Medical-Surgical Nursing Exam 34: NLE Pre-Board (90 Items)
Situation 1: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count.
1. Counting is performed thrice: during the preincision phase, the operative phase and closing phase. Who counts the sponges, needles and instruments?
A. The scrub nurse only
B. The circulating nurse only
C. The surgeon and the assistant surgeon
D. The scrub nurse and circulating nurse.
2. The layers of the abdomen are divided into 5. Arrange the following from the first layer going to the deepest layer:
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/Fat
5. Skin
A.5,4,3,2,1
B.5,4,2,1,3
C.5,4,1,3,2,
D.5,4,1,2,3
3. When is the first sponge instrument count reported?
A. Before closing the subcutaneous layer
B. Before peritoneum is closed
C. Before closing the skin
D. Before the fascia is sutured
4. Like any nursing intervention, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted?
A. Anaesthesiologist
B. Surgeon
C. OR nurse supervisor
D. Circulating nurse
5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
A. MRI and Incidence report
B. CT Scan, MRI, Incidence Report
C. X-ray, and Incidence Report
D. CT scan and Incidence Report
Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills.
6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity?
A. Clamp tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine.
B. Drain urine from the drainage bag into the sterile container
C. Disconnect the tubing from the urinary catheter and let urine floe into a sterile container
D. Wipe the self sealing aspirations port with antiseptic solution and insert a sterile needle into the self sealing self-sealing port.
7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container
8. The best time for collecting the sputum specimen for culture:
A. Before retiring at night
B. Upon waking up in the morning
C. Anytime of the day.
D. Before meal
9. When suctioning the endotracheal tube, the nurse should:
A. Explain procedure to patient: Insert catheter gently applying suction. Withdrawn using twisting motion.
B. Insert catheter until resistance is met; then withdraw slightly, applying suction intermittently as catheter is withdrawn.
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction, catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn.
10. The purpose of NGT IMMEDIATELY after operation is:
A. For feeding or gavage
B. For gastric decompression
C. For lavage, or the cleansing of the stomach content
D. For the rapid return of peristalsis
Situation 3: Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria.
11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as follows:
A. Urethra, Kidney, Bladder
B. Urethra, Bladder wall, trigone, urethral opening
C. Bladder wall, uterine wall and urethral opening
D. Urethral opening, urethral opening bladder.
12. You are the nurse in charge of Mr. Santos. How should you position the patient during cystoscopy?
A. Supine
B. Lithotomy
C. Semi-fowler
D. Trendelenburg
13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him?
A. Cystoscopy is direct visualization and examination by urologist
B. Cystoscopy is done by x-ray visualization of the urinary tract
C. Cystoscopy is done by using lasers on the urinary tract
D. Cystoscopy is an endoscopic procedure of the urinary tract
14. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:
A. Pink-tinged urine
B. Distended bladder
C. Signs of infection
D. Prolonged hematuria
15. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:
A. Bed rest
B. Warm moist soak
C. Early ambulation
D. Hot sitz bath
Situation 4 - Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling catheter for continuous fast dip bladder irrigation which is connected to a straight drainage.
16. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
B. Amber
C. Bright red
D. Pinkish to red
17. The purpose of the continuous bladder irrigation is to:
A. Allow continuous monitoring of the fluid output status
B. Provide continuous flushing of clots and debris from the bladder
C. Allow for proper exchange of electrolytes
D. Ensure accurate monitoring of intake and output
18. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action?
A. Remove his catheter then allow him to void his own
B. Irrigate his catheter
C. Tell him "Go ahead and void. You have an indwelling catheter"
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation
19. You decided to check on Mang Felix's IV fluid infusion. You noted in flow rate, pallor and coldness around the insertion site. What is your assessment finding?
A. Phlebitis
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism
20. Knowing that proper documentation of assessment findings and interventions share important responsibilities of the nurse during first postoperative days, which of the following is the LEAST relevant to document in the case of Mang Felix?
A. Chest pain and vital signs
B. Intravenous infusion rate
C. Amount, color and consistency of bladder irrigation drainage
D. Activities of daily living started
Situation 5: Melamine contamination in milk has brought world wide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient's needs.
21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire retardant properties. Milk and food manufacturers add melamine in order to:
A. It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods.
B. Gives a glazy and more edible look on foods
C. Make milks more tasty and creamy
D. Create an illusion of a high protein content on their products
22. Most of the milks contaminated by melamine came from which country?
A. India
B. China
C. Philippines
D. Korea
23. Which government agency is responsible for testing the melamine content of foods and food products?
A. DOH
B. MMDA
C. NBI
D. BFAD
24. Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine poisoning?
