COLLEGE OF ST.

JOHN ROXAS
De La Salle Supervised

Gov. Atila Balgos Ave., Banica, Roxas City

5800 Capiz, Philippines

College of nursing
ELECTIVE II
Ms. Irene D. Bellosillo, RN

Final Exam
October 23, 2014

1.Pain in the elderly persons requires careful assessment because they:

a.
b.
c.
d.

Experience reduced sensory perception

Have increased sensory perception
Are expected to experience chronic pain
Have decreased pain threshold

2.Which of the following is the most common sign of infection among elderly?
a.
b.
c.
d.

Decrease breath sounds with crackles

Fever
Pain
Change in mental status

3.Priorities when caring for elderly trauma patient:

a.
b.
c.
d.

Circulation, airway, breathing

Disability ( neurologic), airway(breathing)
Airway , breathing, disability(neurologic)
Airway, breathing,circulation

4.Patient who is in acute renal failure, is admitted to Nephrology Unit. Theperiod of oliguria
usually last for about 10 days.Which assessment parameter for kidney function will you use during
the oliguric phase?
a.
b.
c.
d.

Urine output directly related to the amount of IV fluid infused

Urine output is less than 400ml/24hrs.
Urine output of 30-60 ml/hr
No urine output ,kidneys in a state of suspension

5.During the shock state, what is the effect of the renin-aldosterone-angiotensin ystem of renal
infection?
a.
b.
c.
d.

Increase urine output, increase absorption of sodium and water

Decrease urine output, decrease absorption of sodium and water
Increase urine output, decreased absorption of sodium and water
Decrease urine output and increased absorption of sodium and water

6.As you are caring for pt who has acute renal failure, ano of the collaborative interventions you
are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to
treat.
a.
b.
c.
d.

Hyperkalemia
Hypercalcemia
Hypokalemia
Hypertremia

7.James year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis
in his left arm . What diet instructions will you need to reinforce prior to discharge?
a.
b.
c.
d.

Drink plenty of water

Restrict your salt intake
Monitor your fruit intake and eat plenty of bananas
Be sure to eat meat every meal

8.You are preparing the first unit for blood transfusion. From the time you obtain it from the blood
bank, how long should you infuse it?
a.
b.
c.
d.

6 hrs
4 hrs
1 hr
2 hrs

9.What should you do first before you administer blood transfusion?

a. Verify clients identity and blood product , serial number, blood type, cross matching results,
expiration date
b. Verify client identity and blood product, serial number, blood type, cross matching results,
expiration date with another nurse
c. Check IV site and use appropriate BT set and needles
d. Verify physicians order
10.What will you do after the transfusion has started?
a.
b.
c.
d.

Add the total amount of the blood to be transferred to the intake and output
Discontinue the primary IV of Dextrose 5% water
Check the vital signs every 15 mins
Stay with the patient for 15 mins to note for any possible BT reaction.

11.Patient undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions
are
a.
b.
c.
d.

Oliguria and jaundice

Urticaria and wheezing
Hypertension and flushing
Headache, chills and fever

12. Mr. Santos age 89, has terminal cancer, he demonstrates signs of dementia. You should give highest
priority to which nursing diagnosis
a.
b.
c.
d.

Risk for injury

Bathing of hygiene self -care deficit
Ineffective cerebral tissue perfusion
Dysfunctional grieving

13. Patient is scheduled to have lobectomy. The purpose of closed chest drainage following a
lobectomy is:
a.
b.
c.
d.

Expansion of the remaining lungs

Facilitation of coughing
Prevention of mediastinal shift
Promotion of wound healing

14. Colostomy is best defined as:

a. Cutting of colon and bringing the proximal end through the abdominal wall

b. Creating stomal orifice from the ileum

c. Excising a section of the colon and doing an end to end anastomosis
d. Removing the rectum and suturing the colon to the anus
15. The best way to prevent infection around the stoma is to
a.
b.
c.
d.

Wash the stoma and skin around it with hydrogen peroxide

Apply the tincture of benzoic around the stoma daily
Apply warm saline compresses daily until colostomy isregulated
Wash the stoma and skin around it with soup and wter

16. A colostomy patient who wishes to avoid flatulence should not eat the following
a.
b.
c.
d.

Corn and peanuts

Cabbage and asparagus
Mangoes and pineapple
Chewing gum and carbonated beverages

17. The primary purpose of endotracheal tube cuff is to;

a.
b.
c.
d.

