NP3 Nursing Board Exam November 2008 Answer Key 'Nursing Care

of Client with Physiological and Psychosocial Alteration'

Nov. ’08 NP3
Nursing Board/Licensure Exam Answer Key: NP3 Nursing Board Exam November 2008 Answer Key 'Nursing Care of Client with
Physiological and Psychosocial Alteration'
Nursing Board/Licensure Exam Answer Key: NP3 Nursing Board Exam November 2008 Answer Key 'Nursing Care of Client
with Physiological and Psychosocial Alteration'

Situation 1: Leo lives in the squatter area. He 6. The information that an investigator collects
goes to nearby school. He helps his mother from the subjects or participants in a research
gather molasses after school. One day, he was study is usually called:
absent because of fever, malaise, anorexia and A. Hypothesis
abdominal discomfort. B. Data
C. Variable
1. Upon assessment, Leo was diagnosed to have D. Concept
hepatitis A. Which mode of transmission has the
infection agent taken? 7. Which of the following usually refers to the
A. Fecal oral independent variables in doing research?
B. Droplet A. Result
C. Airborne B. Cause
D. Sexual contact C. Output
D. Effect
2. Which of the following is concurrent
disinfection in the case of Leo? 8. The recipients of experimental treatment is an
A. In experimental design or the individuals to be
B. Sanitary disposal of feces, urine and blood observed in a non experimental design are called;
C. Quarantine of the sick individual A. Setting
D. B. Subjects
C. Treatment
3. Which of the following must be emphasized D. Sample
during mother’s class to Leo’s mother?
A. Administration of immunoglobulin to families 9. The device or techniques an investigator
B. Thorough hand washing before and after employs to collect data is called?
eating and toileting A. Sample
C. Use of attenuated vaccines B. Instrument
D. Boiling of food especially meat C. Hypothesis
D. Concept
4. Disaster control should be undertaken when
there are 3 or more hepatitis A cases. Which of 10. The use of another persons ideas or wordings
these measures is a priority? giving appropriate credit results from inaccurate
A. Eliminate fecal contamination from foods attribution of materials to its sources. Which of
B. Mass vaccination of uninfected individuals the following is referred to when another persons
C. Health promotion and education to families idea is inappropriate credited as one’s own?
and communities about the disease it’s cause and A. Plagiarism
transmission. B. Quotation
D. Mass administration of immunoglobulin C. Assumption
D. Paraphrase
5. What is the average incubation period of
Hepatitis A? Situation 3: Mrs. Pichay is admitted to your ward.
A. 30 days The MD ordered “Prepare for thoracentesis this
B. 60 days pm to remove excess air from the pleural cavity.”
C. 50 days
D. 14 days 11. Which of the following nursing responsibilities
is essential in Mrs. Pichay who will undergo
thoracentesis?
Situation 2: As a nurse researcher you must have A. Support and reassure client during the
a very good understanding of the common terms procedure
of concept used in research. B. Ensure that informed consent has been signed
C. Determine if client has allergic reaction to local D. Shave scalp and securely attach electrodes to
anesthesia it
D. Ascertain if chest x-rays and other tests have
been prescribed and completed 18. Mr. Santos is placed on seizure precaution.
Which of the following would be contraindicated?
12. Mrs. Pichay who is for thoracentesis is A. Obtain his oral temperature
assigned by the nurse to which of the following B. Encourage to perform his own personal
positions? hygiene
A. Trendelenburg position C. Allow him to wear his own clothing
B. Supine position D. Encourage him to be out of bed.
C. Dorsal Recumbent position
D. Orthopneic position 19. Usually, how does the patient behave after
his seizure has subsided?
13. During thoracentesis, which of the following A. Most comfortable walking and moving about.
nursing intervention will be most crucial? B. Becomes restless and agitated.
A. Place patient in a quiet and cool room C. Sleeps for a period of time
B. Maintain strict aseptic technique D. Say he is thirsty and hungry.
C. Advice patient to sit perfectly still during
needle insertion until it has been withdrawn from 20. Before, during and after seizure. The nurse
the chest knows that the patient is ALWAYS placed in what
D. Apply pressure over the puncture site as soon position?
as the needle is withdrawn A. Low fowler’s
B. Modified trendelenburg
14. To prevent leakage of fluid in the thoracic C. Side Lying
cavity, how will you position the client after D. Supine
thoracentesis?
A. Place flat in bed Situation 5: Mrs. Damian an immediate post op
B. Turn on the unaffected side cholecystectomy and choledocholithotomy
C. Turn on the affected side patient, complained of severe pain at the wound
D. On bed rest site.

