NLE Sample Questions 4

PRACTICE EXAM IV

1. You are the nurse in an Adult Care Unit. You over-hear one of your co-staff nurse assigned
to Aling Josie who is 78 years old say. that if she refuses to take her medications she will not be given her favorite dessert. You report your co-staff's behavior as

A. Battery C. Negligence
B. Assault D. Malpractice

2. Jake is in the Post Anesthesia Care Unit following a colorectal resection. He has an IV of Dextrose 5% Lactated Ringers Solution. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs, moist respiration and tachypnea. Which of the following will you do FIRST?

A. Notify anesthesiologist C. Place on Fowler's position
B. Increase 02 flow rate D. Reduce IV rate

3. As a head nurse of the unit, which of the following sources should you take into consideration when making effective assignments for the next shift?

A. Seniority preferences
B. Recent performance evaluation
C. Personality traits
D. Client classification data

4. Four clients injured in an automobile accident-enter the emergency department (ED) at the
same time and are immediately seen by a triage nurse. As the triage nurse, you would assign the HIGHEST priority to the client with the:

A. severe head injury and no blood pressure
B. maxillofacial injury and gurling respirations
C. second trimester pregnancy with premature labor
D. lumbar spinal cord injury and lower extremity paralysis

5. When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible?
A. Volunteer nurse, hospital and the nurse in charge
B. The professional organization which the volunteer nurse represents
C. Hospital
D. Volunteer nurse because there is no employer employee relationship

6. Daniel with multiple myeloma complains of deep bone pain. As his nurse, which of the following will you do FIRST?

A. Assess bone pain
B. Administer prescribed analgesic
C. Teach pain relief strategies
D. Support position with pillow

7. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which
laboratory reeult should you expect to find?

A. Increased platelet count
B. Altered blood urea nitrogen(BUN) and creatinine levels
C. Electrolyte imbalance
D. Elevated erythrocyte sedimentation rate (ESR)

8. Mrs Paras is receiving total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of the following indicators will tell you that TPN was effective?

A. laboratory work up
B. adequate hydration
C. weight gain
D. diminish episode of nausea and vomiting

9. While .'ayvee, a bum patient is being transferred from the bum unit to the operating roorri, the IV bottle feB on Jayvee's head. Me sustained a laceration on his forehead. The*nurse was proven guitty of negligence. Which of the following did the nurse fail to do?

A. Hold the IV bottle
B. Check the IV stand
C. Place the IV stand on the foot part of the stretcher
D. Restrain Jayvee

10. While Mrs. Enriquez is receiving chemotherapy which of the following will you include in the pian of care to address her nutritional needs?

A. administer Compazine before meals
B. enrich diet with red meat
C. serve hot soup and food
D. increase the amount of spice in the diet

11. Nurses working in the 35 bed Female Medical Unit were noted to implement new and innovative client care activities long before other units in the hospital. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength?

A. Communication skills C. Vision and passion
B. Knowledge and skills D. Interpersonal abilities

12. Olga is receiving D5W 1 liter regulated al 30 drops/min to be consumed in 8 hrs. It was started at 8am. At 10am her relative informed you that the bottle is empty. Which of the following wiii you do first?

A. refer to nurse manager
B. assess Olga and diet level of fluid left in the bottle
C. discontinue IV and assess Olga
D. replace the IV fluid with prescribed follow-up

13. A research study found out that 60% of patients complaints were due to delayed responses of curses in the emergency department. Which of the following measurement of data was used in this study?
A. Measures of variability C. Frequency distribution
B. Measures of central tendency D. Inferential statistics.

14. During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with :

A. alcohol C. ammonia
B. acetone D. bleach

15. Nino Is being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy?

A. Coverjhe areas with thick clothing material
B. Apply & heating pad to the site
C. Wash skin with water after the therapy.
D. Avoid applying creams and powders to the area

16. You are assigned to the following patients. Which of the following patient is most at risk for metabolic alkalosis?

A. Grace 30 year old post surgical patient who has continuous nasogastric suction
B. Rachel a 55 year old who has just experienced a stroke
C. Helen 70 year old with altered level of consciousness who is unable to access water freely
D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution

17. Studies have shown that the highest incidence of Hodgkin's disease is common among young adults. Juana 20 years old approaches you and tells you "I am worried about the mass on my neck". What should you do as a nurse?

