Nursing Practice Iii Edgeworth

NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part A) Situation 1 – Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure. 1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover? A. Circulating Nurse B. Anaesthesiologist C. Surgeon D. Nursing Aide 2. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss? A. Scrub Nurse B. Surgeon C. Anaesthesiologist D. Circulating Nurse 3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR? A. Rehabilitation department B. Laboratory department C. Maintenance department D. Radiology department 4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team, who else has to be present when a client undergoes laparoscopic surgery? A. Information technician B. Biomedical technician C. Electrician D. Laboratory technician 5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy? A. Security Division B. Chaiplaincy C. Social Service Section D. Pathology department Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. 6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would prompt you to call the doctor? A. Dressing is intact but partially soiled B. Left foot is cold to touch and pedal pulse is absent C. Left leg in limited functional anatomic position D. BP 114/78, pulse of 82 beats/minute 7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given: A. When the client asks for the next dose B. When the patient is in severe pain C. At 11 pm D. At 12 pm 8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation? A. The client reports pain reduction and decreased activity B. The client denies existence of pain C. The client can distract himself during pain episodes D. The client reports independence from watchers 9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as cultural or psychological that influence pain. How can you alter these factors as the nurse? A. Explain all the possible interventions that may cause the client to worry B. Establish trusting relationship by giving his medication on time C. Stay with the client during pain episodes D. Promote client’s sense of control and participation in control by listening to his concerns

10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case? A. Instruct client to observe strict bed rest B. Check for epidural catheter drainage C. Administer analgesia through epidural catheter as prescribed D. Assess respiratory rate carefully Situation 3 – Records are vital tools in any institution and should be properly maintained for specific use and time. 11. The patient’s medical record can work as a double edged sword. When can the medical record become the doctor’s/nurse’s worst enemy? A. When the record is voluminous B. When a medical record is subpoenaed in court C. When it is missing D. When the medical record is inaccurate, incomplete, and inadequate 12. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? A. Department of Interior and Local Government (DILG) B. Metro Manila Development Authority (MMDA) C. Records Management Archives Office (RMAO) D. Department of Health (DOH) 13. In the hospital, when you need the medical record of a discharged patient for research you will request permission through: A. Doctor in charge B. The hospital director C. The nursing service D. Medical records section 14. You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request the old chart? A. Central supply section B. Previous doctor’s clinic C. Department where the patient was previously admitted D. Medical records section 15. Records Management and Archives Office of the DOH is responsible for implementing its policies on record disposal. You know that your institution is covered by this policy if: A. Your hospital is considered tertiary B. Your hospital is in Metro Manila C. It obtained permit to operate from DOH D. Your hospital is PhilHealth accredited Situation 4 – 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. 16. 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 17. 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 18. 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 anesthesiologist 19. 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

20. 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 5 – Nurses hold a variety of roles when providing care to a perioperative patient. 21. Which of the following role would be the responsibility of the scrub nurse? A. Assess the readiness of the client prior to surgery B. Ensure that the airway is adequate C. Account for the number of sponges, needles, supplies, used during the surgical procedure. D. Evaluate the type of anesthesia appropriate for the surgical client 22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? A. Put side rails up and ask the client not to get out of bed B. Send the client to OR with the family C. Allow client to get up to go to the comfort room D. Obtain consent form 23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection? A. Draped B. Pulled C. Clipped D. Shampooed 24. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection? A. Localized heat and redness B. Serosanguinous exudates and skin blanching C. Separation of the incision D. Blood clots and scar tissue are visible 25. Which of the following nursing interventions is done when examining the incision wound and changing the dressing? A. Observe the dressing and type and odor of drainage if any B. Get patient’s consent C. Wash hands D. Request the client to expose the incision wound Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress. 26. Which of the following nursing actions should be initiated first? A. Promote emotional support B. Administer oxygen at 6L/min C. Suction the client every 30 min D. Administer bronchodilator by nebulizer 27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its indication, the nurse will say: A. Relax smooth muscles of the bronchial airway B. Promote expectoration C. Prevent thickening of secretions D. Suppress cough 28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT: A. Avoid emotional stress and extreme temperature B. Avoid pollution like smoking C. Avoid pollens, dust, seafood D. Practice respiratory isolation 29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position? A. Sit in high-Fowler’s position with extended legs B. Sit-up with shoulders back C. Push on abdomen during exhalation D. Lean forward 30-40 degrees with each exhalation