A. Irritability, Backache, Urolithiasis
B. High blood pressure, fever
C. Anuria, Oliguria or Hematuria
D. Fever, Irritability and a large output of diluted urine
25. What kind of renal failure from melamine poisoning cause?
A. Chronic Prerenal
B. Acute, Postrenal
C. Chronic, Intrarenal
D. Acute, Prerenal
Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15.
26. The survival rate for Acute Lymphoid Leukemia is approximately:
A. 25 %
B. 40 %
C. 75 %
D. 95 %
27. Whereas acute non lymphoid leukaemia has survival rate of:
A. 25 %
B. 40 %
C. 75 %
D. 95 %
28. The three main consequence of leukaemia that cause the most danger is:
A. Neutropenia causing infection, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies.
B. Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies.
C. Splenomegaly, hepatomegaly, fractures
D. Invasion by the leukemic cells to the bone causing severe bone pain
29. Gold standard in the diagnosis of leukaemia is by which of the following?
A. Blood culture and sensitivity
B. Bone marrow biopsy
C. Blood biopsy
30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the client for long term therapy. One common side effect, especially of adriamycin is alopecia. The child asks: " Will I get my hair back once again?" The nurse respond is by saying:
A. "Don't be silly, of course you will get your hair back."
B. "We are not sure, let's hope it'll grow."
C. "This side effect is usually permanent, but I will get the doctor to discuss it for you."
D. "Your hair will regrow in 3 -6 months but of different color, usually darker and of different texture."
Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in women. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast Cancer.
31. All of the following are factors that said to contribute to the development of breast cancer EXCEPT:
A. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity and children after age 30.
B. Genetics
C. Increasing age
D. Prolonged intake of tamoxifen (Nolvadex)
32. Protective factors for the development of breast cancer includes which of the following EXCEPT:
A. Exercise
B. Prophylactic Tamoxifen
C. Breast Feeding
D. Alcohol intake
33. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patients that the lumpectomy with radiation.
A. Reduces the fear and anxiety that accompany the diagnosis and treatment of cancer
B. Has about the same 10 years survival rate as the modified radical mastectomy
C. Provides shorter treatment period with a fewer long term complications
D. Preserves the normal appearance and sensitivity of the breast
34. Carmen, is asking the nurse the most appropriate time of the month to do her self-examination of the breast. The MOST appropriate reply by the nurse would be:
A. the 26th day of menstrual cycle
B. 7 - 8 days after conclusion of the menstrual period
C. During her menstruation
D. the same day each month
35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy?
A. Cover the areas with thick clothing materials
B. Apply a heating pad to the site
C. Wash skin with water after therapy
D. Avoid applying creams and powder to the area.
36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breast cancer that is recommended for developing countries is:
A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)
B. an annual hormone receptor assay
C. an annual mammogram
D. a physician conduct a breast clinical examination every 2 years
37. The purpose of performing the breast self examination (BSE) regularly is to discover:
A. fibrocystic masses
B. cancerous lumps
C. areas of thickness or fullness
D. changes from previous BSE
38. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:
A. on the same day of each month
B. right after the menstrual period
C. on the first day of her menstruation
D. on the last day of her menstruation
39. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:
A. thickening of the tissue
B. axillary
C. lumps in the breast tissue
D. change in size and contour
40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client's left shoulder is to:
A. bring the breast closer to the examiner's right hand
B. tense the pectoral muscle
C. balance the breast tissue more evenly on the chest wall
D. facilitate lateral positioning of the breast
Situation - Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse
41. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert?
A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
C. Reassures him that these feelings are normal
D. Help him plan his activities
42. Immediately following the radiation teletherapy, Albert is:
A. Considered radioactive for 24 hours
B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from Radiation
43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms:
A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor
C. Headache, dizziness, blurred vision
D. Severe sore throat, bacteremia, hepatomegaly
44. What nursing diagnosis should be the highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal
45. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C
Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical.
