Rot Exam.docx

Alimannao Hills, Penablanca, Cagayan Second Semester of Academic Year 2016-2017 College of Nursing ROTATIONAL EXAMINATION (BSN II) Start here 

Situation: Nurses in any health care setting use nursing process as a guide in helping out manage the disease processes that might affect our patient. It is indeed a tool for nursing practice. 1. According to Ida Jean Orlando, nursing process is a tool for nursing practice. Which of the following best illustrates the nursing process? 1. Scientific approach 2. Revision may be necessary 3. Steps are autonomous from each other 4. Organize and classified accordingly 5. health team centered 6. Use for problem identification a. 1, 2, 4 and 6 c. 2, 3, 4 and 5 b. 1,3, 4 and 6 d. 2, 4, 5, and 6 2. The purpose of your initial nursing interview is to: a. Record pertinent information in the client’s chart for health team to read b. Assist the client find solutions to her health concerns c. Understand her lifestyle, health needs and possible problems to develop a plan of care d. Make nursing diagnoses for identified problems 3. Mrs. De lima is for admission to the medical ward and you are in charge to take history of the patient. The MOST important initial nursing approach when admitting client is to: a. Introduce the client to the ward staff b. Orient the client to the physical set up of the unit c. Identify the most immediate needs of the client and implement the necessary interventions d. Take vital signs for a baseline assessment 4. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to: a. Talk to the relatives c. Perform auscultation b. Interview the client d.Do a physical assessment 5. which of the following are purposes of performing a physical assessment? 1. gather baseline data about the client’s health 2. confirm and identify nursing diagnosis 3. evaluate physiological outcome of care 4. Make a systematic data gathering from head to toe a. 1,2 and 4 c. 1,3 and 4 b. 2, 3 and 4 d. 1,2 and 3 6. Which of the following is the least nursing activity in performing assessment of patient? a. Laboratory test c. Health History b. Physical Examination d. Systems review 7. Which of the following should be given the highest priority before a physical examination is done to a patient? a. Preparation of the equipment b. Psychological preparation of the client c. Preparation of the environment d. Physical preparation of the client 8. In which of the following situations does the nurse demonstrates the assessment phase of the nursing process? a. The nurse found out that an adult patient’s respiration rate is 38 cpm, notes that it is abnormal and analyzes that breathing could be a problem of the patient

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b. The nurse who baths the patient after determining that the patient is weak and dependent c. The nurse asking comfort of the patient following catheter insertion d. the nurse who inquires the condition of the patient, checks the vital signs for proper documentation upon admission Nurse Jenny is about to examine the patient with suspected gastrointestinal problem. She would begin her assessment by which of the following sequence: 1. Percussion 3. Palpation 2. Percussion 4. Auscultation a. 1234 c. 1423 b. 1234 d. 1324 Which of the following may be examined by palpation? a. Headache c. Gait and balance b. Thyroid glands d. Bowel sounds An old man who appears to be unkempt has an initial diagnosis of Pulmonary Tuberculosis. Which of the following manifestations that could be assessed through auscultation would confirm the case? a. Blood in the sputum collection b. Results of crackles during evaluation c. Intermittent fever for several days d. X-ray result reveals tissue scarring Staff Nurse Pinang is having her duty at the obstetric ward. She is assessing several pregnant clients having their pre-natal visits. Which of the following objective signs during pregnancy can be best assessed through inspection? 1. Chadwick’s sign 5. Hegar’s sign 2. Chloasma 6. Leopold’s maneuver 3. Pregnancy test 7. Fatigability 4. Melasma 8. Ultrasound a. 1,2,4 and 8 only c. 1 and 3 only b. 3,5, and 8 only d. 1, 3 and 5 only Among the five major cardinal signs of inflammation, which sign is done by palpation? i. calor iii. Tumor ii. rubor iv. Dolor a. I and ii c. ii and iii b. I and iii d. ii and iv Which of the following manifestations gathered upon auscultation predisposes the client the risk to impaired tissue oxygenation? a. cyanosis c. wheezing sound b. hyperventilation d. tymphanic sound The nurse plans care for a 14-yr old girl admitted with an eating disorder. On admission, the girl weighs 82 lbs and is 5’4” tall. Laboratory tests indicate severe hypokalemia, anemia and dehydration. The nurse should give which of the following nursing diagnosis the highest priority? a. Body image disturbance related to weight loss b. Self-esteem disturbance related to feelings of inadequacy c. Altered nutrition: Less than body requirements related to decreased intake d. Increased cardiac output related to the potential of dysrhythmia

