NP4 Nursing Board Exam November 2008 Answer Key 'Nursing Care of Client

with Physiological and Psychosocial Alteration'

100 Nursing Board Exam test questions of November 2008 Nurse Licensure Examination (NLE)
Nursing Practice IV Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 1 Board Exam test questions 1 - 50

Nov. 08 NP4

Situation 1: After abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and
instrument count.

1. Counting is performed thrice: During the preincision phase, the operative phase and closing phase. Who counts
the sponges, needles and instruments?
A. The scrub nurse only
B. The circulating nurse only
C. The surgeon and the assistant surgeon
D. The scrub nurse and circulating nurse.

2. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer:
1. Fascia
2. Muscle
3. Peritoneum
4. Subcutaneous/Fat
5. Skin

A. 5,4,3,2,1
B. 5,4,2,1,3
C. 5,4,1,3,2,
D. 5,4,1,2,3

3. When is the first sponge instrument count reported?
A. Before closing the subcutaneous layer
B. Before peritoneum is closed
C. Before closing the skin
D. Before the fascia is sutured

4. Like any nursing intervention, counts should be documented. To whom does the scrub nurse report any
discrepancy of counts so that immediate and appropriate action is instituted?
A. Anaesthesiologist
B. Surgeon
C. OR nurse supervisor
D. Circulating nurse

5. Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing?
A. MRI and Incidence report
B. CT Scan, MRI, Incidence Report
C. X-ray, and Incidence Report
D. CT scan and Incidence Report

Situation 2: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic
nursing skills.

6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should you
collect a urine specimen for culture and sensitivity?
A. Clamp tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine.
B. Drain urine from the drainage bag into the sterile container
C. Disconnect the tubing from the urinary catheter and let urine floe into a sterile container
D. Wipe the self sealing aspirations port with antiseptic solution and insert a sterile needle into the self
sealing self-sealing port.

7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container

8. The best time for collecting the sputum specimen for culture:
A. Before retiring at night
B. Upon waking up in the morning
C. Anytime of the day.
D. Before meal

9. When suctioning the endotracheal tube, the nurse should:
A. Explain procedure to patient: Insert catheter gently applying suction. Withdrawn using twisting motion.
B. Insert catheter until resistance is met; then withdraw slightly, applying suction intermittently as
catheter is withdrawn.
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction, catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is
withdrawn.

10. The purpose of NGT IMMEDIATELY after operation is:
A. For feeding or gavage
B. For gastric decompression
C. For lavage, or the cleansing of the stomach content
D. For the rapid return of peristalsis

Situation 3 Mr. Santos, 50, is to undergo cytoscopy due to multiple problems like scantly urination, hematuria,
and dysuria.

11. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy,
you will enumerate as follows:
A. Urethra, Kidney, Bladder
B. Urethra, Bladder wall, trigone, urethral opening
C. Bladder wall, uterine wall and urethral opening
D. Urethral opening, urethral opening bladder.

12. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy
in:
A. Supine
B. Lithotomy
C. Semi-fowler
D. Trendelenburg

13. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you yell him?
A. Cystoscopy is direct visualization and examination by urologist
B. Cystoscopy is done by x-ray visualization of the urinary tact
C. Cystoscopy is done by using lasers on the urinary tract
D. Cystoscopy is an endoscopic procedure of the unrinary
tract

14. Within 24-48 hours post cystoscopy, it is normal to observe one of the following:
A. Pink-tinged urine
B. Distended bladder
C. Signs of infection
D. Prolonged hematuria
15. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes:
A. Bed rest
B. Warm moist soak
C. Early ambulation
D. Hot sitz bath

Situation 4 Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral
resection. You are assigned to receive him. You noted that he has a 3-way indwelling catheter for continuous fast
dip bladder irrigation which is connected to a straight drainage.

16. Immediately after surgery, what would you expect his urine to be?
A. Light yellow
B. Amber
C. Bright red
D. Pinkish to red

17. The purpose of the continuous bladders irrigation is to:
A. Allow continuous monitoring of the fluid output status
B. Provide continuous flushing of clots and debris from the bladder
C. Allow for proper exchange of electrolytes
D. Ensure accurate monitoring of intake and output

18. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be
your most appropriate action?
A. Remove his catheter then allow him to void his own
B. Irrigate his catheter
C. Tell him Go ahead and void. You have an indwelling catheter
D. Assess color and rate of outflow, if there is a change refer to urologist for possible irrigation

19. You decided to check on Mang Felixs IV fluid infusion. You noted in flow rate, pallor and coldness around the
insertion site. What is your assessment finding?
A. Phlebitis
B. Infiltration to subcutaneous tissue
C. Pyrogenic reaction
D. Air embolism

20. Knowing that proper documentation of assessment findings and interventions share important responsibilities
of the nurse during first post operative days, which of the following is the LEAST relevant to document in the case
of Mang Felix?
A. Chest pain and vital signs
B. Intravenous infusion rate
C. Amount, color and consistency of bladder irrigation drainage
D. Activities of daily living started

Situation 5: Melamine contamination in milk has brought world wide crisis both in the milk production sector as
well as the health and economy. Being aware of the current events is one quality that a nurse should possess to
prove that nursing is a dynamic profession that will adapt depending on the patients needs.

