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rioSET A SeatNo.____--------------------------------------------------------------------------------------------------------------------------------NURSING PRACTICE 3B:NURSING CARE OF CLIENT WITH PHYSIOLOGICALAND PSYCHOSOCIAL ALTERATIONSDIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answersheet provided. STRICTLY NO ERASURE!Situation 1: It is Cancer Consciousness Week and you are participating in an Early Cancer Detection Drive of theDepartment of Health.1. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breastcancer that is recommended for developing countries is:A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE)B. an annual hormone receptor assayC. an annual mammogramD. a physician conduct a breast clinical examination every 2 years2. The purpose of performing the breast self examination (BSE) regularly is to discover:A. fibrocystic masses C. areas of thickness or fullnessB. cancerous lumps D. changes from previous BSE3. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE:A. on the same day of each month C. on the first day of her menstruationB. right after the menstrual period D. on the last day of her menstruation4. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for:A. thickening of the tissue C. lumps in the breast tissueB. axillary D. change in size and contour5. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under theclient’s left shoulder is to:A. bring the breast closer to the examiner’s right handB. tense the pectoral muscleC. balance the breast tissue more evenly on the chest wallD. facilitate lateral positioning of the breastSituation 2: Ensuring safety is one of your most important responsibilities. You will need to provide instruction andinformation to your clients to prevent complications.6. LM has chest tube attached to a pleural drainage system. When caring for LM you should:A. change the dressing daily using aseptic techniqueB. empty the drainage system at the end of the shiftC. palpate the surrounding areas for crepitusD. clamp the chest tube when suctioning7. After pelvic surgery, the sign that would be indicative of a developing thrombophlebitis would be:A. a tender, painful area on the leg C. a pitting edema of the ankleB. pruritus on the calf and ankle D. a reddened area of the ankle8. To prevent recurrent attacks on FT who has glomerulonephritis, you should instruct her to:A. continue to take the same restrictions on fluid intakeB. seek early treatment for respiratory infections

2C. avoid situations that involve physical activityD. take showers instead of tub bath9. GT had a laryngectomy. He is now for discharge. He verbalized his concern regarding his laryngectomy tube beingdislodged. What would you teach him FIRST?A. reinsert another tubing immediately C. recognize that prompt closure of the tracheal openingB. keep calm because there is no immediate D. notify the physician at onceemergency10. When caring for TU after an exploratory chest surgery and pneumonectomy, your PRIORITY would be to maintain:A. chest tube drainage C. ventilation exchangeB. blood replacement D. supplementary oxygenSituation 3: Severe burn is one of the most devastating kinds of injury one can experience. It can affect any group. Youhave been ready to provide holistic care for patients with severe burns.11. A burn that is white, painless, and leathery in texture describes a:A. second degree burn C. deep partial thickness burnsB. third degree or full thickness burn D. first degree or superficial burns12. Critically ill patients are at high risk for the following complication during the emergent phase:A. myocardial infarction C. burn shockB. neurogenic shock D. contractures13. The MOST effective method of delivering pain medication during the emergent phase is:A. intramuscularly C. orallyB. subcutaneously D. intravenously14. Edema presents a significant problem in burn wounds because:A. loss of protein prevents tissue repairB. edema impedes tissue perfusion/oxygenationC. edema provides a milieu for bacterial proliferationD. edema can produce a tourniquet effect15. Which of the following can be a fatal complication of upper airway burns?A. stress ulcers C. shockB. hemorrhage D. laryngeal spasms and swellingSituation 4: You are assigned to take care of four patients with different conditions.16. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine andprednisone? You recognized that KJ understood the teaching when he states, “I must take these medications:A. until the anastomosis heals C. until the supply is overB. during the preoperative period D. for the rest of my life17. After the kidney transplant, you must observe KJ for signs of rejection which includes:A. fever and weight gain C. polyuria and jaundiceB. hematuria and seizure D. moon face and muscle atrophy18. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his physicianthat he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB tells you “I wantto go off dialysis, I’d rather not live than to be in this treatment the rest of my life”. How would you respond to him?A. leave the room and allow him to collect his thoughtsB. tell FB that “ We all have days when we don’t feel like going on”C. tell FB that “ Treatments are only three times a week, you can live with that”D. take a sit next to him and sit quietly319. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which statementby DS indicates the need for further teaching before true informed consent can be obtained?

