board questions 2009
TRANSCRIPT
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Nurse Suzie is administering 12:000PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band?
o Ask the client his name
Wilfred, 30 years old male, was brought to the hospital due to the hospital dues to injuries sustained from a vehicular accident. While being transported to the X-ray department, the straps accidentally broke and the client fell to the floor hitting his head. In this situation, the nurse is:
o Liable along with the employer for the use of a defective equipment that harms the client
While going on evening round, Nurse Edna saw Mrs.
Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna?
o Respect the client’s actions as this provides structure and support the client
Which of the following situations would possibly
cause a nurse to be sued due to negligence? o Nurse gave a client wrong medication and
an hour later, client complained of dyspnea
The nurse is in the hospital canteen and hears two
staff nurses talking about the client confined in room 612. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take?
o Approach the two nurses and tell them that their actions are inappropriate especially in a public place.
When the nurse breaches the duty of confidentiality,
he or she can be disciplined by both employer and the Board of Nursing. In addition to this discipline, he or she can:
o Be held responsible or any damages that result
Which of the following best describes acquaintance rape?
o Sexual intercourse committed with force or with the threat of force without a person’s consent
You are the nurse in an Adult Care Unit. You over-
hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say, that if she refuses to take her medications she will not be given her favorite dessert. You report your co-staff’s behavior as:
o Assault
When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible?
o Volunteer nurse, hospital and the nurse in charge
As a nurse, you accidentally administer 40 mg of
propranolol (Inderal) to a client instead of 10 mg. although client exhibits no adverse reactions to the larger dose. You should:
o Complete an incident report
Baby Liza, 3 months old, with a congenital heart
deformity, has an order from her physician: “Give 3.00 cc of Lanoxin today for one dose only”. Which of the following is the most appropriate action by the nurse?
o Clarify the order with the attending physician
Which of the following nursing intervention should
be given the highest priority when receiving a client in the OR?
o Verify the identification and informed consent
Situation – In the OR, there are safety protocols that
should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome.
Which of the following should be given highest
priority when receiving patient in the OR? o Verify patient identification and informed
consent
Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases.’ When are these procedures best scheduled?
o Last case
OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure…
o strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board
Another nursing check that should not be missed
before the induction of general anesthesia is: o check baseline vital signs
Some lifetime habits and hobbies affect
postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for:
o postoperative respiratory function
Situation – One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.
Irma is terminally ill, she speaks to you in confidence. You now feel that Irma’s family could be helpful if they knew what Irma has told you. What should you do first?
Obtain Irma’s permission to share the information
with the family
Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by:
Coming back periodically and indicating your availability if she would like you to sit with her
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Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves, is depressed. Which of the following would best help him during his depression?
o Sit down and talk with him for a while
Situation: The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided for client can be improved.
The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should:
o Bring the staff nurse to a client’s room and demonstrate a cleansing bath
The staff nurse discusses with the novice nurse the
type of wound dressing that is best to use for a client. Together, they observe how well the dressings absorb the drainage. In what step of the decision making process are they?
o Testing options
To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act responsibly when at work. Which of the following actions of a nurse demonstrates the attitude of responsibility?
o Following standards of practice
The nurse who makes clinical judgment can be
dependent upon to improve the quality of care clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client:
o A post-operative client, Rey, who has a blood pressure of 90/50 mmHg
A good nursing care plan is dependent on a correctly
written nursing diagnosis. It defines a client’s problem and its possible cause. The following is an example of a well written nursing diagnosis:
o Electrolyte imbalance related hypocalcemia
Situation - The practice of nursing goes with
responsibilities and accountability whether you work in a hospital or in the community setting your main objective is to provide safe nursing to your clients?
To provide safe quality nursing care to various clients in any setting, the most important tool of the nurse is:
o Critical thinking to decide appropriate nursing actions
You ensure the appropriateness and safety of your
nursing interventions while caring for various client groups by:
o Using standards of nursing care as your criteria for evaluation
The effectiveness of your nursing care plan for your
clients is determined by o the outcome of nursing interventions
based on plan care
You are assigned to Mrs. Amado, age 49, who was admitted for possible surgery. She complained of
recurrent pain at the upper right quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue?
o Blood pressure measurement of 170/100
While talking with Mrs. Amado, it is most important for the nurse to:
o Do an assessment of the client to determine priority needs
Situation – Errors while providing nursing care to
patients must be avoided and minimized at all times. Effective management of available resources enables the nurse to provide safe quality patient care.
In a hospital were you work, increased incident of
medication error was identified as the number one problem in the unit. During the brain storming session of the nursing service department, probable causes were identified. Which of the following is process related?
o failure to identify client
Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication practice related to this?
o Only officially approved abbreviations may be used in the prescription orders
The hospital has an ongoing quality assurance
program. Which of the following indicates implementation of process standards?
o The nurses check client’s identification band before giving medications
Which of the following actions indicate that Nurse
Jerome is performing outcome evaluation of quality care?
o Interviews nurses for comments regarding staffing
An order for a client was given and the nurse in
charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor?
o Assign another nurse to perform the procedure
Nursing audit aims to:
o Compare actual nursing done to established standards
In Community Health Nursing, despite the
availability and use of many equipment and devices to facilitate the job of the community health nurse, the best tool any nurse should well be prepared to apply is a scientific approach. This approach ensures quality of care even at the community setting. This in nursing parlance is nothing less than the:
o nursing process
Evidence-based care started in medicine as a way to: o Integrate individual experience with
clinical research
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Situation - The psychiatric mental health nurse adheres to standards that ensure quality improvement. The following situations and behaviors are means to achieve this goal.
This is a process wherein the client’s chart is reviewed to compare criteria for quality care with actual practice
o Psychiatric audit
In order to assess “Reliability” as a behavioral characteristic, the nurse would ask herself which of the following questions regarding her recording:
o Did the history of the present problem correlate with the review of growth and development
All of these are advantages of peer review EXCEPT:
o It requires the development of standards for quality care
The nursing team leader wants to involve all the
nurses in participating in their own personal and professional growth through a brainstorming session. One of the most important ground rules is:
o Follow the problem solving approach
“Did the nurse perform in the best possible manner without waste?” aims to describe the nurse’s:
ANS: efficiency
You are the nurse manager of the Medical Unit. Which of the following is a priority for you to consider when planning for the care of group of clients utilizing evidence-based practice?
ANS: Clients’ needs are assessed and individualized care plan are developed for each client
Situation - The purpose of the nursing care plan is to
identify the care for an individual patient based on his problem should be included if it is known. The nurse writes a nursing care plan for a patient based on nursing care standards.