A. Tell her there is nothing to worry if it does not bother her
B. Palpate Juana's neck and explain the possible cause
C. tell her Hodgkin's disease is common among young adults like her.
D. Tell her to see a doctor

18. As a nurse, you accidentally administer 40 mg of Propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, you should:

A. complete an incident report.
B. call the hospital attorney
C. inform the client's family
D. do nothing because the client's condition is stable.

19. You are the nurse manager of the Medical Unit. Which of the following is a priority for you to consider when planning for the care of a group of client utilizing evidence-based practice?

A. Client's care is planned based on the nurse's clinical expertise and latest research findings
B. Standardized care plans &re used on all of the nurse's clients.
C. Standards of care- are developed by the hospital nursing service and should be followed
D. Clients' needs are assessed and individualized care plan are developed for each client.

20. Because of increase incidents of medication error due to wrong transcription of physician medication orders by nurses, a tertiary hospital utilized a computered medication order system. Which of the following procedures may be don3 through the said system?

A. Correct errors in the physician medication order.
B. Eliminate drug interaction.
C. Provide a list of drugs with their generic name.
D. Document drug administration.

SITUATIONAL

Situation 1 - P. Cruz, 65 years old, was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. You are expected to recognize electrocardiographic readings on the cardiac monitor.

21. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium?

A. QRS interval C. P wave
B. ST segment and T wave D. PR interval

22. From an ECG reading, a QRS complex represents

A Ventricular depolarization C. End of ventricular depolarization
B. Ventricular repolarization D. Atrial depolarization

23. Which of the following represents ventricular repolarization?

A. T wave C. QRS complex
B. ST segment D. PR interval

24. It is important that the nurse measures intervals of QRS complex. Which of the following
represent the normal interval of the QRS complex?

A. greater than .20 sec. C. .10 sec
B. . 20 sec D. .12 see to .20 sec.

25. Later in the acute phase of Myocardial Infarction, which of the following typically appears as the first sign of tissue death?

A. ST segment suppression C. Prolonged PR interval
B. Short T wave D. Pathologic Q wave

Situation 2 - To be-able to help our clients with their psychological concerns we have to explore how they view themselves and their body image.

26. When assessing patient's body image, which of the following would be most important to ask?

A. What are your hobbies?
B. What kind of work did you do prior to this illness? .
C. Are your living accommodation all on one level?
D. What kind of food do you like?

27. The most appropriate nursing intervention to facilitate client's acceptance of a change in body image would be to:

A. encourage dependence
B. establish a therapeutic relationship
C. joke with the client
D. establish a social relationship

28. Which of the following responses would indicate that the client is beginning to accept change in his/her body image?

A. Feeling of the dressing over the incision site
B. Stating he/she is too tired to have visitors
C. Discussing his/her stamp collection with the nurse
D. Showing no interest in the dressing change

29. It is important for you to remember, that a sudden change in body image would occur from:

A. weight gain
B. side effects of medication on skin
C. radiation treatment of the breast
D. surgical removal of an eyeball.

30. Before you can help Lorna accept a change in body image you must FIRST;

A. be In agreement with the philosophy of therapy for the client
B. become aware of her own attitude toward mutilation and disfigurement
C. be aware of the attitudes and feelings of the client and her family
D. accept the fact that a person can live with a body part missing.

Situation 3 - Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse.

31. Albert is receiving external radiation therapy and he complains of tatigue 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. Reassure him that these feelings are normal
D. Help him plan his activities and rest period

32. 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

33 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. Headline, dizziness, blurred vision
D. Severe-sore throat, bacteremia, hepatomegaly

34. What nursing diagnosis should be of highest priority?

A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. ineffective tissue perfusion; peripheral, cerebral, cardiovascular, gastrointestinal, renal

35. What intervention should you include in your care plan?

A. inspect his skin for petechiae, bruising, Gl bieeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38°C

Situation 4 --Andrea is admitted to the ER following an assault where she was hit in the face and head. She was brought to the ER by a police woman. Emergency measures were started.

