Skills Lab 101 & 101a

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Questions and Answers
  • 1. 
    You are working on a medical surgical ward, Celine is one of your patients. She is a 27 year old female who is about to undergo caesarian section for her first baby. The doctor gave you an order for catheterization. As a prudent nurse, what should you prepare
    • A. 

      Clean technique.

    • B. 

      Bag technique.

    • C. 

      Sterile technique.

    • D. 

      Septic technique.

  • 2. 
    • A. 

      At the side rails of the bed.

    • B. 

      At the bed frame.

    • C. 

      At the foot of the bed.

    • D. 

      At the head of the bed. d. At the head of the bed.

  • 3. 
    You opened the urine bag. Where should you place it?
    • A. 

      Open gravity drainage system.

    • B. 

      Closed gravity drainage system.

    • C. 

      Open-closed drainage system.

    • D. 

      None of the above.

  • 4. 
    How will you position the female patient for the catheter insertion?
    • A. 

      Supine with legs extended.

    • B. 

      Supine with thighs abducted.

    • C. 

      Supine with knees flexed about two feet apart.

    • D. 

      Supine with legs on the stir ups.

  • 5. 
    You will lubricate the catheter prior to insertion. In a female patient, how many inches of the catheter would you lubricate?
    • A. 

      1-2 inches

    • B. 

      3-4 inches

    • C. 

      1 inch

    • D. 

      7 inches.

  • 6. 
    Prior to catheterization, you will render perineal care to a female client. What solution will you use?
    • A. 

      Feminine wash.

    • B. 

      Antiseptic solution.

    • C. 

      Normal saline solution.

    • D. 

      Sanitary solution.

  • 7. 
    When cleansing the urinary meatus, you will:
    • A. 

      Move the swab upward.

    • B. 

      Move the swab sideways

    • C. 

      Move the swab downwards.

    • D. 

      Move the swab in circular motion.

  • 8. 
    While attempting to insert the catheter, its tip accidentally came in contact with the labia, as a prudent nurse, what should you do?
    • A. 

      Continue on catheter insertion.

    • B. 

      Get a new catheter.

    • C. 

      Apply lubricant to the tip of the catheter.

    • D. 

      Check for the catheters sterility.

  • 9. 
    How many ml of sterile water will you use in inflating the retention balloon to an adult client?
    • A. 

      3 ml

    • B. 

      5 ml

    • C. 

      15 ml

    • D. 

      30 ml

  • 10. 
    While trying to inflate the balloon, the patient complained of pain. The appropriate nursing action would be:
    • A. 

      Continue on insertion.

    • B. 

      Encourage her to take a deep breath.

    • C. 

      Aspirate the instilled fluid and advance the catheter further.

    • D. 

      Introduce 5 ml of sterile water.

  • 11. 
    You have inflated the catheter’s retention balloon, what will you do next?
    • A. 

      Aspirate the sterile water.

    • B. 

      Tape the catheter on the outer thigh.

    • C. 

      Check for patency.

    • D. 

      Retract the catheter.

  • 12. 
    The physician also ordered a cleansing enema for a client. You will be using isotonic solution. An example of this is:
    • A. 

      Fleet phosphate.

    • B. 

      Castor oil.

    • C. 

      Tap water.

    • D. 

      Normal saline solution.

  • 13. 
    You will perform a high cleansing enema. How many position changes would you tell the client to do?
    • A. 

      Two.

    • B. 

      Three.

    • C. 

      One.

    • D. 

      Four.

  • 14. 
    What is the safest solution to use in enema administration?
    • A. 

      Saline solution.

    • B. 

      Oil.

    • C. 

      Fleet phosphate.

    • D. 

      Tap water.

  • 15. 
    Prior to enema, what will you place on the client’s bed?
    • A. 

      Rubber sheet.

    • B. 

      Fenestrated drapes.

    • C. 

      Sterile drapes.

    • D. 

      Wet packs.

  • 16. 
    As a competent nurse, you would know that the appropriate height of the enema can from the patient’s anus is:
    • A. 

      12-24 inches.

    • B. 

      12-18 inches.

    • C. 

      16-20 inches.

    • D. 

      10-12 inches.

  • 17. 
    What is the main purpose of enema administration in a patient who is about to undergo laparotomy?
    • A. 

      To avoid accidental contamination of the abdominal contents.

    • B. 

      To relieve flatulence.

    • C. 

      To expel flatus and impacted stools.

    • D. 

      To expel stools and impacted cerumen.

  • 18. 
    How will you position the patient during enema administration?
    • A. 

      Left sims position.