Given the example of a problem: “Anxiety due to a job interview”. Then “due to” or the reason for the problem should be included if it is known. The initial step in identifying problem is:
ANS: Gather the data about the patient
Given the example of an expected outcome: “Openly
verbalize anxiety about job interview. Identify how he can prepare for the job interview. “Which of these is not a criterion of expected outcomes?
o ANS: An expected outcome is stated in terms of what the nurse will do
The following are reasons for setting deadlines
within which to achieve outcomes of care EXCEPT: ANS: Does not allow plans to be
changed
Which of these is not a relevant nursing order? ANS: Discuss with a patient with
specific means he might prepare for the job interview
Which of these practices on evaluation support
nursing care? Review of care plan is: o A nursing team responsibility
Situation – Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you know that this entails quality assurance programs.
The following mechanisms can be utilized as part of the quality assurance program of your hospital EXCEPT:
ANS: Use of the Nursing Interventions Classification
The use of the Standards of Nursing Practice is
important in the hospital. Which of the following statements best describes what it is?
ANS: The Standards of care includes the various steps of the nursing process and the standards of professional performance
You are taking care of critically ill client and the
doctor in charge calls to order a DNR (do-not-resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone?
o Have 2 nurses validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours
To ensure client safety before starting blood
transfusion the following are needed before the procedure can be done EXCEPT:
o blood should be warmed to room temperature for 30 minutes before blood transfusion is administered
Part of standards of care has to do with the use of
restraints. Which of the following statements is NOT true?
o Check client’s pulse, blood pressure and circulation every 4 hours
Situation – Joint Commission on Accreditation of
Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility.
As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
o Implement a regular maintenance and testing of alarm systems
Overdosage of medication or anesthetic can happen
even with the aid of technology like infusion pumps, sphygmomanometer, and similar devices/machines. As a staff, how can you improve the safety of using infusion pumps?
o Check the functionality of the pump before use
JCAHOs universal protocol for surgical and invasive
procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following EXCEPT:
o Take a video of the entire intra-operative procedure
You identified a potential risk of pre and
postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT:
o Allow client to walk with relative to the OR
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As a nurse, you know you can improve on accuracy
the of patient’s identification by 2 patient identifiers, EXCEPT:
o call the client by his/her case and bed number
Which of the following statements would best
indicate that Ruffy, who is dying, has accepted his impending death?
o “I’m ready to go.”
Marla, 90 years old has planned ahead for her death-philosophically, socially, financially, and emotionally. This is recognized as:
Acceptance that death is inevitable
Situation – You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implications.
You are on night duty in the surgical ward. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound. He is being guarded by policemen from the local police unit. During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hurt Martin. He denied the matter. Which among the following activities will you do first?
Make an incident report
You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?
Make an incident report
You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found out that what is on record does not tally with the drugs used. Which among the following will you do first?
Find out from the endorsement any patient who might have been given narcotics
You are on duty in the medical ward. The mother of
your patient who is also a nurse, came running to the nurses’ station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do first?
Go to see Fiolo and assess for airway patency and breathing problems
You are admitting Jorge to the ward and you found
out that he is positive for HIV. Which among the following will you do first?
Take note of it and plan to endorse this to next shift
Situation - RN’s should always be conscious that the contents in charting are admissible in court as evidence.
If there is any deviation from normal practice or procedure e.g. streptomycin was given by IV not IM, this should documented in the:
o Incident report
Documentation of all nursing activities performed is legally and professionally vital. Which of the
following should NOT be included in the patient’s chart?
o Arguments between nurses and residents regarding treatments
During your morning rounds, Mr. Tipol, 60 year old
widower, tried to sit up and instead of holding to the side rail held the IV stand causing the IV bottle to fall and break. You wrote an incident report to show:
o Document the incident
Erasures, alterations, and additions in medical records and the nurse’s notes can be avoided. The following are some tips on how to do corrections, EXCEPT:
o State the reason for any deviation from normal procedure/practice
Kathy is one of the patient’s. Her uncle, who is a
doctor, wants to read her chart. Your appropriate action would be:
o Instruct Kathy’s uncle to present a written authorization signed by the patient
Situation 11 – Mr. Jose’s chart is the permanent legal
recording of all information that relate to his health care management. As such, the entries in the chart must have accurate data.
Mr. Jose’s chart contains all information about his health care. The functions of records include on following EXCEPT:
o Recording of actions in advance to save time
An advantage of automated or computerized client
care system is: o Information concerning the client can be
easily updated
Information in the patient’s chart is inadmissible in court as evidence when:
o The handwriting is not legible
A telephone order is given to for a client in your ward. What is your most appropriate action?
o Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order
Because of increase incidents of medication error
due to wrong transcription of physician medication orders by nurses, a tertiary hospital utilized a computerized medication order system. Which of the following procedures may be done through the said system?
o Provide a list of drugs with their generic name
Situation – Records contain those comprehensive
descriptions of patient’s health conditions and needs and at the same serve as evidences of every nurse’s accountability in the care giving process. Nursing records normally differ from the institution to institution nonetheless they follow similar patterns of meeting needs for specific types of information. The following pertains to documentation/records management.
This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic
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personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?
o Nursing Health History and Assessment Worksheet
These are sheets/forms which provide an efficient
and time saving way to record information that must be obtained repeatedly at regular and/or short intervals of time. This does not replace the progress notes; instead this record of information on vital signs, intake and output, treatment, postoperative care, post partum care, and diabetic regimen, etc. This is used whenever specific measurements or observations are needed to be documented repeatedly. What is this?
o Graphic Flow Sheets
These records show all medications and treatment provided on a repeated basis. What do you call this record?
o Medicine and Treatment Record
This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in patient care and factors related to daily living activities. This record is used in the change-of-shift reports or during the bedside rounds or walking rounds. What record is this?
o Nursing Kardex
Most nurses regard this as conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?
o Discharge Summary
Situation – Records are vital tools in any institution and should be properly maintained for specific use and time.