46. A burn characterized by pale, white appearance, charred or with exposed and painlessness:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn
47. Which of the following BEST describes superficial partial thickness burn or first degrees burn?
A. Structures beneath the skin and damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged
48. A burn that is said to be "WEEPING" is classified as:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn
49. During the Acute Phase of the burn injury, which of the following is a priority?
A. Wound healing
B. Reconstructive surgery
C. Emotional support
D. Fluid resuscitation
50. While in the emergent phase, the nurse knows that the priority is to:
A. Prevent infection
B. Control pain
C. Prevent deformities and contractures
D. Return the hemodynamic stability via fluid resuscitation
51. The MOST effective method of delivering pain medication during the emergent phase is:
A. intramuscularly
B. subcutaneously
C. orally
D. intravenously
52. When a client accidentally splashes chemicals to his eyes. The initial priority care of the following the chemical burns is to:
A. irrigate with normal saline for 1 to 15 minutes
B. transport to a physician immediately
C. irrigate with water for 15 minutes or longer
D. cover the eyes with a sterile gauze
53. Which of the following can be fatal complication of upper airway burns?
A. stress ulcers
B. hemorrhage
C. shock
D. laryngeal spasm and swelling
54. When a client will rush towards you and he has burning clothes on, it is your priority to do which of the following first?
A. log roll on the grass/ground
B. slap the flames with his hands
C. Try to remove the burning clothes
D. Splash the client with 1 bucket of cool water
55. Once the flames are extinguished, it is most important:
A. cover client with warm blanket
B. Give him sips of water
C. Calculate the extent of this burns
D. Assess the Sergio's breathing
56. During the first 24 hours after thermal injury, you should assess Sergio for:
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia
57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness . You recognize that this most likely indicates that the client is developing:
A. Cerebral hypoxia
B. Hypervolemia
C. Metabolic acidosis
D. Renal failure
58. A 165 lbs trauma client was rushed to the emergency room with full thicknessburns on the whole face, right and left arm, and at the anterior chest sparing the abdominal area. He also has superficial partial thickness burn at the posterior trunk and at the half upper portion of the left leg. He the emergent phase of burns using the parkland's formula, you know that during the first 8 hours of burn the amount of fluid will be given is:
A. 5, 400ml
B. 10,500 ml
C. 9,450 ml
D. 6,750 ml
59. The doctor incorporated insulin on the client's fluid during the emergent phase. The nurse knows that insulin is given because:
A. Clients with burn also develops Metabolic Acidosis
B. Clients with burn also develops hyperglycemia
C. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound healing, regain of consciousness and rapid return of hemodynamic stability.
D. For hyperkalemia
60. The IV fluid of choice for burn as well as dehydration is:
A. 0.45% NaCl
B. NSS
C. Sterile water
D. D5LR
Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.
61. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7th postoperative day
62. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:
A. When Fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in body image
63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when feeling uncomfortable
64. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact my physician and report:
A. If I have any difficulty inserting the irrigating tube into the stoma."
B. If I noticed a loss of sensation to touch in the stromal tissue."
C. The expulsion of flatus while the irrigating fluid is running out."
D. When mucus is passed from the stoma between the irrigations."
65. You would know after teaching Fermin that dietary instruction for him is effective when he states, "It is important that I eat:
A. Soft food that are easily digested and absorbed by my large intestines."
B. Bland food so that my intestines do not become irritated."
C. Food low in fiber so that there is less stool."
D. Everything that I ate before the operation, while avoiding foods that cause gas."
Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit it is important for nurses to gather as much information to be able to address their needs for nursing care.
66. Critically ill patient frequently complain about which of the following when hospitalized?
A. Hospital report
B. Lack of blankets
C. Lack of privacy
D. Inadequate nursing staff
67. Who of the following is at greatest risk of developing sensory problem?
A. Female patient
B. Adolescent
C. Transplant patient
D. Unresponsive patient
68. Which of the following factors may inhibit learning in critically ill patients?
A. Gender
B. Medication
C. Educational level
D. Previous knowledge of illness
69. Which of the following statements does not apply to critically ill patients?
A. Majority need extensive rehabilitation
B. All have been hospitalized previously
C. Are physically unstable
D. Most have chronic illness.
70. Families of critically ill patients desire which of the following needs to be met first by the nurse?
A. Provision of comfortable space
B. Emotional support
C. Updated information on the client's status
D. Spiritual counselling
Situation: Johnny, sought consultation to the hospital before
71. His diagnosis was hyperthyroidism, the following are expected symptoms except:
A. Anorexia
B. Palpitation
C. Fine tremors of the hand
D. Hyper alertness
72. He has to take drugs to treat hyperthyroidism, which of the following will you not expect that the doctor will prescribe?
A. Colace (Docusate)
B. Cytomel (Liothyronine)
C. Tapazole
D. Levothyroxine
73. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding of the medication?
