College of Nursing 1st SEMESTER PRELIM EXAM: 4TH YEAR SKILLS LAB Academic Year 2011-2012

DIRECTIONS: Read each item carefully. For multiple choice questions, choose the best answer among the given choices and shade the box ( [] ) that corresponds to the letter of your answer on the separate answer sheet provided. For identification questions, write your answer on the space provided after the item number on the answer sheet. Strictly no erasures and no pencils allowed. 1. The following personnel need to be notified of the patient's death after confirmation EXCEPT: a. Admitting or Census Department b. Appropriate Agency for Organ Procedures c. Designated Mortician d. None of these

2. Which of the following is done first in performing post mortem care to a deceased client? a. b. c. d. Place small towel under chin. Wash soiled areas of body. Place disposable pads to the perineal area Put away or dispose equipment and supplies used.

3. The following are the usual site for the second identification tag a deceased client's body: a. Toe b. Wrist c. Forehead d. None of these

4. The following are the evaluation criteria the nurse should consider after each post mortem care EXCEPT: a. b. c. d. Body cared for and transported appropriately. All necessary notifications carried out. Family able to carry out rituals, viewing, and spend time with patient as desired. None of these

5. The following are considered correct in performing post mortem care to a deceased client EXCEPT: a. b. c. d. Close patients eyes if open. Remove watch, jewelry and all possessions, and keep it for the time being Put on clean gloves. None of these

6. The following are included in the planning and preparation for the post mortem care EXCEPT: a. b. c. d. Plan for any special religious/cultural practices desired by family.\ Offer to transfer any other patients in room to another location temporarily. Wash hands. None of these

7. The following are considered correct in performing post mortem care to a deceased client EXCEPT: a. b. c. d. Place No visitor Check at Nurses Station sign to door. Place body in supine position with bed flat. Remove pillow under head. None of these

8. The following should be included in the documentation of the post mortem care EXCEPT: a. b. c. d. Time of cessation of Vital Signs. List and documentation of valuable and personal effects. Time body removed from unit, destination and by whom removed. None of these

9. If an autopsy will be performed, what should the nurse do if there are existing IV and other tubings attached to the deceased client? a. Do not remove IV and all other tubings b. Remove the IV but leave other tubings attached c. Remove IV and all other tubings d. None of these

10. The following are the responsibilities of the nurse regarding the deceased client's valuables EXCEPT: a. b. c. d. Valuables with the patient at the time of death should be identified and accounted for Valuables should be sent to the proper department of the institution for safe keeping until family claims for it Valuables taken or given to the patient's family should be voted on the form sheet specified by the institution. None of these

11. The following are considered correct in performing post mortem care to a deceased client EXCEPT: a. b. c. d. Place small towel under chin. Remove soiled dressings & ostomy bags, leave not replaced Wash soiled areas of body. None of these

12. In the care of the body of a deceased client,the following are correct nursing considerations EXCEPT: a. b. c. d. Post mortem care of the body is not rendered unless the physician has pronounced the patient to be dead Indicate the chart time the patient was pronounced dead and the physician pronouncing Have the body cleaned and properly identified None of these

13. What is the primary purpose of placing disposable pads to the perineal area of a deceased client? a. b. c. d. to absorb any stool or urine released as the sphincter muscle relaxes. to prevent ulceration of the skin in the perineal area to maintain the client's integrity even if already deceased none of these

14. Dentures and eyeglasses of a deceased client must be given to which of the following person? a. Mortician b. Physician c. Relatives d. None of these

15. In the care of the body of a deceased client,the following are correct nursing considerations EXCEPT: a. b. c. d. If the patient is communicable the water used in cleaning must be medicated Inform medico legal officer if accident, suicide, homicide, or illegal therapeutic practices causes death Prevent all means of distortion, discoloration or scarring of the body as it is distressed to the family. None of these

16. The following are performed after the post mortem care is done EXCEPT: a. Remove all cover in client's body b. Attach identification tag on body c. Transport body to facility morgue d. None of these