A. “a wire from the generator will be attached to my heart”B. “the physician will make a small incision in my chest wall and place the generator there”C. “I wonder if there is another way to protect these bad rhythms”D. “this implanted defibrillator will protect me from those bad rhythms my heart goes into”20. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates a lackof understanding about his rights as a research study participant?A. “My confidentiality will not be compromised in this study”B. “ I understand the risk associated in this study”C. “I can withdraw from the study anytime”D. “ I’ll have to find a new physician if I don’t complete this study”Situation 5. You are assigned in the neurology stroke unit. To prepare for this assignment, you should be able to answerthe following questions.21. Which of the following statements can BEST describe/define stroke or brain attack?A. it occurs when circulation to a part of the brain is disruptedB. it is usually caused by abuse of prescribed medicationsC. it is caused by a cerebral hemorrhageD. it may be the results of a transient ischemic attack (TIA)22. Several diagnostic tests may be ordered for proper evaluation. The purpose of each of the following diagnosticexamination is correct EXCEPT:A. Cerebral Angiography – is used to identify collateral blood circulation and may reveal site of rupture or occlusionB. ECG – may reveal abnormal electrical activity, such as focal slowing and assess amount of brain waveactivity.C. MRI – may reveal the site of infarction, hematoma and shift of brain structuresD. PET Scanning – may reveal information on cerebral metabolism and blood flow characteristics.23. Which of the following is the MOST common cause of stroke or brain attack?A. embolism C. cerebral arterial spasmB. hemorrhage D. thrombosis24. To guide you in your assessment, it is also important for you to remember that the clinical features of stroke varywith the following factors EXCEPT:A. severity of damage C. artery affectedB. gender D. the extent of collateral circulation25. It is important for you to also teach clients and their families who are at risk to observed primary prevention whichincludes the following EXCEPT:A. maintain serum cholesterol level between 220 and 180 mm/dLB. treat transient ischemic attacks (TIA) earlyC. teach preventive health behaviors (consequences of smoking, obesity, alcoholism, drug abuse) to children ofpatients with strokeD. screen for systolic hypertensionSituation 6:Foot care among patients with peripheral vascular problems is very important.26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions:A. avoid wearing canvas shoes C. avoid use of cornstarch on the footB. avoid using a nail clipper to cut toe nails D. avoid wearing cotton socks27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of suddenonset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold,cadaverous left calf. While the physician determines the appropriate management, you should:A. shave the affected leg in anticipation of surgery C. keep the affected leg level or slightlydependent

4B. place a healing pad around the calf D. elevate the affected calf as high as possible28. Peripheral neuropathies primarily affect:A. sensory functions C. optic functionsB. vascular functions D. motor functions29. Peripheral neuropathy can BEST be controlled by:A. good glucose control C. vitamin supplementB. steroid therapy D. nothing, there is no slowing the process30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a clientwith:A. hypertension C. liver diseaseB. hyperthyroidism D. diabetes insipidusSituation 7: You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are theircommon concerns. You should be able to address their concerns in a holistic manner.31. The WHO analgesic ladder provides the health professional with:A. specific pain management choices based on severity of painB. general pain management choices based on level of painC. pharmacologic and nonpharmacologic pain management choicesD. nonpharmacologic interventions based on level of pain32. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT:A. pruritus C. constipationB. respiratory depression D. physical dependence33. Which of the following statements about cancer pain is NOT true?A. opioids are drugs of choice for severe painB. pain associated with cancer and the terminal phase of the disease occurs in majority of patientsC. under treatment of pain is often due to a clinician’s failure or inability to evaluate or appreciate the severity ofthe client’s problemD. adjuvant medications such as steroids, anti convulsants, nonsteroidal anti-inflammatory drugsenhance pain perception34. TR has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he hasbeen receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, youwould suspect that TR is:A. becoming psychologically dependent C. needing to have the morphine discontinuedB. developing tolerance to the morphine D. exaggerating his