Seal off the lower airway from the nasopharynx

Seal off the lower airway from the esophagus
Seal off the oropharynx from the esophagus
Seal off the lower airway from the upper airway

18. Endotracheal tube size indicated an the tube reflects what measurement
a.
b.
c.
d.

The circumference size of the tube

The length of the tube
The internal diameter of the tube
The length of person airway

19. When do coronary arteries primarily receive blood flow?

a. During inspiration

b. During diastole

c. During expiration

d. During systole

20. Which of the following conditions most commonly results in coronary artery deasease?

a. Atherosclerosis

b. DM

c. MI

d. Renal failure

21. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

a. Plaques obstruct the vein

b. Plaques obstruct the artery
c. Blood clots form outside the vessel wall
d. Hardened vessels dilate to allow the blood to flow through

22. Which of the following risk factors for coronary artery disease cannot be corrected?

a. Cigarette smoking

b. DM

c. Heredity

d. HPN

23. Increase in which of the following serum cholesterol levels put the patients significantly high
risk of coronary artery disease?

a. 100 mg/dl

b. 150 mg/dl

c. 175 mg/dl

d. 200 mg/dl

24. Which of the following actions is the first priority care for a client exhibiting signs and symptoms
of coronary artery disease?

a. Decrease anxiety

b. Enhance myocardial oxygenation

c. Administer sublingual nitroglycerin

d. Educate the client about his symptoms

25. Medical treatment of coronary artery disease includes which of the following procedures?

a. Cardiac catheterization

b. Coronary artery bypass surgery

c. Oral medication administration

d. Percutaneous transluminal coronary angioplasty

26. Prolonged occlusion of the right coronary artery produces an infarction in which of the
following areas of the heart?

a. Anterior

b. Apical

c. Inferior

d. Lateral

27. Which of the following is the most common symptom of myocardial infarction?

a. Chest pain

b. Dyspnea

c. Edema

d. Palpitations

29. Which of the following landmarks is the correct one for obtaining an apical pulse?

a. Left intercostal space, midaxillary line

b. Left fifth intercostal space, midclavicular line
c. Left second intercostal space, midclavicular line
d. Left seventh intercostal space, midclavicular line

30. Which of the following systems is the most likely origin of pain the client describes as knifelike
chest pain that increases in intensity with inspiration?

a. Cardiac

b. Gastrointestinal

c. Musculoskeletal

d. Pulmonary

31. Which of the following blood tests is most indicative of cardiac damage?

a. Lactate dehydrogenase

b. Complete blood count

c. Troponin I

d. Creatine kinase

32. What is the primary reason for administering morphine to a client with myocardial infarction?

a. To sedate the client

b. To decrease the clients pain

c. To decrease the clients anxiety

d. To decrease oxygen demand on the clients heart

33. Which of the following conditions is most commonly responsible for myocardial infarction?

a. Aneurysm

b. Heart failure

c. Coronary artery thrombosis

d. Renal failure

34. What supplemental medication is most frequently ordered in conjuction with furosemide
(Lasix)?

a. Chloride

b. Digoxin

c. Potassium

d. Sodium

35. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What
type of physiologic changes are these?

a. Electrophysiologic

b. Hematologic

c. Mechanical

d. Metabolic

36. Which of the following complications is indicated by a third heart sound (S3)?

a. Ventricular dilation

b. Systemic hypertension

c. Aortic valve malfunction

d. Increased atrial contractions

37. Which of the following diagnostic tools is most commonly used to determine the location of
myocardial damage?

a. Cardiac catheterization

b. Cardiac enzymes

c. Echocardiogram

d. Electrocardiogram

38. What is the first intervention for a client experiencing myocardial infarction?

a. Administer morphine

b. Administer oxygen

c. Administer sublingual nitroglycerin

d. Obtain an electrocardiogram

39. What is the most appropriate nursing response to a myocardial infarction client who is fearful
of dying?

a. Tell me about your feeling right now.

b. When the doctor arrives, everything will be fine.
c. This is a bad situation, but youll feel better soon.
d. Please be assured were doing everything we can to make you feel better.