17. The following are important nursing considerations in accomplishing of necessary papers related to client's death EXCEPT: a. b. c. d. Death certificate is sent to the local health Department Death certificate is accomplished by the physician and signed by him A pathologist must sign the death certificate if autopsy has been performed. None of these

18. What should the nurse do with the deceased client's wrist identification band? a. Remove it and return it to the admission office b. Remove & give it to the mortician at the morgue c. Leave it in place d. None of these

19. You are assisting your charge nurse with post mortem care of a deceased client. The first information you need from the charge nurse is: a. if the family wishes to view the body. b. what the cause of death was. c. the funeral arrangements. d. the patient's medical record.

20. The ability of an individual to cope with death is dependent upon a number of factors. Which person likely will have the most difficulty coping with a death? a. b. c. d. A parent whose 17-year-old child died in an auto accident the night before graduation A child of 8 years whose grandparent dies a week before a planned visit\ The spouse of an alcoholic who is killed in an automobile accident The grandparent of a child born with Tay-Sachs disease

21. A family with five children experiences a stillbirth. While intervening with the family, one member expresses a view that causes special concern for the nurse. This person is: a. A 3-year-old who wonders if the baby will come home after it gets better b. A 5-year-old who cries, believing the death occurred because the child drew with magic markers on one of the baby blankets c. A 13-year-old who assumes blame as punishment for shoplifting d. A 15-year-old who says, "I still can't believe it is true."

22. While the nurse is discussing a client's likely death with family members, one of the offspring inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is: a. "Often, there is a lucid moment during the last hour that lasts about 15 minutes. First look for relaxation followed by clearing of the eyes, looking around, focusing on faces, and clearing of the throat. Call the others in at that time." b. "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." c. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." d. "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with nuchal rigidity. Don't be alarmed when you hear a death rattle in the throat. " 23. Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent takes this as proof that the family truly believes the accusation. This sets up a destructive cycle of family dysfunction. Which nursing diagnosis is most appropriate for this family? a. b. c. d. Impaired family processes related to impaired adjustment Impaired adjustment related to loneliness Loneliness related to fear Dysfunctional grieving related to loss of relationships

24. Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is: a. b. c. d. Preparing the body to look as clean and natural as possible Pulling the sheet over the patient's face until the family is comfortably seated in the room Humor is helpful in relieving stress. However, use humor only after family has left. Calling the physician to verify the time of death before taking the body to the morgue

25. You are bathing a patient with a DNR order when he suddenly stops breathing. You next action should be to: a. b. c. d. Finish the bath and report to the charge nurse Begin CPR Pull the emergency call light at the patient's bedside Stop the bath and place a sheet over the patient's body

26. You are helping a co-worker prepare a body for the morgue. Your co-worker places the head of the bed in a high Fowler's position. Which of the following should be your next action? a. b. c. d. Ensure that dentures are in the patient's mouth Cover the body with clean bed linen Remind the co-worker that the patient should be lying flat with a pillow under the head Gently close the eyelids if they are open

27. The following are considered correct in performing blood glucose testing EXCEPT: a. b. c. d. If glucometer is used, simply follow the manufacturers instruction. Dropping a very small amount of blood Cover the entire patch of strip with blood. Wash hands and don clean gloves.

28. The following are the purposes of blood glucose monitoring for the client EXCEPT: a. b. c. d. investigate the effects on blood glucose of different aspects of their lifestyle to adjust and experiment with their treatment dose to be able to cope with other illnesses or new situations none of these

29. The following are considered incorrect in performing blood glucose testing EXCEPT: a. b. c. d. Inappropriate timing Improper maintenance of glucometers Dust or blood accumulation on the digital display of glucometer None of these

30. The following are the correct timing for blood glucose monitoring EXCEPT: a. before meals b. at bedtime c. after meals d. whenever hypo or hyperglycemia occurs

31. The following are the purposes of blood glucose monitoring from a nurse's perspective EXCEPT: a. b. c. d. to adjust therapies if patients are too ill to do it themselves to monitor for the occurence ofcomplications an educational tool to encourage patient self-management none of these

