CONCEPT: STANDARD PRECAUTIONS The nurse is explaining standard precaution to the client.

. This includes which of the following actions? Wearing protective equipment when doing any nursing procedures The nurse is changing the wound dressing of the client. The MOST appropriate action od the nurse would be to : Open the sterile dressings with the sterile gloves. The client has an order for contact precaution. The nurse is to give her a bath. The precautionary measure that the nurse observes is to use: Gloves and gown. The clinical instructor in the Surgical Unit is teaching the nursing students about the prevention of spread of diseases in the health care environment. hich of the following is the MOST important practical way to prevent the spread of disease? Consistently washing hands The nurse is to perform a sterile procedure while assisting in minor surgery. hich of the following actions of the nurse maintain aseptic techni!ue? Keeping the sterile field within the view " staff nurse in the emergency room is well#li$e by her colleagues because she could easily relate well with the co#wor$ers. %or the past & months she has been absent '#( times. She has been given a written admonishment for unexcused absence. hich of the following is the best course of action of the head nurse? Dismissal CONCEPT: IMPAIRED NURSE hich of the following should be appropriate action of the nurse? Write an incident report and submit to administration To be vigilant when a co#wor$er is suspected of abusing chemicals) it is imperative for the nurse to assess which of the following substances abuse indications Defensive when questions on the discrepancies in the narcotic control E cessive wor! related tardiness" absence and accidents #ccurate but sloppy documentation $ocial isolation %"&"' *ealth care agencies have policies in place for +,o -ot .esuscitate/0,-.1 decisions when the client is either comatose or near death. 2n this situation) which of the following should be the responsibility of the nurse? #scertain that a written order D() from the physician is in place hich of the following should the nurse ta$e into consideration) when the client has ,-. order? *he D() order is not separate from other aspects of client+s care " nurse in the 3ancer Unit is in a !uandary in carrying out a ,-. order due to personal beliefs. hich of the following should be the appropriate action of the nurse in this situation? Consider a change of assignment CONCEPT: COLLABORATION AMONG MULTIDISCIPLINARY TEAM ,octor4s orders are medical interventions that the nurse is expected to implement. 5y education and training the nurse may choose not to follow doctor4s order. hich of the following statement is -OT true? *he nurse has less training than the doctor and clarifying an order is against hospital protocol The nurse carries out nurse#initiated interventions which are referred to as independent

functions. These functions are: #. #ctions based on nursing diagnoses for the benefit of the client and not under supervision from other health team members. " client sustained multiple in6uries from a vehicular accident. To maintain his level of health) he will need the health team. hich of the following illustrate this $ind of interventions? Collaborative " new staff nurse is attending an orientation program. The supervisor emphasi7es close collaboration with the health team as an important function of the nurse. The nurse demonstrate this when she: ,dentifies the community health centers that the client can visit when discharged. " client is admitted with a medical diagnosis of acute gastroenteritis with severe dehydration. The nurse recogni7es that when caring for this client) she will be doing mostly: 8. ,ependent nursing functions &. 2ndependent nursing interventions 9. ,ischarge planning with the physician in charge '. ,elegation of nursing functions to the nursing aide %"&"' CONCEPT: PROBLEMS IN BOWEL MOVEMENT "n active woman in her mid#twenties has been on weight loss diet of low carbohydrates and high protein diet. She is successful on losing weight but is experiencing constipation. hich of the following should the nurse advice the client to ":O2, constipation? Eat nutrient dense food that are low calorie but have high nutrient value and fiber li!e broccoli" berries ;ou are administering soapsuds enema to a client. ,uring the procedure) the cleient complains of abdominal cramping. ;our most appropriate initial nursing approach would be to : Clamp the enema tubing to stop flow of the fluids ;ou are ta$ing care of a client with fecal incontinence. ;ou are aware that this client has a ris$ for in6ury due to: -alls when trying to go to the bathroom " client is brought to the hospital due to severe diarrhea. hich of the following is a ma6or problem of the client re!uiring immediate management by the health team? $evere fluid electrolyte imbalance " client had abdominal surgery under general anesthesia) would most li$ely experience. *olerance for solid food immediately after surgery CONCEPT: NURSING RESEARCH # researcher investigated the effect of crossing of a leg at the !nee during blood pressure measurement on the client+s blood pressure. .articipants were recruited from the outpatients of a government training hospital consisting of /0 males and /0 females"&%to10 years of age with a diagnosis of hypertension. hich of the following describes this type of research? 2uantitative research The researcher explains to the participants the nature of the study. hich of the following describes the action of the researcher? -ull disclosure