36. As Andrea's nurse, what will be your priority interventions?

A. Insert an intravenous catheter
D. Insert an oral or nasopharyngeal airway
C. Obtain arterial blood gases
D. Give 100% oxygen by mask

37. Andres's arterial blood gases reflect respirator/ acidosis. This is most likely related to :

A. partially obstructed airway
B. ineffective breathing pattern
C. head injury
D. pain

38. Andrea loses consciousness. You should prepare for which of Die following FIRST?

A. Placement of a nasogastric tube
B. Placement of a second IV line
C. Endotracheal intubation or surgical airway placement
D. CT scan or the head

39. Andrea's physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to :

A. promote cerebral-tissue fluid movement
B. promote renal perfusion
C. correct acid-base imbalances
D. enhance renal excretion of drugs

40. As Andrea's nurse your goal is to prevent increased intracranial pressure(ICP). Which of the following independent nursing interventions is NOT suited for her?

A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration?
B. Keep head of bed 30-15 degrees elevated
C. Maintain Andrea's head in straight alignment and prevent hip flexion
D. Prevent constipation and increases in intra abdominal pressure

Situation 5 - Specific surgical interventions may be done when lung cancer is detected early,? You have important peri-operative responsibilities in caring for patients with lung
cancer.

41. Horace underwent lobectomy. Which of the following is the purpose of Horace's closed chest drainage post lobectomy ?

A. Facilitation of coughing
B. Promotion of wound healing
C. Expansion of the remaining lung
D. Prevention of mediastinal shift

42. Which of the following observations indicates that the closed chest drainage system is functioning property?

A. Absence of bubbling in the suction control bottle
B. The fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
C. Intermittent bubbling through the long tube of the suction control bottle
D. Less than 25 ml. drainage in the drainage bottle

43. Following lobectomy, you can best help Horace to reduce pain during deep breathing and coughing exercises by:

A. placing him on his operative side during exercises.
B. splinting his diet with both hands during the exercises
C. administering the prescribed analgesic immediately prior to exercises
D. providing rest for six hours before exercises.

44. Peter underwent pneumonectomy. During the immediate postoperative period, deep tracheal suction should be done with extreme caution because:

A. Peter will not be able to tolerate coughing.
B. the tracheobrachial trees are dry
C. the remaining normal lung needs minimal stimulation
D. the bronchial site line may be traumatized

45. On which of the following positions should you place Peter who just underwent pneumonectomy?

A. Prone position
B. On his abdomen or on the side opposite the surgery
C. On his back or on the side of surgery
D. Any position is acceptable

Situation 6 - As a nurse you should be able to address problems and, discomforts experienced by the acutely ill older persons.

46. Pain in the older persons require careful assessment because they;

A. Are expected to experience chronic pain
B. Experienced reduce sensory perception
C. Have increased sensory perception
D. Have a decreased pain threshold

47. Administration of analgesics to the older persons requires careful patient assessment because older people:

A. have increased hepatic, renal, and gastrointestinal function
B. mobilize drug more rapidly
C. have increased sensory perception
D. are more Sensitive to drugs

48. The older person is at higher risk for incontinence because of

A. increased glomerular filtration C. diuretic use
B. decreased bladder capacity D. dilated urethra

49. The most dependable cause of infection in the older person is

A. change in mental status
B. fever
C. decreased breath sounds with crackles
D. pain

50. 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 and fluid
D. ensure accurate monitoring of intake and output

51. 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 on his own.
B. Irrigate the catheter.
C. Toil him to "Go ahead and void.' "You have a catheter."
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation.