40. Which of the following classes of medications protects the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation?

a. Beta-adrenergic blockers

b. Calcium channel blockers

c. Narcotics

d. Nitrates

41. What is the most common complication of a myocardial infarction?

a. Cardiogenic shock

b. Heart failure

c. Arrhythmias

d. Pericarditis

42. What position should the nurse place the head of the bed in to obtain the most accurate reading
of jugular vein distention?

a. High-fowlers

b. Raised 10 degrees

c. Raised 30 degrees

d. Supine position

43. Which of the following parameters should be checked before administering digoxin?

a. Apical pulse

b. Blood pressure

c. Radial pulse

d. Respiratory rate

44. Toxicity from which of the following medications may cause a client to see a green halo around
lights?

a. Digoxin

b. Furosemide

c. Metoprolol

d. Enalapril

45. Which ofthe following symptoms is most commonly associated with left-sided heart failure?

a. Crackles

b. Arrhythmias

c. Hepatic engorgement

d. Hypotension

46. Which of the following symptoms might a client with right-sided heart failure exhibit?

a. Adequate urine output

b. Polyuria

c. Oliguria

d. Polydipsia

47. Which of the following classes of medications maximizes cardiac performance in clients with
heat failure by increasing ventricular contractility?

a. Beta-adrenergic blockers

b. Calcium channel blockers

c. Diuretics

d. Inotropic agents

48. Stimulation of the sympathetic nervous system produces which of the following responses?

a. Bradycardia

b. Tachycardia

c. Hypotension

d. Decreased myocardial contractility

49. Which of the following conditions is most closely associated with weight gain, nausea, and a
decrease in urine output?

a. Angina pectoris

b. Cardiomyopathy

c. Left-sided heart failure

d. Right-sided heart failure

50. What is the most common cause of abdominal aortic aneurysm?

a. Atherosclerosis

b. DM

c. HPN

d. Syphilis

51. In which of the following areas is an abdominal aortic aneurysm most commonly located?

a. Distal to the iliac arteries

b. Distal to the renal arteries

c. Adjacent to the aortic branch

d. Proximal to the renal arteries

52. A pulsating abdominal mass usually indicates which of the following conditions?

a. Abdominal aortic aneurysm

b. Enlarged spleen

c. Gastic distention

d. Gastritis

53. What is the most common symptom in a client with abdominal aortic aneurysm?

a. Abdominal pain

b. Diaphoresis

c. Headache

d. Upper back pain

54. Which of the following symptoms usually signifies rapid expansion and impending rupture of an
abdominal aortic aneurysm?

a. Abdominal pain

b. Absent pedal pulses

c. Angina

d. Lower back pain

55. What is the definitive test used to diagnose an abdominal aortic aneurysm?

a. Abdominal X-ray

b. Arteriogram

c. CT scan

d. Ultrasound

56. Which of the following complications is of greatest concern when caring for a preoperative
abdominal aneurysm client?

a. HPN

b. Aneurysm rupture

c. Cardiac arrhythmias

d. Diminished pedal pulses

57. Which of the following blood vessel layers may be damaged in a client with an aneurysm?

a. Externa

b. Interna

c. Media

d. Interna and Media

58. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most
commonly palpated?

a. Right upper quadrant

b. Directly over the umbilicus
c. Middle lower abdomen to the left of the midline
d. Midline lower abdomen to the right of the midline

59. Which of the following sounds is distinctly heard on auscultation over the abdominal region of
an abdominal aortic aneurysm client?

a. Bruit

b. Crackles

c. Dullness

d. Friction rubs

60. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm?

a. Lower back pain, increased BP, decreased RBC, increased WBC

b. Severe lower back pain, decreased BP, decreased RBC, increased WBC
c. Severe lower back pain, decreased BP, decreased RBC, decreased WBC
d. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC

61. Which of the following complications of an abdominal aortic repair is indicated by detection of
a hematoma in the perineal area?

a. Hernia

b. Stage 1 pressure ulcer

c. Retroperitoneal rupture at the repair site

d. Rapid expansion of the aneurysm

62. Which hereditary disease is most closely linked to aneurysm?

a. Cystic fibrosis

b. Lupus erythematosus

c. Marfans syndrome

d. Myocardial infarction

63. Which of the following treatments is the definitive one for a ruptured aneurysm?

a. Antihypertensive medication administration

b. Aortogram

c. Beta-adrenergic blocker administration

d. Surgical intervention

64. Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

a. Cardiomyopathy

b. Coronary artery disease

c. Myocardial infarction

d. Pericardial Effusion

65. Which of the following types of cardiomyopathy can be associated with childbirth?

a. Dilated

b. Hypertrophic

c. Myocarditis

d. Restrictive

66. Septal involvement occurs in which type of cardiomyopathy?

a. Congestive

b. Dilated

c. Hypertrophic

d. Restrictive

67. Which of the following recurring conditions most commonly occurs in clients with
cardiomyopathy?

a. Heart failure

b. DM

c. MI

d. Pericardial effusion

68. What is the term used to describe an enlargement of the heart muscle?

a. Cardiomegaly

b. Cardiomyopathy

c. Myocarditis

d. Pericarditis

69. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which
of the following conditions?