32. The following are considered correct in performing blood glucose testing EXCEPT: a. b. c. d. Swab alcohol pad to the chosen puncture site for pricking. Squeeze the puncture site hard enough to allow tissue fluids to mix with the sample For better results use a lancing device None of these

33. Blood glucose monitoring is mostly done to clients with the following conditions EXCEPT: a. Gestational diabetes b. Neonatal hypoglycemia c. Diabetic Coma d. None of these

34. A client is admitted to the unit with acute hypoglycemia. Upon assessment, the nurse finds specific effects of the stress response, which include: a. Slurred speech b. Nausea c. Headache d. Emotional lability

35. The glycosylated hemoglobin measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately how many days? a. 80 days b. 30 days c. 120 days d. None of these

36. Ms. J., a 34-year old white female, is in the ER complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700 mg/dL. Given the above Information, which nursing activities should be highest priority? a. Monitoring vital signs b. Obtaining blood glucose results 37. The normal fasting blood glucose in the adult client is: a. 70 to 110 mg/dL b. 60 to 90 mg/dL c. 90 to 120 mg/dL d. None of these c. Assessing neurological status d. Assessing pedal pulses and feet

38. A diabetic clients complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry out first?

a. Withhold the clients next insulin injection b. Test the clients blood glucose level

c. Administer Tylenol as ordered d. Offer fruit juice, gelatin and chicken bouillon

39. Select the most accurate explanation by the nurse to a client who is to have an oral glucose tolerance test and needs to understand the procedure. a. After you drink a concentrated glucose solution, you cannot eat or drink anything until your blood is drawn. b. You will go to the laboratory and your blood will be drawn. c. Your blood will be drawn, you will drink a concentrated glucose solution, and your blood will be drawn again. d. You will eat a large meal and your blood will be drawn two hours later. 40. When performing the blood glucose test on a diabetic client, which of the following should be done after piercing the site? a. Squeeze finger b. Wipe first drop of blood with sterile gauze c. Apply first drop of blood to the test strip d. None of these

41. The following are important considerations when you are using a glucometer EXCEPT: a. b. c. d. Make sure you keep batteries in stock that fit your glucometer. Dispose of your lancets in a puncture-proof container Keep your glucometer and test strips in a clean, dry place. None of these

42. The following are the included in the list of equipments to be gathered prior to performing blood glucose monitoring test EXCEPT: a. Glucometer b. Lancet c. Treatment card d. None of these

43. When performing CBG test on a client, the following considerations must be noted by the nurse EXCEPT: a. b. c. d. Samples should be obtained from the edges of fingers. Fingertips should be avoided as these are more sensitive. Sites should be rotated to prevent skin damage. None of these

44. When using a glucometer when performing the CBG test, the following should be taken into account by the nurse EXCEPT: a. b. c. d. A new test strip should be used each time the procedure is undertaken The machine should be calibrated at regular intervals Only known brands of glucometer should be used for best accuracy None of these

45. Before pricking during a CBG test, the nurse must make sure of the following EXCEPT: a. b. c. d. The skin at the sample site should be clean and dry. Encourage patients to keep their hands cold prior to sampling as this helps good blood flow If possible, ask the patient to wash and dry her or his hands None of these

46. If a client is not getting an accurate result from his/her glucometer, which of the following should he he/she do first? a. Inform health care provider b. Check manufacturers instruction manual c. Purchase a new one d. None of these

47. Erroneous blood glucose readings may be due to the following EXCEPT: a. Outdated or unusable strips b. User error c. Meter needs cleaning d. None of these

48. The following should be done before using the glucometer when checking for a clients blood glucose EXCEPT: a. Check the expiration date on your strips b. Check the code on the bottle of strips c. Calibrate monitor to the correct code d. None of these

49. A client with diabetes is experiencing an increase in blood glucose levels. The nurse realizes this increase could mean an increased stimulation of: a. Cortisol b. Insulin c. Glucagons d. None of these

