PALMR/MALADAPTIVE PATTERNS/ALTERATION IN THOUGHT AND PROCESS

1. In using liquid sterilizer or autoclave machine, which of the following is true?

A. Autoclave is better in sterilizing OR supplies versus liquid sterilizer
B. They are both capable of sterilizing the equipments, however, it is necessary to soak
supplies in the liquid sterilizer for a longer period of time.
C. Sharps are sterilized using autoclave and not cidex.
D. If liquid sterilizer sterilization process is used, rinsing it before using is not necessary.

Situation18: Elle Bishop, 20 years old, is admitted to the medical floor with
complains of fatigue, feeling of breathlessness, weight loss, productive cough
and dyspnea. Diagnostic testing confirmed her of having Emphysema.

2. When the alveoli lose their normal elasticity as a result of emphysema, Nurse Bob
teaches Elle exercises that lead to effective use of the diaphragm because:
a. Inspiration has been markedly prolonged and difficult
b. The residual capacity of the lungs has been increased
c. The client has an increase in the vital capacity of the lungs
d. Abdominal breathing is an effective compensatory mechanism that is
spontaneously initiated

3. Nurse Bob administers oxygen at 2 L/minute via nasal cannula to Elle. The nurse
should observe the client closely for:
a. Cyanosis and lethargy
b. Anxiety and tachycardia
c. Hyperemia and increased respirations
d. Drowsiness and decreased respirations

4. Elle experiences a sudden episode of shortness of breath. The physician diagnoses a

spontaneous pneumothorax. Nurse Bob is aware that the probable cause of the
spontaneous pneumothorax is a:
a. Pleural friction rub
b. Tracheoesophageal fistula
c. Rupture of a subpleural bleb
d. Puncture wound of the chest wall

5. When a spontaneous pneumothorax is suspected in a client with a history of

emphysema, the nurse should call the physician and:
a. Administer 60% oxygen via venturi mask
b. Place the client on the unaffected side
c. Give oxygen 2 L per minute via nasal cannula
d. Prepare for IV administration of electrolytes

SITUATION 19: Aguada, a client with leukemia, is in a clinic for her routine
check-up.
6. Which of the following is unlikely when assessing Aguada?
a. Small abdomen
b. Bruises and petechiae
c. Increased WBC count
d. Dyspnea during exercise

7. When evaluating the extent of Parkinsons disease, a nurse should observe for which
of the following conditions?
A. Bulging eyeball
B. Diminished distal sensation
C. Increased dopamine levels
D. Muscle rigidity
8. Which of the following statements best describes the cause of Parkinsons disease?
A. Loss of myelin sheath surrounding the peripheral nerves. -GBS
B. Degeneration of substantia negra, depleting dopamine.
C. Bleeding into the brain stem, resulting in motor dysfunction.-hemorrhagic
stroke (CVA)
D. An autoimmune disorder that destroys acetylcholine receptor. -MG

9. Which of the following conditions or activity may exacerbate multiple sclerosis? –

stress decreases immunity
A. Pregnancy
B. Range of motion exercise
C. Swimming
D. Urine retention

10. Which of the following symptoms of increased intracranial pressure (ICP) after head
trauma would appear first?
A. Restlessness and confusion
B. Large amounts of very dilute urine.
C. Bradycardia
D. Widened pulse pressure

11. After a brain stem infarction , the nurse would observe for which of the following
conditions?
A. Aphasia
B. Bradypnea
C. Contralateral hemiplegic
D. Numbness and tingling to the face or arm.

12. A client is newly diagnosed with myasthenia gravis. Client teaching would include
which the following conditions as the cause if this disease?
A. A post-viral illness characterized by ascending paralysis.-GBS
B. Loss of myelin shealth surrounding peripheral nerves. -GBS
C. Inability of the basal ganglia to produce sufficient dopamine. -parkinsons
D. Destruction of acetylcholine receptors causing muscle weakness.

13. Which of the following conditions is an early symptoms seen in myestrhenia gravis?
A. Dysphagia
B. Fatigue improving at the end of the day.
C. Ptosis
D. Respiratory distress

14. One hour after receiving pyridostigmin bromide ( Mestinon), A client reports difficulty
swallowing and excessive respiratory secretions. The nurse noptifies the physician and
prepares to administer which of the following medications?
A. Additional pyridostigmine
B. Atropine sulfate
C. Edrophonium chloride ( Tensilon)
D. Neostigmine methylsulfate ( Progtigmin)

15. A client with suspected multiple sclerosis (MS) undergoes a lumbar puncture.Which
of the following abnormalities is typically found in the cerebrospinal fluid of clients with
MS?
A. Increased RBC
B. Increased WBC or pus
C. Increased glucose concentration
 D. Increased protein levels.

