NP4 Nursing Board Exam November 2008 Answer Key 'Nursing Care

of Client with Physiological and Psychosocial Alteration'

Nov. 08 NP4
Nursing Board/Licensure Exam Answer Key: NP4 Nursing Board Exam November 2008 Answer Key 'Nursing Care of
Client with Physiological and Psychosocial Alteration'
Nursing Board/Licensure Exam Answer Key: NP4 Nursing Board Exam November Answer Key 'Nursing Care of Client with
Physiological and Psychosocial Alteration'

Situation 1: After abdominal surgery, the circulating B. CT Scan, MRI, Incidence Report
and scrub nurses have critical responsibility about C. X-ray, and Incidence Report
sponge and instrument count. D. CT scan and Incidence Report

1. Counting is performed thrice: During the

preincision phase, the operative phase and closing Situation 2: An entry level nurse should be able to
phase. Who counts the sponges, needles and apply theoretical knowledge in the performance of
instruments? the basic nursing skills.
A. The scrub nurse only
B. The circulating nurse only 6. A client has an indwelling urinary catheter and
C. The surgeon and the assistant surgeon she is suspected of having urinary infection. How
D. The scrub nurse and circulating nurse. should you collect a urine specimen for culture and
sensitivity?
2. The layer of the abdomen is divided into 5. A. Clamp tubing for 60 minutes and insert a sterile
Arrange the following from the first layer going to needle into the tubing above the clamp to aspirate
the deepest layer: urine.
1. Fascia B. Drain urine from the drainage bag into the sterile
2. Muscle container
3. Peritoneum C. Disconnect the tubing from the urinary catheter
4. Subcutaneous/Fat and let urine floe into a sterile container
5. Skin D. Wipe the self sealing aspirations port with
antiseptic solution and insert a sterile needle into
A. 5,4,3,2,1 the self sealing self-sealing port.
B. 5,4,2,1,3
C. 5,4,1,3,2, 7. To obtain specimen for sputum culture and
D. 5,4,1,2,3 sensitivity, which of the following instruction is
best?
3. When is the first sponge instrument count A. Upon waking up, cough deeply and expectorate
reported? into container
A. Before closing the subcutaneous layer B. Cough after pursed lip breathing
B. Before peritoneum is closed C. Save sputum for two days in covered container
C. Before closing the skin D. After respiratory treatment, expectorate into a
D. Before the fascia is sutured container