52. You decided to check on Mang Felix's IV fluid infusion. You noted a change 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

53. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during the first post operative day, 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 dairy living Started

Situation 8 - Many hospitals form bioethical review committees to ensure better quality of life of patients. You are invited by the nursing service department to participate in their bioethical review committee. You are expected to knew the purpose and apply bioethical principles.

54. Which of the following is the purpose of the ethical review committee?

A. Promote implementation of general standards
B. Enhance health care provider's liability
C. Increase individuals responsibility for decision making
D. Decrease public scrutiny of health care provider's action

57. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20,000/dL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulin has not been successful. Her physician recommended splenectomy. Daria states "I don't need surgery. This will go away on its own.” In considering your response to Daria you must depend on the ethical principle of:

A. Beneficence C. Autonomy
B. Justice D. Advocacy

58. Zorayda is terminally ill and is experiencing severe pain. She as bone and liver metastasis. She has been on morphine for several months now. Zorayda is aware that they are having financial problems. She decides to sign a DNR form. What ethical principle did Zorayda and tier family utilize as basis for their decision to sign a DNR.

A. Justice C. Beneficence
B. Autonomy D. Advocacy

59.Tricia, a staff nurse working in a cancer unit, is considered a role model not only by her colleagues, but also by her patients. She goes out of her way 10 help other. She is very active in their professional organization and she practices what she teaches. What ethical principles is she practicing?
A. Beneficence C. Advocacy
B. Autonomy D. Justice

60. You ore commuting to work riding the LRT.*An older person collapsed and nobody seem to notice her. The security guard tried to make her sit down but she remained unconscious. You saw what happened and you decided to help. With help, you brought the patient to the nearest hospital. You learned later that woman was diabetic. She was on her way to the diabetes clinic to have her fasting blood sugar tested. She developed hypoglycemia. You were able to save a life. You felt good. What principle was applied?

A. Advocacy C. Justice
B. Beneficence . D. Autonomy

Situation 9 - Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.

61. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure.

A. clenching his fist every 2 minutes
B. breathing in and out through the nose with his mouth open
C. tensing the shoulder muscles while lying on his back
D. holding his breath periodically for 30 seconds

62. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication.

A. nausea and vomiting
B. shortness of breath and laryngeal stridor
C. blood tinged sputum and coughing
D. sore throat and hoarseness

63. Immediately alter bronchoscopy, you instructed Fernan to :

A. exercise the neck muscles.
B. breathe deeply
C. regain from coughing and talking
D. clear his throat

64. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to :

A. keep the sterile equipment from contamination
B. assist the physician
C. open and close the three-way stopcock
D. observe the patient's vital signs

65. Right after thoracentesis, which of the following is most appropriate intervention?

A. instruct the patient not to cough or deep breathe for two hours .
B. observe for symptoms of tightness of chest for bleeding
C. place an ice pack to the puncture site
D. remove the dressing to check for bleeding

Situation 10 -As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients.

66. Getty is receiving chemotherapy for cancer. You review Getty's laboratory report and note that he has anemia. To which nursing diagnosis should you give the highest priority.

A. Activity intolerance
B. Impaired oral mucous membrane
C. Impacted tissue perfusion, cerebral, cardiovascular, gastrointestinal
D. Impaired tissue integrity

67. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease.

A. hypertension C. hematuria
B. pain D. weight

68. A difficult problem to deal with when caring for u patient with partial-thickness burns sustained 3 days ago is :

A. alteration in body image C. frequent dressing change
B. maintenance of sterility D. severe pain

69. Which outcome criterion would be most appropriate for a client with a nursing diagnosis ineffective airway clearance.

A. Continued use of oxygen when necessary
B. Breath sounds clear on auscultation
C. Respiratory rate of 24/min
D. Presence of congestion

70. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related to purulent wound drainage.

A. Heart rate of 88 beats/min C. Oral temperature of 38.8 deg C
B. Dry and intact wound dressing D. Wound healing by first intention

Situation 11 - Nurses have important responsibilities when caring for hospitalized acutely ill patients.