15. Chest x-ray was ordered after thoracentesis. 21. Choledocholithotomy is:
When your client asks what is the reason for A. The removal of the gallbladder
another chest x-ray, you will explain: B. The removal of the stones in the gallbladder
A. to rule out pneumothorax C. The removal of the stones in the common bile
B. to rule out any possible perforation duct
C. to decongest D. The removal of the stones in the kidney
D. to rule out any foreign body
22. The simplest pain relieving technique is:
Situation 4: A computer analyst, Mr. Ricardo J. A. Distraction
Santos, 25 was brought to the hospital for B. Taking aspirin
diagnostic workup after he had experienced C. Deep breathing exercise
seizure in his office. D. Positioning

16.Just as nurse was entering the room, the 23. Which of the following statement on pain is
patient who was sitting on his chair begins to true?
have a seizure. Which of the following must the A. Culture and pain are not associated
nurse do first? B. Pain accomplished acute illness
A. Ease the patient to the floor C. Patient’s reaction to pain varies
B. Lift the patient and put him on the bed D. Pain produces the same reaction such as
C. Insert a padded tongue depressor between his groaning and moaning
jaws
D. Restrain patient’s body movement 24. In a pain assessment, which of the following
condition is a more reliable indicator?
17. Mr. Santos is scheduled for CT SCAN for the A. Pain rating scale of 1 – 10
next day, noon time. Which of the following is the B. Facial expression and gestures
correct preparation as instructed by the nurse? C. Physiological responses
A. Shampoo hair thoroughly to remove oil and dirt D. Patients description of the pain sensation
B. No special preparation is needed. Instruct the
patient to keep his head still and stead. 25. When a client complains of pain, your initial
C. Give a cleansing enema and give until 8 AM response is:
A. Record the description of pain Situation 7: Nurse’s attitudes toward the pain
B. Verbally acknowledge the pain influence the way they perceive and interact with
C. Refer the complaint to the doctor clients in pain.
D. Change to a more comfortable position
31. Nurses should be aware of that older adults
Situation 6: You are assigned at the surgical ward are at risk of underrated pain. Nursing
and clients have been complaining of post pain at assessment and management of pain should
varying degrees. Pain as you know is very address the following beliefs EXCEPT:
subjective. A. Older patients seldom tend to report pain than
the younger ones
26. A one-day post operative abdominal surgery B. Pain is a sign of weakness
client has been complaining of severe throbbing C. Older patients do not believe in analgesics,
abdominal pain described as 9 in 1 – 10 pain they are tolerant.
rating. Your assessment reveals bowel sounds on D. Complaining of pain will lead to being labelled
all quadrants and the dressing is dry and intact. a bad patient
What nursing intervention would you take?
A. Medicate client as prescribed 32. Nurses should understand that when a client
B. Encourage client to do-imagery responds favourably to a placebo, it is known as
C. Encourage deep breathing exercise the placebo effect. Placebos do not indicate
D. Call surgeon stat whether or not a client has:
A. Conscience
27. Pentoxidone 5 mg IV every 8 hours was B. Real pain
prescribed for post abdominal pain, which will be C. Disease
your priority nursing action? D. Drug tolerance
A. Check abdominal dressing for possible swelling
B. Explain the proper use of PCA to alleviate 33. You are the nurse in the pain clinic where you
anxiety have client who has difficulty specify the location
C. Avoid overdosing to prevent of pain. How can you assist such client?
dependence/tolerance A. The pain is vague
B. By charting-it hurts all over
D. Monitor VS, more importantly RR C. Identifying the absence and presence of pain
D. Ask the client to point to the painful are by just
28. The client complained of abdominal distention one finger.
and pain. Your nursing intervention that can
alleviate pain is: 34. What symptom more distressing than pain,
A. Instruct client to go to sleep and relax should the nurse monitor when giving opioids
B. Advice the client to close the lips and avoid especially among elderly clients who are in pain?
deep breathing and talking A. Forgetfulness
C. Offer hot and clear soup B. Constipation
D. Turn to sides frequently and avoid too much C. Drowsiness
talking D. Allergic reactions like pruritus