The researcher !uestion for this study may be stated as follows: What is the effect of crossing a leg at the !nee on the blood pressure of the participants hich of the following is appropriate instrument in measuring the dependent variable? Observational rating instrument The researcher found out that the blood pressure measurements are higher when a leg is crossed at the $nee and that the probability is less than 8 in 8<)<<<. ith these findings the researcher concludes that: *here is an increase in blood pressure when a leg is crossed at the !nee CONCEPT: NUTRITION AND NUTRITIONAL DEFICIENCY The nurse is teaching a family to ta$e food with high protein content. She discovers that the family4s consideration is the high cost of food. hich of the following affordable high protein food should the nurse recommend? -ried rice and dried fish ,uring the follow up visit the client as$ the nurse foods that are complete in protein which of the following should the nurse recommend? Eggs coo!ed in any style " mother as$s the nurse what finger food is safe for her toddler. =nowing that children can easily cho$e on food) the nurse should advice the mother to feed the toddler which of the following foods? Cereal li!e cheerio " client diagnosed with peptic ulcer as$s you what food is best to add to his diet so as not to exacerbate his symptoms. hich of the following is the most appropriate food for the client? -requent inta!e of mil! " mother as$s if teenagers re!uire special diet since teenagers rapidly grow at this time. The nurse informs the mother that: 3oys and girls should have food low in calories to prevent adolescent obesity CONCEPT: PHYSICAL EXAMINATION hile ta$ing the health history of the client) she tells the nurse that she has occasional episodes of palpitation that would last for about '( minutes to an hour. To further explore this information) the 5>ST !uestion that the nurse would as$ the client would be: 45ow frequently does this episode of palpitation happen to you67 " female client is in the >mergency Unit with chief complaints of difficulty of breathing and is receiving oxygen inhalation. To obtain a complete health history of the client) the 5>ST nursing approach is to: -ocus on the physical e amination and obtain data from the chart " client has 6ust been transferred to the Surgical Unit after $nee surgery. The nurse needs to assess the circulation of the right lower leg. hich of the following is the 2-2T2"? approach of the nurse? ,nspect the color of the foot hile performing a physical examination to an @& year old male client) the nurse modifies her examination to consider the client4s general wea$ness and reduce ability to move in bed. hich of the following is the MOST appropriate nursing action? $equencing the e amination to minimi8e changing client+s position The nurse is auscultating the client4s heart. hich of the following is the 5>ST position for the client to enable the nurse to hear all areas and high#pitched murmurs? $itting and leaning forward