30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of: A. metabolic alkalosis B. respiratory acidosis C. respiratory alkalosis D. metabolic acidosis Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility. 31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems? A. Limit suppliers to a few so that quality is maintained B. Implement a regular inventory of supplies and equipment C. Adherence to manufacturer’s recommendation D. Implement a regular maintenance and testing of alarm systems 32. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you improve the safety of using infusion pumps? A. Check the functionality of the pump before use B. Select your brand of infusion pump like you do with your cellphone C. Allow the technician to set the infusion pump before use D. Verify the flow rate against your computation 33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following, EXCEPT: A. Mark the operative site if possible B. Conduct pre-procedure verification process C. Take a video of the entire intra-operative procedure D. Conduct ‘time out’ immediately before starting the procedure 34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT: A. Assess potential risk of fall associated with the patient’s medication regimen B. Take action to address any identified risks through Incident Report (IR) C. Allow client to walk with relative to the OR D. Assess and periodically reassess individual client’s risk for falling 35. As a nurse, you know you can improve on accuracy of patient’s identification by 2 patient identifiers, EXCEPT: A. identify the client by his/her wrist tag and verify with family members B. identify client by his/her wrist tag and call his/her by name C. call the client by his/her case and bed number D. call the patient by his/her name and bed number Situation 8 – Team efforts is best demonstrated in the OR. 36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? A. Who is your internist B. Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery? C. Who are your anesthesiologist, internist, and assistant D. Who is your anesthesiologist 37. In the OR, the nursing tandem for every surgery is: A. Instrument technician and circulating nurse B. Nurse anesthetist, nurse assistant, and instrument technician C. Scrub nurse and nurse anesthetist D. Scrub and circulating nurses 38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team? A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse 39. When surgery is on-going, who coordinates the activities outside, including the family? A. Orderly/clerk B. Nurse Supervisor C. Circulating Nurse D. Anesthesiologist

40. The breakdown in teamwork is often times a failure in: A. Electricity B. Inadequate supply C. Leg work D. Communication Situation 9 – Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition. 41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers? A. Apply liberal amount of mineral oil to the area B. Use karaya paste and rings around the stoma C. Clean the area daily with soap and water before applying bag D. Apply talcum powder twice a day 42. What health instruction will enhance regulation of a colostomy (defecation) of clients? A. Irrigate after lunch everyday B. Eat fruits and vegetables in all three meals C. Eat balanced meals at regular intervals D. Restrict exercise to walking only 43. After ileostomy, which of the following condition is NOT expected? A. Increased weight B. Irritation of skin around the stoma C. Liquid stool D. Establishment of regular bowel movement 44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT: A. Increase the irrigating solution flow rate when abdominal cramps is felt B. Insert 2-4 inches of an adequately lubricated catheter to the stoma C. Position client in semi-Fowler D. Hang the solution 18 inches above the stoma 45. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained? A. Sensation of taste B. Sensation of pressure C. Sensation of smell D. Urge to defecate Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of the research process. 46. What does a sample group represent? A. Control group B. Study subjects C. General population D. Universe 47. What is the most important characteristic of a sample? A. Randomization B. Appropriate location C. Appropriate number D. Representativeness 48. Random sampling ensures that each subject has: A. Been selected systematically B. An equal chance of selection C. Been selected based on set criteria D. Characteristics that match other samples 49. Which of the following methods allows the use of any group of research subject? A. Purposive B. Convenience C. Snow-ball D. Quota 50. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. What should be the appropriate method ofor you to use in this care? A. Cluster sampling B. Random sampling C. Startified ampling D. Systematic sampling