16. Which of the following symptoms frequently occurs early in multiple sclerosis (MS)?
A. Hemiparesis C. Grief
B. Diplopia D. Recent memory loss

17. A client is noted to manifest right hemianopsia as a result of his CVA. The nurse
should:

A. Instruct the client to scan his surroundings

B. Corrects the client's misuse of equipment
C. Provide tactile stimulation to the client's
affected extremities
D. Teach the client to look at the position of his
right extremities
18. Which of the following is a sign if autonomic dysreflexia?
A. Hypotension C. Muscle weakness
B. Severe headache D. Sweating all over the body

19. During tonic-clonic seizures in a client lying in bed, the best nursing intervention is:
a. Insert a tongue blade into the client’s mouth.
b. Place a pillow under a client’s head.
c. Check the pulse oximeter.
d. Remove the bedside table.

20. Nurse Gelbert is caring for a client with a chief complaint of muscle weakness as the
day gets late. The client was diagnosed of Myesthenia Gravis.The nurse is assessing Mr.
Gilbert, who is diagnosed of Myesthenia Gravis. Which of the following is the initial
manifestation of Myesthenia Gravis?
A. Diplopia and ptosis
B. Bland facial expression
C. Dysuria
D. Respiratory failure

21. Nurse Gilbert is discussing to a group of students about MG and should include which
diagnostic test for Myesthenia Gravis?
A. Tensilon test C. CSF analysis – MS, GBS
B. PET scan D. CT scan

22. Which of the following is the first line of therapy for Myesthenia Gravis?
A. Pyridostigmine(Mestinon)
B. Corticosteroid
C. Atropine sulfate
D. Cyclosporin (Neoral)

23. Nurse Cyrus is assessing the client for Parkinson’s disease. Which of the following is
the initial sign of Parkinson’s disease?
A. Rigidity
B. Akinesia
C. Bradykinesia
D. Tremors

24. Which of the following is not included in the cardinal signs of Parkinson’s Disease?
A. Tremor
B. Rigidity
C. Bradykinesia
D. Alertness
25. The client is prescribed with Levodopa therapy for his Parkinson’s disease. Which of
the following improvement indicates effectiveness of the Levodopa?
A. Mood
B. Muscle rigidity
C. Appetite
D. Alertness

26. If “cholinergic crisis” occurs in the client who has myasthenia gravis, all
anticholinesterase drugs are withdrawn. To reduce symptoms, which drug should the
nurse be prepared to give?
A. Atropine
B. Ephedrine sulfate
C. Potassium chloride
D. Neostigmin bromide

27. Because medication have been increased for a client with myasthenia gravis, it is
important that the nurse observe for signs of “ cholinergic crisis”. These include:
A. Dilated pupils, profuse diaphoresis, and trembling.
B. Constricted pupils, hypersalivation, and hypotension.
C. Dilated pupils, nausea, and tachycardia.
D. Constricted pupils, dry mucous membranes, and bradycardia.

28. The patient was prescribed Levodopa. What is the action fo this drug?
A. Release dopamine and other catecholamines from neurological storage sites.
B. Decrease acetylcholine availability
C. Activates dopaminergic receptors in the basal ganglia.
D. Increase dopamine availability.

29. During the first 72 hours following a stroke, the nurse should position Mr. Enriquez:
A. In bed and lying on the side
B. With the head of the bed elevated 30 degrees and his head in a midline neutral
position.
C. With the head of the bed elevated 60 degrees and the knee gatch elevated.
D. Flat in bed with his head elevated on a pillow.

30. The Seventh Report of the Joint National Committee on

Prevention, Detection, Evaluation and Treatment of High Blood Pressure, blood pressure of
160/100 mmHg is in what stage of hypertension?
A. Stage I B. Stage II C. Stage III D. Stage IV

31. What is your follow-up teaching with your client having a blood pressure of 120/80 mmHg
based on “Recommendations for Follow-Up Based on Initial Blood Pressure Measurements for
Adults”?
A. Recheck in 2 years
B. Recheck in 1 year
C. Confirm within 2 months
D. Evaluate or refer to source of care within 1 month

32. A nursing student is teaching a patient and family about epilepsy prior to the
patient’s discharge. For which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”
B. “Wear your medical alert bracelet at all times.”
C. “Protect your loved one’s airway during a seizure.”
D.“It’s OK to take over-the-counter medications.”
33.A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical
Mobility related to neuromuscular impairment. You observe a new nurse performing all
these actions. For which action must you intervene?
a. The nurse assists the patient to ambulate to the bathroom and back to bed.
b. The nurse reminds the patient not to look at his feet when he is walking.
c. The nurse performs the patient’s complete bath and oral care.
d. The nurse sets up the patient’s tray and encourages patient to feed himself.