21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire
retardant properties. Milk and food manufacturers add melamine in order to:
A. It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods.
B. Gives a glazy and more edible look on foods
C. Make milks more tasty and creamy
D. Create an illusion of a high protein content on their products

22. Most of the milks contaminated by melamine came from which country?
A. India
B. China
C. Philippines
D. Korea

23. Which government agency is responsible for testing the melamine content of foods and food products?
A. DOH
B. MMDA
C. NBI
D. BFAD

24. Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine
poisoning?
A. Irritability, Back ache, Urolithiasis
B. High blood pressure, fever
C. Anuria, Oliguria or Hematuria
D. Fever, Irritability and a large output of diluted urine

25. What kind of renal failure from melamine poisoning cause?
A. Chronic Pre-renal
B. Acute, Postrenal
C. Chronic, Intrarenal
D. Acute, Prerenal

Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of
almost 1/3 of all cancer that occurs in children under age 15.

26. The survival rate for Acute Lymphoid Leukemia is approximately:
A. 25 %
B. 40 %
C. 75 %
D. 95 %

27. Whrereas acute nonlymphoid leukaemia has survival rate of:
A. 25 %
B. 40 %
C. 75 %
D. 95 %

28. The three main consequence of leukaemia that cause the most danger is:
A. Neutropenia causing infection, anemia causing impaired oxygenationand thrombocytopenia leading
to bleeding tendencies.
B. Central nervous system infiltration, anemia causing impaired oxygenationand thrombocytopenia leading to
bleeding tendencies.
C. Splenomegaly, hepatomegaly, fractures
D. Invasion by the leukemic cells to the bone causing severe bone pain

29. Gold standard in the diagnosis of leukaemia is by which of the following?
A. Blood culture and sensitivity
B. Bone marrow biopsy
C. Blood biopsy

30. Adriamycin, Vincristine, Prednisone and L asparaginase are given to the client for long term therapy. One
common side effect, especially of adriamycin is alopecia. The child asks: Will I get my hair back once again? The
nurse respond is by saying:
A. Dont be silly, of course you will get your hair back.
B. We are not sure, lets hope itll grow.
C. This side effect is usually permanent, but I will get the doctor to discuss it for you.
D. Your hair will regrow in 3 -6 months but of different color, usually darker and of different texture.

Situation: Breast cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in
woman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the
high risk group for breast cancer was recently diagnosed with Breast Cancer.

31. All of the following are factors that said to contribute to the development of breast cancer EXCEPT:
A. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity and children after age
30.
B. Genetics
C. Increasing age
D. Prolonged intake of Tamoxifen (Nolvadex)

32. Protective factors for the development of breast cancer includes which of the following EXCEPT:
A. Exercise
B. Prophylactic Tamoxifen
C. Breast Feeding
D. Alcohol intake

33. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery
with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse
informs the patients that the lumpectomy with radiation.
A. Reduces the fear and anxiety that accompany the diagnosis and treatment of cancer
B. Has about the same 10 years survival rate as the modified radical mastectomy
C. Provides shorter treatment period with a fewer long term complications
D. Preserves the normal appearance and sensitivity of the breast

34. Carmen, is asking the nurse the most appropriate time of the month to do her self-examination of the breast.
The MOST appropriate reply by the nurse would be:
A. the 26th day of menstrual cycle
B. 7 8 days after conclusion of the menstrual period
C. During her menstruation
D. the same day each month

35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin
damage from the radiation therapy?
A. Cover the areas with thick clothing materials
B. Apply a heating pad to the site
C. Wash skin with water after therapy
D. Avoid applying creams and powder to the area.

36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method
for breast cancer that is recommended for developing countries is:
A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)
B. an annual hormone receptor assay
C. an annual mammogram
D. a physician conduct a breast clinical examination every 2 years

37. The purpose of performing the breast self examination (BSE) regularly is to discover:
A. fibrocystic masses
B. cancerous lumps
C. areas of thickness or fullness
D. changes from previous BSE

38. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:
A. on the same day of each month
B. right after the menstrual period
C. on the first day of her menstruation
D. on the last day of her menstruation

39. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:
A. thickening of the tissue
B. axillary
C. lumps in the breast tissue
D. change in size and contour

40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel
under the clients left shoulder is to:
A. bring the breast closer to the examiners right hand
B. tense the pectoral muscle
C. balance the breast tissue more evenly on the chest wall
D. facilitate lateral positioning of the breast

Situation Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary
management you have important responsibilities as a nurse

41. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following
nursing interventions would be most helpful for Albert?
A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
C. Reassures him that these feelings are normal
D. Help him plan his activities

42. Immediately following the radiation teletherapy, Albert is:
A. Considered radioactive fro 24hours
B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from Radiation

43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following
symptoms:
A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor
C. Headache, dizziness, blurred vision
D. Severe sore throat, bacteremia, hepatomegaly

44. What nursing diagnosis should be the highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

45. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C

Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical.