29. Surgical pain might be minimized b which 35. Physical dependence occurs in anyone who
nursing action in the O.R. takes opiods over a period of time. What do you
A. Skill of surgical team and lesser manipulation tell a mother of a ‘dependent’ when asked for
B. Appropriate preparation for the scheduled advice?
procedure A. Start another drug and slowly lessen the opioid
C. Use of modern technology in closing the wound dosage
D. Proper positioning and draping of client. B. Indulge in recreational outdoor activities
C. Isolate opioid dependent to a restful resort
30. Inadequate anesthesia is said to be one of the D. Instruct slow tapering of the drug dosage and
common cause of pain both in intra and post-op alleviate physical withdrawal symptoms.
patients. If general anesthesia is desired, it will
involve loss of consciousness. Which of the Situation 8: The nurse is performing health
following are the 2 general types of GA? education activities for Janevi Segovia, a 30 years
A. Epidural and Spinal old Dentist with Insulin dependent diabetes
B. Subarachnoid block and intravenous Mellitus.
C. Inhalation and Regional
D. Intravenous and inhalation 36. Janevi is preparing a mixed dose of insulin.
The nurse is satisfied with her performance when
she:
A. Draw insulin from the vial of clear insulin first C. Intravenous infusion of normal saline
B. Draw insulin from the vial of the intermediate D. Intravenous infusion of sodium bicarbonate
acting insulin first
C. Fill both syringes with the prescribed insulin 43. Jane eventually developed DKA and is being
dosage then shake the bottle vigorously treated in the emergency room. Which finding
D. Withdraw the intermediate acting insulin first would the nurse expect to note as confirming this
before withdrawing the short acting insulin first. diagnosis?
A. Comatose state
37. Janevi complains of nausea, vomiting, B. Decreased urine output
diaphoresis and headache. Which of the following C. Increased respiration and increase in pH
nursing intervention are you going to carry first? D. Elevated blood glucose level and plasma
A. Withhold the client’s next insulin injection bicarbonate level
B. Test the client’s blood glucose level
C. Administer Tylenol as ordered 44. The nurse teaches Jane to know the
D. Offer fruit juice, gelatine and chicken bouillon difference between hypoglycaemia and
ketoacidosis. Jane demonstrates understanding of
38. Janevi administered regular insulin at 7 A.M. the teaching by stating that glucose will be taken
and the nurse should instruct Jane to avoid of which of the following symptoms develops?
exercising at around: A.
A. 9 to 11 A.M. B. Shakiness
B. After 8 hours C. Blurred vision
C. Between 8 A.M. to 9 A.M. D. Foul breath odor
D. In the afternoon, after taking lunch.
45. Jane has been scheduled to have a FBS taken
39. Janevi was brought at the emergency room in the morning. The nurse tells Jane to eat or
after four month because she fainted in her clinic. drink after midnight. Prior to taking the blood
The nurse should monitor which of the following specimen, the nurse noticed that Jane is holding a
test to evaluate the overall therapeutic bottle of distilled water. The nurse asked Jane if
compliance of a diabetic patient? she drink any, and she said yes. Which of the
A. Glycosylated Hemoglobin following is the best nursing action?
B. Fasting blood glucose A. Administer syrup of ipecac to remove the
C. Ketone levels distilled water from the stomach.
D. Uirne glucose level B. Suction the stomach content using NGT prior
to specimen collection
40. Upon the assessment of HbA1C of Mrs. C. Advice to physician to reschedule to diagnostic
Segovia. The nurse has been informed of a 9 % examination next day
HbA1C result. In this case, she will teach the D. Continue as usual and have the FBS analysis
patient to: performed and specimen be taken.
A. Avoid infection
B. Take adequate food and nutrition Situation 9: Elderly clients usually produce
C. Prevent and recognize hypoglycaemia unusual signs when it comes to different
D. Prevent and recognize hypoglycaemia diseases. The ageing process is a complicated
process and the nurse should understand that it
41. The nurse is teaching plan of care for Jane is an inevitable fact and she must be prepared to
with regards to proper foot care. Which of the care for the growing elderly population.
following should be included in the plan?
A. Soak feet in hot water 46. Hypoxia may occur in the older patients
B. Avoid using mild soap on the feet because of which of the following
C. Apply a moisturizing lotion to dry feet but not physiologic changes associated with aging.
between the toes A. Ineffective airway clearance
D. Always have a podiatrist to cut your toe nails; B. Decreased alveolar surfaced area
never cut them yourself C. Decreased anterior-posterior chest diameter
D. Hyperventilation
42. Another patient was brought to the
emergency room in an unresponsive state and a 47. The older patient is at higher risk for
diagnosis of hyperglycaemic hyperosmolar incontinence because of:
nonketotic syndrome is made. The nurse A. dilated urethra
immediately prepare to initiate which of the B. increased glomerular filtration rate
following anticipated physician’s order? C. diuretic use
A. Endotracheal intubation D. decreased bladder capacity
B. 100 units of insulin
48. Merle, age 86, is complaining of dizziness D. Client is monitored throughout the surgery by
when she stands up. This may the assistant anaesthesiologist
indicate:
A. dementia 54. Another nursing check that should not be
B. a visual problem missed before the induction of general
C. functional decline anesthesia is:
D. drug toxicity A. check for presence underwear
B. check for presence dentures
49. Cardiac ischemia in an older patient usually C. check patient’s ID
produces: D. check baseline vital signs
A. ST-T wave changes
B. Very high creatinine kinase level 55. Some lifetime habits and hobbies affect
C. Chest pain radiating to the left arm postoperative respiratory function. If your client
D. Acute confusion smokes 3 packs of cigarettes a day for the past
10 years, you will anticipate increased risk
50. The most dependable sign of infection in the for:
older patient is: A. perioperative anxiety and stress
A. change in mental status B. delayed coagulation time
B. fever C. delayed wound healing
C. pain D. postoperative respiratory function
D. decreased breath sounds with crackles