16. A good nursing care plan is dependent on a correctly written nursing diagnosis. The following are example of a well written diagnosis: a. Acute pain related to altered skin integrity secondary to hysterectomy b. Electrolyte imbalance related to hypocalcemia c. Altered nutrition related to high fat intake secondary to obesity d. Knowledge deficit related to proctosigmoidoscopy 17. Which of the following diagnoses is appropriately written by the nurse? a. Knowledge deficit related to angiography b. Impaired gas exchange related to collapse of the lungs c. Acute pain related to appendectomy d. Need for low CHO diet related to altered nutrition 18. The doctor’s order reads: Monitor urine output of my patient every hour. After an hour, Nurse Mickey only collected 20 cc from the patient’s catheter and knows that there is a problem in her patient’s urine output as compared to what is normal. In this scenario, the nurse is engaging what step of the nursing process? a. Assessment c. Intervention b. Analysis d. Evaluation 19. The patient says he has “trouble going to sleep”. In order to plan your nursing intervention, you will: a. Observe his sleeping patterns in the next few days b. Ask him what he means with his statement c. Check his physical environment to decrease noise level d. Take his blood pressure before sleeping and upon waking up 20. The client tells the nurse he has less pain today than yesterday. The nurse decides to give him Tylenol instead of Meperidine Hcl (Demerol). The nurse is using which step of the nursing process? a. Planning c. Implementation b. Diagnosis d. Evaluation 21. Which of the following steps in the nursing process is being referred to if the nurse completely writes into the chart the care that she has given to her patient? a. Assessment c. Implementation b. Diagnosis d. Evaluation 22. Which of the following person cannot have an access to the chart of the patient? a. Physical therapist c. Patient b. Lawyer of the family d. Speech therapist 23. Which of the following information about patient care is provided by evaluation as part of the nursing process? a. The patient has agreed with the process b. Nursing assessment was properly done c. Nursing goal is met through the use of certain nursing intervention d. The competence of the nurse is determined in managing patient care 24. Nurse Dayan is having her day off and prefers to stay at home to have some rest. When noon arrives, he gets a call from a neighbor who tells him that their school age child has been experiencing a headache and fever and asks for an advice. Which of the following is the most appropriate response? a. Call for an orderly to seek for divine intervention b. Recommend to bring the child immediately to the hospital c. Observe the child, provide sponge bath and give paracetamol d. Provide health teaching and tell the mother to manage the child well. 25. A nurse notices the mother of a hospitalized 12-month old boy sitting and talking on the telephone while the infant lies to the