CONCEPT: NURSE PATIENT RELATIONSHIP hich of the following best describe the feelings that the nurse experience towards the client? Counter transference The nurse uses the concept of the therapeutic use of self when she: 3ecomes self9 aware and manages his feeling for the client The client is informed that he has a stage 2: colon cancer) he reali7es he is dying and his family has difficulty with his impending death. The nurse deals with his own personal feeling about death and grieving in order to: #ssist client and family e press feelings on their impending loss One afternoon) the nurse enters the room and the client tells the nurse +Stop bothering me) leave me alone. 2 don4t want anyone4s pity./ The most appropriate response of the nurse is to say: 4#lright" , understand and will leave you for a while.7 " therapeutic relationship exists when the: (urse and client wor! together to tal! about how clients needs may be met. CONCEPT: CONTINUOUS PERSONAL AND PROFESSIONAL DEVELOPMENT " post surgical client is assigned to the nurse has an order of pain medication through a patient controlled analgesia 0A3"1. The nurse has no prior experience in the use of A" with clients. 3onsidering the time frame) which of the following is the MOST appropriate action of the nurse? $ecure assistance before implementation The focus of care is to shorten hospital stay by moving clients from acute care setting to community based cares setting which of the following are the components of health care delivery that are important to improve the health of the general public? #cute care and community health care setting hen a nurse acts +professionally/ it implies that she: ,s !nowledgeable" conscientious and responsible to self and others. -ursing as a profession re!uires its member to possess a significant amount of education. The route for an individual to become an .- in the Ahilippines is through completion of: Degree of 3achelor of $cience in (ursing and eligible to ta!e the (urse :icensure E amination To remain current un nursing s$ills $nowledge and theory) a nurse who wor$s in a geriatric unit plans to attend a continuing education program 03A>1 in the care of elderly clients. The following about 3A> are true >B3>AT: ,t is a response to scientific and technological advances to ma!e nurses globally competitive. CONCEPT: NURSING PROCEDURES hen administering oxygen therapy to a client the ?>"ST li$ely to cause anxiety is the use of: (asal cannula hich of the following is a ma6or consideration in determining the method oof oxygen administration to a specific client? .athologic condition of the client The nurse is assisting a client who has an order for postural drainage. To help the client obtain maximum benefits after the procedure) the nurse should: Elevate the head of the bed to promote comfort. hen doing postural drainage for the client) measures should be ta$en to minimi7e

which of the following conditions? 8. %atigue and pain &. CCCCCCC 9. "nxiety and discomfort '. 3oughing %"&"' The nurse is ta$ing care of a client with asthma. ,uring auscultation) she expects to hear whee7ing which would sounds li$e: 5igh pitched musical sounds CONCEPT: BLOOD TRANSFUSION This is the first time the client will have a blood transfusion. *e and his family are very worried about the procedures. ;our MOST appropriate nursing intervention would be: *al! to the client and family and inquire what their fears about blood transfusion The nurse prepares the following e!uipment for blood transfusion >B3>AT: ,; infusion set with gauge && needle The nurse understands that normal saline solution is used to initiate the intravenous infusion rather than dextrose solution before blood transfusion to: #void hemolysis and clumping of red blood cells The nurse stays and observes closely the client after the start of the blood transfusion for possible transfusion reaction which includes the following except: 5ypovolemic reaction "fter starting blood transfusion ) the nurse should ma$e sure that the blood is transfused to the patient within how many hours from the time it started? < hours CONCEPT: CARE OF THE ELDERLY hile examining an elderly female client ) the nurse notes mus$y sour body odor of the client indicating poor hygiene. hich of the following is the MOST appropriate action of the nurse? 5elp the client bathe several times wee!ly The client is wea$ and needs to be moved up in her bed. To reduce shearing force when moving the client the nurse should: =se a draw sheet to put the client in correct position The client has been on bed rest and has reddening of the s$in at bony prominences. hen moving the client up in her bed the nurse places her arms across her chest. This is done to: )educe the surface that will come in contact with the bed. The nurse reports that a client) appears uncomfortable and covers herself with bed sheets on a warm day. The nurse as$s permission to pill out the sheet but noted urine smell and wet bed sheets. She persuades the client to get up and shower. The client refuses and becomes teary eyed. The most appropriate therapeutic statement by the nurse would be: 4, understand how you feel but it is my responsibility to ta!e care of you.7 The client agrees to ta$e a shower. hile the client is being assisted to the bathroom she begins to fall. hich of the following should be the initial action of the nurse Call for immediate help CONCEPT: THERAPEUTIC COMMUNICATION " client in her early twenties was recently diagnosed with breast cancer. She says to the nurse) + hy did this happen to me? ,o 2 deserve this when 2 have been very