A. Death
B. Sore throat
C. Hyperthermia
D. Thrombocytosis
74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the evidence of:
A. Thyroid storm
B. Mediastinal shift
C. Damage to the laryngeal nerve
D. Hypocalcemia tetany
75. Should you check for hemorrhage, you will:
A. Slip your hand under the nape of her neck
B. Check for hypotension
C. Apply neck collar to prevent haemorrhage
D. Observe the dressing if is soaked with blood
76. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the standard procedure, you need to tell Johnny that:
A. Obstructing his vision
B. Restraining his upper and lower extremities
C. Obstructing his hearing
D. Obstructing his nostril with a clamp
77. The BMR is based on the measurement that:
A. Rate of respiration under different condition of activities and rest
B. Amount of oxygen consumption under resting condition over a measured period of time
C. Amount of oxygen consumption under stressed condition over a measured period of time
D. Ratio of respiration to pulse rate over a measured period of time
78. Her physician ordered Lugol's solution in order to:
A. Decrease the vascularity and size of the thyroid gland
B. Decrease the size of the thyroid gland only
C. Increase the vascularity and size of the thyroid gland
D. Increase the size of the thyroid gland only
79. Which of the following is a side effect of Lugol's solution?
A. Hypokalemia
B. Nystagmus
C. Enlargement of the Thyroid gland
D. Excessive salivation
80. In administering Lugol's solution, the precautionary measure should include:
A. Administer with glass only
B. Dilute with juice and administer with a straw
C. Administer it with milk and drink it
D. Follow it with milk of magnesia
Situation: Pharmacological treatment was not effective for Johnny's hyperthyroidism and now he is scheduled for Thyroidectomy.
81. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON CRITICAL. If the instrument are introduced directly into the blood stream or into any normally sterile cavity or area of the body it is classified as:
A. Critical
B. Semi critical
C. Non critical
D. Ultra critical
82. Instruments that do not touch the patient or have contact only to the intact skin is classified as:
A. Critical
B. Semi critical
C. Non critical
D. Ultra critical
83. If an instrument is classified as Semi Critical an acceptable method of making the instrument ready for surgery is through:
A. Sterilization
B. Decontamination
C. Disinfection
D. Cleaning
84. While critical items and should be:
A. Clean
B. Decontaminated
C. Sterilized
D. Disinfected
85. As a nurse, you know that intact skin as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin or mucous membranes should be:
A. Disinfected
B. Sterile
C. Clean
D. Alcoholized
86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Johnny to:
A. Perform range and motion exercise on the head or neck
B. Apply gentle pressure against the incision when swallowing
C. Cough and deep breathe every hours
D. Support head with the hands when changing position
Situation - Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.
87. Andrea's respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:
A. Biot's
B. Kussmaul's
C. Cheyne Stokes
D. Eupnea
88. What do you call the triad of sign and symptoms seen in a client with increasing ICP?
A. Virchow's Triad
B. The Chinese triad
C. Cushing's Triad
D. Charcot's Triad
89. Which of the following is true with the Cushing's Triad seen in head injuries?
A. Narrowing of Pulse Pressure, Cheyne stokes respiration, Tachycardia
B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmaul's respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia
90. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?
A. Ineffective airway clearance
B. Ineffective breathing pattern
C. Impaired gas exchange
D. Activity Intolerance
* * * * * * * * * * * * * * * *
Answers
Here are the answers for the exam. Unfortunately, rationales are not given. If you need clarifications or disputes, please direct them to the comments section and we'll be glad to give you an explanation.
1. D
2. D
3. B
4. B
5. C
6. D
7. A
8. B
9. B
10. B
11. C
12. B
13. D
14. A
15. B
16. D
17. B
18. D
19. B
20. D
21. D
22. B
23. D
24. D
25. B
26. C
27. B
28. A
29. B
30. D
31. D
32. D
33. D
34. B
35. D
36. A
37. D
38. A
39. D
40. C
41. D
42. D
43. A
44. C
45. A
46. C
47. B
48. B
49. A
50. D
51. D
52. C
53. D
54. A
55. D
56. C
57. A
58. A
59. D
60. D
61. D
62. A
63. B
63. A
64. A
65. D
66. C
67. D
68. B
69. B
70. B
71. A
72. A
73. B
74. C
75. A
76. D
77. B
78. A
79. D
80. B
81. A
82. C
83. C
84. C
85. A
86. D
87. C
88. C
89. B
90. B