Situation 11: Sterilization is the process of

Situation 10 – In the OR, there are safety removing ALL living microorganism. To be free of
protocols that should be followed. The OR ALL living microorganism is sterility.
nurseshould be well versed with all these to
safeguard the safety and quality of patient 56. There are 3 general types of sterilization use
delivery outcome. in the hospital which one is not included?
A. Steam sterilization
51. Which of the following should be given B. Chemical sterilization
highest priority when receiving patient in the OR? C.
A. Assess level of consciousness D. Sterilization by boiling
B. Verify patient identification and informed
consent 57. Autoclave or steam steam under pressure is
C. Assess vital signs the most common method of sterilization in the
D. Check for jewelry, gown, manicure, and hospital. The nurse knows that the temperature
dentures and time is set to the optimum level to destroy
not only the microorganism, but also the spores.
52. Surgeries like I and D (incision and drainage) Which of the following is the ideal setting of the
and debridement are relatively short procedures autoclave machine?
but considered ‘dirty cases’. When are these A. 10,000 degree Celsius for 1 hour
procedures best scheduled? B. 5,000 degree Celsius for 30 minutes
A. Last case C. 37 degree Celsius for 15 minutes
B. In between cases D. 121 degree Celsius for 15 minutes
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference 58. It is important that before a nurse prepares
the material to be sterilized, A chemical indicator
53. OR nurses should be aware that maintaining strip should be placed above the package,
the client’s safety is the overall goal of nursing preferably, Muslin sheet. What is the color of the
care during the intraoperative phase. As the striped produced after autoclaving?
circulating nurse, you make certain that A. Black
throughout the procedure… B. Blue
A. the surgeon greets his client before induction C. Gray
of anesthesia D. Purple
B. the surgeon and anesthesiologist are in
tandem 59. Chemical indicators communicate that:
C. strap made of strong non-abrasive materials A. The items are sterile
are fastened securely B. That the items had undergone sterilization
around the joints of the knees and ankles and process but not necessarily sterile
around the 2 hands around C. The items are disinfected
an arm board.
D. That the items had undergone disinfection D. Request the client to expose the incision
process but not necessarily disinfected wound