level of pain35. The guidelines for choosing appropriate nonpharmacologic intervention for pain include all of the following EXPECT:A. effectiveness for patient C. skill of the clinician health professionalB. pain problem identification D. type of opioid being usedSituation 8: To be able to provide care for patients in the critical areas, you should look into factors that will enhanceyour ability to provide quality nursing care.36. Research study show that nurses who work with critically patients as opposed to nurses who work with less acutepatient:A. are more satisfied with their role C. are most acceptable to burn outB. move a greater support system D. experience greater stress37. Which of the components of HARDINESS has been linked to burnout?A. less commitment to work C. a sense of control over the patientB. perception of change D. sense of control to life

538. Nurses who work with critically ill patients should base their practice on all of the following EXCEPT:A. recognition and appreciation of a person’s unique and social environmental relationshipsB. delegated responsibilityC. thorough knowledge of the interrelatedness of body systemD. appreciation of the collaborative role of all health team members39. Common aspects of the critical care nursing role include:A. disaster management C. direct care providerB. staff liaison D. community referral40. Which of the following interventions would support your patient’s circadian rhythm cycle?A. putting a wall clock up on your patient’s roomB. decreasing environmental noiseC. encouraging normal bowel movementD. dimming light during normal sleeping timeSituation 9: To ensure continuity of care and for legal purposes, you have important responsibilities to accuratelydocument all nursing activities.41. For the past 24 hours, TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluidintake of 800 ml. TD’s urine is dark amber. These assessments indicate which nursing diagnosis?A. Impaired urinary elimination C. Excessive fluid volumeB. Deficient fluid volume D. Imbalanced nutrition: less than body requirement42. Which document addresses the patient’s right to information, informed consent and treatment refusal?A. Code for Nurses C. Patient’s Bill of RightsB. Nursing Practice Act D. Standard of Nursing Practice43. You are caring for GG with a history of falls. The FIRST PRIORITY when caring for GG who is at risk for falls is:A. instruct GG not to get out of bed unassistedB. keep the bedpan available so she does not have to get out of bedC. placing the call light for easy accessD. keep the bed at the lowest position ever44. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm.You notice that JJ is restless, slightly diaphoretic, and has a temperature of 37.8 deg C, heart rate of 10 beats/min.;regular, slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. Which nursing diagnosistakes HIGHEST PRIORITY?A. decreased cardiac output C. acute painB. anxiety D. risk for imbalanced body temperature45. FF, has a nursing diagnosis of “Risk for injury related to adverse effects of potassium-wasting diuretics”. What’s thecorrect written client outcome for this diagnosis?A. FF states the importance of eating potassium rich foods dailyB. Upon discharge, FF knows which food sources are rich in potassiumC. Upon discharge, FF correctly identifies three potassium rich foodsD. FF knows all the complications of the disease processSituation 10: You are taking care of LC who develops acute respiratory distress. An endotracheal tube had to beinserted to correct the hypoxia.46. The primary purpose of the endotracheal tube cuff is to:A. seal off the oropharynx from the nasopharynx C. seal off the oropharynx from the esophagusB. seal off the lower airway from the esophagus D. seal off the lower airway from the upper airway47. Endotracheal tube size indicated on the tube reflects what measurements:A. the circumference size of the tube C. the internal diameter of the tube

B. the length of the tube D. the length of the person’s airway648. In adults, an inflated E-T tube cuff is necessary for mechanical ventilation primarily because:A. it seals off the lower airway from the upper airwayB. it prevents air from getting into the stomachC. it seals off the nasopharynx from the oropharynxD. it prevents stomach contents from getting into the lungs49. Endotracheal tube size indicated on the tube reflects what measurements:A. the internal diameter of the tube C. the circumference size of the tubeB. the length of the person’s airway D. the length of the tube50. Which of the following statements is TRUE about securing the artificial airway?A. artificial airways must be secured directly to the patientB. the airway is generally sutured in placeC. a nasotracheal tube does not require securingD. the inflated cuff provides sufficient securingSituation 11: Because of the serious effects of severe burns, management requires a multidisciplinary approach. Youhave important responsibilities