    • B. 

      Right sims position.

    • C. 

      Dorsal recumbent position.

    • D. 

      Side lying position.

  • 19. 
    You primed the enema tubing’s and rectal tube before introducing the solution to the patient. The rationale behind this action is:
    • A. 

      To avoid unnecessary distention.

    • B. 

      To promote asepsis.

    • C. 

      To expel air in the tubing.

    • D. 

      To instill air into the rectum.

  • 20. 
    Prior to insertion of the rectal tube, you will:
    • A. 

      Cleanse the patient’s buttocks.

    • B. 

      Cleanse the tip of the rectal tube.

    • C. 

      Lubricate at least 2 inches of the tube.

    • D. 

      Lubricate the entire tube.

  • 21. 
    • A. 

      This position facilitates the flow of solution to the stomach.

    • B. 

      This position facilitates the flow of solution to the small intestines.

    • C. 

      This position facilitates the flow of solution to the colons.

    • D. 

      This position facilitates the flow of solution to the anus.

  • 22. 
    Upon insertion of the rectal tube, you instructed your client to take a deep breath, because
    • A. 

      This will relieve her anxiety.

    • B. 

      This will relax the rectum

    • C. 

      This will relax the internal anal sphincter.

    • D. 

      This will alleviate her pain.

  • 23. 
    While inserting the rectal tube, you encountered resistance. The appropriate action will be:
    • A. 

      Assess for bowel sounds and check the tubes patency.

    • B. 

      Slowly administer the enema solution.

    • C. 

      Run a small amount of solution to the tube.

    • D. 

      Lower the enema can.

  • 24. 
    The appropriate length of rectal tube to be inserted a 27 year old client is:
    • A. 

      3-4 inches.

    • B. 

      2-2.5 inches.

    • C. 

      1-2 inches.

    • D. 

      5 inches

  • 25. 
    While instilling the solution for enema, your patient  suddenly complained of fullness. The appropriate nursing action to do is:
    • A. 

      Slow the flow of the solution.

    • B. 

      Stop the flow of the solution for 1 minute.

    • C. 

      Twist the tube to facilitate the flow.

    • D. 

      Raise the enema can.

  • 26. 
    • A. 

      Lower the enema can and continue administering the solution.

    • B. 

      Remove the tube and encourage the patient to defecate.

    • C. 

      Remove the tube and encourage the patient to retain the solution.

    • D. 

      Place Celine in a side lying position.

  • 27. 
    How long will you encourage the patient to hold the solution after enema administration?
    • A. 

      At least 30 minutes.

    • B. 

      At least 5-10 minutes.

    • C. 

      For an hour.

    • D. 

      For 3 hours.

  • 28. 
    A commonly used hypertonic enema is:
    • A. 

      Castile soap.

    • B. 

      Mineral oil.

    • C. 

      Tap water.

    • D. 

      Fleet phosphate.

  • 29. 
    All enema solutions have side effects, except:
    • A. 

      Soapsuds.

    • B. 

      Saline.

    • C. 

      Tap water.

    • D. 

      Mineral oil

  • 30. 
    You are going to give fleet phosphate enema. How many ml of solution will you administer?
    • A. 

      90-120 ml.

    • B. 

      500 ml.

    • C. 

      500-100 ml

    • D. 

      200 ml

  • 31. 
    You are aware that upon enema tube insertion, you will direct it:
    • A. 

      Towards the rectum.

    • B. 

      Towards the umbilicus

    • C. 

      Along the spine

    • D. 

      Towards the cecum.

  • 32. 
    Celine’s last menstrual period was on November 3, 2008. What is her EDD?
    • A. 

      August 10, 2009

    • B. 

      August 15, 2009

    • C. 

      August 10,2008

    • D. 

      August 15, 2008

  • 33. 
    Celine’s fundic height is 32cm. What would be her estimated AOG?
    • A. 

      28 weeks and 5 days.

    • B. 

      37 weeks and 7 days.

    • C. 

      28 weeks and 6 days

    • D. 

      30 weeks and 5 days.

  • 34. 
    What would be the client’s fundic height if her AOG is 24 weeks?
    • A. 

      At the level of the umbilicus.

    • B. 

      Below the symphysis pubis.

    • C. 

      Two finger breaths above the umbilicus.

    • D. 

      At the xiphoid process.

  • 35. 
    You performed Leopold’s maneuver. The third maneuver is also known as the:
    • A. 

      Pelvic grip

    • B. 

      Pawlick’s grip

    • C. 

      Pavlick grip

    • D. 

      Paulick’s grip.