4. Like any nursing intervention, counts should be 8. The best time for collecting the sputum specimen
documented. To whom does the scrub nurse report for culture:
any discrepancy of counts so that immediate and A. Before retiring at night
appropriate action is instituted? B. Upon waking up in the morning
A. Anaesthesiologist C. Anytime of the day.
B. Surgeon D. Before meal
C. OR nurse supervisor
D. Circulating nurse 9. When suctioning the endotracheal tube, the
nurse should:
5. Which of the following are 2 interventions of the A. Explain procedure to patient: Insert catheter
surgical team when an instrument was confirmed gently applying suction. Withdrawn using twisting
missing? motion.
A. MRI and Incidence report
B. Insert catheter until resistance is met; then D. Prolonged hematuria
withdraw slightly, applying suction intermittently as 15. Leg cramps are NOT uncommon post
catheter is withdrawn. cystoscopy. Nursing intervention includes:
C. Hyperoxygenate client insert catheter using back A. Bed rest
and forth motion B. Warm moist soak
D. Insert suction, catheter four inches into the tube, C. Early ambulation
suction 30 seconds using twirling motion as D. Hot sitz bath
catheter is withdrawn.
Situation 4 – Mang Felix, a 79 year old man who is
10. The purpose of NGT IMMEDIATELY after brought to the Surgical Unit from PACU after a
operation is: transurethral resection. You are assigned to receive
A. For feeding or gavage him. You noted that he has a 3-way indwelling
B. For gastric decompression catheter for continuous fast dip bladder irrigation
C. For lavage, or the cleansing of the stomach which is connected to a straight drainage.
content
D. For the rapid return of peristalsis 16. Immediately after surgery, what would you
expect his urine to be?
Situation 3 – Mr. Santos, 50, is to undergo A. Light yellow
cytoscopy due to multiple problems like scantly B. Amber
urination, hematuria, and dysuria. C. Bright red
D. Pinkish to red
11. You are the nurse in charge of Mr. Santos.
When asked what are the organs to be examined 17. The purpose of the continuous bladders
during cystoscopy, you will enumerate as follows: irrigation is to:
A. Urethra, Kidney, Bladder A. Allow continuous monitoring of the fluid output
B. Urethra, Bladder wall, trigone, urethral opening status
C. Bladder wall, uterine wall and urethral opening B. Provide continuous flushing of clots and debris
D. Urethral opening, urethral opening bladder. from the bladder
C. Allow for proper exchange of electrolytes
12. You are the nurse in charge of Mr. Santos. D. Ensure accurate monitoring of intake and output
When asked what are the organs to be examined
during cystoscopy in: 18. Mang Felix informs you that he feels some
A. Supine discomfort on the hypogastric area and he has to
B. Lithotomy void. What will be your most appropriate action?
C. Semi-fowler A. Remove his catheter then allow him to void his
D. Trendelenburg own
B. Irrigate his catheter
13. After cystoscopy, Mr. Santos asked you to C. Tell him “Go ahead and void. You have an
explain why there is no incision of any kind. What indwelling catheter”
do you yell him? D. Assess color and rate of outflow, if there is a
A. Cystoscopy is direct visualization and change refer to urologist for possible irrigation
examination by urologist
B. Cystoscopy is done by x-ray visualization of the 19. You decided to check on Mang Felix’s IV fluid
urinary tact infusion. You noted in flow rate, pallor and coldness
C. Cystoscopy is done by using lasers on the around the insertion site. What is your assessment
urinary tract finding?
D. Cystoscopy is an endoscopic procedure of the A. Phlebitis
unrinary B. Infiltration to subcutaneous tissue
tract C. Pyrogenic reaction
D. Air embolism

14. Within 24-48 hours post cystoscopy, it is normal 20. Knowing that proper documentation of
to observe one of the following: assessment findings and interventions share
A. Pink-tinged urine important responsibilities of the nurse during first
B. Distended bladder post operative days, which of the following is the
C. Signs of infection
LEAST relevant to document in the case of Mang C. Chronic, Intrarenal
Felix? D. Acute, Prerenal
A. Chest pain and vital signs
B. Intravenous infusion rate Situation: Leukemia is the most common type of
C. Amount, color and consistency of bladder childhood cancer. Acute Lymphoid Leukemia is the
irrigation drainage cause of almost 1/3 of all cancer that occurs in
D. Activities of daily living started children under age 15.