46. A burn characterized by pale, white appearance, charred or with exposed and painlessness:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn

47. Which of the following BEST describes superficial partial thickness burn or first degrees burn?
A. Structures beneath the skin and damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

48. A burn that is said to be WEEPING is classified as:
A. Superficial partial thickness burn
B. Deep partial thickness burn
C. Full thickness burn
D. Deep full thickness burn

49. During the Acute Phase of the burn injury, which of the following is a priority?
A. Wound healing
B. Reconstructive surgery
C. Emotional support
D. Fluid resuscitation

50. While in the emergent phase, the nurse knows that the priority is to:
A. Prevent infection
B. Control pain
C. Prevent deformities and contractures
D. Return the hemodynamic stability via fluid resuscitation

NP4 Nursing Board Exam November Answer Key 'Nursing Care of Client with
Physiological and Psychosocial Alteration'
100 Nursing Board Exam test questions of November 2008 Nurse Licensure Examination (NLE)
Nursing Practice IV Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 2 Board Exam test questions 51 - 100
51. The MOST effective method of delivering pain medication during the emergent phase is:
A. intramuscularly
B. subcutaneously
C. orally
D. intravenously

52. When a client accidentally splashes chemicals to his eyes. The initial priority care of the following the chemical
burns is to:
A. irrigate with normal saline for 1 to 15 minutes
B. transport to a physician immediately
C. irrigate with water for 15 minutes or longer
D. cover the eyes with a sterile gauze

53. Which of the following can be fatal complication of upper airway burns?
A. stress ulcers
B. hemorrhage
C. shock
D. laryngeal spasm and swelling

54. When a client will rush towards you and he has burning clothes on, it is your priority to do which of the
following first?
A. log roll on the grass/ground
B. slap the flames with his hands
C. Try to remove the burning clothes
D. Splash the client with 1 bucket of cool water

55. Once the flames are extinguished, it is most important:
A. cover client with warm blanket
B. Give him sips of water
C. Calculate the extent of this burns
D. Assess the Sergios breathing

56. During the first 24 hours after thermal injury, you should assess Sergio for:
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia

57. A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both
upper extremities two days ago begins to exhibit extreme restlessness . You recognize that this most likely
indicates that the client is developing:
A. Cerebral hypoxia
B. Hypervolemia
C. Metabolic acidosis
D. Renal failure

58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right
and left arm, and at the anterior chest sparing the abdominal area. He also has superficial partial thickness burn at
the posterior trunk and at the half upper portion of the left leg. He the emergent phase of burns using the
parklands formula, you know that during the first 8 hours of burn the amount of fluid will be given is:
A. 5, 400ml
B. 10,500 ml
C. 9,450 ml
D. 6,750 ml

59. The doctor incorporated insulin on the clients fluid during the emergent phase. The nurse knows that insulin is
given because:
A. Clients with burn also develops Metabolic Acidosis
B. Clients with burn also develops hyperglycemia
C. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound
healing, regain of consciousness and rapid return of hemodynamic stability.
D. For hyperkalemia

60. The IV fluid of choice for burn as well as dehydration is:
A. 0.45% NaCl
B. NSS
C. Sterile water
D. D5LR

Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY
CARE CLASS.

61. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7th postoperative day

62. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:
A. When Fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in body image

63. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if
Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid
insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable

64. You are aware that teaching about colostomy care is understood when Fermin states, I will contact my
physician and report:
A. If I have any difficulty inserting the irrigating tub into the stoma.
B. If I noticed a loss of sensation to touch in the stoma tissue.
C. The expulsion of flatus while the irrigating fluid is running out.
D. When mucus is passed from the stoma between the irrigations.

65. You would know after teaching Fermin that dietary instruction for him is effective when he states, It is
important that I eat:
A. Soft food that are easily digested and absorbed by my large intestines.
B. Bland food so that my intestines do not become irritated.
C. Food low in fiber so that there is less stool.
D. Everything that I ate before the operation, while avoiding foods that
cause gas.

Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit it
is important for nurses to gather as much information to be able to address their needs for nursing care.