The patient’s medical record can work as a double edged sword. When can the medical record become the doctor’s/nurse’s worst enemy?
o When the medical record is inaccurate, incomplete, and inadequate
Disposal of medical records in government
hospitals/institutions must be done in close coordination with what agency?
o Records Management Archives Office (RMAO)
In the hospital, when you need the medical record of
a discharged patient for research, you will request permission through:
o Medical records section
You readmitted a client who was in another
department a month ago. Since you will need the previous chart, from whom do you request the old chart?
o Medical records section
Records Management and Archives Offices of the DOH is responsible for implementing its policies on record disposal. You know that your institution is covered by this policy if:
o It obtained permit to operate from DOH
The nurse notes effectiveness of interventions in using subjective and objective data in the:
progress notes
The following are SOAP (subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. What is the objective data?
o Has periods of crying; frequently verbalizes fear of what diagnostic tests will reveal
Nursing care plans provide very meaningful data for
the patient profile and initial plan because the focus is on the:
o Patient’s responses to health and illness as a total person in interaction with the environment
The use of interpersonal decision making,
psychomotor skills, and application of knowledge expected in a role of a licensed health care professional in the context of public health welfare and safety is an example of:
ANS. Competence
Which of these feedbacks from individual participants indicate maximum gain from the staff development program?
ANS: I have a “Do it now” project for myself. i.e., to approach my clinical supervisor regularly to discuss nursing care of our clients
Registered nurses can be identified as a:
ANS: Organization
a strategy for change that focuses on teaching workers new technology is:
ANS: training
Some strategies to maintain professional health are
listed below. Which is NOT necessarily correct? ANS: Read fiction and nonfiction
materials
a means of facilitating professional staff development is by building upon skills, abilities, and experience of each practitioner is called:
o the novice to expert model
Situation– You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession.
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Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an:
o Novice nurse Benner’s “Proficient” nurse level is different from
the other levels in nursing expertise in the context of having:
o A holistic understanding and perception of the client
As you become socialized into the nursing “culture”
you become a patient advocate. Advocacy is explained by the following EXCEPT:
o Demonstrating loyalty to the institution’s rights
Modern day nursing has led to the development of
the expanded role of the nurse as seen in the function of a:
o Clinical nurse specialist
You join a continuing education program to help you:
o Update your knowledge and skills related to field of interest
Situation - The PRC regulates the practice of 42
professions in the Philippines.
What is the basic requirement of the state for a nurse to practice her profession?
o A nursing licensure
The Code of Good Governance for the profession in the Philippines shall be adapted by:
o All Filipino professionals
The standardized guidelines and procedures for the implementation of Continuing Professional Education (CPE) for all professional. Resolution Numbers 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be:
o 60 credit units for 3 years
The Board of Nursing is vested with power to issue, suspend, or revoke for cause, the:
o Certificate of Registration
RA 9173 stipulates the removal examination of the nurse licensure examination shall be taken:
o Within the same year after the last failed examination
Situation - For personal and professional
development, the nursing staff decided to hold a staff development program, “Self enhancement through Assertiveness”.
An appropriate assessment tool to maximize gathering of needs of nurses is through:
o Survey
A priority objective of the program is: o Develop art and skills of therapeutic use of
self
The most effective way to practice assertiveness skills is through:
o role play
The least satisfactory method to evaluate the effectiveness of the program is through:
o Attendance
situation - The supervising nurse received report that a staff nurse is displaying frequent irritation, anger and even indifference toward client and co-workers.
The initial action of the supervisor would be to:
o Call the nurse for a one on one conference
The nurse expressed increasing feelings of dissatisfaction. The supervising nurse intervenes therapeutically by taking on the role of:
o Counselor by actively listening
Coupled with poor work performance, mental and
physical fatigue and actual withdrawal from client contact and nursing duties, the nurse can be said to be suffering from:
o Personality maladjustment
A priority in the nurse’s personal development program would be to:
o Help her find value and meaning in her work
The most relevant professional program for her
would be: o Behavior modification
Situation – The staff nurse supervisor requests all
the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes.
The plan of the nurse supervisor is an example of o primary prevention
When Mrs. Guerrero, a nurse, delegates aspects of
the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guerrero
o is assigning the responsibility to the aide but not the accountability for those tasks
Kokey, the new nurse, appears tired and sluggish
and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should
o empathize with the nurse and listen to her
Process of formal negotiations of working conditions between a group registered nurses and employer is
o collective bargaining
You are attending a certification program on
cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is
o inservice education
Situation – Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience.
An example of a management function of a nurse is: o Directing and evaluating the staff nurses
Your head nurse in the unit believes that the staff
nurses are not capable of decision making so she
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makes the decisions for everyone without consulting anybody. This type of leadership is:
o Autocratic leadership
When the head nurse in your ward plots and approves your work schedules and directs your work, she is demonstrating:
o Authority
The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:
o Change IV infusions
You made a mistake in giving the medicine to the wrong client. You notify the client’s doctor and write an incident report. You are demonstrating:
o Accountability
Situation – As the CPE is applicable for all professional nurse, the professional growth and development of Nurses with specialties shall be addressed by a Specialty Certification Council. The following questions apply to these special groups of nurses.
Which of the following serves as the legal basis and statute authority for the Board of Nursing to promulgate measures to effect the creation of a Specialty Certification Council and promulgate professional development programs for this group of nurse-professionals?
o R.A. 7164
By force of law, therefore, the PRC-Board of Nursing release Resolution No. 14 Series of 1999 entitled: “Adoption of a Nursing Specialty Certification Program and Creation of Nursing Specialty Certification Council.” This rule-making power is called:
o Quasi-Legislative Power
Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council, which two (2) of the following serves as the strongest justification for its enforcement?
Advances made in science and technology have provided the climate for specialization in almost all aspects of human endeavor; and
As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, industry and services imposed by the national laws of countries all over the world; and
Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge; and
Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and
enhancing the quality of nursing care.
ANS: a & d are strong justifications
Which of the following IS NOT a correct statement as
regards Specialty Certification? o The Board of Nursing intended to create
the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals.
The NSCC was created for the purpose of
implementing the Nursing Specialty policy under the direct supervision and stewardship of the Board of Nursing. Who shall comprise the NSCC?
o A Chairperson, chosen from among the Regulatory Board Members; a Vice Chairperson appointed by the BON at large; two other members also chosen at-large; and one representing the consumer group;
Situation – As a Nurse, you have specific
responsibilities as professional. You have to demonstrate specific competencies.
The essential components of professional nursing
practice are all the following EXCEPT: Culture You are assigned to care for four (4) patients. Which
of the following patients should you give first priority?
Emy, who was previously lucid but is now unarousable
Brenda, the Nursing Supervisor of the intensive care
unit (ICU) is not on duty when a staff nurse committed a serious medication error. Which statement accurately reflects the accountability of the nursing supervisor?
Brenda should be informed when she goes back on duty
Which barrier should you avoid, to manage your
time wisely? Procrastination
You are caring for Vincent who has just been
transferred to the private room. He is anxious because he fears he won’t be monitored as closely as he was in the Coronary Care Unit. How can you allay his fear?