Situation 5: Melamine contamination in milk has 26. The survival rate for Acute Lymphoid Leukemia
brought world wide crisis both in the milk production is approximately:
sector as well as the health and economy. Being A. 25 %
aware of the current events is one quality that a B. 40 %
nurse should possess to prove that nursing is a C. 75 %
dynamic profession that will adapt depending on D. 95 %
the patient’s needs.
27. Whrereas acute nonlymphoid leukaemia has
21. Melamine is a synthetic resin used for survival rate of:
whiteboards, hard plastics and jewellery box covers A. 25 %
due to its fire retardant properties. Milk and food B. 40 %
manufacturers add melamine in order to: C. 75 %
A. It has a bacteriostatic property leading to D. 95 %
increase food and milk life as a way of preserving
the foods. 28. The three main consequence of leukaemia that
B. Gives a glazy and more edible look on foods cause the most danger is:
C. Make milks more tasty and creamy A. Neutropenia causing infection, anemia causing
D. Create an illusion of a high protein content on impaired oxygenationand thrombocytopenia leading
their products to bleeding tendencies.
B. Central nervous system infiltration, anemia
22. Most of the milks contaminated by melamine causing impaired oxygenationand
came from which country? thrombocytopenia leading to bleeding tendencies.
A. India C. Splenomegaly, hepatomegaly, fractures
B. China D. Invasion by the leukemic cells to the bone
C. Philippines causing severe bone pain
D. Korea
29. Gold standard in the diagnosis of leukaemia is
23. Which government agency is responsible for by which of the following?
testing the melamine content of foods and food A. Blood culture and sensitivity
products? B. Bone marrow biopsy
A. DOH C. Blood biopsy
B. MMDA
C. NBI 30. Adriamycin, Vincristine, Prednisone and L
D. BFAD asparaginase are given to the client for long term
therapy. One common side effect, especially of
24. Infants are the most vulnerable to melamine adriamycin is alopecia. The child asks: “ Will I get
poisoning. Which of the following is NOT a sign of my hair back once again?” The nurse respond is by
melamine poisoning? saying:
A. Irritability, Back ache, Urolithiasis A. “Don’t be silly, of course you will get your hair
B. High blood pressure, fever back.”
C. Anuria, Oliguria or Hematuria B. “We are not sure, let’s hope it’ll grow.”
D. Fever, Irritability and a large output of diluted C. “This side effect is usually permanent, but I will
urine get the doctor to discuss it for you.”
D. “Your hair will regrow in 3 -6 months but of
25. What kind of renal failure from melamine different color, usually darker and of different
poisoning cause? texture.”
A. Chronic Pre-renal
B. Acute, Postrenal
Situation: Breast cancer is the 2nd most common
type of cancer after lung cancer and 99% of which, 36. Based on the DOH and World Health
occurs in woman. Survival rate is 98% if this is Organization (WHO) guidelines, the mainstay for
detected early and treated promptly. Carmen is a early detection method for breast cancer that is
53 year old patient in the high risk group for breast recommended for developing countries is:
cancer was recently diagnosed with Breast Cancer. A. a monthly breast self examination (BSE) and an
annual health worker breast examination (HWBE)
31. All of the following are factors that said to B. an annual hormone receptor assay
contribute to the development of breast cancer C. an annual mammogram
EXCEPT: D. a physician conduct a breast clinical examination
A. Prolonged exposure to estrogen such as an every 2 years
early menarche or late menopause, nulliparity and
children after age 30. 37. The purpose of performing the breast self
B. Genetics examination (BSE) regularly is to discover:
C. Increasing age A. fibrocystic
D. Prolonged intake of Tamoxifen (Nolvadex) masses