71. Domingo. 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. His physician was considering dementia. Side rails were placed to ensure that he will not fall from bed. At 2:00 am, the call light at his room was on. You came in and saw Domingo slumped on the floor moaning. His daughter told you that he got out of bed to go to the toilet. He climbed over the side rail but his foot got caught in the beddings. He has an open wound on his forehead. Which among the following will you do FIRST?

A. Transfer him to bed
B. Apply restraints
C. Ensure airway, breathing, circulation
D. Call his physician

72. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Based on the ECG obtained on admission at the ER and clinical findings, the physician gave a diagnosis of myocardial infarction(MI) and prescribed IV morphine to relieve continuing pain. A primary goal of nursing care for Aimee is to recognize life-threatening complications of Ml. As Aimee's nurse, you have to anticipate occurrence of complications. Take note that the major cause of death after an Ml is:

A. Cardiac arrhythmias C. Cardiogenic shock
B. Heart failure D. Pulmonary embolism

73. The cardiac mentor uxlicates thai Cedric's heart rate has increased to 150 beats per/minute. Shortly after this increase, you notice Cedric is in ventricular tachycardia. After reporting this to the physician, you anticipate that the physician will order:

A. intracardiac epinephrine
B. insertion of a pacemaker
C. bolus of Lidocaine
D. manual cardiopulmonary resuscitation (CPR)

74. Hermie with a left-sided lie art failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. You should recognize this as signs and symptoms of:
A. cardiogenic shock C. acute pulmonary edema
B. right-sided heart failure D. pneumonia

75. You are caring for Lulu who has acute pulmonary edema. To immediately promote oxygenation and relief of dyspnea, you should first:

A. perform chest physiotherapy
B. have her take deep breaths and cough
C. place Lulu on high fowler's position
D. administer oxygen

Situation 12 - Acute respiratory distress is life threatening. Your presence and critical decision making as a nurse are important.

76. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. When assessing Frank you would expect to find;

A. an altered mental status C. a slowed rate of breathing
B. hypertension D. tenacious secretion

77. Frank's respiratory status necessitates endotracheal intubation and positive pressure ventilation. Your most immediate nursing intervention for Frank at this time would be to:

A. facilitate Frank's verbal communication
B. maintain sterility of the ventilation system
C. assess his response to the equipment
D. prepare him for emergency surgery

78. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, you should:

A. Apply suction while inserting the catheter
B. use short and jabbing movements of the catheter to loosen secretions
C. Hyperoxygenate with 100% oxygen before and after suctioning
D. suction two In three times in quick succession to remove all secretions

79. As a nurse you should observe Bernard, who has a restrictive airway disease, for early indications of respiratory acidosis, which include;

A. lightheadedness C. bradycardia
B. bradypnea D. restlessness

80. The physician orders low concentration oxygen to be given continuously for Kenneth who
has a chronic obstructive pulmonary disease to prevent:

A. an excessive drying of the respiratory mucosa
B. depression of the respiratory center
C. rupture of emphysematous bullae
D. a decrease in red blood cell formation

Situation 13 - As a nurse you have to be prepared to care for patients receiving blood transfusion. The physician has ordered 3 units of whole blood to be transfused to Diego following a repair of a dissecting aneurysm of the aorta.

81. You are preparing a unit of whole blood for transfusion. From the time you obtain it from the b'xxj bank how long should you infuse it?

A. 4 hours C. 2 hours
B. 1 hour D. 6 hours

82. What should you do FIRST before you administer blood transfusion?

A. Check IV site and use appropriate BT set and needle
D. Verify physician’s order
C. Verify client identity and blood product blood product, serial number, blood type, cross matching results, expiration date with another nurse
D. Verify client identity and blood product, serial number, blood type, cross matching results, expiration date

83. As Diego's nurse what will you do after the transfusion has been started?

A. Discontinue the primary 17 of Dextrose 5% water
B. Stay with Diego for 15 minutes to note for any possible BT reaction
C. Check his vital signs every 15 minutes
D. Add the total amount of the blood to be transfused to the intake and output

84. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are

A. oliguria and jaundice
B. urticaria and wheezing
C. hypertension and flushing
D. headache, chills, fever

85. In case Diego will experience an acute hemolytic reaction, what will be your priority intervention?

A. Immediately stop the blood transfusion, infuse Dextrose 5% in water and call the physician
B. Slow Die blood transfusion and monitor the patient closely
C. Immediately stop the blood transfusion, notify the blood bank and administer antihistamines
D. Immediately stop the blood transfusion, infuse normal saline solution, call the physician, notify the blood bank

Situation 14 - 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.