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crib crying. Which of the following statement would be the most appropriate response? a. “Your baby is crying and needs your attention now” b. “Let’s check your baby together to see what he needs c. “Why do you think your baby is crying at this time?” d. “ When did you last feed your baby?” Mr. Rody is nervous about a colonoscopy scheduled tomorrow. The nurse described the last test by explaining that it allows which of the following? a. Visual examination of the large intestine b. Visual examination of the esophagus and stomach c. Radiographic examination of the large intestine d. Flouroscopic examination of the small bowel Dorothea Orem is the proponent of the theory self care or self care deficit out of which it has three kinds of compensation. Which of the following situations can be described as a partial type of compensation? SELECT ALL THAT APPLY a. A healthy baby boy b. A patient who was given a general anesthesia c. An adolescent patient having fever d. A mother that is already ten days post partum e. An elderly who has 4 sided paralysis Head Nurse Alex was about to resign from her work because of bigger opportunities abroad. She plans to go to Brunei and serve the royal family there. Which of the following nursing theories could best help her in the new environment that she is about to work to? a. Transcultural Nursing c. 7 subsystems b. 21 Nursing problems d. Unitary Human being Which of the following situations best describe the theory of Florence Nightingale? a. Nursing is an interpersonal process of therapeutic interactions between the patient and the nurse b. Nursing primarily focuses on the notion that centers around three components of care, core and cure c. Nursing is the application of the art and human science through transpersonal caring transactions d. Nurses should focus on changing and manipulating the patient’s milieu for his/her faster recovery The four phases of the nurse-client relationship includes orientation, identification, exploitation and resolution. The following best defines the resolution phase except: a. Discharge instruction usually begins at this phase b. This phase is also known as termination c. Known to be as the last phase of the nurse-client relationship d. Client’s needs are already met in this phase A patient was taken care by the nurse for 3 days wrote her a personal letter thanking her of the warmth and extraordinary concern shown by the nurse. The patient is demonstrating which of the following criteria in communication? a. Feedback c. Flexibility b. Efficiency d. Appropriateness Communication can be best understood as: a. Mutual interchange of ideas in which the option of all participants are modified b. Establishment of rapport and sympathy between persons through oral and written language c. involvement of two or more persons in reciprocal exchange of information d. The transmission of ideas from sender to receiver with little or no distortion One of the initial communication skills necessary in a nursepatient relationship is the establishment of mutual confidence and trust between the nurse and the patient. This condition is called:

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a. Transference c. Empathy b. Contract d. rapport A year ago, patient Manny had an attack of cerebrovascular accident (CVA). He suffered a left-sided paralysis and thus could not function well. This may be the case because according to one theorist, a unitary man is an energy filed in constant interaction with the environment. As a nurse, you know that this is according to: a. Jean Watson c. Rosemarie Rizzo Parse b. Martha Rogers d. Ida Jean Orlando Lydia Hall originated the term nursing process. she also proposed the theory of care, core and cure. Which option best illustrates the care part? a. Represents nurturance and is exclusive to nursing b. Involves the therapeutic use of self and emphasizes the use of reflection c. Focuses on nursing related to the physician’s order d. None of the above The Aetas of Agugaddan can still benefit from health teaching without their traditions being altered. This is according to: a. Imogene King c. Han Selye b. Betty Neuman d. Madelein Leininger A Mormon patient is admitted in your hospital. As a nurse, you must be aware that: a. He may refuse blood transfusion b. He will refuse to entertain business transactions on Sabbath c. That the patient will not eat “dinuguan” d. He may wear a special undergarment under his hospital gown that symbolizes dedication to god A patient who is a Jehovah’s witness is scheduled to have a bowel resection for colon cancer. When planning care for the patient, the nurse should be aware that: a. the resected colon and surrounding will be buried b. surgery must be delayed until a pastor visits c. holy communion should be given on the day of the surgery d. the patient will most likely refuse any blood transfusion Nurse Uno is in charge of a diabetic client having stage 3 decubitus ulcer. Which of the following management if done by Nurse Uno will NOT held her any liabilities because she can do it autonomously? SELECT ALL THAT APPLY a. Performing wound care to the patient b. Assessing the intravenous site of the patient c. Doing a nursing care plan to prioritize health needs d. Giving insulin with doctor’s order e. Proper feeding of the patient The patient was hit by a truck while driving along the highway. Upon arrival at the nearby hospital, the patient died. The nurse notes that the patient’s body is pale and cyanotic. This is referred to as: a. Algor Mortis c. Rigor mortis b. Bobot Mortis d. Livor mortis The nurse is emptying the client’s urinal when she notices that the urine is dark amber, cloudy and has an unpleasant odor. The nurse would suspect the client with what condition? a. Urinary incontinence c. UTI b. Urinary frequency d. Urinary urgency You were able to pass by a crowded place where a certain network is conducting its audition for the next search of talented artists. Suddenly, one of the participants experiences dizziness. This is otherwise called as: a. syncope c. vertigo b. vitiligo d. hypothermia Lola Basyang has difficulty hearing words and sounds. She also has difficulty in seeing things with her naked eye. These are the main reason why his sons and daughters do not communicate

