Situation 3 - Mr.

Silverio, 56 years old, has had significant problem with alcohol abuse for the past 15 years. His wife brings him to the emergency department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. He has ascites and esophageal varices. 10. Assessment of Mr. Silverio would reveal all of the following, except: a. Bulging flanks b. Protruding umbilicus c. Abdominal distension d. Bluish discoloration of the umbilicus 11. Which laboratory value would the nurse expect to find in a client as a result of liver failure? a. Decreased serum creatinine b. Decreased sodium c. Increased ammonia d. Restricted sodium 12. The major dietary treatment for ascites calls for: a. High protein b. Increased potassium c. Restricted fluids d. Restricted sodium

13. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding. Base on this information, the first action the nurse should take is to: a. Deflate the esophageal balloon b. Encourage him to take the deep breath c. Monitor his vital signs d. Notify the physician 14. Because the detoxification of alcohol damages tissues a high-calorie diet, fortified with vitamins should be encouraged to protect Mr. Silverio's: a. Liver b. Kidneys c. Adrenals d. Pancreas Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in the clinic. 45. In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit? a. Cold, clammy skin b. Increased pulse rate c. Elevated blood pressure d. Cyanosis of the nail beds

46. Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity? a. An inflammation of the inner ear b. Insufficient cerebral oxygenation c. A sudden drop in blood pressure d. Decreased level of serum glucose 47. Aisa is to receive a liquid iron preparation. Which of the following directions would be appropriate for the nurse to teach Aisa's mother? a. Administer this at least an hour before meals b. Explain that loose stools are common with iron c. Have Aisa take the diluted iron preparation through a straw d. Avoid giving Aisa orange or other citric juices with the iron preparation 48. Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion? a. Serum hepatitis b. Allergic response c. Pulmonary edema d. Hemolytic reaction

Situation 14 - Arman Adriatico is admitted to hospital with extensive carcinoma of the descending portion of the colon with metastasis to the lymph nodes. 59. The operative procedure that would probably be perform to Mr. Adriatico is a (an): a. lleostomy b. Colectomy c. Colostomy d. Cecostomy 60. The primary step toward long-range goals in Mr. Adriatico's rehabilitation involves his: a. Mastery of techniques of ostomy care b. Readiness to accept an altered body function c. Awareness of available community resources d. Knowledge of the necessary dietary modifications 61. When teaching Mr. Adriatico to care for a new stoma, the nurse should advice him that irrigations be done at the same time every day. The time selected should: a. Be appropriate hour before breakfast b. Provide ample uninterrupted bathroom use at home c. Approximate Mr. Adratico's usual daily time for elimination d. Be about halfway between the two largest meals of the day

62. When performing the colostomy irrigation, the nurse inserts the catheter into the stoma: a. 5cm b.10cm c.15cm d.20cm 63.Mr. Adriatico should follow a diet that is: a. Rich in protein b. Low in fiber content c. High in carbohydrate d. As close to normal possible 5. Most common manifestation of Anemia a. Weight loss b. Fatigue c. Ahorexia d. Poor digestion Situation: Mark, 14 years old has acute lymphocytic leukemia.

61. Mark's father asks why a combination of drugs is being used to treat the leukemia. The nurse must know that the rationale for using several drugs is that: a. Many drugs are new and need to be tested with other drugs b. They act on cells in different stages of mitosis and produce a more rapid reduction in the number of leukemic cells c. Side effects of some drugs will be decreased by the action of other drugs. d. The period of treatment for Mark will be much shorter than if drugs are given one at a time 62. Mark is placed on reverse isolation and his mother asks why this is necessary. An appropriate response by the nurse would be: a. Myelosuppression and immunosuppression result from both the disease and its treatment b. Red blood cells are increased as a result of the disease c. The platelet reduction found in leukemia fosters infection d. Increased bone marrow activity predisposes the child to infection