86. Critically ill patients frequently complain about which of the following when hospitalized?

A. Hospital food C. Lack of privacy
B. Lack of blankets D. Inadequate nursing staff

87. Who of the following is at greatest risk of developing sensory problem?

A. Female patient C. Transplant patient
B. Adolescent patient D. Unresponsive patient

88. 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

90. 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 client's status
D. Spiritual counseling

91. The WHO Analgesic ladder provides the health professional with:

A. pharmacologic and nonpharmacologic pain management choices
B. general pain management choices based on level of pain
C. nonpharmacologic interventions based on level of pain
D. specific pain management choices based on severity of pain

92. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT;

A. physical dependence C. respiratory depression
B. pruritus D. constipation

93. Which of the following statements about cancer pain is NOT TRUE?

A. Undertreatment of pain is often due to a clinician's failure to evaluate the severity of the client's problem
B. Adjuvant medications such as steroids, anticonvulsants, nonsteroidal antinflammatory drugs enhance pain perception.
C. Opioids are drugs of choice for, severe pain
D. Pain associated with cancer and the terminal phase of the disease occurs in majority of patients

94. Jack has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that Jack is:

A. becoming psychologically dependent
B. needing to have the morphine discontinued
C. developing tolerance to the morphine
D. exaggerating his level of pain

95. The guidelines for choosing appropriate nonpharmacologic interventions for pain include all of the following EXCEPT:

A. pain problem identification
B. Type of opioid being used
C. skill of the health professional
D. effectiveness for patient

Situation 16 - The nurses accurate assessment is very crucial in preventing complication during the severe post burn period.

96. Dino sustained circumferential thermal bums of the left upper extremity and chest. You noted that pulse could not be appreciated in his injured extremity. Which of the following will you do FIRST?

A. Elevate the injured extremity to increase blood flow to the heart
B. Remove the dead tissues which impede circulation
C. Try to take the pulse in the uninjured extremity
D. Notify the physician immediately as this requires emergency intervention

97. While unloading containers with chemicals from a truck, Mark accidentally spilled the whole can of corrosive chemicals all over his body. Which of the following would you consider as the priority intervention in the emergency management of Mark?

A. Maintain a patent airway
B. Wash the chemical off with cool water
C. Assess for associated injuries
D. Remove all clothing containing the chemical.

98. You are assigned in the Bum Unit and you are going to evaluate the status of Raymond who sustained a burn injury 12 hours ago and has a urinary output of 200 ml since the injury. Which of the following will you do FIRST?

A. Increase the rate at the IV fluid.
B. Administer the prescribed Furosemide (Lasix) ,
C. Check catheter for kinks.
D. Increase the oral intake to 30 ml/hr.

99. Kathy, who has partial-thickness burns on the face, inquires about skin care after discharge. Which of the following should you include in your discharge teaching?

A. Continue to eat high caloric high food for the next month
B. Wear a pressure garment daily for one year
C. Avoid sunlight for the next three months
D. Avoid facial makeup for at least a year

100. You are caring for Lenard who sustained severe burn injury and he is in the emergent phase of bum injury. As his nurse, you gathered the following: Hemoglobin 13.5 g/100 ml,, hematocrit 50%, serum Na 130 mEq/L How will you explain the laboratory results?

A. These are due to hemodilution from rapid IV fluid replacement.
B. All the laboratory tests are within normal range
C. They are slightly abnormal but will normalize once IV fluids have been started
D. These are due to a loss of scrum and interstitial fluid through the burn wound.