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with her frequently. What are these conditions that are commonly associated with aging? SELECT ALL THAT APPLY a. presbyopia c. presbycusis b. paresthesia d. paresis BPH is a disorder of the prostate which is characterized by abnormal enlargement of the gland. BPH therefore stands for: a. Benign Prostatic Hyperplasia b. Benign Prostatic hypertrophy c. benign prostatic hypothalamus d. Both a and b are correct Your aunt verbalizes that her daughter sleeps while pacing along the hallway. Sometimes, she was surprised that her daughter would wake up in the kitchen or in the living room. As a nurse, you know that this condition is: a. Bruxism c. Somnambulism b. Somnamloquism d. Bromhidrosis A telephone order is given to a client in your ward. What is your most appropriate action? a. Copy the order on to the chart and sign the physician’s name as close to his original signature as possible b. Repeat the order back to the physician, copy onto the order sheet and indicate that it’s a telephone order c. Write the order in the client’s chart and have the head nurse co-sign it d. Tell the physician that you cannot take the order but you will call the supervisor The following are guidelines that must be followed when receiving telephone orders except: a. speak slowly and clearly b. read the order back to the prescriber after dictating his orders c. have it sign by the physician within 24 hours d. Do abbreviations as you can for fast recording The nurse, implementing health teaching regarding pulse and blood pressure to the adult male client recognizes that the client requires further teaching when he states: a. “My heart rate normally increases during activity” b. “ My heart rate will gradually increase as I get older” c. “Stress may increase my heart rate” d. “ Certain medications can affect my cardiovascular system” The following statements are true about body temperature except: a. Core body temperature measures the temperature of deep tissues b. Elderly people are at risk for having hypothermia due to decreased thermoregulatory control c. highest body temperature is usually between 8 pm to 12 midnight d. Sympathetic response stimulation decreases body heat production Baby Tonting was rushed to the emergency room because of high grade fever. The nursing aide immediately prepares a basin with water and let the nurse perform tepid sponge bath. After several minutes, what method of heat loss is promoted? a. radiation c. convection b. Conduction d. Evaporation Which of the following pulse sites is used in determining circulation to the lower leg? A. Popliteal B. Pedal C. Posterior Tibial D. Femoral Nurse Sandra was instructed to monitor the vital signs of a patient every 30 minutes. The following nursing actions are correct when taking the radial pulse except: A. Assess the pulse rate, rhythm, volume and bilateral equality B. Use the thumb to palpate the pulse

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C. Use middle two to three fingertips to palpate the pulse at the inner wrist D. Apply moderate pressure For which of the following clients would you take an apical pulse rather than a radial pulse? A. A client in shock B. A client with an arrhythmia C. A client less than 24 hours postoperative D. To check a client’s response to changing from a lying to a sitting position When measuring the blood pressure, the following are nursing considerations except: A. Ensure that the client is rested B. Use appropriate size of BP cuff C. Inflate and deflate BP cuff 2-3 mmHg/sec D. Read upper meniscus of mercury In taking the blood pressure of a client, the nurse must consider appropriate size of the blood pressure cuffs in relation to the client’s arm. If the cuff is too narrow, the blood pressure reading will be: A. Erroneously elevated B. Erroneously low C. Erroneously high or low D. No significant difference in measurement Which of the following sites for body temperature measurement is safe and non-invasive? A. Oral B. Rectal C. Axillary D. Tympanic membrane The following are appropriate nursing actions when taking oral temperature except: A. Use a thermometer with pear-shaped bulb B. Wash the thermometer from the bulb to the stem before use C. Place the bulb of the thermometer on either side of the frenulum D. Take oral temperature for 2-3 minutes When taking the body temperature using the axillary site, the nurse should perform which of the following? Select all that apply. A. Pat the axilla dry if very moist B. Instruct the client to take a deep breath during insertion of the thermometer C. Place the bulb in the center of the axilla D. Take axillary temperature for 6-9 minutes All except one of the following nursing actions are appropriate when taking rectal temperature. A. Assist client to assume Sim’s position B. Lubricate thermometer with water-soluble lubricant before use C. Instruct client to strain during insertion of the thermometer D. Hold the thermometer in place for 2-3 minutes Nurse Amy is to obtain the body temperature of a 2-year old boy using the tympanic thermometer. Which of the following is an appropriate action by the nurse during insertion? A. Pull the pinna straight back and slightly downward B. Pull the pinna of the ear backward and upward C. Point the probe slightly posterior toward the eardrum D. Pull the pinna upward and slightly backward During physical health assessment, the nurse must remember important nursing considerations. The following are appropriate nursing actions when performing physical examination to a client except: A. Ensure privacy of the client throughout the procedure B. Prepare the needed articles and equipment before the procedure C. Assess the abdomen following this sequence: RLQ, RUQ, LUQ, LLQ