  • 36. 
    The third maneuver, aims to determine:
    • A. 

      Determine the fetal’s degree of flexion.

    • B. 

      Determine the location of back and extremities of the fetus.

    • C. 

      Determine if the fetus is already engaged.

    • D. 

      Determine the fetal attitude.

  • 37. 
    • A. 

      Place the infant in a side lying position and suction.

    • B. 

      Place the infant in a trendelenburg position and suction.

    • C. 

      Place the infant tin a side lying position and rub dry.

    • D. 

      Place the infant in a side lying position under a drop light.

  • 38. 
    <!--[if !supportLists]-->what would the nurse suction first and why?
    • A. 

      The mouth because it has more secretions than the nose.

    • B. 

      The nose because it has less secretions than the mouth.

    • C. 

      The nose to prevent aspiration.

    • D. 

      The mouth to prevent aspiration.

  • 39. 
    You are performing APGAR scoring. The baby is acrocyanotic, apical pulse rate of 138 bpm, good vigorous cry, with good muscle tone and respiration of 40 cpm. What is the initial apgar score?
    • A. 

      8

    • B. 

      6

    • C. 

      9

    • D. 

      7

  • 40. 
    The nurse checked for the infant’s temperature using the rectal route. This is done because:
    • A. 

      Rectal route is most convenient.

    • B. 

      Rectal route is accurate and it also determines the presence of imperforate anus.

    • C. 

      Rectal route is accurate and effective.

    • D. 

      Rectal route is the safest.

  • 41. 
    You are using aseptic technique upon cleaning the infants umbilical cord in order to:
    • A. 

      Promote the infants well-being.

    • B. 

      To keep the cord from exposure.

    • C. 

      To prevent infection

    • D. 

      To speed up drying process.

  • 42. 
    After cleaning the cord, the nurse applied a sterile cord clamp. This is done in order to:
    • A. 

      Prevent bleeding.

    • B. 

      Hasten the drying process.

    • C. 

      Aid in infants breathing.

    • D. 

      Keep the cord fresh

  • 43. 
    The nurse gave crede’s prophylaxis to the fetus. You are aware that this will:
    • A. 

      Prevent conjunctivitis due to syphilis.

    • B. 

      Prevent blindness secondary to herpes.

    • C. 

      Prevent blindness secondary to gonorrhea.

    • D. 

      Prevent blindness due to candidiasis.

  • 44. 
    The nurse gave Vit K IM to the infant’s vastus lateralis muscle. You are aware that this action is appropriate because:
    • A. 

      This muscle the most convenient site for injection.

    • B. 

      Because this is the most developed muscle in the infant’s body.

    • C. 

      Because vit K is irritating to the subcutaneous tissue.

    • D. 

      Aquamephyton is the generic name of vit k.

  • 45. 
    • A. 

      The cord can get contaminated.

    • B. 

      Wet cord is a good breeding ground for antibodies.

    • C. 

      Wet cord is a good breeding ground for bacteria.

    • D. 

      Wet cord can be a source of malnutrition.

  • 46. 
    While examining the newborn, you noticed a soft spot between his parietal and frontal bones, you are aware that this is the:
    • A. 

      Suture lines.

    • B. 

      Cranium

    • C. 

      Anterior fontanel.

    • D. 

      Posterior fontanel.

  • 47. 
    You are aware that the posterior fontanel is:
    • A. 

      At the temporal bone.

    • B. 

      At the frontal bone.

    • C. 

      Diamond in shape.

    • D. 

      Triangular in shape.

  • 48. 
    Premature closure of the fontanels is known as:
    • A. 

      A. Craniosystosis

    • B. 

      B. Craniostenosis.

    • C. 

      C. Craniumsystosis.

    • D. 

      D. Craniophlebitis.

  • 49. 
    The neonate’s normal body length is:
    • A. 

      44-52cm

    • B. 

      46-57cm

    • C. 

      46-54cm

    • D. 

      42-54cm

  • 50. 
    You advised your classmate to do a pregnancy test, the result came positive, you are aware that her urine contains:
    • A. 

      Somatrophin

    • B. 

      Gonadotrophin

    • C. 

      Androgen

    • D. 

      Albumin

  • 51. 
    Your patient complained of delay in urine stream and pain while voiding. this is known as:
    • A. 

      Dysuria and nocturia

    • B. 

      Dysuria and hesitancy

    • C. 

      Dysuria and urgency

    • D. 

      Dysuria and frequency

  • 52. 
    Your patient voids rusty brown urine. You would suspect:
    • A. 

      Melena

    • B. 

      Albuminuria

    • C. 