60. If a nurse will sterilize a heat and moisture Situation 13: The preoperative nurse collaborates
labile instruments, it is according to AORN with the client significant others, and healthcare
recommendation to use which of the following providers.
method of sterilization?
A. Ethylene oxide gas 66. To control environmental hazards in the OR,
B. Autoclaving the nurse collaborates with the following
C. Flash sterilizer departments EXCEPT:
D. Alcohol immersion A. Biomedical division
B. Chaplancy services
Situation 12 – Nurses hold a variety of roles when C. Infection control committee
providing care to a perioperative patient. D. Pathology department
61. Which of the following role would be the
responsibility of the scrub nurse? 67. An air crash occurred near the hospital
A. Assess the readiness of the client prior to leading to a surge of trauma patient. One of the
surgery last patients will need surgical amputation but
B. Ensure that the airway is adequate there are no sterile surgical equipments. In this
C. Account for the number of sponges, needles, case, which of the following will the nurse expect?
supplies, used during the surgical procedure. A. Equipments needed for surgery need not be
D. Evaluate the type of anesthesia appropriate for sterilized if this is an emergency necessitating life
the surgical client saving measures
B. Forwarding the trauma client to the nearest
62. As a perioperative nurse, how can you best hospital that has available sterile equipment is
meet the safety need of the client after appropriate
administering preoperative narcotic? C. The nurse will need to sterilize the item before
A. Put side rails up and ask the client not to get using it to the client using the regular sterilization
out of bed setting at 121 degree Celsius in 15 minutes.
B. Send the client to OR with the family D. In such cases, flash sterilizer will be use at 132
C. Allow client to get up to go to the comfort degree Celsius in 3 minutes.
room
D. Obtain consent form 68. Tess, the PACU nurse discovered that Malou,
who weights 110 lbs prior to surgery, is in severe
63. It is the responsibility of the pre-op nurse to pain 8 hours after cholecystectomy. Upon
do skin prep for patients undergoing\ surgery. If checking the chart, Malou found out that she has
hair at the operative site is not shaved, what an order of Demerol 100 mg I.M. prn for pain.
should be done to make suturing easy and lessen Tess should verify the order with:
chance of incision infection? A. Nurse supervisor
A. Draped B. Anesthesiologist
B. Pulled C. Surgeon
C. Clipped D. Intern on duty
D. Shampooed
69. Rosie, 57, who is diabetic is for debridement if
64. It is also the nurse’s function to determine incision wound. When the circulating nurse
when infection is developing in the surgical checked the present IV fluid, she found out that
incision. The perioperative nurse should observe there is no insulin incorporated as ordered. What
for what signs of impending infection? should the circulating nurse do?
A. Localized heat and redness A. Double check the doctor’s order and call the
B. Serosanguinous exudates and skin blanching attending MD
C. Separation of the incision B. Communicate with the ward nurse to verify if
D. Blood clots and scar tissue are visible insulin was incorporated or not
C. Communicate with the client to verify if insulin
65. Which of the following nursing interventions is was incorporated
done when examining the incision wound and D. Incorporate insulin as ordered
changing the dressing?
A. Observe the dressing and type and odor of
drainage if any 70. The documentation of all nursing activities
B. Get patient’s consent performed is legally and professionally vital.
C. Wash hands Which of the following should NOT be included in
the patients chart?
A. Presence of prosthetic devices such as Situation 15: Basic knowledge on Intravenous
dentures, artificial limbs hearing aid, etc. solutions is necessary for care of clients with
B. Baseline physical, emotional, and psychosocial problems with fluids and electrolytes.
data
C. Arguments between nurses and residents 76. A client involved in a motor vehicle crash
regarding treatment presents to the emergency department with
D. Observed untoward signs and symptoms and severe internal bleeding. The client is severely
interventions including contaminant intervening hypotensive and unresponsive. The nurse
factors. anticipates which of the following intravenous
solutions will most likely be prescribed to
Situation 14 – Team efforts is best demonstrated increase intravascular volume, replace immediate
in the OR. blood loss and increase blood pressure?
A. 0.45 % sodium chloride
71. If you are the nurse in charge for scheduling B. Normal saline solution
surgical cases, what important information do you C. o.33% sodium chloride
need to ask the surgeon? D. Lactated ringer’s solution
A. Who is your internist
B. Who is your assistant and anesthesiologist, and 77. The physician orders the nurse to prepare an
what is your preferred isotonic solution. Which of the following IV
time and type of surgery? solution would the nurse expect the intern to
C. Who are your anesthesiologist, internist, and prescribe?
assistant A. 5 % dextrose in water
D. Who is your anesthesiologist B. 10 % dextrose in water
C. 0.45 % sodium chloride