32. Protective factors for the development of breast B. cancerous

cancer includes which of the following EXCEPT: lumps
A. Exercise
B. Prophylactic Tamoxifen C. areas of thickness or fullness
C. Breast Feeding D. changes from previous BSE
D. Alcohol intake
38. If you are to instruct a postmenopausal woman
33. A patient diagnosed with breast cancer has about BSE, when would you tell her to do BSE:
been offered the treatment choices of breast A. on the same day of each
conservation surgery with radiation or a modified month
radical mastectomy. When questioned by the B. right after the menstrual
patient about these options, the nurse informs the period
patients that the lumpectomy with radiation. C. on the first day of her menstruation
A. Reduces the fear and anxiety that accompany D. on the last day of her menstruation
the diagnosis and treatment of cancer
B. Has about the same 10 years survival rate as 39. During breast self-examination, the purpose of
the modified radical mastectomy standing in front of the mirror it to observe the
C. Provides shorter treatment period with a fewer breast for:
long term complications A. thickening of the
D. Preserves the normal appearance and sensitivity tissue
of the breast B.
axillary
34. Carmen, is asking the nurse the most
appropriate time of the month to do her self- C. lumps in the breast tissue
examination of the breast. The MOST appropriate D. change in size and contour
reply by the nurse would be:
A. the 26th day of menstrual cycle 40. When preparing to examine the left breast in a
B. 7 – 8 days after conclusion of the menstrual reclining position, the purpose of placing a small
period folded towel under the client’s left shoulder is to:
C. During her menstruation A. bring the breast closer to the examiner’s right
D. the same day each month hand
B. tense the pectoral muscle
35. Carmen being treated with radiation therapy. C. balance the breast tissue more evenly on the
What should be included in the plan of care to chest wall
minimize skin damage from the radiation therapy? D. facilitate lateral positioning of the breast
A. Cover the areas with thick clothing materials
B. Apply a heating pad to the site Situation – Radiation therapy is another modality of
C. Wash skin with water after therapy cancer management. With emphasis on
D. Avoid applying creams and powder to the area.
multidisciplinary management you have important D. Deep full thickness burn
responsibilities as a nurse
47. Which of the following BEST describes
41. Albert is receiving external radiation therapy superficial partial thickness burn or first degrees
and he complains of fatigue and malaise. Which of burn?
the following nursing interventions would be most A. Structures beneath the skin and damage
helpful for Albert? B. Dermis is partially damaged
A. Tell him that sometimes these feelings can be C. Epidermis and dermis are both damaged
psychogenic D. Epidermis is damaged
B. Refer him to the physician
C. Reassures him that these feelings are normal 48. A burn that is said to be “WEEPING” is
D. Help him plan his activities classified as:
A. Superficial partial thickness burn
42. Immediately following the radiation teletherapy, B. Deep partial thickness burn
Albert is: C. Full thickness burn
A. Considered radioactive fro 24hours D. Deep full thickness burn
B. Given a complete bath
C. Placed on isolation for 6 hours 49. During the Acute Phase of the burn injury,
D. Free from Radiation which of the following is a priority?
A. Wound healing
43. Albert is admitted with a radiation induced B. Reconstructive surgery
thrombocytopenia. As a nurse you should observe C. Emotional support
the following symptoms: D. Fluid resuscitation
A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor 50. While in the emergent phase, the nurse knows
C. Headache, dizziness, blurred vision that the priority is to:
D. Severe sore throat, bacteremia, hepatomegaly A. Prevent infection
B. Control pain
44. What nursing diagnosis should be the highest C. Prevent deformities and contractures
priority? D. Return the hemodynamic stability via fluid
A. Knowledge deficit regarding thrombocytopenia resuscitation
precautions
B. Activity intolerance
C. Impaired tissue integrity 51. The MOST effective method of delivering pain
D. Ineffective tissue perfusion, peripheral, cerebral, medication during the emergent phase is:
cardiovascular, gastrointestinal, renal A. intramuscularly
B. subcutaneously
45. What intervention should you include in your C. orally
care plan? D. intravenously
A. Inspect his skin for petechiae, bruising, GI
bleeding regularly 52. When a client accidentally splashes chemicals
B. Place Albert on strict isolation precaution to his eyes. The initial priority care of the following
C. Provide rest in between activities the chemical burns is to:
D. Administer antipyretics if his temperature A. irrigate with normal saline for 1 to 15 minutes
exceeds 38 C B. transport to a physician immediately
C. irrigate with water for 15 minutes or longer
Situation: Burn is cause by transfer of heat source D. cover the eyes with a sterile gauze
to the body. It can be thermal, electrical radiation or
chemical. 53. Which of the following can be fatal complication
of upper airway burns?
46. A burn characterized by pale, white A. stress ulcers
appearance, charred or with exposed and B. hemorrhage
painlessness: C. shock
A. Superficial partial thickness burn D. laryngeal spasm and swelling
B. Deep partial thickness burn
C. Full thickness burn
54. When a client will rush towards you and he has hasten wound healing, regain of consciousness
burning clothes on, it is your priority to do which of and rapid return of hemodynamic stability.
the following first? D. For hyperkalemia
A. log roll on the grass/ground
B. slap the flames with his hands 60. The IV fluid of choice for burn as well as
C. Try to remove the burning clothes dehydration is:
D. Splash the client with 1 bucket of cool water A. 0.45% NaCl
B. NSS
55. Once the flames are extinguished, it is most C. Sterile water
important: D. D5LR
A. cover client with warm blanket
B. Give him sips of water Situation: ENTEROSTOMAL THERAPY is now
C. Calculate the extent of this burns considered a specialty in nursing. You are
D. Assess the Sergio’s breathing participating in the OSTOMY CARE CLASS.

61. You plan to teach Fermin how to irrigate the

56. During the first 24 hours after thermal injury, colostomy when:
you should assess Sergio for: A. The perineal wound heals And Fermin can sit
A. hypokalemia and hypernatremia comfortably on the commode
B. hypokalemia and hyponatremia B. Fermin can lie on the side comfortably, about the
C. hyperkalemia and hyponatremia 3rd postoperative day
D. hyperkalemia and hypernatremia C. The abdominal incision is closed and
contamination is no longer a danger
57. A client who sustained deep partial thickness D. The stools starts to become formed, around the
and full thickness burns of the face, whole anterior 7th postoperative day
chest and both upper extremities two days ago
begins to exhibit extreme restlessness . You 62. When preparing to teach Fermin how to irrigate
recognize that this most likely indicates that the colostomy, you should plan to do the procedure:
client is developing: A. When Fermin would have normal bowel
A. Cerebral hypoxia movement
B. Hypervolemia B. At least 2 hours before visiting hours
C. Metabolic acidosis C. Prior to breakfast and morning care
D. Renal failure D. After Fermin accepts alteration in body image