good to others?/ .rovide reassurance by recogni8ing how difficult her situation must be. The nurse found a &@ year old client who had hysterectomy crying while alone in her room. hat should be the nurse4s initial approach? #s! her what seems to be troubling her. The doctor orders the insertion of nasogastric tube for the client who refused to eat. She has severe weight loss. She remove the tube and says) +2 don4t need that thing/ the most appropriate nursing response is: *ell me what you don+t li!e about the tube6 " client is admitted to the hospital for diabetes accompanied by her son. The son is telling the nurse about his difficulty in ta$ing care of his mother. The nurse is using non#therapeutic communication when she says: >aybe putting her in a home for elderly people will be best for her.7 The nurse is establishing her presence to the client as part of her nursing care. This is best interpreted as: 3eing with the client always CONCEPT: PERIOPERATIVE NURSING 2n the immediate postoperative period) the nurse assesses coarse) high pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should 2MM>,2"T>?;: $uction the tracheostomy tube hich of the following expected outcomes for the patient is MOST relevant for the nursing diagnosis) /at ris$ for imbalanced nutrition related to impaired swallowing/? Oral inta!e increased The nurse is preparing "nthony for discharge. The following are instructions regarding stoma and postlaryngectomy care >B3>AT: 2nstruct client to assume supine position as necessary. CONCEPT: NURSING LEADERSHIP AND MANAGEMENT The nurse who effectively analy7es the communication process recogni7es that messages are: :erbal and -on#verbal 5asically) communication is part and parcel of planning to manage client care. hich of the following s$ills should be included? Select all that apply. 8. %ocusing &. Observing 9. "ttending '. 3larifying (. .esponding D. Teaching 8)&)9)' The most controversial way of communicating doctor4s orders is by phone. 2t becomes valid and legal only when: signed by the physician who gave the order To facilitate effective communication between an immediate post# op client and the nurse) heEshe should: assists the client to a comfortable and safe position while heEshe explains what measures are being done The nurse instructs the nursing attendant to perform cleansing enema until the return flow clear. The nursing attendant understood the instruction when she says +2 willF/

+stop the enema only if the return flow is without formed fecal material./

CONCEPT: POST OPERATIVE INFECTION -urse Mercy is setting up for an emergency 3esarean Section. The linen pac$s were damp although these were 6ust ta$en from the sterili7er. The nurse4s "AA.OA.2"T> action is: change the damp linen pac$. The clinical instructor assigned a nursing student to assist in the operation. hen the nursing student entered the O. suite) her curly long hair was not completely covered by the head cap. hat would the circulating nurse do? assist the nursing student to tuc$#in all her hair inside the head cap "fter the surgeon finished doing the surgical hand scrub) she came in to the O. suite swinging her hands casually. The scrub nurse would do which of the following "AA.OA.2"T> action? Offer a sterile towel to dry her hands. hen the intern in# charge did the s$in prep and catheteri7ed the patient) the circulating nurse noticed when the intern withdrew the catheter from the vagina. hat is your "AA.OA.2"T> and 2MM>,2"T> action? "pply the dressings and tape and then remove his gloves CONCEPT: SURGERY AND POST ANESTHESIA CARE UNIT The nurse who admitted the patient recogni7es that 5ilroth 22 procedure means: gastro6e6unostomy "fter admitting the client to the A"3U) the %2.ST action of the nurse should be: "ssess patency of airway "s the nurse monitors the client she notices a bright red spot on the dressings which measures ' cm diameter. The nurse would initially do which "AA.OA.2"T> nursing intervention? "ssess for presence of drain 2n assisting the client to do deep breathing) coughing and turning to the sides on the first post operative day) which nursing action would be MOST helpful for the client? apply abdominal splint 0pillow1 while coughing. The client complained of abdominal pain) nausea and vomiting with abdominal distention. The nurse anticipates which of the following A.2O.2T; management after referring to the surgeon? Aossible surgery CONCEPT: STANDARD NURSING CARE Mrs. 3. Serdenio is currently enrolled in the masters program at the State University and is currently writing her thesis. She applied as a chief nurse in St. Gohn4s *ospital and was accepted. Since her assumption to office) she has been signing documents as a Masters graduate affixing +.-) M"-/ to her name. The action of the chief nurse constitutes a: Misrepresentation The charge nurse reported to the chief nurse that the ,emerol (< cc vial inventory has been incorrect for the last &' hours. The MOST appropriate action of the narcotic nurse is: review endorsement of clients who received ,emerol within the last &' hours. " staff nurse was found charting blood glucose result without actually doing the procedure. hat is the "AA.OA.2"T> initial action of the senior nurse?