34. You are providing care for a patient with an acute hemorrhage stroke. The patient’s
husband has been reading a lot about strokes and asks why his wife did not receive
alteplase. What is your best response?
a. “Your wife was not admitted within the time frame that alteplase is usually
given.”
b. “This drug is used primarily for patients who experience an acute heart attack.”
c. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
d. “Your wife had gallbladder surgery just 6 months ago and this prevents the use of
alteplase.”

35. You are supervising a senior nursing student who is caring for a patient with a right
hemisphere stroke. Which action by the student nurse requires that you intervene?
a. The student instructs the patient to sit up straight, resulting in the patient’s
puzzled expression.
b. The student moves the patient’s tray to the right side of her over-bed tray.
c. The student assists the patient with passive range-of-motion (ROM) exercises.
d. The student combs the left side of the patient’s hair when the patient combs only
the right side.

36.Damage to which area of the brain results in receptive aphasia?

a. Parietal lobe
b. Occipital lobe
c. Temporal
d. Frontal

37. Normal cerebrospinal fluid contains all the following except:

a. White blood cells-for protection
b. Glucose
c. Clear liquid
d. Protein-indicates bacterial infection

38. The nurse identifies a nursing diagnosis of “Altered nutrition: less than body
requirements related to inability to feed self, “for a patient with right-sided hemiplegia.
Which of the following interventions is most appropriate to improve the patient’s
nutrition?
a. Assist the patient to eat with his left hand.
b. Provide a semi soft or pureed diet.
c. Stroke the patient’s throat.
d. Provide a wide variety of food choices on the meal tray.

39. A client with a severe brain injury receives IV mannitol and corticosteroids in the
emergency department. The desired effect of this treatment is to:
a. Improved renal function
b. Reduce cerebal edema
c. Promote cerebal vasodilation
d. Prevent central nervous system infection

40. A client with Parkinson’s disease is on Levodopa therapy. Improvement in which

following indicates an effective therapy?
 a. Alertness
b. Mood
c. Appetite
d. Muscle rigidity

41. A 67-year-old man has been admitted to the hospital for a surgical procedure.
During the admission process, the nurse asks whether he has a living will or a durable
power of attorney. The patient asks, "What is a living will?" The best response by the
nurse would be which of the following?
a. "A living will and a durable power of attorney are both advance directives."
b. "A living will states your wishes regarding future healthcare if you become
unable to give instructions."
c. "A living will identifies a person who will make healthcare decisions in the event
you are unable to do so."
d. "I will tell a case manager that you would like additional information."

42. A child's immunization may cause discomfort during administration, but the benefits
of protection from disease, both for the individual and society, outweigh the temporary
discomforts. Which principle is involved in this situation?
a. Fidelity
b. Beneficence
c. Nonmaleficence
d. Respect for autonomy

43. A client who had a "Do Not Resuscitate" order passed away. After verifying there is
no pulse or respirations, which of the following intervention the nurse should do next?
a. Have family members say goodbye to the deceased
b. Call the transplant team to retrieve vital organs
c. Remove all tubes and equipment (unless organ donation is to take place), clean
the body, and position appropriately.
d. Call the funeral director to come and get the body

44. A client's family member says to the nurse, "The doctor said he will provide palliative
care. What does that mean?" Which of the following is the nurse best response?
a. "Palliative care is given to those who have less than 6 months to live."
b. "Palliative care aims to relieve or reduce the symptoms of a disease."
c. "The goal of palliative care is to affect a cure of a serious illness or disease."
d. "Palliative care means the client and family take a more passive role and the
doctor focuses on the physiological needs of the client. The location of death will
most likely occur in the hospital setting."

45. A nurse is putting together an educational seminar on advance directives. What

information would be included in the materials?
a. A patient may change a treatment decision in an advance directive if the
patient's health care agent approves the change.
b. When admitted to the hospital, a patient must appoint a Durable Power of
Attorney for health care decisions.
c. A health care facility must provide a patient informational material advising
them of their rights to declare their desires concerning treatment decisions.
d. A health care facility is required to provide a patient an attorney when the
patient is signing a living will.