a. Pericarditis

b. Hypertension

c. Obliterative

d. Restrictive

70. Which of the following types of cardiomyopathy does not affect cardiac output?

a. Dilated

b. Hypertrophic

c. Restrictive

d. Obliterative

71. Which of the following cardiac conditions does a fourth heart sound (S4) indicate?

a. Dilated aorta
b. Normally functioning heart
c. Decreased myocardial contractility
d. Failure of the ventricle to eject all the blood during systole

80. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?

a. Antihypertensive

b. Beta-adrenergic blockers

c. Calcium channel blockers

d. Nitrates

81. If a patient with a documented myocardial infarction suddenly develops a loud systolic murmur,
the most likely cause is which of the following?
a. pulmonary embolism
c. ruptured papillary muscle

b. congestive heart failure

d. increased systemic vascular resistance

82. A patient with unstable angina has an IABP inserted. Hemodynamics are: HR = 148 (sinus
tachycardia); MAP = 40 mm Hg; PAOP = 25 mm Hg; CI = 1.4 L/min/m2. Which of the following
should be included in this patient's plan of care?
a. checking timing of the IABP, decreasing balloon to 1:2 frequency
b. STAT echocardiogram, furosemide (Lasix), checking timing of the IABP
c. dobutamine (Dobutrex), isoproterenol (Isuprel), 12-lead ECG
d. adenosine, stat Hgb and HCT, dobutamine (Dobutrex)s
83. The family of a critically ill patient wishes to spend the night, which is contrary to visiting policy.
The nurse's best action would be to:
a. adhere to the visiting policy.
b. allow the family to stay in the room
c. obtain a motel room near the hospital where the family may spend the night
d. allow one or two family members to stay, then evaluate the patient's response

One day following gastroplasty surgery an obese male has a sudden onset of restlessness, dyspnea and
chest pain. His heart rate is 122/min., and auscultation of heart sound reveals an increased intensity of a
pulmonary S2.
84. These findings should lead the nurse to suspect that the patient has developed:
a. aspiration pneumonia
c. a pleural effusion.

b. a spontaneous pneumothorax.
d. a pulmonary embolus

85. The nurse should expect which of the following to confirm the patient's diagnosis?
a. chest x-ray and arterial blood gases
c. blood enzyme studies

b. pulmonary radioisotope scan

d. pulmonary artery pressures

86. The nursing staff is resisting being assigned to a disruptive patient. An appropriate resolution
would be to:

a. request the physician to transfer the patient

b. rotate the patient assignment among staff.
c. confront the family and demand an end to the disruptive behavior.
d. hold a nursing team conference to discuss possible alternative

A patient who is 72 hours postoperative repair of a ruptured abdominal aortic aneurysm suddenly
becomes dyspneic and his respiratory rate increases from 24 to 40/min. An arterial blood gas sample
obtained while the patient is receiving oxygen via a nasal cannula at 6L/min reveals the following results:
pH 7.50
pCO2 31
pO2 48
A chest x-ray is obtained and a "ground-glass-like appearance" is reported. Auscultation of the lungs
reveals basilar crackles that were not previously present.
87. On the basis of this information, the nurse should suspect that the patient has developed:
a. a pulmonary embolus
c. chronic obstructive pulmonary disease.

b. bacterial pneumonia
d. acute lung injury (ALI).

88. Members of the nursing staff are developing written patient education materials for a group of
patients with diverse reading abilities. It would be most effective for the staff to:
a. design individual handouts for each patient.
b. develop a computer-based education series.
c. write the materials at a fourth-grade reading level.
d. limit text and provide color pictures.