      Hematuria

    • D. 

      Ketonuria

  • 53. 
    This type of catheter is used only during spot urine specimen collection or when measuring the residual urine.
    • A. 

      Three way foley catheter.

    • B. 

      Two way foley catheter.

    • C. 

      Straight catheter.

    • D. 

      Caude catheter.

  • 54. 
    Silicone catheter can be used for up to:
    • A. 

      2 months

    • B. 

      3 days

    • C. 

      20 minutes

    • D. 

      Once

  • 55. 
    You advised your classmate to do a pregnancy test, the result came positive, you are aware that her urine contains:
    • A. 

      Albumin

    • B. 

      Somatotrophin

    • C. 

      Gonadotrophin

    • D. 

      Oxytocin

  • 56. 
    Maria’s last menstruation l period was 3 months ago, she is suspecting pregnancy. Upon palpation of her fundus, you would anticipate that it is at the level of the:
    • A. 

      Umbilicus

    • B. 

      Below the pelvis

    • C. 

      Above symphysis pubis.

    • D. 

      Two fingerbreaths above the umbilicus.

  • 57. 
    Maria’s LMP was April 20, 2009. When is her EDD?
    • A. 

      January 26, 2010

    • B. 

      January 25, 2010

    • C. 

      January 27, 2009

    • D. 

      January 27, 2010

  • 58. 
    You will be performing Leopold’s maneuver, what will you instruct your client to do prior to the procedure?
    • A. 

      Take deep breaths to relax the abdomen.

    • B. 

      Void to avoid escape of urine due to pressure on the abdomen.

    • C. 

      Void to promote relaxation.

    • D. 

      Instruct the client that there will be some discomfort.

  • 59. 
    What will you do, prior to palpating the fundus of a pregnant client?
    • A. 

      Wash hands and don gloves.

    • B. 

      Wash and warm the hands.

    • C. 

      Cut fingernails and wash hands.

    • D. 

      Cleanse the abdomen and warm hands.

  • 60. 
    The nurse who is assigned at the pediatric ward observed that Toby, a 3 year old boy is having nocturnal enuresis. You are aware that:
    • A. 

      Enuresis is a voluntary passing of urine and normal.

    • B. 

      Enuresis is an involuntary passing of urine and abnormal.

    • C. 

      Enuresis is an involuntary passing of urine and normal.

    • D. 

      Enuresis is a voluntary passing of urine and abnormal.

  • 61. 
    Nocturnal frequency is often associated with:
    • A. 

      Age

    • B. 

      Stress

    • C. 

      Bladder habbits

    • D. 

      Work

  • 62. 
    Your patients last urine output was 1 hour ago and amounts to 40ml. upon palpation of her bladder, you noted that it is firm, distended and displaced to one side of the midline. You will suspect for:
    • A. 

      urinary incontinence

    • B. 

      urinary retention

    • C. 

      urinary frequency

    • D. 

      urinary hesitancy

  • 63. 
    The nurse will administer an enema solution to a 5 year old boy. How will she position the child?
    • A. 

      Semi-fowlers.

    • B. 

      Supine.

    • C. 

      Dorsal recumbent

    • D. 

      Sitting position

  • 64. 
    The physician ordered digital removal of fecal impaction. Before disimpaction, it is suggested that:
    • A. 

      Carminative enema be given 30 minutes prior.

    • B. 

      Oil retention enema be given 30 minutes prior.

    • C. 

      Return flow enema be given 30 minutes prior.

    • D. 

      Cleansing enema be given 30 minutes prior.

  • 65. 
    While doing digital removal of fecal impaction, the nurse periodically assess for:
    • A. 

      Change in pulse rate and blood pressure.

    • B. 

      Respiratory rate and temperature.

    • C. 

      None

    • D. 

      Both

  • 66. 
    Drug of choice for crede’s prophylaxis.
    • A. 

      Nitramycin sulfate

    • B. 

      Erythromycin eye solution

    • C. 

      Erythromycin eye ointment

    • D. 

      Silver mitrate

  • 67. 
    Upon the delivery of the placenta, the nurse noticed that it is dark and has small globular shaped masses on it. Upon knowing this, the  placental presentation is known as:
    • A. 

      Schultze

    • B. 

      Dancan

    • C. 

      Schultz

    • D. 

      Duncan

  • 68. 
    After the delivery of the baby, the mother exhibited sudden gush of blood from her vagina. This is one of the signs of:
    • A. 

      Placental separation.

    • B. 

      Operculum

    • C. 

      Rupture of membranes.

    • D. 

      Second stage of labor.