66. Critically ill patient frequently complain about which of the following when hospitalized?
A. Hospital report
B. Lack of blankets
C. Lack of privacy
D. Inadequate nursing staff

67. Who of the following is at greatest risk of developing sensory problem?
A. Female patient
B. Adolescent
C. Transplant patient
D. Unresponsive patient

68. Which of the following factors may inhibit learning in critically ill patients?
A. Gender
B. Medication
C. Educational level
D. Previous knowledge of illness

69. Which of the following statements does not apply to critically ill patients?
A. Majority need extensive rehabilitation
B. All have been hospitalized previously
C. Are physically unstable
D. Most have chronic illness.

70. Families of critically ill patients desire which of the following needs to be met first by the nurse?
A. Provision of comfortable space
B. Emotional support
C. Updated information on the clients status
D. Spiritual counselling

Situatuon: Johnny, sought consultation to the hospital before

71. His diagnosis was hyperthyroidism, the following are expected symptoms except:
A. Anorexia
B. Palpitation
C. Fine tremors of the hand
D. Hyper alertness

72. He has to take drugs to treat hyperthyroidism, which of the following will you not expect that the doctor will
prescribe?
A. Colace (Docusate)
B. Cytomel (Llothyronine)
C. Tapazole (
D. (Levothyroxine)

73. The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding of
the medication?
A. Death
B. Sore throat
C. Hyperthermia
D. Thrombocytosis

74. You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the
evidence of:
A. Thyroid storm
B. Mediastinal shift
C. Damage to the laryngeal nerve
D. Hypocalcemia tetany

75. Should you check for haemorrhage, you will:
A. Slip your hand under the nape of her neck
B. Check for hypotension
C. Apply neck collar to prevent haemorrhage
D. Observe the dressing if is soaked with blood

76. Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the
standard procedure, you need to tell Johnny that:
A. Obstructing his vision
B. Restraining his upper and lower extremities
C. Obstructing his hearing
D. Obstructing his nostril with a clamp

77. The BMR is based on the measurement that:
A. Rate of respiration under different condition of activities and rest
B. Amount of oxygen consumption under resting condition over a measured period of time
C. Amount of oxygen consumption under stressed condition over a measured period of time
D. Ratio of respiration to pulse rate over a measured period of time

78. Her physician ordered lugols solution in order to:
A. Decrease the vascularity and size of the thyroid gland
B. Decrease the size of the thyroid gland only
C. Increase the vascularity and size of the thyroid gland
D. Increase the size of the thyroid gland only

79. Which of the following is a side effect of lugols solution?
A. Hypokalemia
B. Nystagmus
C. Enlargement of the Thyroid gland
D. Excessive salivation

80. In administering Lugols solution, the precautionary measure should include:
A. Administer with glass only
B. Dilute with juice and administer with a straw
C. Administer it with milk and drink it
D. Follow it with milk of magnesia

Situation: Pharmacological treatment was not effective for Johnnys hyperthyroidism and now he is scheduled for
Thyroidectomy.

81. Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON
CRITICAL. If the instrument are introduced directly into the blood stream or into any normally sterile cavity or area
of the body it is classified as:
A. Critical
B. Semi critical
C. Non critical
D. Ultra critical

82. Instruments that do not touch the patient or have contact only to the intact skin is classified as:
A. Critical
B. Semi critical
C. Non critical
D. Ultra critical

83. If an instrument is classified as Semi Critical an acceptable method of making the instrument ready for surgery
is through:
A. Sterilization
B. Decontamination
C. Disinfection
D. Cleaning

84. While critical items and should be:
A. Clean
B. Decontaminated
C. Sterilized
D. Disinfected

85. As a nurse, you know that intact skin as an effective barrier to most microorganisms. Therefore, items that
come in contact with the intact skin or mucous membranes should be:
A. Disinfected
B. Sterile
C. Clean
D. Alcoholized

86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid
cancer. Prior to total thyroidectomy, you should instruct Johnny to:
A. Perform range and motion exercise on the head or neck
B. Apply gentle pressure against the incision when swallowing
C. Cough and deep breathe every hours
D. Support head with the hands when changing position

Situation Andrea is admitted to the ER following an assault where she was hit on the face and head. She was
brought to the ER by a police woman. Emergency measures were stated.

96. Andreas respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:
A. Biots
B. Kussmauls
C. Cheyne Stokes
D. Eupnca

97. What do you call the triad of sign and symptoms seen in a client with increasing ICP?
A. Virchows Triad
B. The Chinese triad
C. Cuschings Triad
D. Charcots Triad

98. Which of the following is true with the Cushings Triad seen in head injuries?
A. Narrowing of Pulse Pressure, Cheyne strokes respiration, Tachycardia
B. Widening Pulse pressure, Irregular respiration, Bradycardia
C. Hypertension, Kussmauls respiration, Tachycardia
D. Hypotension, Irregular respiration, Bradycardia

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 clients 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