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D. When assessing the chest, it is best to place the client in side-lying position The nurse should be aware that the correct sequence of methods when assessing the abdomen is: A. Inspection, palpation, auscultation and percussion B. Inspection, percussion, palpation and auscultation C. Inspection, auscultation, percussion and palpation D. Inspection, palpation, percussion and auscultation The client should be sitting upright during palpation of which of the following areas? A. Head and neck B. Heart C. Breast D. Abdomen A nurse is assessing the client’s ear and hearing. Which of the following refers to the test used in comparing air conduction to bone conduction? A. Weber’s test B. Rinne’s test C. Buerger’s test D. Romberg test During a routine examination, the nurse is unable to locate the client’s popliteal pulse. Which of the following would be the appropriate next step? A. Check for a femoral pulse B. Check for a pedal pulse C. Ask another nurse to try to locate the pulse D. Take the client’s blood pressure on that thigh The nurse demonstrates correct breast palpation technique when she uses: A. The heel of her hand B. The index finger only C. The index finger and the thumb D. The pads of her fingertips The following are appropriate nursing actions when auscultating the abdomen for bowel sounds except: A. Ask when the client last ate B. Warm the hands and stethoscope diaphragms C. Use the bell of the stethoscope D. Listen for active bowel sounds When assessing the neurologic system, the nurse performs the following test for tactile discrimination except: A. Finger-to-nose test B. One-and two-point discrimination test C. Stereognosis D. Extinction phenomenon When donning sterile gloves using the open method, which of the following are appropriate nursing actions? Select all that apply. A. Place the package of gloves on a clean, dry surface B. Open the outer package without contaminating the gloves or the inner package C. Grasp the glove for the dominant hand by its folded cuff edge with the thumb and first finger of the non-dominant hand D. Touch only the outside of the cuff to avoid contaminating the inside E. Pick up the other glove with sterile gloved fingers under the cuff F. Adjust each glove and carefully pull the cuffs up While donning sterile gloves (open method), the cuff of the first glove rolls under itself about ¼ inch. The nurse is correct when she performs which of the following? A. Remove the glove and start over with a new pair B. Leave the cuff rolled under C. Ask a colleague to assist by unrolling the cuff D. Wait until the second glove is in place and then unroll the cuff with the other sterile hand Which of the following nursing actions is correct when pouring sterile solution?