ANSWER KEY NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part A) Situation 1 – Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure. 1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover? Circulating Nurse 2. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss? Anaesthesiologist 3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR? Radiology department 4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team, who else has to be present when a client undergoes laparoscopic surgery? Biomedical technician 5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy? Social Service Section Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. 6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would prompt you to call the doctor? Left foot is cold to touch and pedal pulse is absent 7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given: At 11 pm 8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation? The client can distract himself during pain episodes 9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as cultural or psychological that influence pain. How can you alter these factors as the nurse? Promote client’s sense of control and participation in control by listening to his concerns 10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case? Assess respiratory rate carefully Situation 3 – Records are vital tools in any institution and should be properly maintained for specific use and time. 11. The patient’s medical record can work as a double edged sword. When can the medical record become the doctor’s/nurse’s worst enemy? When the medical record is inaccurate, incomplete, and inadequate 12. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? Department of Health (DOH) 13. In the hospital, when you need the medical record of a discharged patient for research you will request permission through: Medical records section 14. You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request the old chart? Medical records section 15. Records Management and Archives Office of the DOH is responsible for implementing its policies on record disposal. You know that your institution is covered by this policy if: It obtained permit to operate from DOH Situation 4 – 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.

16. Which of the following should be given highest priority when receiving patient in the OR? Verify patient identification and informed consent 17. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these procedures best scheduled? Last case 18. 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… 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. 19. Another nursing check that should not be missed before the induction of general anesthesia is: check baseline vital signs 20. 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: delayed wound healing Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. 21. Which of the following role would be the responsibility of the scrub nurse? Account for the number of sponges, needles, supplies, used during the surgical procedure. 22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? Put side rails up and ask the client not to get out of bed 23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection? Clipped 24. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection? Localized heat and redness 25. Which of the following nursing interventions is done when examining the incision wound and changing the dressing? Observe the dressing and type and odor of drainage if any Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress. 26. Which of the following nursing actions should be initiated first? Administer bronchodilator by nebulizer 27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its indication, the nurse will say: Relax smooth muscles of the bronchial airway 28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT: Practice respiratory isolation 29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position? Lean forward 30-40 degrees with each exhalation 30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of: respiratory acidosis Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility. 31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems? Implement a regular maintenance and testing of alarm systems 32. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you improve the safety of using infusion pumps? Check the functionality of the pump before use 33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following, EXCEPT: Take a video of the entire intra-operative procedure

34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT: Allow client to walk with relative to the OR 35. As a nurse, you know you can improve on accuracy of patient’s identification by 2 patient identifiers, EXCEPT: call the client by his/her case and bed number Situation 8 – Team efforts is best demonstrated in the OR. 36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery? 37. In the OR, the nursing tandem for every surgery is: Scrub and circulating nurses 38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team? Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist 39. When surgery is on-going, who coordinates the activities outside, including the family? Circulating Nurse 40. The breakdown in teamwork is often times a failure in: Communication Situation 9 – Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition. 41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers? Apply liberal amount of mineral oil to the area 42. What health instruction will enhance regulation of a colostomy (defecation) of clients? Eat balanced meals at regular intervals 43. After ileostomy, which of the following condition is NOT expected? Increased weight 44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT: Increase the irrigating solution flow rate when abdominal cramps is felt 45. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained? Sensation of pressure Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of the research process. 46. What does a sample group represent? General population 47. What is the most important characteristic of a sample? Representativeness 48. Random sampling ensures that each subject has: An equal chance of selection 49. Which of the following methods allows the use of any group of research subject? Convenience 50. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. What should be the appropriate method ofor you to use in this care? Cluster sampling