write an incident report hile ma$ing your A.M. shift endorsement) you saw the nursing attendant receiving a pac$age from a patient4s watcher. ;our "AA.OA.2"T> action would be: review wth the nursing attendant the hospital policy. The 3ode of >thics states that the nurse4s primary commitment is to the client whether an individual or family) group or community. hich nursing activity would best demonstrate the ethical principle called 6ustice? the nurses providing care to maximi7e health according to available resources.

S2TU"T2O- D: -urse %ely is in charge of a client who was admitted for management of acute episode of cholecystitis. -urse %ely did her admission assessment. She understands that the pain is characteri7ed as: tenderness and rigidity of the upper right abdomen radiating to the midsternal area. To confirm the diagnosis of cholecystitis) the attending physician ordered the procedure that can detect gallstones as small a 8 to & cm and inflammation. -urse %ely would prepare the client for which specific diagnostic procedure? Ultrasonography The diagnosis was confirmed as cholecystitis with gallstones. The doctor prepared the client for the removal of his gallbladder. The client as$s the nurse +how will this procedure affect my digestion?/ the nurse4s Most correct response would be: /The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications/ .eviewing the laboratory findings of the client) the nurse found which findings are elevated? 8. hite blood cell count &. Total serum bilirubin 9. "l$aline phosphate '. .ed blood cell count (. 3holesterol D. Serum amylase 8)&)9) " T#Tube was inserted and the doctor ordered: HMonitor the amount ) color) consistency and odor of drainage/. hich of the following procedures can the nurse perform without the doctor4s order? >mptying the drainage CONCEPT: APPENDICITIS 5ased on the initial assessment on admission) the nurse is loo$ing for positive manifestations of appendicitis) which includes the following >B3>AT: Thrombocytopenia " positive sin of appendicitis is located and rebound tenderness on palpation at which !uadrant on the abdomen. .ight lower !uadrant Maryrose is scheduled to undergo appendectomy. Areparation for appendectomy includes the following. Select all that apply. 8. 2ntravenous infusion &. ?axative 9. Aurbic area shaving '. >nema

(. Shower D. Aain medication 5.8)9)( The nurse would monitor for signs of peritonitis) a potential postoperative complications. The manifestations include the following >B3>AT: Tachycardia 2ntravenous therapy was prescribed to Maryrose. hich of the following is -OT an indication of the therapy? %or parenteral nutrition CONCEPT: DRUG ADMINISTRATION " nurse is obligated to carry out a physician4s order >B3>AT: 5elieves an order to be inappropriate or inaccurate. hen do you carry out the order of a physician? hen the physician has signed his orders. " nurse encounters a client who refuses to ta$e a prescribed medication. hat is the "AA.OA.2"T> action of the nurse? ?et the client sign a waiver. 2n case of telephone order) the concerned physician needs to countersign the order within: "s soon as possible The nurse should ensure that all components of medications are documented. 2dentify all these components. 8. ,osage) route and fre!uency &. -ame of client and medication 9. ,ate and time the medication was ordered. '. ,osage) route) fre!uency and strength. (. Ahysician4s signature and specialty D. Ahysician4s signature and A.3 licensure number. "ll except ' and ( SITUATION 9: Nurse Mercy is assig e! i "#e $e!ica%& surgica% u i" a ! $'s" '( "#e c%ie "s assig e! "' #er )ere e%!er%y c%ie "s* %or a client complaining of mild musculos$eletal pain) the nurse will anticipate that the treatment for this client4s level of discomfort will include which of the following? "cetaminophen Mercy was to in6ect :itamin 5 intramuscularly t another elderly patient. 5efore in6ecting) the nurse explained that the client may feel some discomfort this is an example of: "nticipatory response Mr. Iome7) J8 years old has a history of chronic bac$ pain. > thin$s that his family perceives him as a +wea$ling/ because he often as$ for pain medication. hich of the following is the most therapeutic response of the nurse? +3hronic bac$ pain is very difficult to manageK use pain medication because that is what it is for./ Mang Aedring has chronic pain due to osteoarthritis but has impaired speech. hich of the following is the MOST appropriate to determine his medication need for pain? "s$ing the client to rate his pain on a scale of < to 8< by writing on a magic slate. "ling Guana) DJ) diabetic) complained of elevated blood glucose since she strained her bac$ a wee$ ago despite following her diet and drug prescription. ;our best