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A. Return excess solution from sterile receptacle to the bottle B. Place the bottle of sterile solution within the sterile field C. Hold bottle 4-6 inches above receptacle on the sterile field D. Remove cap of bottle and place it with the underside lid down on a flat surface The nurse demonstrates correct bed bathing when she followed which of the following steps sequentially? 1. Observe standard protocol. 2. Position the bed at a comfortable working height. 3. Remove the top sheet by starting at client’s shoulders and moving linen down toward client’s feet. 4. Using a bath mitt, wash and dry the face, arms and hands, chest and abdomen, legs and feet, back and then the perineum 5. Place bath blanket over the top sheet. 6. Help the client put on a clean gown 7. Assist the client with grooming aids. 8. Remove client’s gown while keeping the client covered with bath blanket. 9. Lower the side rail on the side close to you. Keep the other side rail up. A. 1, 2, 5,8,9,3,4,6,7 B. 1, 2, 9,5,8,4,3,7,6 C. 1, 2, 9,5,3,8,4,7,6 D. 1, 2, 5,3,7,8,4,6,9 During a bath, the nurse observes that a client has dry skin on the extremities. The nurse’s best intervention is to: A. Bath the client more frequently using soap B. Use an emollient on the dry skin C. Massage the skin with alcohol D. Apply foot powder The nurse is to provide oral care to an unconscious client. She is correct when she positions the client: A. Semi- fowlers B. Supine with head of bed elevated C. Supine with head of bed lowered D. Side-lying with head of bed lowered Which of the following is inappropriate nursing action when collecting a clean-catch midstream urine specimen for routine analysis? A. Collect early morning, first voided specimen B. Do perineal care before collection of specimen C. Discard the first flow of urine D. Collect 30-60 ml of urine in the container Which of the following is correct nursing action when collecting urine specimen from a client with indwelling urethral catheter? A. Collect urine specimen from the urinary drainage bag B. Flush the catheter with sterile NSS before collection of urine specimen C. Detach the catheter from the connecting tube D. Use sterile needle and syringe to aspirate urine specimen from the drainage port When administering oral liquid medication to a six-month old infant, the nurse should: A. Quickly squirt the drug from a syringe along the side of the mouth B. Sweeten the drug with honey and give using a teaspoon C. Quickly squirt the drug from a syringe to the back of the mouth D. Mix the drug in the infant’s formula and offer with the next feeding A nurse observes a mother administering ear drops to her fouryear old child who has acute otitis media. Which of the following actions, if done by the mother indicates that the administration was performed correctly? A. Removing wax in the affected ear with a cotton swab prior to the procedure

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B. Pulling the pinna of the affected ear upward and back when administering the drug C. Pulling the pinna of the affected ear backward and downward when administering the drug D. Placing the child in a recumbent position for several minutes after the procedure When preparing medications from vials, which of the following is an inappropriate nursing action? A. Prepare the medication vial for drug withdrawal. Mix the solution by shaking the vial B. Remove the protective cap or clean rubber cap of a previously opened vial with an antiseptic wipe C. Insert the needle into the upright vial through the center of the rubber cap D. Invert the vial and withdraw the prescribed amount of medication In administering an intramuscular injection, the nurse should include which of the following steps? Select all that apply. A. Clean the site with an antiseptic swab starting at the center and moving outward B. Inject the medication using the Z-track method C. Hold the barrel of the syringe steady with the dominant hand and aspirate with the non-dominant hand D. Inject the medication steadily and slowly while holding the syringe steady E. Withdraw the needle, apply gentle pressure at the site with a dry sponge and massage the site When inserting a rectal suppository, all of the following are correct nursing actions except: A. Assist the client in a dorsal recumbent position B. Put on a glove on the hand and lubricate the gloved index finger C. Instruct the client to relax by breathing through the mouth and insert the suppository gently into the anal canal. D. Press the client’s buttocks together for a few minutes When a nurse returns to her client to remove the heating pad 30 minutes after application, the client requested that she leave it in place. The nurse demonstrates correct knowledge when she explains to the client that: A. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactorily when assessed B. It will be acceptable to leave the pad in place as long as it is moist heat C. Heat application for longer than 30 minutes can actually cause a rebound effect (constriction) D. Heat application for longer than 30 minutes is acceptable as long as it will not exceed an hour During patient transfer, the nurse should consider increasing the base of support by: A. Bending the knees slightly B. Spacing the feet further apart C. Leaning slightly backward D. Tensing the abdominal muscles When transferring a patient with right sided paralysis from bed to stretcher, where should the stretcher is positioned in relation to his bed? A. Parallel to side bed B. Diagonally at the foot of the bed C. At a 45-degree near the middle of the bed D. Right at the foot of the bed Which of the following does not demonstrate proper transfer technique in moving a client from sitting on the side of the bed to a chair? A. Have the client sits first on the edge of the chair and then pushes back fully

