. 15ml/hour D. 30ml/hour 7. A patient experiences orthostatic hypotension while receiving Furosemide (Lasix). The nurse should do which of the following? A. Administer IV fluid as ordered B. Administer a vasodilator as prescribed C. Instruct her to sit up several minutes before standing D. Insert an indwelling Foley catheter to track output 8. Basing on the symptoms presented by the patient, what would be the priority nursing diagnosis applicable for the patient? A. Impaired airway clearance related to productive cough B. Altered breathing pattern related to difficulty of breathing C. Fluid volume excess related to accumulation of fluid in the body as manifested by edema D. Impaired circulation related to decrease circulating blood volume 9. A client age 59, is transferred to the medical ward after being treated with nitroglycerin for an angina attack. To prevent further chest pain, the doctor prescribed beta-adrenergic blocker Propanolol (Inderal). The nurse assesses the patient before administering each dose. Which finding should prompt the nurse to withhold the drug and notify the doctor?

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A. Complains of chest pain C. Pulse rate greater than 90 beats/minute B. Systolic blood pressure less than 90 mmHg D. Diastolic blood pressure more than 80 mmHg The client was rushed in the emergency room because of the attack of hypertension. Upon checking the blood pressure the result was 150/100 mmHg. The client is scheduled for admission and most likely be given with an IVF of: A. D5LRS C. D5W B. D5NSS D. D5 0.3 NaCl A post MI client is complaining of chest pain after doing his ADLs and ask the nurse how to alleviate the pain. The nurse responds best by which of the following? A. Do relaxation technique like deep breathing exercises B. Just take a rest and the chest pain will subside C. Let me give you oxygen inhalation to alleviate the pain D. I have to give you nitroglycerin as prescribed by the physician The patient is has a CTT inserted in his chest wall. Upon assessing the tube, the nurse noticed that the bottle has continuous bubbling sound. Basing on the assessment, what is the best nursing priority? A. Inform the physician immediately B. Clamp the tube C. Record the data as normal assessment D. Let the patient take a deep breath and apply pressure in the insertion area During head-to-toe assessment, an emphysema patient suddenly experience severe difficulty of breathing accompanied by coughing. The nurse knows that the best nursing intervention to the patient is which of the following? A. Administer oxygen inhalation via nasal canula and the rate must be base on the patients alleviation of the symptom B. Let the patient breath in cuff hands C. Help the patient assume high-fowlers position D. Give Nebulization as ordered by the physician Ten minutes after infusing 1 pack of FWB to a patient with anemia, the patient suddenly experience severe headache accompanied with dizziness, chest pain and difficulty of breathing. Based on the manifestations, what blood transfusion reaction most likely happening to the patient? A. Allergic reaction C. Febrile reaction B. Anaphylactic Shock D. Hemolytic reaction What is the common reaction that may happen during the first 15 minutes of blood transfusion needs to be monitored? A. Allergic reaction C. Febrile reaction B. Anaphylactic Shock D. Hemolytic reaction Which of the following interventions is the most appropriate thing to do by the nurse when febrile reaction occurs during blood transfusion? A. Stop the blood transfusion and notify the physician immediately B. Assess the patient and record the data gathered C. Give Paracetamol as prescribed by the physician D. Stop the transfusion and open the IV line Which of the following nursing diagnosis that needs immediate response during blood transfusion? A. Altered temperature: Febrile C. Fluid volume excess B. Decrease cardiac output D. Acute pain

True or False 18. The rationale behind rotating injection site for insulin administration is to prevent lypodystropy. 19. The only insulin that can be given IV is short acting insulin. 20. The best site for insulin administration is the abdomen. 21. Clients with a glucose level of 200 before eating a regular meal must be given insulin. 22. Before doing strenuous activity, the client must take insulin as prescribed by the physician. 23. During diuretic therapy, the client must be closely monitored for signs and symptoms of electrolyte imbalances. 24. The strongest classification of diuretic therapy is loop diuretic. 25. The best parameter to consider that the client is properly hydrated is normal urine output. 26. After removal of CTT, the client must lie on the affected side to prevent entry of air into the pleural space.

27. The rationale behind insertion of CTT is to prevent increase pressure in the pleural spaces by removing excess air, water or blood inside the pleural spaces. 28. When the patient experience haemolytic reaction during blood transfusion, the nurse must stop the transfusion immediately and notify the physician. 29. Sterile gloving must always be done by the nurse in every procedure the nurse will perform. 30. Anything beyond the sterile field is always considered as unsterile. Identification: 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

Normal sodium level Normal osmolality level Blood transfusion reactions

Commonly occurs on the first 15 minutes of Blood Transfusion The only IV that is compatible with blood products Classification of diuretics

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