72. In the OR, the nursing tandem for every D. 0.5 % dextrose in 0.9% sodium chloride
surgery is:
A. Instrument technician and circulating nurse 78. The nurse is making initial rounds on the
B. Nurse anesthetist, nurse assistant, and nursing unit to assess the condition or assigned
instrument technician clients. The nurse notes that the client’s IV site is
C. Scrub nurse and nurse anesthetist cool, pale and swollen and the solution is not
D. Scrub and circulating nurses infusing. The nurse concludes that which of the
following complications has been experienced by
73. While team effort is needed in the OR for the client?
efficient and quality patient care delivery, we A. Infection
should limit the number of people in the room for B. Phlebitis
infection control. Who comprise this team? C. Infiltration
A. Surgeon, anesthesiologist, scrub nurse, D. Thrombophlebitis
radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating 79. A nurse reviews the client’s electrolytes
nurse, anesthesiologist laboratory report and notes that the potassium
C. Surgeon, assistant surgeon, anesthesiologist, level is 3.2 mEq/L. Which of the following would
scrub nurse, pathologist the nurse note on the lectrocardiogram as a
D. Surgeon, assistant surgeon, anesthesiologist, result of the laboratory value?
intern, scrub nurse A. U waves
B.
74. Who usually act as an important part of the C. Elevated T waves
OR personnel by getting the wheelchair or D. Elevated ST segment
stretcher, and pushing/pulling them towards the
operating room? 80. One patient has a runaway IV of 50 %
A. Orderly/clerk dextrose. To prevent temporary excess of insulin
B. Nurse Supervisor or transient hyperinsulin reaction what solution
C. Circulating Nurse you prepare in anticipation of the doctor’s order?
D. Anesthesiologist A. Any IV solution available to KVO
B. Isotonic solution
75. The breakdown in teamwork is often times a C. Hypertonic solution
failure in: D. Hypotonic solution
A. Electricity
B. Inadequate supply 81. An informed consent is required for:
C. Leg work A. Closed reduction of a fracture
D. Communication B. Insertion of intravenous catheter
C. Irrigation of the external ear canal
D. Urethral catheterization A. Cover the soaking vessel to contain the vapour
B. Double the amount of high level of disinfectant
82. Which of the following is not true with regards C. Test the potency of the high level of
to the informed consent? disinfectant
A. It should describe different treatment D. Prolong the exposure time according to
alternatives manufacturer’s direction
B. It should contain a thorough and detailed
explanation of the procedure to be done 89. To achieve sterilization using disinfectants,
C. It should describe the client’s diagnosis which of the following is used?
D. It should given an explanation of the client’s A. Low level disinfectants immersion in 24 hours
prognosis B. Intermediate level disinfectants immersion in
12 hours
83. You know that the hallmark of nursing C. High level disinfectants immersion in 1 hour
accountability is the: D. High level disinfectants immersion in 10 hours
A. Accurate documentation and reporting
B. Admitting your mistakes 90. Bronchoscope, Thermometer, Endoscope, ET
C. Filing an incidence report tube, Cytoscope are all BEST sterilized using
D. Reporting a medication error which of the following?
A. Autoclaving at 121 degree Celsius in 15
84. A nurse is assigned to care for a group of minutes
clients. On review of the client’s medical records B. Flash sterilizer at 132 degree Celsius in 3
the nurse determines that which client is at risk minutes
for excess fluid volume? C. Ethylene Oxide gas aeration for 20 hours
A. The client taking diuretics D. 2% Glutaraldehyde immersion for 10 hours
B. The client with renal failure
C. The client with an ileostomy Situation 17: The OR is divided in three zones to
D. The client who requires gastrointestinal control traffic flow and contamination.
suctioning
91. What OR attires are worn in the restricted
85. A nurse is assigned to care for a group of area?
clients. On review of the client’s medical records, A. Scrub suit, OR shoes, head cap
the nurse determines that which client is at risk B. Head cap scrub suit, mask, OR shoes
for deficient fluid volume? C. Mask, OR shoes, scrub suit
A. A client with colostomy D. Cap, Mask, gloves, shoes
B. A client with congestive heart failure
C. A client with decreased kidney function 92. Nursing intervention for a patient on low dose
D. A client receiving frequent wound irrigation IV insulin therapy includes the following EXCEPT:
A. Elevation of serum ketones to monitor ketosis
Situation 16: As a perioperative nurse, you are B. Vital signs including BP
aware of the correct processing methods for C. Estimate serum potassium
preparing instruments and other devices for D. Elevation of blood glucose levels
patient use to prevent infection.
93. The doctor ordered to incorporate 1000 “u”
86. As an OR nurse, what are your foremost insulin to the remaining on going IV. The strength
considerations for selecting chemical agents for is 500/ml. How much should you incorporate into
disinfection? the IV solution?
A. Material compatibility and efficiency A. 10 ml
B. Odor and availability/ B. 2 ml
C. Cost and duration of disinfection process C. 0.5 ml
D. Duration of disinfection and efficiency D. 5 ml