50. The following are symptoms of hyperglycemia EXCEPT: a. Increase in appetite b. Blurriness in vision c. Dry and itchy skin d. None of these

Situation - The physician has ordered 3 units of whole blood to be transfused to Clark Kent following a repair of a dissecting aneurysm of the aorta. 51. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it? a. 6 hours b. 1 hour c. 4 hours d. 2 hours

52. What should you do FIRST before you administer blood transfusion? a. verify client 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 needle d. verify physicians order 53. As Clarks nurse, what will you do AFTER the transfusion has started? a. add the total amount of blood to be transfused to the intake and output b. discontinue the primary IV of Dextrose 5% Water c. check the vital signs every 15 minutes d. stay with WQ for 15 minutes to note for any possible BT reactions 54. Clark is undergoing blood transfusions 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

55. In case Clark 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. stop the blood transfusion and monitor the patient closely c. immediately stop the BT, infuse NSS, call the physician, notify the blood bank d. immediately stop the BT, notify the blood bank and administer antihistamines 56. A female patient needs a whole blood transfusion. In order for transfusion services (the blood bank) to prepare the correct product a sample of the patients blood must be obtained for: a. A complete blood count and differential. b. A blood type and cross-match. c. A blood culture and sensitivity. d. A blood type and antibody screen.

57. Logan asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always require cross-matching? a. packed red blood cells b. platelets c. plasma d. granulocytes

58. A month after receiving a blood transfusion an immunocompromised male patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has: a. Nothing related to the blood transfusion. b. Graft-versus-host disease (GVHD). c. Myelosuppression d. An allergic response to a recent medication.

59. A child is admitted with a serious infection. After two days of antibiotics, he is severely neutropenic. The physician orders granulocyte transfusions for the next four days. The mother asks the nurse why? The nurse responds: a. b. c. d. This is the only treatment left to offer the child. This therapy is fast and reliable in treating infections in children. The physician will have to explain his rationale to you. Granulocyte transfusions replenish the low white blood cells until the body can produce its own.

60. A neighbor tells nurse Maureen he has to have surgery and is reluctant to have any blood product transfusions because of a fear of contracting an infection. He asks the nurse what are his options. The nurse teaches the person that the safest blood product is: a. An allogenic product. b. A directed donation product. c. An autologous product. d. A cross-matched product.

61. Louie who is to receive a blood transfusion asks the nurse what is the most common type of infection he could receive from the transfusion. The nurse teaches him that approximately 1 in 250,000 patients contract: a. Human immunodeficiency disease (HIV). b. Hepatitis C infection. c. Hepatitis B infection. d. West Nile viral disease.

62. A male patient with blood type AB, Rh factor positive needs a blood transfusion. The Transfusion Service (blood bank) sends type O, Rh factor negative blood to the unit for the nurse to infuse into this patient. The nurse knows that: a. This donor blood is incompatible with the patients blood. b. Premedicating the patient with diphenhydramine hydrochloride (Benadryl) and acetaminophen (Tylenol) will prevent any transfusion reactions or side effects. c. This is a compatible match. d. The patient is at minimal risk receiving this product since it is the first time he has been transfused with type O, Rh negative blood. 63. Dr. Rodriguez orders 250 milliliters of packed red blood cells (RBC) for a patient. This therapy is administered for treatment of: a. Thrombocytopenia. b. Anemia. c. Leukopenia. d. Hypoalbuminemia.