46. A nurse is teaching a staff seminar on patient confidentiality. Which of the following
statements would be included in the presentation?
a. Verbal consent is sufficient to allow family members to see a patient's medical
records.
b. If a family member is at the hospital, he or she would be entitled to an update
 on the patient's status.
c. All hospital staff may have access to a patient's medical records
d.Consent to disclosure is implied when a patient is transferred from one health
provider or facility to another.

47. A nurse may be convicted of false imprisonment for which behavior?

a. Putting the patient in fear of being harmed
b. Touching the patient without his/her consent
c. Putting a patient in restraints to prevent him from leaving
d. Yelling and screaming at the patient for trying to get out of bed without
assistance

48. Even though the nurse may obtain the clients signature on a form, obtaining
informed consent is the responsibility of the:
a. Client
b. Physician
c. Student Nurse
d. Charge Nurse

49. Evidence-based public health utilizes which of the following guidelines?

a. Application of program planning frameworks
b. Conducting evaluations
c. Disseminating what has been learned
d. All of the above

50. Finding resources to implement evidence-based practice (EBP) in community health

will continue to be a challenge because of the emphasis on quality care, equal
distribution of health care resources, and cost control. Which of the following would
demonstrate a creative strategy to implementing EBP?
a. Adopting quality indicators for evaluating websites claiming to contain EBP
b. Avoiding the issue of community politics
c. Creating the role of a knowledge manager
d. Making decisions on behalf of the community

Situation 14: Basic knowledge on Intravenous solutions is necessary for care of

clients with problems with fluids and electrolytes.

51. A client involved in a motor vehicle crash presents to the emergency department with
severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse
anticipates which of the following intravenous solutions will most likely be prescribed to
increase intravascular volume, replace immediate blood loss and increase blood pressure?
A. 0.45 % sodium chloride
B. Normal saline solution
C. o.33% sodium chloride
D. Lactated ringer’s solution

52. The physician orders the nurse to prepare an isotonic solution. Which of the following IV
solution would the nurse expect the intern to prescribe?
A. 5 % dextrose in water
B. 10 % dextrose in water
C. 0.45 % sodium chloride
D. 0.5 % dextrose in 0.9% sodium chloride

53. The nurse is making initial rounds on the nursing unit to assess the condition or assigned
clients. The nurse notes that the client’s IV site is cool, pale and swollen and the solution is
not infusing. The nurse concludes that which of the following complications has been
experienced by the client?
A. Infection
 B. Infiltration
C. Phlebitis
D. Thrombophlebitis

54. A nurse reviews the client’s electrolytes laboratory report and notes that
the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the
electrocardiogram as a result of the laboratory value?
A. U waves
B. Elevated T waves
C. P waves
D. Elevated ST segment

55. One patient has a runaway IV of 50 % dextrose. To prevent temporary excess of insulin
or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
order?
A. Any IV solution available to KVO
B. Isotonic solution
C. Hypertonic solution
D. Hypotonic solution

56. An informed consent is required for:

A. Closed reduction of a fracture
B. Insertion of intravenous catheter
C. Irrigation of the external ear canal
D.Urethral catheterization

57. Which of the following is not true with regards to the informed consent?
A. It should describe different treatment alternatives
B. It should contain a thorough and detailed explanation of the procedure to be done
C. It should describe the client’s diagnosis
D. It should given an explanation of the client’s prognosis

58. You know that the hallmark of nursing accountability is the:

A. Accurate documentation and reporting
B. Admitting your mistakes
C. Filing an incidence report
D. Reporting a medication error

59. A nurse is assigned to care for a group of clients. On review of the client’s medical
records the nurse determines that which client is at risk for excess fluid volume?
A. The client taking diuretics
B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning

60. A nurse is assigned to care for a group of clients. On review of the client’s medical
records, the nurse determines that which client is at risk for deficient fluid volume?
A. A client with colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigation

Situation: As a perioperative nurse, you are aware of the correct processing

methods for preparing instruments and other devices for patient use to prevent
infection.

61. As an OR nurse, what are your foremost considerations for selecting chemical agents for
disinfection?
A. Material compatibility and efficiency
B. Odor and availability/
 C. Cost and duration of disinfection process
D. Duration of disinfection and efficiency

62. Before you used disinfected instrument it is essential that you:

A. Rinse with tap water followed by alcohol
B. Wipe the instrument with sterile water
C. Dry the instrument thoroughly
D. Rinse with sterile water

63. You have a critical heat labile instrument to sterilize and are considering to use high
level of disinfectant. What should you do?
A. Cover the soaking vessel to contain the vapour
B. Double the amount of high level of disinfectant
C. Test the potency of the high level of disinfectant
D. Prolong the exposure time according to manufacturer’s direction

64. To achieve sterilization using disinfectants, which of the following is used?

A. Low level disinfectants immersion in 24 hours
B. Intermediate level disinfectants immersion in 12 hours
C. High level disinfectants immersion in 1 hour
D. High level disinfectants immersion in 10 hours

65. Bronchoscope, Thermometer, Endoscope, ET tube, Cystoscope are all BEST sterilized
using which of the following?
A. Autoclaving at 121 degree Celsius in 15 minutes
B. Flash sterilizer at 132 degree Celsius in 3 minutes
C. Ethylene Oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 10 hours

Situation: The OR is divided in three zones to control traffic flow and

contamination.

66. 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

67. Nursing intervention for a patient on low dose IV insulin therapy includes the following
EXCEPT:
A. Elevation of serum ketones to monitor ketosis
B. Vital signs including BP
C. Estimate serum potassium
D. Elevation of blood glucose levels

68. The doctor ordered to incorporate 1000 “u” insulin to the remaining ongoing IV. The
strength is 500/ml. How much should you incorporate into the IV solution?
A. 10 ml
B. 2 ml
C. 0.5 ml
D. 5 ml

69. Multiple vial-dose-insulin when in use should be:

A. Kept at room temperature
B. Kept in the refrigerator
C. Kept in narcotic cabinet
D. Store in the freezer

70. Insulin using insulin syringe are given using how many degrees of needle insertion?
A. 45
 b. 180
c. 90
d. 100

71. In a client with myasthenia gravis, priority nursing care is directed to conserve the
client’s energy and:
a. Ensure a safe environment
b. Maintain respiratory function
c. Provide psychological support and reassurance
d. Promote comfort and relieve pain

72. Gullian Bare’ is an autoimmune attack of the peripheral nerve myelin. The major
precipitating factor or predisposing event that may lead to this syndrome is a/an:
a. Change in weather
b. Exposure to allergens
c. Infection
d. Poor nutrition

73. Nurse Hannah is monitoring a client who has sustained a head injury following a
motorcycle accident. She would determine that the intracranial pressure (ICP) is rising if
which of the following vital sign trends is noted?
a. Increasing temperature, increasing pulse, increasing respirations, decreasing BP
b. Increasing temperature, increasing pulse, decreasing respirations, increasing BP
c. Decreasing temperature, increasing pulse, increasing respirations, decreasing BP
d. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

74. A client with spinal cord injury is at risk for experiencing autonomic dysreflexia. The
nurse would carefully monitor for which of the following manifestations?
a. Tachycardia
b. Hypotension
c. Severe, throbbing headache
d. Cyanosis of the head and neck

75. A client newly diagnosed with trigeminal nerve neuralgia asks the nurse to explain
why it hurts so much when an episode occurs. The nurse would explain that the pain in
trigeminal neuralgia is the result of which of the following?
a. Stimulation of the nerve by temperature or pressure
b. Irritation due to cellular effects of hypoglycemia
c. Release of epinephrine during the flight-or-fight response
d. An immune system reaction to cold and influenza virus

76. A client with hiatal hernia chronically experiences heartburn following meals. The
nurse
should plan to teach the client to avoid which action because it is contraindicated with a
hiataL hernia?
A. Lying recumbent following meals
B. Consuming small, frequent, bland meals
C. Raising the head of the bed on 6-inch blocks
D. Taking H2-receptor antagonist medication

77. A 66-year-old client has been complaining of sleeping more, increased

urination, anorexia, weakness, irritability, depression, and bone pain that
interferes with her going outdoors. Based on these assessment findings, the
nurse would suspect which of the following disorders?
a. Diabetes mellitus
b. Diabetes insipidus
 c. Hypoparathyroidism
d. Hyperparathyroidism

78. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment
finding would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen

79. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease."