87. Before you used disinfected instrument it is 94. Multiple vial-dose-insulin when in use should
essential that you: be:
A. Rinse with tap water followed by alcohol A. Kept at room temperature
B. Wipe the instrument with sterile water B. Kept in the refrigerator
C. Dry the instrument thoroughly C. Kept in narcotic cabinet
D. Rinse with sterile water D. Store in the freezer

88. You have a critical heat labile instrument to 95. Insulin using insulin syringe are given using
sterilize and are considering to use high level of how many degrees of needle insertion?
disinfectant. What should you do? A. 45
B. 180
C. 90
D. 15

Situation 18: Maintenance of sterility is an

important function a nurse should perform in any
OR setting.

96. Which of the following is true with regards to

sterility?
A. Sterility is time related items are not
considered sterile after a period of 30 days of
being not in use.
B. for 9 months sterile items are considered
sterile as long as they are covered with sterile
muslin cover and stored in a dust proof covers.
C. Sterility is event related, not time related.
D. For 3 weeks, items double covered with muslin
are considered sterile as long as they have
undergone the sterilization process

97. 2 organizations endorsed that sterility are

affected by factors other that the time itself,
these are:
A. The PNA and the PRC
B. AORN and JCAHO
C. ORNAP and MCNAP
D. MMDA and DILG

98. All of these factors affect the sterility of the

OR equipments, these are the following except:
A. The material used for packaging
B. The handling of the materials as well as its
transport
C. Storage
D. The chemical or process used in sterilizing the
material

99. When you say sterile, it means:

A. The material is clean.
B. The material as well as the equipments are
sterilized and had undergone a rigorous
sterilization process
C. There is a black stripe on the paper indicator
D. The material has no microorganism nor spores
present that might cause an infection

100. In using liquid sterilizer versus autoclave

machine, which of the following is true?
A. Autoclave is better in sterilizing OR supplies
verus liquid sterilizer
B. They are both capable of sterilizing the
equipments, however, it is necessary to soak
supplies in the liquid sterilizer for a longer period
of time.
C. Sharps are sterilized using autoclave and not
cidex.
D. If liquid sterilizer sterilization process is used,
rinsing it before using is not necessary.