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B. Have the client grasps the nurse around the neck for stability while standing C. Place the chair parallel to the bed D. The nurse rocks from the front to the rear foot The nurse had provided the client with health teachings regarding the use proper use of crutches. Which of the following statements by a client indicate correct knowledge of crutch walking? A. “At rest, the top of the crutch should be higher than my axilla.” B. “My elbow should be flexed about 60 degrees.” C. “When walking, I will place the crutch approximately 12 inches in front of me.” D. “When walking, the top of the crutch should be 2-3 fingerbreadths below the axilla.” The nurse is assisting a client who has been ordered by the physician not to bear weight on one extremity, what is the appropriate gait for the client to use when crutch walking? A. two-point gait B. three-point gait C. four-point gait D. five-point gait The most accurate method of assessing the placement of NGT is: A. Aspiration of gastric contents B. Testing the pH of gastric contents C. X-ray study D. Auscultate at the epigastric area after introducing air into NGT Which of the following is an inappropriate nursing intervention when administering NGT feeding? A. Assist the client in Fowler’s position in bed B. Assess tube placement and residual feeding contents C. Hang the feeding bag 24 inches above the point of insertion of NGT D. Instill 50-100 ml of water into the NGT after feeding Which of the following is the appropriate position of an adult client during enema administration? A. Left lateral B. Right lateral C. Supine D. Semi-fowlers When administering a cleansing soapsuds enema, a client experiences cramping and had the urge to defecate. Which of the following nursing interventions is most appropriate? A. Quickly finish instilling the remaining solution B. Tell the client to hold his breath and bear down C. Stop the flow for 30 seconds and restart the flow at a slower rate D. Tell the client that this is normal and not to worry During the straight catheterization of a female client, the catheter slips into the vagina. The nurse should do which of the following nursing actions? A. Leave the catheter in place and ask another nurse to perform the procedure B. Remove the catheter and redirect it to the urinary meatus C. Remove the catheter, wipe it with sterile gauze and insert it to the urinary meatus D. Leave the catheter in place and get a new sterile catheter During the insertion of an indwelling catheter into a male client, he complained discomfort as the nurse inflates the balloon. What is the most appropriate nursing action? A. Aspirate the fluid, advance the catheter farther and re-inflate the balloon B. Aspirate the fluid, withdraw the catheter slightly and re-inflate the balloon C. Aspirate the fluid, remove the catheter and insert a new catheter

D. Remove the syringe from the balloon: discomfort is normal and temporary 94. A nurse is providing home care teachings to a client with a longterm indwelling catheter. Which of the following statements by the client indicates a need for further teaching? A. “I should use clean technique when emptying the collecting bag.” B. “I will have warm tub bath to ease the irritation from having the catheter.” C. “I will keep the collecting nag below the level of the bladder at all times.” D. “I will drink cranberry juice to decrease the chances of developing an infection.” 95. The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions? A. Tell the client to take deep breaths B. Place the client in a sitting position C. Apply pressure below the diaphragm D. Strike the back with a cupped hand 96. The nurse is providing instructions to a client about coughing and deep breathing exercises. These include which of the following? A. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals B. Huff coughing every 2 hours and as needed C. Forceful coughing as many times as tolerated D. Diaphragmatic and purse-lip breathing 5-10 times four times a day 97. Which of the following statements by the client indicates correct understanding regarding the proper use of an incentive spirometer? A. “I should inhale slowly and steadily to keep the balls up.” B. “I should breathe out as fast and hard as possible into the device.” C. “The entire device should be washed thoroughly in water once a week.” D. “I should use the device three times a day, after meals.” 98. A nurse is performing nasopharyngeal suctioning on a client. Which of the following actions represents proper nasopharyngeal suction technique? A. Hyper oxygenate the client with 100% oxygen for 30 minutes before and after suctioning B. Insert the catheter approximately 20cm while applying suction C. Gently rotate the catheter while applying suction D. Allow 20-30 second intervals between each suction and limit suctioning to 15 minutes in total 99. To evaluate effectiveness of suctioning, the nurse should perform which of the following nursing actions? A. Auscultate heart sounds B. Check the client’s skin color C. Assess the respiratory rate and rhythm D. Auscultate the chest for clear breath sounds 100. After collecting the sputum specimen, which nursing intervention is most appropriate? A. Administer oxygen as needed B. Provide mouth care C. Offer the client with food D. Encourage client to ambulate “The only way to discover the limits of the possible is to go beyond them into the impossible”

Prepared by: KAREN MAE S. ALCANTARA, RN