58. A 165 lbs trauma client was rushed to the 63. When observing a return demonstration of a
emergency room with full thickness burns on the colostomy irrigation, you know that more teaching
whole face, right and left arm, and at the anterior is required if Fermin:
chest sparing the abdominal area. He also has A. Lubricates the tip of the catheter prior to
superficial partial thickness burn at the posterior inserting into the stoma
trunk and at the half upper portion of the left leg. He B. Hangs the irrigating bag on the bathroom door
the emergent phase of burns using the parkland’s cloth hook during fluid
formula, you know that during the first 8 hours of insertion
burn the amount of fluid will be given is: C. Discontinues the insertion of fluid after only 500
A. 5, 400ml ml of fluid has been instilled
B. 10,500 ml D. Clamps of the flow of fluid when felling
C. 9,450 ml uncomfortable
D. 6,750 ml
64. You are aware that teaching about colostomy
59. The doctor incorporated insulin on the client’s care is understood when Fermin states, “I will
fluid during the emergent phase. The nurse knows contact my physician and report:
that insulin is given because: A. If I have any difficulty inserting the irrigating tub
A. Clients with burn also develops Metabolic into the stoma.”
Acidosis B. If I noticed a loss of sensation to touch in the
B. Clients with burn also develops hyperglycemia stoma tissue.”
C. Insulin is needed for additional energy and C. The expulsion of flatus while the irrigating fluid is
glucose burning after the stressful incidence to running out.”
D. When mucus is passed from the stoma between Situatuon: Johnny, sought consultation to the
the irrigations.” hospital before

65. You would know after teaching Fermin that 71. His diagnosis was hyperthyroidism, the
dietary instruction for him is effective when he following are expected symptoms except:
states, “It is important that I eat: A. Anorexia
A. Soft food that are easily digested and absorbed B. Palpitation
by my large intestines.” C. Fine tremors of the hand
B. Bland food so that my intestines do not become D. Hyper alertness
irritated.”
C. Food low in fiber so that there is less stool.” 72. He has to take drugs to treat hyperthyroidism,
D. Everything that I ate before the operation, while which of the following will you not expect that the
avoiding foods that doctor will prescribe?
cause gas.” A. Colace (Docusate)
B. Cytomel (Llothyronine)
Situation: Based on studies of nurses working in C. Tapazole (
special units like the intensive care unit and D. (Levothyroxine)
coronary care unit it is important for nurses to
gather as much information to be able to address 73. The nurse knows that Tapazole has which of
their needs for nursing care. the following side effect that will warrant immediate
withholding of the medication?
66. Critically ill patient frequently complain about A. Death
which of the following when hospitalized? B. Sore throat
A. Hospital report C. Hyperthermia
B. Lack of blankets D. Thrombocytosis
C. Lack of privacy
D. Inadequate nursing staff 74. You asked questions as soon as she regained
consciousness from thyroidectomy primarily to
67. Who of the following is at greatest risk of assess the evidence of:
developing sensory problem? A. Thyroid storm
A. Female patient B. Mediastinal shift
B. Adolescent C. Damage to the laryngeal nerve
C. Transplant patient D. Hypocalcemia tetany
D. Unresponsive patient
75. Should you check for haemorrhage, you will:
68. Which of the following factors may inhibit A. Slip your hand under the nape of her neck
learning in critically ill patients? B. Check for hypotension
A. Gender C. Apply neck collar to prevent haemorrhage
B. Medication D. Observe the dressing if is soaked with blood
C. Educational level
D. Previous knowledge of illness 76. Basal Metabolic rate is assessed on Johnny to
determine his metabolic rate. In assessing the BMR
69. Which of the following statements does not using the standard procedure, you need to tell
apply to critically ill patients? Johnny that:
A. Majority need extensive rehabilitation A. Obstructing his vision
B. All have been hospitalized previously B. Restraining his upper and lower extremities
C. Are physically unstable C. Obstructing his hearing
D. Most have chronic illness. D. Obstructing his nostril with a clamp