80.After undergoing Billroth I gastric surgery, the client experiences fatigue and
complains of numbness and tingling in the feet and difficulties with balance. On the basis
of these symptoms, the nurse suspects which postoperative complication?
A. Stroke
B. Pernicious anemia
C. Bacterial meningitis
D. Peripheral arterial disease

81. The nurse obtains an admission history for a client with suspected peptic ulcer
disease (PUD). Which client factor documented by the nurse would increase the risk for
PUD?
A. Recently retired from a job
B. Significant other has a gastric ulcer
C. Occasionally drinks 1 cup of coffee in the morning
D. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis

82. The nurse is caring for a client with ulcerative colitis. Which finding does the nurse
determine is consistent with this diagnosis?
A. Hypercalcemia
B. Hypernatremia
C. Frothy, fatty stools
D. Decreased hemoglobin

83. The nurse has provided dietary instructions to a client with a diagnosis of peptic
ulcer disease. Which client statement indicates that education was effective?
A. "Baked foods such as chicken or fish are all right to eat."
B. "Citrus fruits and raw vegetables need to be included in my daily diet."
C. "I can drink beer as long as I consume only a moderate amount each day."
D. "I can drink coffee or tea as long as I limit the amount to 2 cups daily."

84. A client with peptic ulcer disease states that stress frequently causes exacerbation of
the disease. The nurse determines that which item mentioned by the client is most likely
to be responsible for the exacerbation?
A. Sleeping 8 to 10 hours a night
B. Ability to work at home periodically
C. Eating 5 or 6 small meals per day
D. Frequent need to work overtime on short notice
85. Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the
nurse instructs the client about the medication. Which statement made by the client
indicates a need for further teaching?
A. "The medication will cause constipation."
B. "I need to take the medication with meals."
C. "I may have increased sensitivity to sunlight."
D."This medication should be taken as prescribed."

86. A client with ulcerative colitis has a prescription to begin a salicylate compound
medication to reduce inflammation. What instruction should the nurse give the client
regarding when to take this medication?
A. On arising
B. After meals
C. On an empty stomach
D. 30 minutes before meals

Situation: Elderly clients usually produce unusual signs when it comes to different
diseases. The ageing process is a complicated process and the nurse should
understand that it is an inevitable fact and she must be prepared to care for the
growing elderly population.

87. Hypoxia may occur in the older patients because of which of the following physiologic
changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation
88. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity

89. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:
A. Dementia
B. functional decline
C. a visual problem
D. drug toxicity

90. Cardiac ischemia in an older patient usually produces:

A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion

91. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. Pain
D. decreased breath sounds with crackles

Situation: In the OR, there are safety protocols that should be followed. The OR
nurse should be well versed with all these to safeguard the safety and quality of
patient delivery outcome.

92. Which of the following should be given highest priority when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
 D. Check for jewelry, gown, manicure, and dentures

93. Surgeries like I and D (incision and drainage) and debridement are relatively short
procedures but considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference

94. OR nurses should be aware that maintaining the client’s safety is the overall goal of
nursing care during the intraoperative phase. As the circulating nurse, you make certain that
throughout the procedure:
A. the surgeon greets his client before induction of anesthesia
B. the surgeon and anesthesiologist are in tandem
C.strap made of strong non-abrasive materials are fastened securely around the joints of
the knees and ankles and around the 2 hands around an arm board.
D. Client is monitored throughout the surgery by the assistant anaesthesiologist

95. Another nursing check that should not be missed before the induction of
general anesthesia is:
A. check for presence underwear
B. check for presence dentures
C. check patient’s ID
D. check baseline vital signs

96. Some lifetime habits and hobbies affect postoperative respiratory function. If your
client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased
risk for:
A. perioperative anxiety and stress
B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory function

Situation: Maintenance of sterility is an important function a nurse should perform

in any OR setting.

97. Which of the following is true with regards to sterility?

A. Sterility is time related items are not considered sterile after a period of 30 days of
being not in use.
B. for 9 months sterile items are considered sterile as long as they are covered with
sterile muslin cover and stored in a dust proof covers.
C. Sterility is event related, not time related.
D. For 3 weeks, items double covered with muslin are considered sterile as long as they
have undergone the sterilization process

98. Two (2) organizations endorsed that sterility are affected by factors other that the time
itself, these are:
A. The PNA and the PRC
B. AORN and JCAHO
C. ORNAP and MCNAP
D. MMDA and DILG

99. All of these factors affect the sterility of the OR equipment, these are the following
except:
A. The material used for packaging
B. The handling of the materials as well as its transport
C. Storage
D. The chemical or process used in sterilizing the material

100. When you say sterile, it means:

A. The material is clean.
B. The material as well as the equipments are sterilized and had undergone a rigorous
sterilization process
C. There is a black stripe on the paper indicator
D. The material has no microorganism nor spores present that might cause an infection