64. A male patient needs to receive a unit of whole blood. What type of intravenous (IV) device should the nurse consider starting? a. b. c. d. A small catheter to decrease patient discomfort The type of IV device the patient has had in the past, which worked well A large bore catheter The type of device the physician prefers

65. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing: a. An anaphylactic transfusion reaction b. An allergic transfusion reaction c. A hemolytic transfusion reaction d. A pyrogenic transfusion reaction

66. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the childs mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate? a. b. c. d. Ask the mother to leave while the blood transfusion is in progress Encourage the mother to reconsider Explain the consequences without treatment Notify the physician of the mothers refusal

67. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? a.Hemoglobinuria (cola-colored urine) b.Chest pain c.Urticaria d.Distended neck veins

68. Which of the following blood tests should be performed before a blood transfusion? a. Prothrombin and coagulation time b. Blood typing and cross-matching 69. How should the blood be warmed? a. microwave b. under a warm running water c. through a blood warmer d. blower c. Bleeding and clotting time d. Complete blood count (CBC) & electrolyte levels.

70. A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be: a. Call the physician b. Slow the flow rate c. Stop the blood immediately d. Relieved the antihistamines symptoms with an ordered

71. A client is scheduled to receive a blood transfusion. During the transfusion, the nurse should observer for which sign or symptoms of a transfusion reaction? a. Dizziness b. Chills c. Hypothermia d. Hyperreflexia

72. During blood transfusion, the patient manifest tachycardia, distended neck vein and increase CVP reading, the nurse should a. Obtain vital signs b. Call the physician c. Stop the infusion d. Decrease the rate of infusion.

73. What drug can be added directly into the blood during a transfusion? a. nothing b. adrenaline c. antibiotics d. diuretics

74. To ensure the client safety before starting blood transfusion the following are needed before the procedure can be done EXCEPT: a. take baseline vital signs b. blood should be warmed to room temperature for 30 minutes before blood transfusion is administered c. have two nurses verify client identification, blood type, unit number and expiration date of blood d. get a consent signed for blood transfusion 75. A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings? a. Hypotension, backache, low back pain, fever. b. Wet breath sounds, severe shortness of breath. c. Chills and fever occurring about an hour after the infusion started. d. Urticaria, itching, respiratory distress.

76. 500ml of blood was ordered for blood transfusion. Your nursing responsibility before the start of blood transfusion is: a. check the amount of blood available b. check the label of the bottle with blood c. check if Benadryl is ordered for injection d. check the vital signs

77. You stressed to him and to the finally the importance of the following food that will help in the production of RBC, EXCEPT: a. kangkong b. egg yolk c. broccoli d. ampalaya

78. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:

a. An anaphylactic transfusion reaction b. An allergic transfusion reaction

c. A hemolytic transfusion reaction d. A pyrogenic transfusion reaction

79. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should: a. Obtain vital signs b. Stop the transfusion c. Assess the pain further d. Increase the flow of normal saline

80. Which of the following is not true about blood transfusion therapy? a. Blood products are required when large volume of blood or body fluids has been lost. b. All blood sets require a filter. c. 1 unit of blood must be infused for 6 hours. d. Transfusion must be stopped if hemolytic reactions occur. Fill in the missing information in the box. Blood Type A B AB O ANTIGEN 81. 85. 89. 93. ANTIBODY 82. 86. 90. 94. CAN RECEIVE BLOOD FROM 83. 87. 91. 95. 84. 88. 92. 96. CAN DONATE BLOOD TO

97. Which of the following statements is not true about the purpose of post mortem care? a. preparing the patient for viewing by family b. ensuring proper identification of the client prior to transportation to the morgue or funeral home c. to determine who will take care of the last will and testament of the client d. maintaining vital organs, if donation is planned. 98. It refers to the stiffening of the body, developing within two to four hours of death. a. rigor mortis b. algor mortis c. livor mortis 99. It refers to the reduction of body temperature with loss of skin elasticity. a. rigor mortis b. algor mortis c. livor mortis d. ragor mortis

d. ragor mortis

100. Which of the following statements is not true about the responsibilities of the health care team during post mortem care? a. Physicians must certify the death b. Trained staff members will provide information to the family regarding organ donation. c. Nurses are responsible for coordination of all postmortem care. d. Nurses can certify the death in the absence of the physician.

TO GOD BE THE GLORY!!!

...Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you.
~ Harper Collins, A Return To Love: Reflections on the Principles of A Course in Miracles