as a nurse.51. When caring for DS, who sustained 40% severe flame burn yesterday, which among these interventions should beyour PRIORITY?A. provide a calm, efficient and safe environmentB. keep the body parts in good alignment to prevent contracturesC. assess for airway, breathing and circulation problemsD. assess the injury for signs of sepsis52. Your primary therapeutic goal for DS during the ACUTE PHASE is:a. wound healing c. emotional supportb. reconstructive surgery d. fluid resuscitation53. CV who sustained upper torso and neck burns. Which action is MOST likely to cause a functional contracture?a. hourly hyperextension neck exercisesb. helping the patient to a position of comfortc. encouraging self-cared. discouraging pillows behind the head54. AW, 3 year old boy just sustained full thickness burns of the face, chest and neck. What will be your PRIORITYnursing action?a. Risk for infection related to epidermal disruptionb. Impaired urinary elimination related to fluid lossc. Ineffective airway clearance related to edemad. Impaired body image related to physical appearance55. FG, with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascularchecks to detect:a. hypothermia c. arteriosclerotic changesb. ischemia d. adequate wound healingSituation 12: Infection can cause debilitating consequences when host’s resistance is compromised and environmentalfactors are favorable. As a nurse you have important roles and responsibilities in infection control.56. EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. To assess her risk factors, whatquestion should you ask?a. “Have you taken any analgesic recently?”b. “Do you have pain at your back?”c. “Do you hold your urine for a long time before voiding?”d. “Have you had any sore throat lately?”

757. While caring for a patient with an infected surgical incision, you observe for signs of systemic response. These includeall of the following EXCEPT:a. a febrile state due to release of pyrogensb. anorexia, malaise, and weaknessc. loss of appetite and paind. leukopenia due to increased WBC production58. One of the MOST effective nursing procedures for reducing nosocomial infection is:a. proper handwashing techniqueb. aseptic wound carec. control of upper respiratory tract infectiond. administration of prophylactic antibiotic59. A wound that has hemorrhaged has increased risk for infection because:a. dead space and dead cells provide a culture mediumb. retrograde bacterial contamination may occurc. the tissue becomes less resilientd. of reduced amounts of oxygen and nutrients are available60. You are instructing EP regarding skin tests for hypersensitivity reactions. You should teach her to:a. stay out of the sun until the skin tests are readb. come back on the specified date to have the skin tests readc. wash skin test areas with soap and water dailyd. keep skin test areas moist with mild lotion.Situation 13: TR attends a Health Education Class on colostomy care. The following are taken up: types of ostomies,indications and care.61. A colostomy can BEST be defined as:a. cutting the colon and bringing the proximal end through the abdominal wallb. creating a stomal orifice from the ileumc. excising a section of the colon and doing an end-to-end anastomosisd. removing the rectum and suturing the colon to the anus.62. When an abdominoperineal resection is done, the patient should be informed he/she will have a;a. temporary colostomy c. transverse loop colostomyb. permanent colostomy d. double-barreled63. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT:a. corn and peanuts c. mangoes and pineapplesb. cabbage and asparagus d. chewing gum and carbonated beverages64. During the first post operative week, the nurse can BEST help the patient with a colostomy to accept the change inbody image by:a. changing the dressing just prior to mealsb. encouraging the patient to observe the stoma and its carec. deodorizing the room periodically with a spray cand. applying a large bulky dressing over the stoma to decrease odorsSituation 14: These are gastrointestinal disease that can compromise life and that would necessitate extensive surgicalmanagement. You are assigned to take care of a patient with such a condition.66. BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy.Before surgery, a low residue diet is ordered. You explain to BC that this is necessary to:a. prevent irritation of the intestinal mucosab. reduce the amount of stool in the large bowelc. limit production of flatus in the intestinesd. lower the bacterial count in the GI tract8