63. In preparing Mark for a lumbar puncture, which of the following approaches is most appropriate? a. Tell him just before the procedure is to be done. b. Use dolts and puppets to show what will be done. c. Let Mark play with the equipment that will be used during the procedure. d. Explain steps in the procedure using correct terminology. 64. When Mark is well enough to return to school, his parents should be taught to keep him home when children in school are known to have: a. Colds b. Chickenpox c. Otitis media d. Gastroenteritis Situation: Marina, 45 year-old woman admitted to the hospital is newly diagnosed with uicerative colitis. 65. The symptom most characteristic of ulcerative colitis is: a. weight gain b. constipation c. vomiting d. abdominal pain

66. Uicerative colitis is: a. inflammation of the colon which begins initially in the rectum and sigmoid colon b. superficial erosion of the gastric lining with little inflammation c. decreased or absent peristalsis in the colon d. hemiation of the mucosa of the colon 67. The physician orders for her to be NPO for several days. The importance of NPO status is to a. prevent vomiting and aspiration of food b. allow adequate time for the colon to rest and heal c. decrease abdominal distention d. allow diagnostic testing to be completed 68. Upon discharge, she is recommended a low residue diet. The purpose of this diet is to: a. increase peristalsis b. provide bulk c. increase amount of fecal material d. provide nonirritating foods Situation 6: Justice Yu is scheduled for cholecystectomy in the morning.

20. From the recovery room he was brought back to the ward with nasogastric tube, the rationale for his having NGT is to: a. prevent abdominal distention b. prevent nausea and vomiting c. promote hydration . d. promote drainage 21. Post operative order is NPO. You will tell him that feeding begin as soon as: a. abdominal spasm b. peristalsis returns c. forty-eight hours is over d. absence of bowel sound is appreciated 22. Which of these is not likely to happen as his post operative complication: a. Pancreatitis b. post operative jaundice c. bile leakage d. ventricular hypertrophy

23. The rationale of your supervising properly how he does the coughing exercise is to prevent him from developing: a. Bronchlectasis b. Bronchopneumonia c. atelectasis d. pneumonia Situation: Mr. Reyes, 59 years old is a frequent visitor of Lions Club. Lately, he became inefficient with his work and complaining of dizziness. 28. You stressed to him and to the finally the importance of the following food that will help in the production of RBC, EXCEPT: a. kangkong b. egg yolk c. broccoli d. ampalaya 29.500 ml of blood was ordered for his blood transfusion. Your nursing responsibility before the start of blood transfusion is: a. check the amount of blood available b. check the label of the bottle with blood c. check if Benadryl is ordered for injection d. check the vital signs

30. Your health teaching to his family is to serve food rich In Iron and this is: a. egg yolk b. ampalaya c. liver d. lean meat Situation: Mrs. Madonna, 46 years old, is brought to the hospital with complaints of nausea, vomiting, and severe epigastric pain. Initial care includes insertion of nasogastric tube (NGT). 76. Which of the following steps should the nurse take first when preparing to insert a nasogastric tube? a. Wash hands b. Apply sterile gloves c. Apply a mask and gown d. Open ail necessary kits and tubing 77. The nurse on duty is inserting a nasogastric tube. Mr. Javier begins to gag. Which actions should the nurse take? a. Remove the inserted tube and notify the physician b. Stop the insertion, allow the client to rest, then continue inserting the tube c. Encourage the client to take deep breaths through the mouth while the tube is being inserted d. Pause until the gagging stops, tell the client to take a few sips of water and swallow as the tube is inserted.

78. Which of the following steps, if taken by the nurse after insertion of nasogastric tube could harm Mr. Javier. a. Affix the nasogastric tube to the nose with tape b. Check tube placement by aspirating stomach contents using a piston syringe c. Check tube placement by instilling 100ml of water into the tube to check for stomach filling d. Document in the chart the insertion, method used to check tube placement, and client's response to the procedure 79. Which of the following drug forms can be administered through a nasogastric tube? a. Enteric b. Oral c. Parenteral d. Sublingual