89. The mother of an infant with severe persistent pulmonary hypertension of the newborn
(PPHN) would like to hold her infant. The infant's oxygen saturation is 88-92% at rest and the
mean blood pressure is 28. The nurse's best response would be to:
a. explain signs and symptoms that demonstrate instability of the infant.
b. assist the mother in holding the infant skin-to-skin.
c. encourage the mother to talk to the infant.
d. show the mother how to provide gentle infant massage.
90. In caring for a patient with salicylate intoxication, the critical care nurse would anticipate which
of the following as a primary treatment measure?
a. administration of protamine sulfate
b. administration of glucose.
c. transfusion of packed RBCs
d. replacement of fluid and electrolytes
91. An adolescent with the developmental age of a 4-year-old requires placement of a chest tube.
The best way to prepare the patient for this procedure is to:
a. use short simple sentences and limit descriptions to concrete explanations
b. show the patient a chest tube and explain how it will feel
c. explain in detail why a chest tube is needed and how it works.
d. tell the parents what will be done so they can explain it to their child.
92. An 8-year-old is admitted with a gunshot wound to the head, accidentally inflicted by an older
sibling. The parents are overcome with grief, and appear to be ignoring the following statements
made by the older sibling: "It was an accident; I didn't mean to do it; I'm sorry!" Which of the
following actions by the nurse would be most appropriate?

a. Discuss the importance of gun safety with the older sibling while the parents are at the bedside.
b. Seek additional support for the parents for ways they can assist the older sibling
c. Tell the parents that they need to provide support for the older sibling.
d. Tell the older sibling, "Accidents happen; I know you didn't mean to do it."
93. Which of the following laboratory findings is indicative of the syndrome of inappropriate ADH
secretion (SIADH)?
a. an elevated serum sodium, elevated urine sodium and elevated urine specific gravity
b. a decreased serum sodium, elevated urine sodium and elevated urine specific gravity
c. a decreased serum sodium, decreased urine sodium and decreased urine specific gravity
d. an elevated serum sodium, decreased urine sodium and decreased urine specific gravity

For question 94
A 3-year-old is admitted to the ICU with a 10-hour history of an acute-onset asthma attack. Initial
assessment reveals the following:
HR 160 pH 7.25
RR 48 pCO2 35
BP 112/76 pO2 40
T 32C (oral) HCO3- 22
94. In this situation, the nurse would expect initial treatment to include:
a. administration of NaHCO3.
c. racemic epinephrine.

b. fluid resuscitation.
d. intubation.

95. A 2-year-old with heart failure is experiencing manifestations of digoxin (Lanoxin) toxicity. BP is
94/60 and the electrocardiogram reveals supraventricular tachycardia with a heart rate of 200.
The critical care nurse would anticipate which of the following interventions?
a. performance of cardioversion
c. performance of vasovagal maneuvers

b. administration of activated charcoal

d. monitoring of HR and rhythm

96. A 13-year-old with asthma is readmitted just a week after discharge from the hospital. On
questioning, the nurse learns that the patient refuses to use the inhalers at school. The nurse
should:
a. talk to the teen about long term consequences of the disease if the treatment plan is not followed.
b. talk to the school nurse to find out why they are not monitoring the meds at school.
c. help the parents set up a disciplinary contract with the teen
d. arrange for the teen to attend an asthma support group

97. You are caring for a patient with esophageal cancer. Which task could be delegated to the
nursing assistant?
a. Assist the patient with oral hygiene.
b. Observe the patients response to feedings.
c. Facilitate expression of grief or anxiety.
d. Initiate daily weights.

98. Which patient is at greatest risk for pancreatic cancer?

a. An elderly black male with a history of smoking and alcohol use
b. A young, white obese female with no known health issues
c. A young black male with juvenile onset diabetes
d. An elderly white female with a history of pancreatitis

99. The disease progress of cancers, such as cervical or Hodgkins, can be classified according to a
clinical staging system. Place the description of stages 0-IV in the correct order.
a. Metastasis
b. Limited local spread
c. Cancer in situ
d. Tumor limited to tissue of origin
e. Extensive local and regional spread
_____, _____, _____, _____, _____
100. In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be
the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team
leader RN?
a. A patient with severe anemia secondary to GI bleeding
b. A patient who needs enemas and antibiotics to control GI bacteria
c. A patient who needs pre-op teaching for bowel resection surgery
d. A patient who needs central line insertion for chemotherapy