70. Families of critically ill patients desire which of 77. The BMR is based on the measurement that:
the following needs to be met first by the nurse? A. Rate of respiration under different condition of
A. Provision of comfortable space activities and rest
B. Emotional support B. Amount of oxygen consumption under resting
C. Updated information on the client’s status condition over a measured period of time
D. Spiritual counselling C. Amount of oxygen consumption under stressed
condition over a measured period of time
D. Ratio of respiration to pulse rate over a A. Clean
measured period of time B. Decontaminated
C. Sterilized
78. Her physician ordered lugol’s solution in order D. Disinfected
to:
A. Decrease the vascularity and size of the thyroid 85. As a nurse, you know that intact skin as an
gland effective barrier to most microorganisms.
B. Decrease the size of the thyroid gland only Therefore, items that come in contact with the intact
C. Increase the vascularity and size of the thyroid skin or mucous membranes should be:
gland A. Disinfected
D. Increase the size of the thyroid gland only B. Sterile
C. Clean
79. Which of the following is a side effect of lugol’s D. Alcoholized
solution?
A. Hypokalemia 86. You are caring for Johnny who is scheduled to
B. Nystagmus undergo total thyroidectomy because of a diagnosis
C. Enlargement of the Thyroid gland of thyroid cancer. Prior to total thyroidectomy, you
D. Excessive salivation should instruct Johnny to:
A. Perform range and motion exercise on the head
80. In administering Lugol’s solution, the or neck
precautionary measure should include: B. Apply gentle pressure against the incision when
A. Administer with glass only swallowing
B. Dilute with juice and administer with a straw C. Cough and deep breathe every hours
C. Administer it with milk and drink it D. Support head with the hands when changing
D. Follow it with milk of magnesia position

Situation: Pharmacological treatment was not Situation – Andrea is admitted to the ER following
effective for Johnny’s hyperthyroidism and now he an assault where she was hit on the face and head.
is scheduled for Thyroidectomy. She was brought to the ER by a police woman.
Emergency measures were stated.
81. Instruments in the surgical suite for surgery is
classified as either CRITICAL, SEMI CRITICAL and 96. Andrea’s respiration is described as waxing and
NON CRITICAL. If the instrument are introduced waning. You know that this rhythm of respiration is
directly into the blood stream or into any normally defined as:
sterile cavity or area of the body it is classified as: A. Biot’s
A. Critical B. Kussmaul’s
B. Semi critical C. Cheyne Stokes
C. Non critical D. Eupnca
D. Ultra critical
97. What do you call the triad of sign and
82. Instruments that do not touch the patient or symptoms seen in a client with increasing ICP?
have contact only to the intact skin is classified as: A. Virchow’s Triad
A. Critical B. The Chinese triad
B. Semi critical C. Cusching’s Triad
C. Non critical D. Charcot’s Triad
D. Ultra critical
98. Which of the following is true with the Cushing’s
83. If an instrument is classified as Semi Critical an Triad seen in head injuries?
acceptable method of making the instrument ready A. Narrowing of Pulse Pressure, Cheyne strokes
for surgery is through: respiration, Tachycardia
A. Sterilization B. Widening Pulse pressure, Irregular respiration,
B. Decontamination Bradycardia
C. Disinfection C. Hypertension, Kussmaul’s respiration,
D. Cleaning Tachycardia
D. Hypotension, Irregular respiration, Bradycardia
84. While critical items and should be:
99. In a client with a Cheyne stokes respiration,
which of the following is the most appropriate
nursing diagnosis?
A. Ineffective airway clearance
B. Ineffective breathing pattern
C. Impaired gas exchange
D. Activity Intolerance

100. You know the apnea is seen in client’s with

cheyne stoke respiration, APNEA is defined as:
A. Inability to breath in a supine position so the
patient sits up in bed to breathe.
B. The patient is dead, the breathing stops
C. There is an absence of breathing for a period of
time usually 15 seconds or more
D. A period of hypercapnea and hypoxia due to
cessation of respiratory effort inspite of normal
respiratory functioning