explanation would be Ahysiologic and physiologic stress can elevate blood glucose level CONCEPT: NURSING RESEARCH A "ea$ researc#ers +r'+'se! a s"u!y ' "#e i !i,i!ua% e((ec" '( +re'+era"i,e "eac#i g ' "#e ear%y a$-u%a"i' '( )'$e )#' #a,e u !erg' e a-!'$i a% #ys"erec"'$y* Targe" +'+u%a"i' are )'$e a!$i""e! ' "#e sa$e !ay ('r "'"a% a-!'$i a% #ys"erec"'$y* hich of the following is the MOST appropriate method to use? >xperimental method hich of the following designs would be MOST appropriate to use in attempting to determine of the participant4s early ambulation after they will be given preoperative teachings? Time series design 2n the proposed study) the researchers defined the selected groups and as$ what sample si7e should be used. Since there are many !ualifiers that to some extent samples must be specific to the study) the general rule in the sample si7e is to: >stablish number of variables. The independent variable that is manipulated is: Areoperative teachings 2n treating the data to be collected) the researcher will use which of the following statistical tools? Aearson r coefficient of correction SITUATION: PAIN AND PAIN MANAGEMENT "lbert came to the hospital with chest pain and fever. "fter thorough assessment by the doctor he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. ,escribe this position. Sit the client upright and lean forward. The nurse is aware that pericarditis pain varies from mild to severe and is typically aggravated by: 2nspiration) coughing and movement of the upper body "lbert4s mother as$s why the client4s breathing is shallow. The 3O..>3T response of the nurse would be: +.espiratory movement intensifies pericardial pain/ "lbert is prescribed -S"2, every four hours to relieve fever) inflammation and pericardial pain. To maximi7e the effect of the drug) the nurse would administer it: .ound the cloc$ on a consistent basis. The nurse wants to $now if the client is aware of the side effects of -S"2,. hat would be the MOST appropriate !uestion of the nurse? +*ave you ever vomited blood or noticed very blac$ stool?/ CONCEPT: ACROMEGALY -urse 3arla is aware that acromegaly is a condition when growth hormone occurs in excess in adulthood or after epiphyses of the long bones have fused. The following are the typical physical features of the disorder) >B3>AT: The client grows taller The client was prescribed Octreotide "cetate0Sandostatin1. -urse 3arla would monitor for which of the following side effects? "bdominal pain

8. &. 9. '.

%or effective dosing) Octreotide "cetate must be administered by which appropriate route) three times wee$ly? Subcutaneously Ariority discharge plans should include which of the following. Select all that apply. %asting blood sugar monitoring 5one assessment 2nta$e and output Urine output 8)& and 9 "cromegaly often developed insidiously that nurses should understand that the client with disorder would see$ medical care because of: changes in appearance.

CONCEPT: HEALTHY LIFESTYLE " client who has been diagnosed with gout as$s which food to avoid so that the family can provide support. hich food highest in purine content should the nurse exclude from the dietary plan? ?iver " 9< years old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that exercise can help to $eep the total cholesterol to a desired level of: &<< mgEdl Gune) hypertensive client is ta$ing herbal substance for his hypertension. *e was prescribed antihypertensive medication. The client would li$e to continue ta$ing his herbal substance to lower hs 5A. The nurses MOST "AA.OA.2"T> action is: tell the client that herbal substances have no proven therapeutic effects Gune was placed on a low sodium diet. The wife as$s the nurse which foods to include in the client4s diet while at home. The nurse would instruct to include the following: %ruits and vegetables hile the nurse was chec$ing the 5A of the client) the wife was intently observing the nurse. The wife as$s the nurse how to ensure accurate measurement of 5A reading. 2dentify all that the nurse mentioned that will ensure accurate 5A reading. 8. Ta$ing the 5A 8( minutes after inta$e of antihypertensive drug. &. Measuring the 5A after the client has been seated for ( minutes. 9. Seating the client with arm bared supported and at heart level '. Using the cuff with rubber bladder that encircles at least @<L of the arm (. Iauges of 5A apparatus should be calibrated every D months. D. The client should rest !uietly for ( minutes before reading and can tal$ while 5A is being chec$ed. 8)&)9)') CONCEPT: DIA.ETES MELLITUS %rom the nursing history obtained from the client) which information is MOST li$ely related to the development of gangrene on the client4s left toe? "ccidental cut on big toe while cutting toenails. The physician ordered bilateral lower extremities ,oppler Ultrasound. hich of the following is the physician interested to find out through this diagnostic test? occlusion of large vessels and arterioles The senior nurse as$ed Marina to list nursing interventions for the nursing diagnosis +2neffective tissue perfusion: peripheral/. %rom the following list prepared by

Marina) which intervention will he senior nurse consider to be 3O-T."2-,23"T>,? maintain both e tremities in a dependent position hen Marina chec$ed the capillary blood glucose of the client at Dpm before meals as instructed by the senior nurse the result showed D( mgEdl. hich of the following will Marina do %2.ST? Give ?uice as prescribed in the insulin scale pre9meals. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse reports that Marina should improve in which of the following? compliance to standards

CONCEPT: HYPERTHYROIDISM A 34 year !" #e$a!e %!&e'( )&(* Gra+e, "&,ea,e )a, a"$&((e" # r (rea($e'(- T*e .*y,&%&a' .re,%r&/e" Pr .*y! T*yra%&! 0.r .y!(*& 1ra%&!2 ( (rea( (*e "&, r"er 5efore the nurse administers the medication) which of the following is MOST relevant for the nurse to as$? 4When was the last time you too! alcohol67 The client is prepared for surgery in about ten days time. ?ugol4s solution ' gtts A.O. was prescribed for 8< days. The client as$ed the nurse for purpose of drug. hich response of the nurse is correct? it decreases the ris!s for thyroid crisis. hen the client returns to the unit after surgery) which techni!ue is MOST appropriate to monitor bleeding from the incision? #ssess for dampness at the bac! of the client+s nec! hich of the following assessment findings when observed in a post thyroidectomy client is indicative of a thyroid crisis? 5igh fever "t the start of thyroid replacement post thyroidectomy) the nurse must monitor for side effects. hich side effects would the nurse expect to assess? Select all that apply: 8. *ypertension &. Tremors 9. *irtuism '. 2nsomnia (. Tachycardia D. *yperglycemia %"&" < and / CONCEPT: ETHICAL PRINCIPLES IN NURSING " client is being positioned for radical mastectomy and a couple of clinical cler$s wanted to come in to watch surgery. The circulating nurse advise them to enter the O. suite later. %oremost) the decision of the nurse is directed towards: preserving privacy -urse =ristine is to in6ect ,emerol J(mg to a post TU.A 0transurethral resection of the prostate1 client who is in pain. hen she chec$ed the -arcotic cabinet she found a vial that is almost empty. She was able to aspirate D<mg only. -urse =ristine decided to in6ect it instead of ma$ing the client wait until the next ,emerol vial is available. The action of the nurse violates which of the following ethical principle? 3eneficence -urse -ora is assigned on A.M. shift for the month of Gune. She re!uested the head