101. The physician tells the patient that there will be an initial course of treatment with continued
maintenance treatments and ongoing observation for signs and symptoms over a prolonged period
of time. You can help the patient by reinforcing that the primary goal for this type of treatment is:
a. Cure

b. Control

c. Palliation

d. Permanent remission

102. For a patient who is experiencing side effects of radiation therapy, which task would be the
most appropriate to delegate to the nursing assistant?
a. Assist the patient to identify patterns of fatigue.
b. Recommend participation in a walking program.
c. Report the amount and type of food consumed from the tray.
d. Check the skin for redness and irritation after the treatment.
103. For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following side
effects should be reported to the physician?
a. Fatigue

b. Nausea and vomiting

c. Paresthesia

d. Anorexia

104. For a patient who is receiving chemotherapy, which laboratory result is of particular
importance?
a. WBC

b. PT and PTT

c. Electrolytes

d. BUN

105. When assigning staff to patients who are receiving chemotherapy, what is the major
consideration about chemotherapeutic drugs?
a. During preparation, drugs may be absorbed through the skin or inhaled.
b. Many chemotherapeutics are vesicants.
c. Chemotherapeutics are frequently given through central nervous access devices.
d. Oral and venous routes are the most common.
106. You have just received the morning report from the night shift nurses. List the order of
priority for assessing and caring for these patients.

a. A patient who developed tumor lysis syndrome around 5:00 AM

b. A patient with frequent reports of break-through pain over the past 24 hours
c. A patient scheduled for exploratory laparotomy this morning
d. A patient with anticipatory nausea and vomiting for the past 24 hours

107. In monitoring patients who are at risk for spinal cord compression related to tumor growth,
what is the most likely early manifestation?
a. Sudden-onset back pain

b. Motor loss

c. Constipation

d. Urinary hesitancy

108. Chemotherapeutic treatment of acute leukemia is done in four phases. Place these phases in
the correct order.
a. Maintenance
_____, _____, _____, _____

b. Induction

c. Intensification

d. Consolidation

109. For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in
which laboratory value?
a. Sodium

b. Calcium

c. Potassium

d. Hematocrit

110. A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion
(SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the
physician, you would anticipate which initial order for the treatment of this patient?
a. A fluid bolus as ordered
b. Fluid restrictions as ordered
c. Urinalysis as ordered
d. Sodium-restricted diet as ordered

SITUATION: Mr. Ramos was barbecuing outdoors when the gas tank exploded. He sustained second
degree and third degree burns of the anterior portion of BOTH arms, the upper half of his anterior trunk
and the anterior and posterior portions of his left lower extremity.
111. The BEST initial management of burns that can be employed at the scene is generally which of
the following:
a. Pour cold water over the burned areas
c. Rinse the area with mild soap and water

b. Apply clean dressing to the affected area

d. Apply tomato juice and ointment over the area

112. At the emergency room, the nurse assessed the extent of the burn on the patient's body. Based
on the rules of nine. Which of the following is the BEST estimate of the burn?
a. 36%

b. 45%

c. 27%

d. 54%

113. Which one of the following .blood value determinations is most likely be useful to evaluate the
adequacy of the fluid replacement?
a. Creatinine levels

b. Blood urea nitrogen

c. Hematocrit level

d. C02 tension

114. The nurse is administering the prescribed IVF. When she evaluated the patient, she suspected
fluid overload because of which finding?
a. Dark and scant urine output
c. Bradycardia and hypotension

b. Moist rates
d. Facial flushing and twitching

115. The doctor orders MAFENIDE for application over the bum area. The nurse understands that
one disadvantage of this drug is that:
a. It causes lactic acidosis
c. It has minimal eschar penetration

b. It must be constantly applied

d. It is bacteriostatic

SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. He had undergone
lobectomy on the left lower lung. A two-bottle drainage system is inserted.
116. The patient is placed on bed post-operatively in what position?
a. Prone

b. Trendelenburg

c. Right side

d. Left side

117 Water-seal chest drainage involves attaching the chest tube to a:

a. Suction machine directly
b. Rubber tube/glass tube that is submerged underwater
c. Rubber tube that is left open to air
d. A closed drainage bottle with sterile water and no external opening

118. If the nurse sees fluid moving up and down during inspiration and expiration on the water seal
bottle, she should:
a. Do nothing as this is expected
b. Immediately check the bottle for leaks
c. Call the physician immediately and damp the chest tube
d. Cover the wound with wet sterile gauze and send someone to calf the physician

119. If the nurse sees vigorous and continuous bubbling in the second bottle, she should:
a. Momentarily clamp the tube to note for air leak
b. Administer oxygen to the patient
c. Attempt to change a new bottle
d. Pull the chest tube out to remove the air leak