67. Several days prior to bowel surgery, the patient may be given sulfasuxidine and neomycin, primarily to:a. soften the stool by retaining water in the colonb. reduce the bacterial content of the colonc. empty the bowel of solid wasted. promote rest of the bowel by minimizing peristalsis68. To promote perineal wound healing after an abdominoperineal resection, you should encourage BC to assume:a. dorsal recumbent positionb. left or right Sim’s positionc. left or right side lying positiond. knee-chest position69. BC returns from surgery with a permanent colostomy. During the 24 hours, the colostomy does not drain. You, as thenurse should realize that this is a result of:a. the absence of intestinal motilityb. a presurgical decrease in fluid intakec. proper functioning of the nasogastric tubed. intestinal edema following surgery70. On the second day following abdominoperineal resection, you anticipate that the colostomy stoma will appear:a. moist, pink, with flushed skin and painful when touchedb. moist, red and raised above the skin surfacec. dry, pale pink and with flushed skind. dry, purple and depressed below the skin surfaceSituation 15: Specific surgical interventions may be done when lung cancer is detected early. You have important perioperativeresponsibilities in caring for patients with lung cancer.71. GM is scheduled to have lobectomy. The purpose of closed chest drainage following a lobectomy is:a. expansion of the remaining lungb. facilitation of coughingc. prevention of mediastinal shiftd. promotion of wound healing72. Following thoracic surgery, you can BEST help GM to reduce pian during the deep breathing and coughing exercisesby:a. splinting the patient’s chest with both hands during the exercisesb. administering the prescribed analgesic immediately prior to exercisesc. providing rest for 6 hours before exercisesd. placing the patient on his/her operative side during exercises73. During the immediate post operative period following a pneumonectomy, deep tracheal suction should be done withextreme caution because:a. the remaining normal lung needs minimal stimulationb. the patient will not be able to tolerate coughingc. the tracheobronchial tree are dryd. the bronchial suture line maybe traumatized74. What should you do as a nurse when the chest tubing is accidentally disconnected?a. reconnect the tube c. notify the physicianb. change the tubing d. clamp the tubing75. Which of the following observations indicates that the closed chest drainage system is functioning properly?a. less than 25 ml drainage in the drainage bottleb. absence of bubbling in the suction-control bottlec. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspirationd. intermittent bubbling through the long tube of the suction control bottle.

9Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. As a nurse of BLwhich of the following nursing diagnosis will be your PRIORITY?76. BL was brought to the Emergency Room for severe left flunk pain, nausea and vomiting. The physician gave atentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be yourPRIORITY?a. imbalance nutrition: less than body requirementsb. impaired urinary eliminationc. acute paind. risk for infection77. Which of the following is the appropriate intervention for BL who has ureterolithiasis?a. inserting an indwelling urinary catheterb. administering opioid analgesics preferably intravenouslyc. administering intravenous solution at a keep vein open rated. inserting a nasogastric tube (low suction)78. You are caring for YA, 30 year old business woman, with renal stones. Her skin and mucous membranes are dry andher 24 hour intake and output record reveal an oral intake of 900 ml and a urinary output of 700 ml. Her urine is darkamber. Based on the above data, your nursing diagnosis is:a. imbalance nutrition, less than body requirementsb. fluid volume deficitc. impaired urinary eliminationd. knowledge deficit regarding health79. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urinespecimen for culture and sensitivity?a. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urineb. drain urine from the drainage bag into the sterile containerc. disconnect the tubing from the urinary catheter and let urine flow into a sterile containerd. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle80. You are caring for WE, a 56 year old man who is dehydrated and with urinary incontinent. Upon physical examination,you noted perineal excoriation. What will be your PRIORITY intervention?a. orient him to time, person and placeb. offer the bed pan every 4 hoursc. encourage oral fluid intaked. keep the perineal area clean, and drySituation 17: You are caring for several patients with various disease problems.81. You are obtaining a history of MR. who is admitted with acute chest pain. Which question will be MOST HELPFUL foryou to ask?a. Why do you think you had a heart attack?b. Do you need anything now?c. What seem you doing when the pain started?d. Has anyone in your family been sick lately?82. BO who received general anesthesia returns from surgery. Post-operatively, which nursing diagnosis takes HIGHESTPRIORITY for BO?A. impaired physical mobility related to surgeryB. decrease fluid volume related to blood and fluid loss from surgeryC. risk for infection related to anesthesiaD. acute pain related to surgery