nurse if she can be on night or morning instead to be able to tutor her & sons in the elementary. The head nurse emphasi7ed that it is her turn to go on A.M. duty. The action of the head nurse exemplifies which of the following? #uthority " scrub nurse is assisting an emergency 3aesar Section on a 9M year old laundry woman. 5efore closing the peritoneum) the surgeon as$s +how old is the client?/ *olding the %allopian tube) the surgeon as$s for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said) +,octor there is no signed consent for tubal ligation/. The nurse 6ust demonstrated which of the following? #dvocacy "n officer in charge 0O231 signs a document for the chief nurse who went on leave. The Officer in 3harge signs her full name over the name of the chief nurse. The proper way to sign for the chief nurse who is on leave is: write 4for7 before the title of the chief nurse then sign your name above it.

CONCEPT: PERIOPERATIVE NURSING Scrub and circulating nurse should perform sponge count during which phases of an abdominal hysterectomy procedure? Select all that apply. 8. 5efore the procedure &. 5efore closing the endometrium 9. 5efore the closing of the peritoneum '. "t the s$in closure (. hen the scrub nurse goes for a lunch #ll e cept /

The O. nurse $nows that the correct way to count sponges is: scrub nurse and circulating nurse count singly" audible and concurrently. The scrub nurse and circulating nurse also counted the sharps and miscellaneous items li$e instruments before the procedure. 3ontinuous accounting for these items can primarily: minimi8e in?uries and or liabilities to sterile surgical team. The circulating nurse will document +surgical count/ in which of the following? intraoperative record hen the surgeon as$ed for suture to close the abdomen) sponge count has not been completed. hich of the following is the "AA.OA.2"T> action of the scrub nurse? informs the surgeon that sponge count has not been completed.

CONCEPT: REPORTING AND DOCUMENTING The change shift report of nurses describes the following >B3>AT: nurses preferred off duties hen the staff nurse on duty encounters a problem that cannot solved using nursing $nowledge) s$ills and available resources) it is 5>ST for the nurse to consult the: 5ead nurse hen the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists in the transition from one environment to another) she is doing a: )eferral " nurse has to attend a committee meeting for two hours. She delegates her wor$ to another nurse. hat primary consideration should be observed? competency to perform the given function.

hen a telephone order is made) it should be documented by the nurse who is receiving the order. The following should be included in the order to be executed >B3>AT: *ime the call was made and its duration

CONCEPT: NURSING 3URISPRUDENCE hich of the following 5>ST describes the responsibility of the nurse as a witness in a case in court? .rotect the patient hich doctrine is invo$ed if an abdominal x#ray of a post operative patient shows a forcep inside the abdomen? )es ,psa :aquitor hen nurse "be presents the patients chart as evidence of a case) this is called aEan: Duces *ecum hen a case is already filed in court) it is a court rule not to discuss the matter outside the court. This is .. $ub9?udice CONCEPT: POLYCYTHEMIA VERA ;ou planned the nursing care of the client together with the nursing student. ;ou as$ed the nursing student to enumerate the clinical manifestations of a client with polycythemia vera. ;ou expected the nursing student to enumerate the following manifestations: Generali8ed pruritus The nursing student reviews the laboratory findings and finds which blood result are elevated? )3C" W3C " .latelet count Ahlebotomy was ordered as part of the therapy. ;ou instructed the client and emphasi7ed that the procedure can be repeated. The clien in!uired) +what is the primary aim of the procedure?4 your "AA.OA.2"T> response is: 4!eep the hematocrit within the normal range7 The companion as$s why the client was advised to avoid iron supplements or vitamins. The 3O..>3T response of the nurse would be: 4these supplements enhance the production of )3C7 The client complained of generali7ed pruritus. The following are appropriate nursing intervention >B3>AT: 3athe in tepid or cool water followed by cocoa based lotion application