Assign the same nurse to him when possible
Situation 18 – There are various developments in health education that the nurse should know about:
The provision of health information in the rural areas
nationwide through television and radio programs and video conferencing is referred to as:
o Telehealth program
A nearby community provides blood pressure screening, height and weight measurement, smoking cessation classes and aerobics class services. This type of program is referred to as
o outreach program
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Part of teaching client in health promotion is responsibility for one’s health. When Ciara states she needs to improve her nutritional status this means:
o Client will decide the goals and interventions required to meet her goals
Nurse Eunice is providing tertiary prevention to Mrs.
Vento. An example of tertiary prevention is o Identifying complication of diabetes
Mrs. Olivia has schedule for Pap Smear. She has a
strong family history of cervical cancer. This is an example of
o secondary prevention
Situation – Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.
Randy has chest tubes attached to a pleural drainage
system. When caring for him you should: change the dressing daily using aseptic techniques
Fanny, came in from PACU after pelvic surgery. As
Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be:
a tender, painful area on the leg
To prevent recurrent attacks on Terry who has acute glomerulonephritis, you should instruct her to:
seek early treatment for respiratory infections
Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first?
Notify the physician at once
When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:
ventilation exchange
Situation - As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.
Items that enter sterile tissue or vascular system are categorized as critical items and should be:
o Sterilized
As an OR nurse, what are your foremost
considerations for selecting chemical agents for disinfection?
o Material compatibility and efficiency
Before you use a disinfected instrument, it is essential that you:
o Wrap the instrument with sterile towel
You have a critical heat labile instrument to sterilize and are considering to use a high level disinfectant. What should you do?
o Prolong the exposure time according to manufaturer’s direction
As a nurse, you know that the intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin should be:
o Disinfected Situation 6- The OR is divided into three zones to
control traffic flow and contamination. What OR attires are worn in the restricted area?
o Head cap, scrub suit, mask, OR shoes
Which of the following nursing intervention should be given the highest priority when receiving a client in the OR?
o Verify the identification and informed consent
Conversation while in the operation is ongoing is
minimized because: o It enhances the spread of microorganism
to the incision site
Spaulding categorized instruments according to use. Where do you classify endoscopic instrument?
o High level disinfected instruments
In the OR, “Surgical Conscience” means: o Honest adherence to surgical aseptic
techniques all the time
Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer genral anesthesia through inhalation. What is the identifying color of the tank which contains “laughing gals”?
o Blue
On a traffic light, yellow means “proceed with caution”. In the field of healthcare, where do you discard your used tissue papers?
o Green bin
An instrument tray with black striped autoclave/steam chemical indicator tape communicates that the instrument tray.
o Is sterile
During a meal, a client with hepatitis B dislodges her
IV line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
o bleach
Situation – In the hospital, you aware that we are helped by the use of a variety of equipment/devices to enhance quality patient care delivery.
You are to initiate an IV line to your patient, Ken, 5, who is febrile. What IV administration set will you prepare?
o Microset
Ken is diagnosed to have measles. What will your protective personal attire include?
o . Face mask
What will you do to ensure that Ken, who is febrile, will have a liberal oral fluid intake?
o Provide a calibrated pitcher of drinking water and juice at the bedside and monitor
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Before bedtime, you went to ensure Ken’s safety in bed. You will do which of the following:
o Put the side rails up Ken’s room is fully mechanized. What do you teach
the watcher and Ken to alert the nurses for help? o C. Call system
Situation – Infection can cause debilitating
consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.
Honrad, who has been complaining of anorexia and
feeling tired, develops jaundice. After a workup he is diagnosed of having Hepatitis A. His wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be:
“You should contact your physician immediately about getting gammaglobulin.”
Voltaire develops a nosocomial respiratory tract
infection. He asks you what that means? Your best response would be:
“You acquired the infection after you have been admitted to the hospital.”
As a nurse you know that one of the complications
that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is:
infection
A solution used to treat Pseudomonas wound infection is:
Dakin’s solution
Which of the following is most reliable in diagnosing a wound infection?
Culture and sensitivity Situation – NURSES are involved in maintaining a
safe and healthy environment. This is part of quality care management.
The first step in decontamination is: removal of the patients clothing and jewelry and
then rinsing the patient with water
For a patient experiencing pruritus, you recommend which type of bath ANS: colloidal (oatmeal)
Induction of vomiting is indicated for the accidental poisoning patient who has ingested.
aspirin
Which of the following term most precisely refer to an infection acquired in the hospital that was not present or incubating at the time of hospital admission?
Nosocomial infection
Which of the following guidelines is not appropriate to helping family members cope with sudden death?
Obtain orders for sedation of family members
The code of ethics for nurses has an interpretive statement that provides:
o Guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the profession
Which of the following is the best example of the
ethical principle of fidelity? o Keeping a promise to return to the client’s
room at a given time
The Code of Nurses o Delineates all obligations and responsibility
of the nurse
The obligation to correctly perform one’s assigned duties is:
o Responsibility
Among children candidates for organ transplant,
when all selected children have appropriate tissue matches for the same donated organ, the basis for the decision as to which child gets the organ is that the organ is given to the child who:
o Will receive the most benefit from the new organ
Situation - any hospitals form bioethical review
committees to ensure better quality of life of patients. You are invited by the nursing service department to participate in their bioethical review committee. You are expected to know the purpose and apply bioethical principles.
Which of the following is the purpose of the ethical review committee?
o Promote implementation of general standards
Daria who is admitted to the hospital with
autoimmune thrombocytopenia and a platelet count of 20,000/æL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulin has not been successful. Her physician recommended splenectomy. Daria state “I don’t need surgery. This will go away on its own.” In considering your response
o Advocacy
Zorayda is terminally ill and is experiencing severe pain. She as bone and liver metastasis. She has been on morphine for several months now. Zorayda is aware that they are having financial problem. She decides to sign a DNR form. What ethical form did Zorayda and her family utilize as basis for their decision to sign a DNR.