83. WW is blind. She is admitted for treatment of gastroenteritis. Which nursing diagnosis takes HIGHEST PRIORITY forWW?10A. anxiety C. activity intoleranceB. risk for injury D. impaired physical mobility84. You are documenting your care for CC who has iron deficiency anemia. Which nursing diagnosis is MOSTappropriate?A. ineffective breathing pattern C. deficient fluid volumeB. impaired gas exchange D. ineffective airway clearance85. RR, age 89, has terminal cancer, he demonstrates signs of dementia. You should give HIGHEST PRIORITY to whichnursing diagnosis:A. risk for injury C. ineffective cerebral tissue perfusionB. bathing or hygiene self care deficit D. dysfunctional grievingSituation 18: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissectinganeurysm of the aorta.86. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, howlong should you infuse it?A. 6 hours C. 4 hoursB. 1 hour D. 2 hours87. What should you do FIRST before you administer blood transfusion?A. verify client identity and blood product, serial number, blood type, cross matching results, expiration dateB. verify client identity and blood product serial number, blood type, cross matching results, expiration datewithanother nurseC. check IV site and use appropriate BT set and needleD. verify physician’s order88. As WQ’s nurse, what will you do AFTER the transfusion has started?A. add the total amount of blood to be transfused to the intake and outputB. discontinue the primary IV of Dextrose 5% WaterC. check the vital signs every 15 minutesD. stay with WQ for 15 minutes to note for any possible BT reactions89. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:A. oliguria and jaundice C. hypertension and flushingB. urticaria and wheezing D. headache, chills, fever90. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physicianB. stop the blood transfusion and monitor the patient closelyC. immediately stop the BT, infuse NSS, call the physician, notify the blood bankD. immediately stop the BT, notify the blood bank and administer antihistaminesSituation 19. The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in thekidney’s functions can cause disease. As a nurse it is important that you understand the rationale behind the treatmentregimen used.91. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10days. Which assessment parameter for kidney function will you use during the oliguric phase?A. urine output directly related to the amount of IV fluid infusedB. urine output is less than 400 ml/24 hours

C. urine output of 30-60 ml/hourD. no urine output, kidneys in a state of suspension92. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?A. increased urine output, increased absorption of sodium and water11B. decreased urine output, decreased absorption of sodium and waterC. increased urine output, decreased absorption of sodium and waterD. decreased urine output, increased absorption of sodium and water93. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do isto start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:A. hyperkalemia C. hypokalemiaB. hypercalcemia D. hypernatremia94. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. Whatdiet instructions will you need to reinforce prior to his discharge?A. drink plenty of water C. monitor your fruit intake and eat plenty of bananasB. restrict your salt intake D. be sure to eat meat every meal95. BN, is also advised not to use salt substitute in the diet because:A. salt substitute contain potassium which must be limited to prevent arrhythmiasB. limiting salt substitutes in the diet prevents a buildup of waste products in the bloodC. fluid retention is enhanced when salt substitutes are included in the dietD. a substance in the salt substitute interferes with fluid transfer across the capillary membraneSituation 20. You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are commonconcerns experienced by them. You should be able to address the concerns in a holistic manner.96. Pain in the elder persons require careful assessment because they:A. experienced reduce sensory perceptionB. have increased sensory perceptionC. are expected to experience chronic painD. have a decreased pain threshold97. Administration of analgesics to the older persons requires careful patient assessment because older people:A. are more sensitive to drugsB. have increased hepatic, renal and gastrointestinal functionC. have increased sensory perceptionD. mobilize drugs more rapidly98. The elderly patient is at higher risk for urinary incontinence because of:A. increased glomerular filtration C. decreased bladder capacityB. diuretic use D. dilated urethra99. Which of the following is the MOST COMMON sign of infection among the elderly?A. decreased breath sounds with crackles C. painB. fever D. change in mental status100. Priorities when caring for the elderly trauma patient:A. circulation, airway, breathing C. airway, breathing, disability (neurologic)B. disability (neurologic), airway, breathing D. airway, breathing, circulation