Nursing Practice III b.

Output
c. Cause
Situation: Leo lives in the squatter area. He goes to nearby
d. Effect
school. He helps his mother gather molasses after school.
8. The recipients of experimental treatment are an
One day, he was absent because of fever, malaise, anorexia,
experimental design or the individuals to be
and abdominal discomfort.
observed in a non-experimental design are called;
1. Upon assessment, Leo was diagnosed to have a. Setting
hepatitis a. Which mode of transmission has the b. Treatment
infection agent taken? c. Subjects
a. Fecal-oral d. Sample
b. Droplet 9. The device or techniques an investigator employs to
c. Airborne collect data is called;
d. Sexual contact a. Sample
2. Which of the following is concurrent disinfection in b. Hypothesis
the case of Leo? c. Instrument
a. Investigation of contact d. Concept
b. Sanitary disposal of feces, urine and blood 10. The use of another person’s ideas or wrong doings
c. Quarantine of the sick individual without giving appropriate credit result from
d. Removing all detachable objects in the room, inaccurate or incomplete attribution of materials to
cleaning lighting and air duct surfaces in the its sources. Which of the following is referred to
ceiling, and cleaning everything downward when another person’s idea is inappropriate credited
to the floor. as one’s own;
3. Which of the following must be emphasized during a. Plagiarism
mother’s class to Leo’s mother? b. Assumption
a. Administration of immunoglobulin to c. Quotation
families d. Paraphrase
b. Thorough hand washing before and after
Situation: Mrs. Pichay is admitted to your ward. The MD
eating and toileting
ordered “prepare for thoracentesis this pm to remove excess
c. Use of attenuated vaccines
air from the pleural cavity.
d. Boiling of food especially meat
4. Disaster control should be undertaken when there 11. Which of the following nursing responsibilities is
are 3 or more hepatitis A cases. Which of these essential in Mrs. Pichay who will undergo
measures is a priority? thoracentesis?
a. Eliminate fecal contamination from foods a. Support and reassure client during the
b. Mass vaccination of uninfected individuals procedure
c. Health promotion and education to families b. Ensure that informed consent has been
and communities about the disease it’s signed
cause and transmission c. Determine if client has allergic reaction to
d. Mass administration of immunoglobulin local anesthesia
5. What is the average incubation period of Hepatitis d. Ascertain if chest x-rays and other tests
A? have been prescribed and completed
a. 30 days 12. Mrs. Pichay who is for thoracentesis is assigned by
b. 60 days the nurse to which of the following position?
c. 50 days a. Trendelenburg position
d. 14 days b. Supine position
c. Dorsal recumbent position
Situation: as a nurse researcher you must have a very good
d. Orthopneic position
understanding of the common terms of concept used in
13. During thoracentesis, which of the following nursing
research.
intervention will be most crucial?
6. The information that an investigator collects from a. Place patient in a quiet and cool room
the subjects or participants in a research study is b. Maintain strict aseptic technique
usually called; c. Advise patient to sit perfectly still during
a. Hypothesis needle insertion until it has been
b. Variable withdrawn from the chest
c. Data d. Apply pressure over the puncture site as
d. Concept soon as the needle is withdrawn
7. Which of the following usually refers to the 14. To prevent leakage of fluid in the thoracic cavity,
independent variables in doing research? how will you position the client after thoracentesis?
a. Result a. Place flat in the bed
 b. Turn on the unaffected side a. The removal of the gallbladder
c. Turn on the affected side b. The removal of the stones in the gallbladder
d. On bed rest c. The removal of the stones in the common
15. Chest X-ray was ordered after thoracentesis. When bile duct
your client asks what is the reason for another chest d. The removal of the stones in the kidney
x-ray, you will explain: 22. The simplest pain-relieving technique is:
a. To rule out pneumothorax a. Distraction
b. To rule out any possible perforation b. Deep breathing exercise
c. To decongest c. Taking aspirin
d. To rule out any foreign body d. Positioning
23. Which of the following statement on pain is TRUE?
Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was
a. Culture and pain are not associated
brought to the hospital for diagnostic workup after he had
b. Pain accompanies acute illness
experienced seizure in his office.
c. Patient’s reaction to pain Varies
16. Just as the nurse was entering the room, the patient d. Pain produces the same reaction such as
who was sitting on his chair begins to have a seizure. groaning and moaning
Which of the following must the nurse do first? 24. In pain assessment, which of the following condition
a. Ease the patient to the floor to rule out is a more reliable indicator?
pneumothorax a. Pain rating scale of 1 to 10
b. Lift the patient and put him on the bed b. Facial expression and gestures
c. Insert a padded tongue depressor between c. Physiological responses
his jaws d. Patient’s description of the pain sensation
d. Restraint patient’s body movement 25. When a client complains pain, your initial response
17. Mr. Santos is scheduled for CT SCAN for the next day, is:
noon time. Which of the following is the correct a. Record the description of pain
preparation as instructed by the nurse? b. Verbally acknowledge the pain
a. Shampoo hair thoroughly to remove oil and c. Refer the complaint to the doctor
dirt d. Change to a more comfortable position
b. No special preparation is needed. Instruct
Situation: You are assigned at the surgical ward and Clients
the patient to keep his head still and stead
have been complaining of post pain at varying Degrees. Pain
c. Give a cleansing enema and give fluids until 8
as you know, is very subjective.
AM
d. Shave scalp and securely attach electrodes to 26. A one-day postoperative abdominal surgery client
it has been complaining of severe throbbing abdominal
18. Mr. Santos is placed on seizure precaution. Which of pain described as 9 in a 1-10 pain rating. Your
the following would be contraindicated? assessment reveals bowel sounds on all quadrants
a. Obtain his oral temperature and the dressing is dry and intact. What nursing
b. Encourage to perform his own personal intervention would you take?
hygiene a. Medicate client as prescribed
c. Allow him to wear his own clothing b. Encourage client to do imagery
d. Encourage him to be out of bed c. Encourage deep breathing and turning
19. Usually, how does the patient behave after his d. Call surgeon stat
seizure has subsided? 27. Pentoxidone 5 mg IV every 8 hours was Prescribed
a. Most comfortable walking and moving for post abdominal pain. Which will be your priority
about. nursing action?
b. Becomes restless and agitated a. Check abdominal dressing for possible
c. Sleeps for a period of time swelling
d. Say he is thirsty and hungry b. Explain the proper use of PCA to alleviate
20. Before, during and after seizure. The nurse knows anxiety
that the patient is ALWAYS placed in what position? c. Avoid overdosing to prevent
a. Low fowler’s dependence/tolerance
b. Side lying d. Monitor VS, more importantly RR
c. Modified Trendelenburg 28. The client complained of abdominal distention and
d. Supine pain. Your nursing intervention that can alleviate
pain is:
Situation: Mrs. Damian an immediate post op
a. Instruct client to go to sleep and relax
cholecystectomy and choledocholithotomy patient,
b. Advice the client to close the lips and avoid
complained of severe pain at the wound site.
deep breathing and talking
21. Choledocholithotomy is: c. Offer hot and clear soup
 d. Turn to sides frequently and avoid too much a. Start another drug and slowly lessen the
talking opioid dosage
29. Surgical pain might be minimized by which nursing b. Indulge in recreational outdoor activities
action in the O.R. c. Isolate opioid dependent to a restful resort
a. Skill of surgical team and lesser manipulation d. Instruct slow tapering of the drug dosage
b. Appropriate preparation for the scheduled and alleviate physical withdrawal
procedure symptoms
c. Use of modern technology in closing the
Situation: The nurse is performing health education activities
wound
for Janevi Segovia, a 30-year-old Dentist with insulin
d. Proper positioning and draping of clients
dependent Diabetes Miletus.
30. Inadequate anesthesia is said to be one of the
common causes of pain both in intra and post op 36. Janevi is preparing a mixed dose of insulin. The nurse
patients. If general anesthesia is desired, it will is satisfied with her performance when she:
involve loss of consciousness. Which of the following a. Draw insulin from the vial of clear insulin
are the 2 general types of GA? first
a. Epidural and Spinal b. Draw insulin from the vial of the
b. Subarachnoid block and intravenous intermediate acting insulin first
c. Inhalation and regional c. Fill both syringe with the prescribed insulin
d. Intravenous and inhalation dosage then shake the bottle vigorously
d. Withdraw the intermediate acting insulin
Situation: Nurse’s attitude toward the pain influence the way
first before withdrawing the short Acting
they perceive and interact with clients in pain.
insulin first
31. Nurses should be aware that older adults are at risk 37. Janevi complains of nausea, vomiting, diaphoresis
of underrated pain. Nursing assessment and and headache. Which of the following nursing
management of pain should address the following intervention are you going to carry out first?
beliefs EXCEPT: a. Withhold the client’s next insulin injection
a. Older patient seldom tends to report pain b. Test the client’s blood glucose level
than the younger once c. Administer Tylenol as ordered
b. Pain is a sign of weakness d. Offer fruit juice, gelatin and chicken bouillon
c. Older patients do not believe in analgesics, 38. Janevi administered regular insulin at 7 am and the
they are tolerant nurse should instruct Jane to avoid exercising at
d. Complaining of pain will lead to being label around:
ed a ‘bad’ patient a. 9 to 11 A.M
32. Nurse should understand that when a client b. Between 8 A.M to 9 A.M
responds favorable to a place, it is known as the c. After 8 hours
‘placebo effect’. Placebos do not indicate Whether or d. In the afternoon, after taking lunch
not a client has: 39. Janevi was brought at the emergency room after
a. Conscience four months because she fainted in her clinic. The
b. Disease nurse should monitor which of the following test to
c. Real pain evaluate the overall therapeutic compliance of a
d. Drug tolerance diabetic patient?
33. You are the nurse in the pain clinic where you have a. Glycosylated hemoglobin
client who has difficulty specifying the location of b. Ketone levels
pain. How can you assist such client? c. Fasting blood glucose
a. The pain is vague d. Urine glucose level
b. By charting- it hurts all over 40. Upon the assessment of Hba1c of Mrs. Segovia, the
c. Identify the absence and presence of pain nurse has been informed of a 9% Hba1c result. In this
d. As the client to point to the painful are by case, she will teach the patient to:
just one finger a. Avoid infection
34. What symptom, more distressing than pain, should b. Prevent and recognize hyperglycemia
the nurse monitor when giving opioids, especially c. Take adequate food and nutrition
among elderly clients who are in pain? d. Prevent and recognize hypoglycemia
a. Forgetfulness 41. The nurse is teaching plan of care for Jane with
b. Drowsiness regards to proper foot care. Which of the following
c. Constipation should be included in the plan?
d. Allergic reactions like pruritis a. Soak feet in hot water
35. Physical dependence occurs in anyone who takes b. Avoid using mild soap on the feet
opioids over a period of time. What do you tell a c. Apply a moisturizing lotion to dry feet but
mother of a ‘dependent’ when asked for advice? not between the toes
 d. Always have a podiatrist to cut your toe a. Dilated urethra
nails; never cut them yourself b. increased glomerular filtration rate
42. Another patient was brought to the emergency room c. Diuretic use
in an unresponsive state and a diagnosis of d. Decreased bladder capacity
hyperglycemia hyperosmolar nonketotic syndrome is 48. Merle, age 86, is complaining of dizziness when she
made. The nurse immediately prepares to initiate stands up. This may indicate:
which of the following anticipated physician’s order? a. Dementia
a. Endotracheal intubation b. Functional decline
b. 100 unites of NPH insulin c. A visual problem
c. Intravenous infusion of normal saline d. Drug Toxicity
d. Intravenous infusion of sodium bicarbonate 49. Cardiac ischemia in an older patient usually
43. Jane eventually developed DKA and is being treated produces:
in the emergency room. Which finding would the a. ST-T wave changes
nurse expect to note as confirming this diagnosis? b. Chest pain radiating to the left arm
a. Comatose state c. Very high creatinine kinase level
b. Decreased urine output d. Acute confusion
c. Increased respiration and an increase in pH 50. The most dependable sign of infection in the older
d. Elevated blood glucose level and low patient is:
plasma bicarbonate level a. Change in mental status
44. The nurse teaches Jane to know the difference b. Fever
between hypoglycemia and ketoacidosis. Jane c. Pain
demonstrates understanding of the teaching by d. Decreased breath sounds with crackles
stating the glucose will be taken if which of the
Situation: In the OR, there are safety protocols that should
following symptoms develops?
be followed. The OR nurse should be well versed with all
a. Polyuria
these to safeguard the safety and quality of patient delivery
b. Shakiness
outcome.
c. Blurred Vision
d. Fruity breath odor 51. Which of the following should be given highest
45. Jane has been scheduled to have FBS taken in the priority when receiving patient in the OR?
morning. The nurse tells Jane not to eat or drink a. Assess level of consciousness
after midnight. Prior to taking the blood specimen b. Verify patient identification and informed
the nurse noticed that Jane is holding a bottle of consent
distilled water. The nurse asked Jane if she drink any, c. Asses vital signs
and she said “yes.” Which of the following is the best d. Check for jewelry, gown, manicure, and
nursing action? dentures.
a. Administer syrup of ipecac to remove the 52. Surgeries like I and D (incision and drainage and
distilled water from the stomach debridement are relatively short procedures but
b. Suction the stomach content using NGT prior considered ‘dirty cases’ when are these procedures
to specimen collection best scheduled?
c. Advice a physician to reschedule to a. Last case
diagnostic examination next day b. In between cases
d. Continue as usual and have the FBS analysis c. According to availability of anesthesiologist
performed and specimen be taken d. According to the surgeon’s preference
53. Or nurses should be aware that maintaining the
Situation: Elderly clients usually produce unusual signs When
client’s safety is the overall goal of nursing care
it comes to different diseases. The ageing process is a
during the intraoperative phase. As the circulating
complicated process and the nurse understand that it is an
nurse, you make certain that throughout the
inevitable fact and she must be prepared to care for the
procedure…
growing elderly population.
a. The surgeon greets his client before
46. Hypoxia may occur in the older patient because of induction of anesthesia
which of the following physiologic changes b. The surgeon and anesthesiologist are in
associated with aging. tandem
a. Ineffective airway clearance c. Strap made of strong non-abrasive
b. Decreased alveolar surfaced area materials are fastened securely around the
c. Decreased anterior-posterior chest joints of the knees and ankles and around
diameter the 2 hands around an arm board.
d. Hyperventilation d. Client is monitored throughout the surgery
47. The older patient is at higher risk for incontinence by the assistant anesthesiologist.
because of:
 54. Another nursing check that should not be missed Situation: Nurses hold a variety of roles when providing care
before the induction of general anesthesia is: to a perioperative patient.
a. Check for presence underwear
61. Which of the following role would be the
b. Check for presence dentures
responsibility of the scrub nurse?
c. Check patient’s ID
a. Assess the readiness of the client prior to
d. Check baseline vital signs
surgery
55. Some lifetime habits and hobbies affect
b. Ensure that the airway is adequate
postoperative respiratory function. If your client
c. Account for the number of sponges,
smokes 3 packs of cigarettes a day for the past 10
needles, supplies, used during the surgical
years, you will anticipate increased risk for:
procedure
a. Perioperative anxiety and stress
d. Evaluate the type of anesthesia appropriate
b. Delayed coagulation time
for the surgical client
c. Delayed wound healing
62. As a perioperative nurse, how can you best meet the
d. Postoperative respiratory infection
safety need of the client after administering
Situation: Sterilization is the process of removing ALL living preoperative narcotic?
microorganism. To be free of ALL living microorganism is a. Put side rails up and ask the client not to
sterility. get out of bed
b. Send the client to OR with the family
56. There are 3 general types of sterilization use in the
c. Allow client to get up to go to the comfort
hospital, which one is not included?
room
a. Steam sterilization
d. Obtain consent form
b. Physical sterilization
63. It is the responsibility of the pre-op nurse to do skin
c. Chemical sterilization
prep for patients undergoing surgery. If hair at the
d. Sterilization by boiling
operative site is not shaved, what should be done to
57. Autoclave or steam under pressure is the most
make suturing easy and lessen chance of incision
common method of sterilization in the hospital. The
infection?
nurse knows that the temperature and time is set to
a. Draped
the optimum level to destroy not only the
b. Pulled
microorganism, but also the pores. Which of the
c. Clipped
following is the ideal setting of the autoclave
d. Shampooed
machine?
64. It is also the nurse’s function to determine when
a. 10,000°C for 1-hour
infection is developing in the surgical incision. The
b. 5,000°C for 30 minutes
perioperative nurse should observe for what signs of
c. 37°C for 15 minutes
impending infection?
d. 121°C for 15 minutes.
a. Localized heat and redness
58. It is important that before a nurse prepare the
b. Serosanguinous exudates and skin blanching
material to be sterilized, a chemical indicator strip
c. Separation of the incision
should be placed above the package, preferably,
d. Blood clots and scar tissue are visible
Muslim sheet. What is the color of the striped
65. Which of the following nursing interventions is done
produced after autoclaving?
when examining the incision wound and changing
a. Black
the dressing?
b. Blue
a. Observe the dressing and type and odor of
c. Gray
drainage if any
d. Purple
b. Get patient’s consent
59. Chemical indicators communicate that:
c. Wash hands
a. The items are sterile
d. Request the client to expose the incision
b. That the items had undergone sterilization
wound
process but not necessarily sterile
c. The items are disinfected Situation: The preoperative nurse collaborates with the
d. That the items had undergone disinfection Client significant others, and healthcare providers.
process but not necessarily disinfected
66. To control environmental hazards in the Or, the
60. If a nurse will sterilize a heat and moisture labile
nurse collaborates with the following departments
instruments, it is according to AORN
EXCEPT:
recommendation to use which of the following
a. Biomedical division
method of sterilization?
b. Infection control committee
a. Ethylene oxide gas
c. Chaplaincy services
b. Autoclaving
d. Pathology department
c. Flash sterilizer
67. An air crash occurred near the hospital leading to a
d. Alcohol immersion
surge of trauma patient. One of the last patients will
 need surgical amputation but there no sterile c. Who is your anesthesiologist, internist, and
surgical equipment. In this case, which of the assistant?
following will the nurse expect? d. Who is your anesthesiologist
a. Equipment’s needed for surgery need not be 72. In the OR, the nursing tandem for every surgery is:
sterilized if this is an emergency a. Instrument technician and circulating nurse
necessitating life saving measures b. Nurse anesthetist, nurse assistant, and
b. Forwarding the trauma client to the nearest instrument technician
hospital that has available sterile equipment c. Scrub nurse, nurse anesthetist
is appropriate d. Scrub and circulating nurse
c. The nurse will need to sterilize the item 73. While team effort is needed in the OR for efficient
before using it to the client using the regular and quality patient care delivery, we should limit the
sterilization setting at 121 degree Celsius in number of people in the room for infection control.
15 minutes Who comprises this team?
d. In such cases, Flash sterilizer will be use at a. Surgeon, anesthesiologist, scrub nurse,
132°C in 3 minutes radiologist, orderly
68. Tess, the PACU nurse, discovered that Malou, who b. Surgeon, assistants, scrub nurse, circulating
weighs 110lbs prior to surgery, is in severe pain 3 hrs nurse, anesthesiologist
after cholecystectomy. Upon checking the chart, c. Surgeon, assistant surgeon, anesthesiologist,
Malou found out that she has an order of Demerol scrub nurse, pathologist
100 mg I.M prn for pain. Tess should verify the order d. Surgeon, assistant surgeon, anesthesiologist,
with: intern, scrub nurse
a. Nurse supervisor 74. Who usually act as an important part of the OR
b. Surgeon personnel by getting the wheelchair or stretcher, and
c. Anesthesiologist pushing/pulling them towards the operating room?
d. Intern on duty a. Orderly/clerk
69. Rosie, 57 who is diabetic is for debridement if b. Nurse supervisor
incision wound. When the circulating nurse checked c. Circulating nurse
the present IV fluid, she found out that there is no d. Anesthesiologist
insulin incorporated as ordered. What should the 75. The breakdown in teamwork is often times a failure
circulating nurse do? in:
a. Double check the doctor’s order and call the a. Electricity
at ending MD b. Inadequate supply
b. Communicate with the ward nurse to verify c. Leg work
if insulin was incorporated or not d. Communication
c. Communicate with the client to verify if
Situation: Basic knowledge on Intravenous solution is
insulin was incorporated
necessary for care of clients with problems with fluids and
d. Incorporate insulin as ordered
electrolytes.
70. The documentation of all nursing activities
performed is legally and professionally vital. Which 76. A client involved in a motor vehicle crash presents to
of the following should NOT be included in the the emergency department with severe internal
patient’s chart? bleeding. The client is severely hypotensive and
a. Presence of prosthetic devices such as unresponsive. The nurse anticipates which of the
dentures, artificial limbs hearing aid, etc. following intravenous solutions will most likely be
b. Baseline physical, emotional, and prescribed to increase intravascular volume, replace
psychosocial data immediately blood loss and increase blood pressure?
c. Arguments between nurses and residents a. 0.45% sodium chloride
regarding treatments b. 0.33% sodium chloride
d. Observed untoward signs and symptoms and c. Normal saline solution
interventions including contaminant d. Lactated ringer’s solution
intervening factors 77. The physician orders the nurse to prepare an isotonic
solution. Which of the following IV solution would
Situation: Team efforts is best demonstrated in the OR.
the nurse expect the intern to prescribe?
71. If you are the nurse in charge for scheduling surgical a. 5% dextrose in water
cases, what important information do you need to b. 0.45% sodium chloride
ask the surgeon? c. 10% dextrose in water
a. Who is your internist d. 5% dextrose in 0.9% sodium chloride
b. Who is your assistant and anesthesiologist, 78. The nurse is making initial rounds on the nursing unit
what is your preferred time and type of to assess the condition of assigned clients. The nurse
surgery? notes that the client’s IV site is cool, pale and swollen
 and the solution is not infusing. The nurse concludes Situation: as a perioperative nurse, you are aware of the
that which of the following complications has been correct processing methods for preparing instruments and
experienced by the client? other devices for patient use to prevent infection.
a. Infection
86. As an OR nurse, what are your foremost
b. Phlebitis
considerations for selecting chemical agents for
c. Infiltration
disinfection?
d. Thrombophlebitis
a. Material compatibility and efficiency
79. A nurse reviews the clients electrolyte laboratory
b. Odor and availability
report and notes that the potassium level is 3.2
c. Cost and duration of disinfection process
mEq/L. Which of the following complications has
d. Duration of disinfection and efficiency
been experienced by the client?
87. Before you use a disinfected instrument, it is
a. U waves
essential that you:
b. Absent P waves
a. Rinse with tap water followed by alcohol
c. Elevated T waves
b. Wrap the instrument with sterile water
d. Elevated ST segment
c. Dry the instrument thoroughly
80. One patient had a “runaway’ IV of 50% dextrose. To
d. Rinse with sterile water
prevent temporary excess of insulin or transient
88. You have a critical heat labile instrument to sterilize
hyper insulin reaction what solution you prepare in
and are considering to use high level disinfectant.
anticipation of doctor’s Order?
What should you do?
a. Any IV solution available to KVO
a. Cover the soaking vessel to contain the
b. Isotonic solution
vapor
c. Hypertonic solution
b. Double the amount of high-level disinfectant
d. Hypotonic solution
c. Test the potency of a high-level disinfectant
81. An informed consent is required for:
d. Prolong the exposure time according to
a. Closed reduction of a fracture
manufacturer’s direction
b. Irrigation of the external ear canal
89. To achieve sterilization using disinfectants, which of
c. Insertion of intravenous catheter
the following is used?
d. Urethral catheterization
a. Low level disinfectants immersion in 24
82. Which of the following is not true with regards to be
hours
informed consent?
b. Intermediate level disinfectants immersion
a. It should describe different treatment
in 12 hours
alternatives
c. High level disinfectants immersion in 1 hour
b. It should contain a thorough and detailed
d. High level disinfectant immersion in 10
explanation to the procedure to be done
hours
c. It should describe the client’s diagnosis
90. Bronchoscope, thermometer, Endoscope, ET tube,
d. It should explain the client’s prognosis
Cystoscope are all BEST sterilized using which of the
83. You know that the hallmark of nursing accountability
following?
is the:
a. Autoclaving at 121 degree Celsius in 125
a. Accurate documentation and reporting
minutes
b. Admitting your mistakes
b. Flash sterilizer at 132 degree Celsius in 3
c. Filling an incident report
minutes
d. Reporting a medication error
c. Ethylene oxide gas aeration for 20 hours
84. A nurse is assigned to care for a group of clients. On
d. 2% Glutaraldehyde immersion for 10 hours
review of the client’s medical records, the nurse
determines that which client is at risk for excess fluid Situation: The OR is divided into three zones to control traffic
volume? flow and contamination.
a. The client taking diuretics
b. The client with renal failure 91. What OR attires are worn in the restricted area?
c. The client with an ileostomy a. Scrub suites, OR shoes, head cap
d. The client who requires gastrointestinal b. Head cap, scrub suit, mask, OR shoes
suctioning c. Mask, OR shoes, scrub suit
85. A nurse is assigned to care for a group of clients. On d. Cap, mask, gloves, shoes
review of the client’s medical records, the nurse 92. Nursing intervention for a patient on low dose IV
determines that which client is at risk for deficient insulin therapy includes the following EXCEPT:
fluid volume? a. Elevation of serum ketones to monitor
a. A client with colostomy ketosis
b. A client with congestive heart failure b. Vital signs including BP
c. A client with decreased kidney function c. Estimate serum potassium
d. A direct receiving frequent wound irrigation d. Elevation of blood glucose levels
 93. The doctor ordered to incorporate 1000” u” insulin 100. In using liquid sterilizer versus autoclave machine,
to the remaining on –going IV. The strength is which of the following is true?
500/ml. how much should you incorporate into the a. Autoclave is better in sterilizing OR supplies
IV solution? versus liquid sterilizer
a. 10ml b. They are both capable of sterilizing the
b. 0.5ml equipment, however, it is necessary to soak
c. 2 ml supplies in the liquid sterilizer for a longer
d. 5ml period of time
94. Multiple vial-dose-insulin when in use should be c. Sharps are sterilizes using autoclave and not
a. Kept at room temperature cidex
b. Kept in narcotic cabinet d. If liquid sterilizer is used rinsing it before
c. Kept in the refrigerator using is not
d. Store in the freezer
95. Insulins using insulin syringe are given using how
many degrees off needle insertion?
a. 45
b. 180
c. 90
d. 15

Situation: 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 hot
considered sterile after a period of 30 days
of being not 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 cover.
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 than 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
equipment, 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 equipment are
sterilized and had undergone a rigorous
sterilization process
c. There is black stripe on the paper indicator
d. The material has no microorganism nor
spores present that might cause an
infection