Advocacy
Tricia, a staff nurse in a cancer unit, is considered a role model not only by her colleagues, but also by her patients. She goes out of her way to help other. She is very active in their professional organization and she practices what she teaches. What ethical principle is she practicing?
o Justice
You are commuting to work riding the LRT. An older person collapsed and nobody seems to notice her. The security guard tried to make her sit down but she remained unconscious. You saw what happened and you decided to help. With help, you brought the patient to the nearest hospital. You learned later that woman was diabetic. She was on her way to the diabetes clinic to have her fasting blood sugar tested. She developed hypoglycemia. You were able
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to save a life. You felt good. What principle was applied?
o Beneficence Situation - Ninety year old Purita is confined at the
medical unit for respiratory ailment for which a breathing apparatus is prescribed for her to use while she sleeps. She refuses to wear it continuously though she fully understands the medical indication for it
Which of these ethical principles can guide the nurse in her action?
o Nonmaleficence
Purita has six children who are already adults. They differ in their opinion whether or not to allow their mother to decide for herself. The nurse would encourage family conference for:
o Consensus building
Breathing treatments are to be given to Purita. In anticipation that Purita might refuse, Dinio, one of the children requests that he be the one to sign consent in behalf of their mother. The nurse explains that Purita is rational in her thinking and which of these clients’ right must be regarded?
o Right to refuse treatment
Which of these would be the nurse’s priority following the treatment principle of least restrictive alternative?
o One to one staffing Purita talks about her joy in having responsible and
accomplished children and recalls challenging career as a lawyer. She is demonstrating a sense of:
o Ego integrity Situation – The nurse’s understanding of ethico-legal
responsibilities will guide his/her nursing practice. The principles that govern right and proper conduct
of a person regarding life, biology and the health professions is referred to as:
o Bioethics
The purpose of having a nurses’ code of ethics is: o To help the public understand professional
conduct expected of nurses
The most important nursing responsibility where ethical situations emerge in patient
o Be accountable for his or her own actions
You inform the patient about his rights which include the following EXCEPT:
o Right to obtain information about another patient
This principle states that a person has unconditional
worth and has the capacity to determine his own destiny:
o Autonomy
Situation – As Filipino Professional Nurses we must be knowledgeable about the Code of Ethics for Filipino Nurses and practice these by heart. The next questions pertain to this Code of Ethics.
Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
o The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a
Code of Ethics for Nurses which the Board of Nursing promulgated.
Based on the Code of Ethics for Filipino Nurses, what
is regarded as the hallmark of nursing responsibility and accountability?
o Health, being a fundamental right of every individual
Which of the following nurses’ behavior is regarded
as a violation of the Code of Ethics of Filipino Nurses?
o A nurse endorsing a person running for congress.
A nurse should be cognizant that professional
programs for specialty certification by the Board of Nursing are accredited through the:
o Nursing Specialty Certification Council
Mr. Jimmy, R.N. works in a nursing home, and he knows that one of his duties is to be an advocate for his patients. Mr. Santos knows a primary duty of an advocate is to:
o safeguard the well being of every patient
Lizette, a head nurse in a surgical unit, hears one of the staff nurse say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide the staff nurse in the use of touch, which of the following would be the BEST response of Lizette?
o “Touch serves as a connection between the nurse and the patient”
George, a 43 year old executive is scheduled for
cardiac bypass surgery. While being prepared of surgery, he says to the nurse “I am not going to have the surgery. I may die because of the risk”. Which response by the nurse is most appropriate?
o “This must be very frightening for you. Tell me how you feel about the surgery”
Mr. Chris Martinez has been confined for three days.
His wife helped take care of him and he has observed her to be “too involved” in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse.
o “What are your thoughts about your wife’s involvement in your care?”
The major components of the communication
process are: o Message, sender, channel, receiver and
feedback
Informal communication takes place when individuals talk and is best described by saying the participants:
o have no particular agenda or protocol
The mother of a 9-month old infant is concerned
that the head circumference of her baby is greater than the chest circumference. The BEST response by nurse is:
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o “This is normal until the age of 1 year, when the chest will be greater.”
Which of the following will work best when the
nurse is communicating with an infant? o Use an adult voice just as you would for
anyone
The tone and pitch of the voice, volume, inflection, speed, grunts and other vocalization are preferred to by which of the following terms?
o Paraverbal clues
Which of the following remark indicates that the client’s relative understood the discharge instruction for wound care?
o “I will report any redness or swelling of the wound”
After cystoscopy, Mr. Santos asked you to explain
why there is no incision of any kind. What do you tell him?
o “Cystoscopy is an endoscopic procedure of the urinary tract”
Situation - The nurse visited the Reyes family to
check on their two growing children, aged 7 and 4 years. Upon her visit she observed that common areas of arguments between Mr. and Mrs. Reyes are about conflicting ways of bringing up their children. Mrs. Reyes is lax and tolerant while Mr. Reyes often insists strict ways to a point of over protectiveness from what he perceives as unsafe i.e., community and neighbours that cannot be trusted.
Mr. Reyes remarked “I am way about visiting- with all the media news about child kidnapping and robberies.” – The Nurse’s BEST response would be:
o “I acknowledge what you are saying. My concern is the health care of your family and information are strictly confidential.”
Mrs. Reyes expressed that her socializing with
neighbors is limited because her husband thinks she is getting overly friendly with a guy next door. Which of the following would the nurse emphasize as basic?
o Keeping trust in the relationship
For the nurse to be effective in developing rapport with the family it is essential that she keeps her appointment on time and stick to a care plan. She is applying the principle of:
o Consistency and predictability
Which of these communicate unconditional acceptance of Anita and her situation?
o “You are safe here and I am ready to listen”
Situation - Through the nurse-patient relationship, the nurse intervenes utilizing effective communication techniques. The following are varied situations in a psychiatry ward.
The patient verbalizes, “Masama ang pakiramdam ko. Hindi ako nakatulog kagabi.” A therapeutic response of the nurse would be:
o “Maari mo bang sabihin sa akin ang mga naiisip at nararamdaman mo?”
Soledad is terminally ill of cancer. Looking sad she expresses. “Wala na yata akong pag-asang mabuhay pa.” A response which fosters hope is:
o “Mukhang napakabigat ang dinaramdam ninyo. Andito po ako at puwede tayong mag-usap.”
Camilia verbalizes, “Pinaguusapan nila ako. Ayaw nila ako.” A therapeutic response is:
o “Nalulungkot ba ang pakiramdam mo?”
During socialization Nicanor was provoked, became furious and started shouting “Walang hiya kayo! Ako ang bida ditto!” The nurse’s action is:
o Take him away from the group until he manages to have control of himself
Nicanor become verbally assaultive to the nurse. He
says, “Ikaw, nurse, wala kanga lam! Marunong pa ako saiyo, e. Ano ba ang pinagmamalaki mo!” The nurse responds therapeutically by:
o Acknowledging his behavior, put him in his right senses; respond with, “Oo nga, galit ka sa nurse pero hindi tama na naninigaw ka.”
Situation – As a nurse, you should be aware and
prepared of the different roles you play. What role do you play when you hold all client’s
information entrusted to you in the strictest confidence?
o Patient’s advocate
As a nurse, you can help improve the effectiveness of communication among healthcare givers by:
o One-on-one oral endorsement
As a nurse, your primary focus in the workplace is
the client’s safety. However, personal safety is also a concern. You can communicate hazards to your co-workers through the use of the following EXCEPT:
o Posting IR in the bulletin board
As a nurse, what is one of the best way to reconcile medications across the continuum of care?
o Communicate a complete list of the patient’s medication to the next provider of service
As a nurse, you protect yourself and co-workers
from misinformation and misrepresentations through the following EXCEPT:
o Endorsement thru trimedia to advertise your favorite disinfectant solution
Situation – The nurse engages the client in a nurse-
patient interaction
The best time to inform the client about terminating the nurse-patient relationship is:
o at the start of the relationship
The client says, “I want to tell you something but can you promise that you will keep this a secret?” A therapeutic response of the nurse is:
o “Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety.”
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When the nurse respects the client’s self-disclosure, this is a gauge for the nurse’s”
ANS: professionalism
Rapport has been established in the nurse-client relationship. The client asks to visit the nurse after his discharge. The appropriate response of the nurse would be:
o “The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge.”
The client has not been visited by relatives for
months. He gives a telephone number and requests the nurse to call. An appropriate action of the nurse would be:
o Assist the client to bring his concern to the attention of the social worker.
Situation – The nurse is often met with the following situations when clients become angry and hostile.
To maintain a therapeutic eye contact and body
posture while interacting with angry and aggressive individual, the nurse should:
o keep an “open posture, e.g. Hands by sides but palms turned outwards
During the pre-interaction phase of the N-P
relationship, the nurse recognizes this normal INITIAL reaction to an assaultive or potentially assaultive person.
o Display empathy towards the patient
Which of the following is an accurate way of reporting and recording an incident?
o “When asked about his relationship with his father, client clenched his jaw/teeth, made a fist and turned away from the nurse.”
To encourage thought, which of the following approaches is NOT therapeutic?
o “Why do you feel angry?”
A patient grabs a chair and about to throw it. The nurse best responds saying,
o “Stop! Put that chair down.”
Situation – It is common that clients ask the nurse personal questions.
Anticipation of personal questions is given adequate
attention during which phase of the nurse patient relationship?
o Working phase If the client asks for the nurse’s telephone number,
which of these responses is NOT appropriate? o “It is confidential I just don’t give it to
anyone.”
When the client asks about the family of the nurse, the MOST appropriate response is:
o Give a brief and simple response and focus
on the client.
When the nurse is asked a personal question, which
of these reactions indicate a need for her to introspect?
o His/Her right to privacy is being intruded.
It is 10 o’clock on your watch. The client asks, “What time is it?” The nurse’s appropriate response is:
o “It is 10 o’clock.”
Situation – Cathy, mother of 2 young kids, 36 years
old, had a mammogram and was told that she has breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.
Considering her level of anxiety, the nurse can best assist Cathy by:
o Giving her clear but brief information at the level of her understanding
Cathy blames God for her situation. She is easily
provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Cathy is grieving for her self and is in the stage of:
o anger The nurse visits Cathy and prods her to eat her food.
Cathy replies, “What’s the use? My time is running out.” The nurse’s best response would be:
o “You sound like you are giving up.”
The nurse feels sad about Cathy’s illness and tells her head nurse during the end of shift endorsement that, “it’s unfair for Cathy to have cancer when she is still so young and with two kids.” The best response of the head nurse would be:
o Advise the nurse to “be strong and learn to control her feelings”
Realizing that she feels angry about Cathy’s
condition, the nurse learns that being self-aware is a conscious process that she should do in any situation like this because:
o The nurse has to be therapeutic at all times and should not be affected
Situation - while working in a tertiary hospital, you
are assigned to the medical ward. Your client, Mr. Diaz, is concerned that he cannot
pay his hospital bills and professional fees. You refer him to a:
o Social worker
Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to:
o Receive emotional support
A diabetic hypertensive client, Mrs. Linao, needs a change in diet improve her health status. She should be referred to a:
o Dietician
When collaborating with other health team members, the best description of Nurse Rita’s role is:
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o Shares and implements orders of the health team to ensure quality care
Nurse Rita is successful in collaborating with health
team members about the care of Mr. Linao. This is because she has the following competencies:
o Communication, trust, and decision making
Situation - The following questions refers to nurse’s
efforts to do collaboration and teamwork. Select the best answer.
The most important role of the nurse as a member
of the team is to: o Coordinate the physiological care and
management of clients
A biological/medical approach to patient care utilizes which of the following?
o Somatic therapy
Which of these nursing actions belong to the secondary level of preventive intervention?
o Providing emergency psychiatric services
When the nurse identifies a client who has attempt to commit suicide the nurse should:
o Refer the client to the psychiatrist
The community health nurse was invited by the principal of an elementary school and was asked to give a task to parents. An appropriate topic would be:
o Disciplining children at home and in school
Situation - Collaborative planning is essential if nursing and health care are to be made available to all people.
Perioperative examples of collaboration are the
following EXCEPT: o Collaboration with other OR personnel
regarding the practices of surgeons collecting exobirant professional fees.
the nurses collaborate with other members of the
health profession to improve the integrity of the hospital working environment through the following ways EXCEPT:
o Joining the Mayo Uno Labor Union
An example of a collaborating effort on public service particularly during summer is:
c. Clean and Green
When does a nurse reject the interdependence of providers and patients in achieving access to health care?
o “Our hospital does not honor visiting doctors”
Individual patients and society as a whole benefit
from nursing participation in decisions made about health care. This is exemplified in:
o Following the decision of CGFNS to retake Test III and V to validate the visa screen for the U.S.
Situation - The perioperative nurse collaborates with the client, significant others healthcare providers.
Patient outcomes reflect the collaborative interdisciplinary effort and independent nursing activities. Who is the primary partner of the nurse in health care?
c. The client
To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT:
o Chaplaincy services
Waste disposal poses a big problem for the hospital. Biological wastes (i.e., amputated limbs) disposal should be coordinated with the following agencies EXCEPT:
o Crematorium . MMDA o DOH DILG
Tess, the PACU nurse discovered that Malou, who
weighs 110lbs prior to surgery, is in severe pain 3 hours after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. pm for pain. Tess should verify the order with:
c. Surgeon
Rosie, 57, who is diabetic, is for debridement of incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should be circulating nurse do?
o Communicate with the ward nurse to verify if insulin was incorporated or not
Situation – Concerted work efforts among members
of the surgical team is essential to the success of the surgical procedure.
The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover?
ANS: Circulating nurse
The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss?
o ANS: Anesthesiologist Surgery schedules are communicated to the OR
usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR?
o ANS Radiology department Minimally invasive surgery is very much into
technology. Aside from the usual surgical team, who else has to be present when a client undergoes laparoscopic surgery?
o ANS: Laboratory technician
In massive blood loss, prompt replacement of
compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy?
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o Pathology department
Situation – Nurses hold a variety of roles when providing care to a perioperative patient.
Which of the following role would be the responsibility of the scrub nurse?
o Account for the number of sponges, needles, supplies, used during the surgical procedure
As a perioperative nurse, how can you best meet the
safety need of the client after administering preoperative narcotic?
o Put side rails up and ask client not to get out of bed
It is the responsibility of the pre-op nurse to do skin
prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection?
ANS. Clipped
It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection?
o Serosanguinous exudates and skin blanching
Which of the following nursing interventions is done
when examining the incision wound and changing the dressing?
o Wash hands
Situation – Team efforts is best demonstrated in the OR
If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
o Who is your assistant and anesthesiologist,
and what is your preferred time and type of surgery
In the OR, the nursing tandem for every surgery is:
o Scrub and circulating nurses
While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?
o Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
When surgery is on-going, who coordinates the
activities outside, including the family? o Nurse supervisor
The breakdown in teamwork is often times a failure
in: o Communication
Situation – As a member of the health and nursing
team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.
While eating his meal, Matthew accidentally dislodges his IV line and bleeds. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with
o Bleach
You are a member of the infection control team of the hospital. Based on a feedback during the meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority activity?
o Establish policies for surveillance and monitoring.
Part of your responsibility as a member of the
diabetes core group is to get referrals from the various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4 patients are referred to you. How would you start prioritizing your activities?
o Determine their learning needs then prioritize
You have been designated as a member of the task
force to plan activities for the Cancer Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity?
o Clarify objectives of the activity with the task force before contacting the support groups
You are invited to participate in the medical mission
activity of your alumni association. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. You thought it is also your chance to share what you can do for others. What will be your most important role where you can demonstrate the impact of nursing in health?
o Conduct health education on healthy lifestyle
BOARD EXAMINATION – NURSING PROCEDURES COLOSTOMY CARE 1. Gather equipment. 2. Place the patient in supine position. 3. Wash hands. 4. Don gloves. 5. Remove old pouch by grasping pouch and gently pulling away from skin. (You may use warm water or an adhesive solvent to loosen the seal.) 6. Discard gloves. 7. Wash hands and don new pair of gloves. 8. Gently wash stoma area with warm, soapy water. 9. Dry skin thoroughly. 10. Assess (and document after procedure): Stoma: Appearance Peristomal skin: Condition Feces: Amount, color, consistency, and presence of unusual odor Emotional status 11. Temporarily cover stoma with a gauze pad to absorb drainage during ostomy care. 12. Apply skin prep in a circular motion. (Allow to air dry for approximately 30 seconds.)
Page 15 of 16 13. Apply skin barrier in a circular motion. 14. Measure stoma using a stoma guide. 15. Cut ring to size. 16. Moisten ring with warm water and rub it until sticky, or remove paper backing from adhesivebacked ring. 17. Center ring over the stoma, gently pressing it to the skin. (Smooth out any wrinkles to prevent seepage of effluent.) 18. Center faceplate of bag over stoma and gently press down until completely closed. 19. Document procedure and assessments from step 10 (above): Example: Colostomy bag changed, stoma pink, peristomal skin intact without signs of irritation. 70 mL of liquid greenish stool discarded with old colostomy bag. Patient looked away during procedure and appeared to ignore nurse’s verbal communication.
COLOSTOMY IRRIGATION 1. Explain procedure to the patient and encourage participation. 2. Position in a side-lying position or sitting on the toilet in bathroom if bed rest is not necessary. 3. Place bedpan on top of a disposable pad beneath stoma (if patient is in bed). 4. Fill solution bag with prescribed type and amount of irrigating solution, expelling air from irrigating tube prior to insertion. 5. Hang solution bag 12 to 18 inches above the stoma. 6. Don gloves. 7. Remove stoma appliance. 8. Place irrigation drainage sleeve over the stoma, attaching it snugly to prevent seepage of fluid onto the skin. 9. Place opposite end of drainage sleeve into bedpan or toilet.
10. Dilate stoma, if ordered, by gently inserting the lubricated tip of gloved fifth finger into stoma (use a massaging motion to relax the intestinal muscle until maximum dilation is accomplished). 11. Lubricate tip of stoma cone or catheter. 12. Insert stoma cone or catheter by using a rotating motion until it fits snugly (about 3 inches). Do not insert against resistance. 13. Open tubing clamp, allowing irrigating solution to flow into the bowel slowly. (If cramping occurs, stop flow until cramps subside.) 14. After instillation of fluid, remove cone or catheter, and allow colon to empty. 15. Gently massage the abdomen to encourage emptying of colon (usually takes up to half an hour). 16. Empty and remove irrigation sleeve. 17. Discard old gloves and don new pair. 18. Clean area around stoma. 19. Apply colostomy appliance. 20. Wash hands. 21. Document type and amount of irrigation solution instilled; size, color, and consistency of returned solution; patient response; and complications. Example: Colostomy irrigated with ——mL NS. Solution returned with moderate amount loose, greenish fecal material. No complaints during procedure. States she irrigates colostomy once a day at home.
Medical-Surgical DRESSING CHANGE, STERILE 1. Explain procedure to the patient. 2. Wash hands. 3. Place bedside table near the area to be dressed. 4. Gather supplies and place on bedside table. 5. Place a disposable cuffed bag within reach of the work area. 6. Position and drape the patient in a comfortable position, exposing the area to be dressed. 7. Open sterile gloves and retain the inside of the glove package for use as a sterile field. 8. Open sterile gauze pads and all supplies needed, and drop them onto the sterile field. 9. Open the prescribed cleansing agents and pour onto at least two gauze pads. 10. Don nonsterile gloves. 11. Place a towel or waterproof pad under wound area. 12. Remove tape and soiled dressing (soak dressing in sterile saline if it adheres to wound), noting the appearance of the wound, drain placement (if any), suture or skin closure integrity; and amount, color, and consistency of the drainage on the dressing. 13. Discard the dressing in a cuffed trash bag. 14. Remove and place gloves into the trash bag. 15. Wash hands. 16. Don sterile gloves. 17. Use gauze pads (which may be lifted with sterile forceps) to cleanse the wound with prescribed antiseptic solution. Cleanse the wound from the center outward, using a new gauze pad for each outward motion. NOTE: Iodine solutions may cause skin irritation if they are left on the skin between dressing changes. 18. Discard used gauze pads into the cuffed bag, away from the sterile field. 19. Apply sterile dressings to the incision or wound site one at a time. (If a drain is present, use a precut dressing to fit around the drain.) 20. Apply ABD pad if needed. (The blue line down the middle of the pad marks the outside surface.) the technique of applying several layers (the number of layers depends on the size of the wound area and the patient) of saline-soaked dressings next to the wound and covering these with dry dressings. 21. Apply tape over the dressing or secure it with Montgomery ties. 22. Discard supplies and used gloves into a trash bag. 23. Wash hands. 24. Document observations of the wound, dressing, drainage, dressing change, and patient response. Example: Abdominal dressing changed. Small amount serosanguineous drainage on old dressing. Wound cleansed with H2O2. Wound edges approximated well. ENEMA ADMINISTRATION 1. Explain procedure to the patient. 2. Provide privacy. 3. Gather all equipment. 4. Position the patient in left side-lying position with the right knee flexed (dorsal recumbent position for infants and small children). 5. Place waterproof pad under the patient’s hips and buttocks, and drape to expose anal area only. 6. Prepare the solution as ordered. 7. Lubricate 2 inches of rectal tube to facilitate insertion. 8. Open the clamp to allow solution to run through and expel air from tubing. Reclamp tubing.
Page 16 of 16 9. Place a bedpan near the bedside. 10. Don gloves. 11. Instruct the patient to take slow deep breaths to facilitate relaxation. 12. Separate the buttocks and insert rectal tube, directing it toward the umbilicus about 3 to 4 inches. 13. Raise the enema container about 12 to 18 inches above the rectum and open the regulating clamp. 14. Administer the fluid slowly. 15. Lower the container or clamp the tubing if the patient experiences cramping.Medical-Surgical 16. After the solution is instilled, close the clamp and remove the rectal tube. 17. Instruct the patient to retain solution as long as possible (5 to 10 minutes for cleansing enema, 30 minutes for retention enema). 18. Assist the patient to the bathroom or position him or her on the bedpan. 19. Discard equipment. 20. Remove gloves and wash hands. 21. Document the type and amount of enema solution administered; approximate amount, color, and consistency of expelled material; and patient response. Example: Positioned on left side, NS enema, 500 mL given. Lg. amt. formed brown stool returned with enema solution. Complained of abdominal cramping during procedure. Quietly watching TV following procedure. PEDIATRIC ADAPTATION The amount of enema solution used for infants and small children ideally is ordered by the physician. Caution should be used if it is necessary to give an enema to a premature or low-birth-weight infant. A 5- to 10-mL syringe attached to a number 5 feeding tube can be used for the procedure. Solutions may usually be given to other children as follows: Age Amount of Solution Tube Insertion Infant 100 mL 1 in 2–4 yr 200 mL 2 in 4–10 yr 200–400 mL 3 in Over 10 yr 500 mL 3 in
NASOGASTRIC TUBE INSERTION 1. Gather the necessary equipment. 2. Explain procedure to the patient. 3. Wash hands. 4. Position the patient in a sitting position.Medical-Sur 5. Check nostrils for patency by asking the patient to breathe through one naris while occluding the other. 6. Measure length of NG tubing to be inserted by measuring the distance from tip of nose to ear-lobe and from ear-lobe to about 1 inch beyond base of xiphoid process. Use a small strip of adhesive tape to mark the measured distance on the tube. 7. Don gloves and lubricate tube in water or a watersoluble lubricant. (Never use mineral oil or petroleum jelly.) 8. Ask the patient to tilt his or her head backward, and gently advance the NG tube into an unobstructed nostril; direct tube toward back of throat and down. 9. As the tube approaches the nasopharynx, ask the patient to flex head toward chest (to close the trachea) and allow him or her to swallow sips of water or ice chips as the tube is advanced into the esophagus (about 3 to 5 inches each time the patient swallows). NOTE: If the patient coughs or gags, check the mouth and oropharynx. If the tube is curled in the mouth or throat, withdraw the tube to the pharynx and repeat attempt to insert the tube. 10. Ask the patient to continue swallowing until the tube reaches the premeasured mark.
11. Check for proper tube placement in the stomach by aspirating with a syringe for gastric drainage or by instilling about 20 mL of air into the NG tube while listening with a stethoscope for a gurgling sound over the stomach. 12. Secure the tube after checking for proper placement by cutting a 3-inch strip of 1-inch tape and then splitting the tape lengthwise at one end, leaving 1 inch intact at the opposite end 13. Place the intact end of the tape on top of the patient’s nose, and wrap one side of the split tape end around the tube and secure on a nostril. Repeat with the other split tape end. 14. Connect the NG tube to suction if ordered, or clamp.Medical-Surgical 15. Wrap adhesive tape around the distal end of the tubing and attach a safety pin through the tape tab to the patient’s gown. 16. Document the size and type of tube inserted. Note the nostril used and the patient’s tolerance of the procedure. Document how placement was validated and whether tubing was left clamped or attached to other equipment. Example: Number 10 NG tube placed per R naris and secured with tape. Procedure tolerated well. Tube placement validated by auscultation while instilling air into stomach. Distal tubing clamped. PEDIATRIC ADAPTATION Infant Follow adult procedure with these adaptations: 1. Sharply bend NG tube about 1/4 to 1/2 inch from tip. (There is a sharp bend “downward” almost immediately after insertion of tube into the nostril.) 2. Flex the infant’s head gently onto the chest with your nondominant hand. Nasogastric tube insertion; method of securing tube with tape3. With the dominant hand, insert the tube using a downward motion almost immediately after the tube enters the nostril. 4. Because the infant’s chest is small and sounds are conducted throughout the chest and abdomen, auscultation of sounds may give a false impression of placement. Other standard methods of placement validation may be used. A sensitive method of placement validation for the infant is to place your hand flat over the stomach area while forcing 2 to 3 mL of air through the tube. Vibrations that reveal the location of the tube tip can usually be felt through the abdominal wall. Toddler or Preschooler 1. Demonstrate the procedure on a doll. 2. One or two additional people are usually needed to help restrain the child. The parent should not be asked to assist with child restraint.