NPT

1. A 17-year old is admitted following an automobile accident He is very anxious,

dyspneic, and in severe pain. The left chest wall moves in during inspiration and
balloons out when he exhales. The nurse understands these symptoms are most
suggestive of:

a. Hemothorax
b. Flail chest
c. Atelectasis
d. Pleural effusion

2. A young man is admitted with a flail chest following a car accident. He is

intubated with an endotracheal tube and is placed on a mechanical ventilator
(control mode, positive pressure). Which physical finding alerts the nurse to an
additional problem in respiratory function?

a. Dullness to percussion in the third to 5th intercostals space, midclavicular line

b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases

3. The nurse is caring for a client who has just had a chest tube attached to a
water seal drainage system (Pleur-evac). To ensure that the system functions
effectively the nurse should:

a. Observe for intermittent bubbling in the water seal chamber

b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client

4. The nurse enter the room of a client who has a chest tube attached to a water
seal drainage system and notices the chest tube is dislodge from the chest. The
most appropriate nursing intervention is to:

a. Notify the physician

b. Insert a new chest tube
c. Cover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives

5. A 71-year old is admitted to the hospital with congestive heart failure. She has
shortness of breath and a +3 - 4 peripheral edema. The care plan to reduce the
client's edema should include nursing strategies for:

a. Establishing limits on activity

b. Fostering a relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids

Situation 2 - Oxygen is the most vital physiologic need for survival.

6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He has
long history of emphysema. Mr. Sison is admitted to the hospital because of a
respiratory infection, which has not improved with outpatient therapy. Which
finding would the nurse expect to observe during Mr. Sison's nursing assessment?

a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity

7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the
oxygen via the low-flow system recognizes that this method of delivery:

a. Mixes room air with oxygen

b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract

8. Which statement by Mr. Sison indicates that client teaching regarding oxygen
therapy has been effective?

a. "I was feeling fine so I removed my nasal prongs."

b. "I've increased my fluids to six glasses of water daily."
c. "Don’t forget to come back quickly when you get me out of the bed; I don't want to be
without my oxygen for too long."
d. "My family was angry when I told them they could not smoke in my room."

9. Supplemental low-flow oxygen therapy is prescribed for a man with

emphysema. Which is the most essential for the nurse to initiate?

a. Anticipate the need for humidification

b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Schedule nursing care to allow frequent observations of the client

Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse for
the past 15 years. His wife brings him to the emergency department because he is
increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver.
He has ascites and esophageal varices.

10. Assessment of Mr. Silverio would reveal all of the following, except:
a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. Bluish discoloration of the umbilicus

11. Which laboratory value would the nurse expect to find in a client as a result of
liver failure?

a. Decreased serum creatinine

b. Decreased sodium
c. Increased ammonia
d. Restricted sodium

12. The major dietary treatment for ascites calls for:

a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium

13. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding.

Base on this information, the first action the nurse should take is to:

a. Deflate the esophageal balloon

b. Encourage him to take the deep breath
c. Monitor his vital signs
d. Notify the physician

14. Because the detoxification of alcohol damages tissues a high-calorie diet,

fortified with vitamins should be encouraged to protect Mr. Silverio's:

a. Liver
b. Kidneys
c. Adrenals
d. Pancreas

Situation 4 - Rape is one of the most tragic things that could happen to anyone especially
with young girls. Incidence such as these could develop into a crisis situation involving not
only the rape victims but also their families.

15. This type of crisis could be an example of which of the following?

a. Combination of developmental and situational

b. Situational
c. Emotional
d. Developmental

16. Noemi, a staff nurse in the emergency room, realizes that she has an
important role to play as a patient advocate to rape victims. To demonstrate this
role, she takes note of one of the responsibilities?

a. Since this is a legal case, call the press about the incidence of rape
b. Perform thorough physical assessment and documenting objectively all the evidences of
rape
c. Ask the patient to stay in one isolated room first to provide privacy while attending to
other patients
d. Provide emotional support first and postponed physical assessment when patient is
already calm

17. Which of the following is a form of active, focused, emotional environmental

first aid for patients in crisis?

a. Attitude therapy
b. Psychotherapy
c. Crisis intervention
d. Re-motivation technique

18. Which of the following is true with regards to crisis?

a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help

19. If help is not provided in a crisis situation, an individual may spontaneously

resolve in negatively or positively by returning to pre-crisis state, usually within
which of the following duration?

a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. 4-6 weeks

Situation 6 - One Important fact that will guide the nurse in the practice of the profession is
her knowledge of the nursing law.

20. The nurse practice Act of 1991 regulates the practice of nursing in the
Philippines. Which of the following statements about this Act is true?

a. This Act delineates the practice of nursing and midwifery

b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. The Act defines the practice of nursing in the Philippines

21. When a nurse starts working In a hospital but without a written contract,
which of the following is expected of her?

a. She's not bound to perform according to the standards of nursing practice

b. Provides nursing care within the acceptable standards of nursing practice
c. She's not obligated to provide professional service
d. The employer does not hold the nurse responsible for her action

22. A patient, G8P5, refused to be injected with the 3rd dose of Depoprovera. The
nurse insisted inspite of the patients refusal and forcibly injected the
contraceptive. She can be sued for which of the following?

a. Misrepresentation
b. Assault and Battery
c. Malpractice
d. Negligence

23.A patient has been in the ICU for 2 weeks. The relatives have consented to a
"Do not resuscitate order," When the patient develops a cardiac arrest, the nurse
will carry out which of the following actions?

a. Only medication will be given

b. All ordinary measure will be stopped
c. Basic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped

24. When a patient falls from bed, which of the following is your immediate
action?

a. Report to the head nurse and calls someone to help

b. Determine any injury or harm
c. Refer to the resident on duty
d. Put back patient to bed

Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the office and
he remains conscious. Police officers brought her to the hospital.

25. You have to observe for increase intracranial pressure. Which of the following
is not a sign of increased intracranial pressure?

a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness