Dec 2007 Nursing Board

NURSING PRACTICE 1 – Foundation of PROFESSIONAL Nursing Practice 1. Nurse Suzie is administering 12:00 PM 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? A. B. C. D.

Ask the client if she is Mrs. Santos Ask the client his name Ask the room mate if the client is Mrs. Santos Compare the ID band with the bed bag

2. Lizette, a head nurse in surgical unit, hears one of the staff nurses 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? A. B. C. D.

“Use touch when the situation calls for it” “Touch serves as a connection between the nurse and the patient” “Use touch with discretion” “Touch is used in physical assessment”

3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly? A. B. C. D.

The cane and one foot or both feet are on the floor at all lines He advances the cane followed by the left leg Client keeps the cane on the right side along the weak leg Client leans to the left side which stronger

4. George, a 43 year old executive, is scheduled for cardiac bypass surgery. While being prepared for 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? A. “Without the surgery you will most likely die sooner” B. “There are always risks involved with surgery.” C. “There is a client in the other room who had successful surgery and you can talk to him” D. “This must be very frightening for you. Tell me how you feel about the surgery” 5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction b the nurse? A. B. C. D.

Report to the physician the effects of the medication or urination Take the medicine early in the morning Take a full glass of water with the medicine Measure frequency of urination in 24 hours

6. Nurse Glenda gets a call from a neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? A. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood B. Recommend to bring the child immediately to the hospital C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve. Bring the child to the hospital 7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular accident. While being transported to the X-ray department, the straps accidentally broke and the client to the floor hitting his head. In this situation, the nurse is: A. Not responsible because of the doctrine of respondent superior B. Free from any negligence that caused harm to the patient C. Liable along with the employer for the use of a defective equipment that harms the client D. Totally responsible for the negligence 8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna? A. B. C. D.

Ignore the incidence Report the incidence to the head nurse Respect the client’s actions as this provides structure and support to the client Call her attention so she can go to sleep

9. A client asks for advice on low cholesterol food. You advise the client to eat the following: A. B. C. D.

Chicken liver, cow liver, eggs Lean beef and pork, egg white, fish Balut, salted eggs, duck and chicken egg Pork liempo, cow brain, lungs and kidney

10. The code of ethics for nurses has an interpretative statement that provides: A. Continuity of care for the improvement of the client B. Guide for carrying out nursing responsibilities that the provide quality care and for the ethical obligation of the profession C. Standards of care in carrying out nursing responsibilities D. Identical care to all clients in any setting 11. Which of the following situations would possibly cause a nurse to be sued due to negligence?

A. Nurse gave a client wrong medication and an hour later, client complained of dyspnea B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the client’s medicine cup C. As the nurse was about to administer edication, the client questioned why the medication is still given when in fact the physician discontinued it D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error and complained 12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital? A. B. C. D.

Diabetic client type 2 Client with chronic obstructive pulmonary disease (COPD)\ Client wit second degree burns Client with psoriasis

13. 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? A. B. C. D.

“Don’t worry. I will call the attention of your wife” “Your wife is just trying to help because she is worried about you” “What are your thoughts about your wife’s involvement in your care”? “Your wife can assist you well in your care and recovery:

14. The nurse is in the hospital canteen and hears who 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? A. Approach the two nurses and tell them their actions are inappropriate especially in a public place B. Wait till nurses finish the discussion ad report the situation to the supervisor C. Sa nothing to avoid embarrassing the staff nurses D. Remain quiet and ignore the discussion 15. The son Mr. Rosario, a 76 year old man, reports to the nursing the community health center that his father has been getting out of bed at night and walks around the house in the early hours of the morning causing him to fall and injure himself. Which instruction will you give? A. Apply restrains during the night hours only B. Advise hospitalization to prevent future accidents C. Keep a radio or TV for company and to orient the client D. Have some check on the client frequently at night SITUATIONAL

Situation 1 – Preparation and administration of the medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save patient’s lives. 16. You are to administer an intramuscular injection to Dulce, 1 ½ year old girl. The most appropriate site to administer the drug is: A. Dorso gluteal region B. Ventral forearm

C. Vastus lateralis D. Gluteal region

17. An infant is ordered to receive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 drops/minute. How many drops per minute should flow rate be? A. 60 drops per minute B. 21 drops per minute

C. 30 drops per minute D. 15 drops per minute

18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? A. 42 drops B. 20 drops

C. 60 drops D. 32 drops

19. Mr. Largo is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minute should the IV be regulated? A. 13-14 drops B. 17-18 drops

C. 10-12 drops D. 15-16 drops

20. The physician ordered Nembutal Na gr XX. The bottle contains 100 mg/capsule. How many capsules will be administered to the client? A. 1 capsule B. 1 ½ capsule

C. 2 capsule D. ½ capsule

Situation 2 – The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved 21. 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: A. B. C. D.

Tell the nurse how to give bed baths correctly Ask another staff nurse to do the bed baths instead Provide a manual to be read on giving bed baths Bring the staff nurse to a client’s room and demonstrate a cleansing bath

22. 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? A. Testing option C. Defining the problem B. Considering effects on result D. Making final decisions 23. 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? A. B. C. D.

Thinking of alternative methods of nursing care Sharing ideas regarding patient care Following standards of practice Planning other approaches for patient care

24. The nurse who makes clinical judgment can be depended upon to improve the quality of care clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. B. C. D.

Roman, a client who is ambulatory and for surgery tomorrow A post-operative client. Rey, who has a blood pressure of 90/50 mmHg Mr. Abad, a client who needs instructions for home medications Fred, a client who received pain medication 5 minutes ago

25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines client’s problem and its possible cause. The following is an example of a well written nursing diagnosis: A. B. C. D.

Acute pain related to altered skin integrity secondary to hysterectomy Electrolyte imbalance related to hypocalcemia Altered nutrition related to high fat intake secondary to obesity Knowledge deficit related to proctosigmoidoscopy

Situation 3 – You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV 26. When caring for a dying client you will perform which of the following activities? A. B. C. D.

Encourage the client to reach optimal health Assist client perform activities of daily living Assist the client towards a peaceful death Motivate client to gain independence

27. The client prepares for her eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of: A. Acceptance

C. Denial

B. Resolution

D. Bargaining

28. The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM to Mrs. Leyba. Demerol is available in a mutidose vial labelled 100mg/ml while Vistaril comes in an ampule labelled 50mg/ml. you are to give the both medications in one injection. You will: A. B. C. D.

Withdraw the medication from the vial first then from the ampule Inject air into the vial, then into the ampule Inject air into the ampule, aspirate desired dose, then into the vial Withdraw medication from the ampule then from the vial

29. When giving Demerol 50 mg from the multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml, what is the total volume that will inject to the client? A. 2 ml B. 1 ml

C. 1.5 ml D. 1.75 ml

30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity? A. Blisters B. Reddening of the skin

C. Pressure sores D. Pustules

Situation 4 – You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility: 31. Ramil’s right leg is injured and Nurse Karen has to move him from the bed to a wheel chair. Which of the following is the appropriate nursing action of Nurse Karen? A. B. C. D.

Put the client on the edge of the bed and place the wheelchair at her back Face the client and place the wheelchair on her left side Put the client on the bed and place the wheelchair on the other side of the bed Put the client on the edge of the bed and place the wheelchair on the client’s left side

32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented? A. B. C. D.

Adduction of the shoulder Lateral flexion of the sternocleidosmatoid muscle Hyperextension of the knees Anterior flexion of lumbar curvature

33. Joseph prefers to be in high fowler’s position most of the time. The nurse should prevent which of the following? A. Posterior flexion of the lumbar curvature B. Internal rotation of the shoulder C. External rotation of the hip

D. Adduction of the shoulder 34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first? A. B. C. D.

Move the patient to the edge of the bed near the nurse Adjust the bed to the flat position Lock the wheels of the bed Raise the bed rails opposite the nurse

35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Sandbags B. Firm mattress

C. Pillow D. High foot board

Situation 5 – As you begin work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them. 36. An ambulatory client, Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. B. C. D.

Turning off the lights to promote sleep and rest Instructing the client about the use of the call system Raising the side rails Placing the bed in high position

37. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? A. B. C. D.

Impaired mobility related to pain secondary to an abdominal incision Impaired movements related to pain due to surgery Impaired mobility related to surgery Severe pain related to surgery

38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. B. C. D.

Encourage the client to log roll when turning Encourage the client to do self-care Instruct the client to do deep breathing exercises Ambulate the client in the ward premises every twenty minutes

39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. Fr the past 3 days, Mr. Lozano’s hygiene and grooming needs have been met by the nursing

staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? A. B. C. D.

Involving family in meeting client’s personal needs Meeting his needs till he is ready to perform self-care Preparing a day to day activity list to be followed by client Involving Mr. Lozano in his care

40. Mr. Ernest Lopez is terminally ill and he chose to be at home with his family. What nursing actions are best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. Provide support to the family members by teaching ways to care for their loved one C. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family Situation 6 – Myrna, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 41. In both quantitative qualitative research, the used of a frame of references is required. Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursing’s body of knowledge B. Organizes the development of study and links the findings to the nursing’s body of knowledge C. Provides logical structure of the research findings D. Identifies concepts and relationships between concepts 42. Myrna needs to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. Locating and identifying resources B. Reading and recording notes

C. Clarifying a research topic D. Using the library

43. The primary purpose for reviewing literature is to: A. Organize materials related to the problem of interest B. Generate broad background and understanding of information related to the research problem of interest C. Select topics related to the problem of interest D. Gather current knowledge of the problem of interest 44. In formulating the research hypothesis, researcher Myrna should state the research question as A. What is the response of the staff nurses to the health values? B. How is variable “health value” perceived in a population?

C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 45. The proposed study shows the relationship between the variables. Which of the following id the independent variables? A. B. C. D.

Staff nurses in a selected college of nursing Health values Health promotion activities Relationship between health values and health promotion activities

Situation 7 – While working in a tertiary hospital, you are assigned to he medical ward 46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a: A. Nurse supervisor B. Social worker

C. Bookkeeping department D. physician

47. 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: A. Receive emotional support B. To be part of a research study

C. Provide financial assistance D. Assist with chemotherapy

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should referred to a: A. Nutritionist B. Dietitian

C. Physician D. Medical Pathologist

49. When collaborating with other health team members, the best description of Nurse Rita’s role is: A. B. C. D.

Encourages the client’s involvement in his care Shares and implements orders of the health team to ensure quality care She listens to the individual views of the team members Helps client set goals of care and discharge

50. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has following coptencies: A. B. C. D.

Communication, trust, and decision making Conflict management, trust, negotiation Negotiation, decision making Mutual respect, negotiation, trust

Situation 8 – The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in a community setting to your main objective is to provide safe nursing to your clients? 51. To provide safe quality nursing care to various clients in any setting, the most important tool of the nurse is: A. B. C. D.

Critical thinking to decide appropriate nursing actions Understanding of various nursing diagnoses Observation skills for data collection Possession of in scientific knowledge about client needs

52. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. B. C. D.

Creating plans of care for particular clientele Identifying the correct nursing diagnoses for clients Making a thorough assessments of client needs and problems Using standards of nursing care as your criteria for evaluation

53. The effectiveness of your nursing care plan for your clients is determined by A. B. C. D.

The number of nursing procedures performed to comfort the client The amount of medications administered to the client as ordered The number of times the client calls the nurse The outcome of nursing interventions based on plan of care

54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgery. She complained of recurrent pain at the right upper 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? A. B. C. D.

Blood pressure measurement of 170/100 Complaint of hot flashes Report of pain after ingestion of fatty food Complaint of frequent bouts of dizziness

55. While talking with Mrs. Amado, it is most important for the nurse to: A. B. C. D.

Schedule the laboratory exams ordered for her Do an assessment of the client to determine priority needs Tell the client that your shift ends after eight hours Have the client sign an informed consent

Situation 9 – Oral care is an important part of hygienic practices and promoting client comfort. 56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dry ness and presence of sores. Which of the following is BEST to use for oral care?

A. Lemon glycerine B. Hydrogen peroxide

C. Mineral oil D. Normal saline solution

57. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. B. C. D.

Put the client on a sidelying position with head of bed lowered Keep the client dry by placing towel under the chin Wash hands and observe appropriate infection control Clean mouth with oral swabs in a careful and an orderly progression

58. The advantages of oral care for a client include all of the following, EXCEPT: A. B. C. D.

Decreases bacteria in the mouth and teeth Reduces need to use commercial mouthwash w/c irritate the buccal mucosa Improves client’s appearance and self-confidence Improves appetite and taste of food

59. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouth wash to avoid rinsing the buccal cavity. B. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs. C. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums. D. Suctioning as needed while cleaning the buccal cavity. 60. Your client has difficulty of breathing and mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moisten by using: A. B. C. D.

Salt solution Water Petroleum jelly Mentholated ointment

Situation 10 - 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. 61. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session department, probable causes were identified. Which of the following process related? A. Interruptions B. Use of unofficial abbreviations C. Lack of knowledge

D. Failure to identify client 62. Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication practice is related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Record C. Only officially approved abbreviations maybe used in the prescription orders D. Encourage clients to ask question about their medications 63. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. B. C. D.

The nurses check client’s identification band before giving medications The nurse reports adverse reaction to drugs Average waiting time for medication administration is measured The unit has well ventilated medication room

64. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation quality care? A. B. C. D.

Interviews nurses for comments regarding staffing Measures waiting time for clients per nurse’s call Checks equipment for its calibration schedule Determines whether nurses perform skin assessment every shift

65. 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? A. B. C. D.

Assign another nurse to perform the procedure Ask the nurse to find a way to learn the procedure Tell the nurse to read the procedure manual Do the procedure with the nurse

Situation 11 – Mt. Jose’s chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data 66. Mr. Jose’s chart contains all information about his health care. The functions of records include all following EXCEPT: A. Means of communication that health team members use to communicate their contributions to their client’s health care B. The client’s record also shows a document of how much health care agencies will be reimbursed for their services C. Educational resource for student of nursing and medicine D. Recording of actions in advance to save time

67. An advantage of automated or computerized client care system is: A. B. C. D.

The nurse diagnoses for a client’s data can be accurately determined Cost of confinement will be reduced Information concerning the client can be easily updated The number of people to take care of the client will be reduced

68. Information in the patient’s chart is inadmissible in court as evidence when: A. B. C. D.

A client’s family refuses to have it used The client objects to its use The handwriting is not legible It has too many abbreviations that are “unofficial”

69. Nursing audit aims to: A. B. C. D.

Provide research data to hospital personnel Study client’s illness and treatment regimen closely Compare actual nursing done to established standards Provide information to health-care providers

70. A telephone order is given for a client in your ward. What is your most appropriate action? A. Copy the order on the chart and sign the physician’s name as close to his original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the client’s chart and have the head nurse co-sign it D. Tell the physician that you cannot take the order but you will call the nurse supervisor Situation 12 – Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of clients with various conditions. 71.

Which of the following client conditions should miss Roque’s priority in the pediatric unit? A. The baby whose fantanelle is bulging and firm while asleep B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. A baby who is waiting after being awakened by the banging of the door D. A baby boy whose circumcision has yellowish exudates

72. When suctioning the endoctracheal tube, the nurse should: A. Explain procedure to patient, insert catheter gently applying suction, withdrawn using twisting motion

B. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter is withdrawn C. Hyperoxygenate client then insert catheter using back and forth motion D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn 73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. While Doris is doing the sponge bath, what action of Doris needs correction? A. B. C. D.

Answering the phone while wearing gloves used for sponge bath Rolling the patient like a dog to back rub Lining the rubber mat with bed sheet as incontinence pad for the patient Turning the patient on the left side with slightly elevated

74. Dina sustained a fracture on the ulna and a cast will be applied. What nursing action before cast application is most important for Nurse Roque to do? A. B. C. D.

Use baby powder to reduce irritation under the cast Assess sensation of each arm Evaluate skin temperature in the area Check radial pulses bilaterally and compare

75. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? A. B. C. D.

Upon waking up, cough deeply and expectorate into container Cough after pursed lip breathing Save sputum for two days in covered container After respiratory treatment, expectorate into a container

Situation 13 – infections are quite commonly the reasons for a client’s hospitalization. Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care. 76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? A. B. C. D.

Neutrophils 60% White blood cells (WBC) 9000/mm Erythrocyte sedimentation (ESR) is 39mm/hr. Iron 75mg/100ml

77. Surgical sepsis is observed when: A. B. C. D.

Inserting an intravenous catheter Disposing of syringes and needles in puncture proof containers Washing hands before changing wound dressing Placing dirty soiled linen in moisture resistant bags

78. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. B. C. D.

Client was exposed to the infection 2 days ago but without any symptoms Oral temperature shows fever Acute symptoms are no longer visible Client “feels sick” but can do normal activities

79. Which of the following laboratory test results indicate presence of an infectious process? A. B. C. D.

Erythrocyte sedimentation rate (ESR) 12mm/hr White blood cells (WBC) 18,000/mm3 Iron 90g/100ml Neutrophils 67%

80. Among the clients you are assigned to take care of, who is most susceptible to infection? A. B. C. D.

Diabetic client Client with burns Client with pulmonary emphysema Client with myocardial infarction

Situation 14 – 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. 81. Using Benner’s stages of nursing expertise, you are the beginning nurse practitioner. You will rank your self as a/an: A. B. C. D.

Competent nurse Novice nurse Proficient nurse Advanced beginner

82. Benner’s “proficient” nurse level is different from the other levels in nursing expertise in the context of having: A. B. C. D.

The ability to organize and plan activities Having attained an advanced level of education A holistic understanding and perception of the client Intuitive and analytic ability in new situations

83. As you become socialized into the nursing “culture” you become a patient advocate. Advocacy is explained by the following EXCEPT: A. Respecting a person’s right to be autonomous B. Demonstrating loyalty to the institution’s rights C. Shared respect, trust and collaboration in meeting health needs

D. Protecting and supporting another person’s rights 84. Modern day nursing has led to development of the expanded role of the nurse as seen in the function of a: A. Clinical nurse specialist B. Critical care nurse

C. Community health nurse D. Staff nurse

85. You join a continuing education program to help you: A. B. C. D.

Earn credits for license renewal Get in touch with colleagues in nursing Enhance your basic knowledge Update your knowledge and skills related to field of interest

Situation 15 – When creating your lesson plan for cerebrosvascular disease or STROKE, it is important to include the risk factors of stroke 86. The most important risk factor is: A. Cigarette smoking B. Hypertension

C. Binge drinking D. Heredity

87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: A. Embolic stroke B. Hemorrhagic stroke

C. Diabetic stroke D. Thrombotic stroke

88. Hemorrhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: A. Phlebitis B. Trauma

C. Damage to blood vessel D. Aneurysm

89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? A. Amphetamines B. Cocaine

C. Shabu D. Demerol

90. A Participant in the STROKE class asks what is the risk factor of stroke. Your best response is: A. B. C. D.

“More red blood cells thicken blood and make clots more possible” “Increased RBC count is linked to high cholesterol” “More red blood cells increases hemoglobin content” “High RBC increases blood pressure”

Situation 16 – Accurate computation prior to drug administration is a basic skill all nurses must have. 91. Rudolf is a diagnosed with amoebiasis and is to receive Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that client will received per oral administration? A. 1,000 mg tid B. 500 mg tid

C. 1,500 mg tid D. 250 mg tid

92. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. Which of the following should Nurse Paulo prepare for each oral dose? A. 5 ml B. 1.25 ml

C. 2.5 ml D. 10 ml

93. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez. Since Potassium Chloride is high risk drug, Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug? A. B. C. D.

Check the pump setting every 2 hours Teach the client how the infusion pump operates Have another nurse check the infusion pump setting Set the alarm of the pump load enough to be heard

94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: “give 3.00 cc of Lanoxin today for 1 day only”. Which of the following is the most appropriate action by the nurse? A. B. C. D.

Clarify order with the attending physician Discuss the order with the pediatric heart specialist in the unit Administer Lanoxin intravenously as it is the usual route of administration Refer to the medication administration record for previous administration of Lanoxin

95. When Nurse Norma was about to administer he medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse? A. Hold the administration of the client’s medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the client’s medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurse’s station and prepare accordingly

Situation 17 – You are taking care of Mrs. Santillan, 48 year old woman who is unconscious after a cerebrovascular accident. You are aware that there are many physical complications due to immobility. 96. You should be alert for the following complications she may experience EXCEPT: A. Impaired mobility B. Contractures and muscle atrophy

C. Hypostatic pneumonia D. Pressure sores

97. Proper positioning of an immobilized unconsciousness client is important to the following reasons EXCEPT: A. B. C. D.

Maintain skin integrity Promotes optimal lung expansion Prevent injuries and deformities of the musculo-skeletal system Facilitates rest and sleep

98. When positioning your client, you should observe good body mechanics for your self and the client. This means that the nurse: A. B. C. D.

Uses back muscles Assumes correct body alignment and efficient use of muscles to avoid injury Observe rhythmic movements when moving about Uses large muscles only

99. You are going to move Mrs. Santillan, a 150lbs. unconscious woman. Some principles to use when moving the client include the following EXEPT: A. Prepare to move the client by taking a deep breath and tightening abdominal and gluteal muscles. B. Maintain wide base of support with feet and knees flexed C. Push or pull using arms and legs instead of lifting D. Move close to the object to be moved leaning or bending at the waist 100. After moving Mrs. Santillan to the desired position, which action will you avoid? A. B. C. D.

*** END ***

Avoid friction between bony prominences Place pillow to client position client’s extremities Apply restraints Raise bed rails

NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child 1. Registered nurses can be identified as a: A. Organization B. Culture

C. Group D. Subculture

2. 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 organ is that the organ is given to the child who: A. B. C. D.

Will receive the most benefit from new organ Is most likely to die without the transplant Is selected by the lottery system for available organs Is at the top of the list and has waited the longest tome

3. The nurse uses what equipment to check for fluid between the parietal and visceral layers of the tunica vaginalis, the outermost covering of the testes? A. 30 cc syringe B. Transilluminator

C. Fluid meter D. Manometer

4. Which of the following examples best defines the term role reversal? A lazy person becomes very productive in the family The good child takes on a bad child role A person who has been a good provider quits his or her job The child assumes a caregiver role toward the caregiver 5. When a nurse breaches the duty of confidentially, he she can be disciplined by both the employer and Board of Nursing. In addition to this discipline, he or she can: A. B. C. D.

Be held responsible for any damages that result Be fined by the federal government Be sentenced for up to 1 year in jail Immediately lose his or her nursing license

6. A strategy for change that focuses on teaching workers new technology is: A. Normative-reeducative B. Training

C. Providing information D. Power coercive

7. The nurse knows that the occurrence of the shoulder dystocia during labor is most likely related to:

A. Polyhydramnios B. Maternal Age

C. Preterm birth D. Macrosomia

8. The nurse instructs the mother that when overstimulated the infant will: A. B. C. D.

Show increased alertness and eye contact Respond with coordinated, synchronous body movement Look away to reduce the intensity of the interaction Drift off to deep sleep to shut out the interaction

9. Some strategies to maintain professional health are listed below. Which is NOT necessarily correct? A. B. C. D.

Networking with others in the health care field Join a professional organization Goal setting Read fiction and nonfiction materials

10. The nurse is assessing an 8-month-old infant for head lag, pulling the infant by the hands from a supine to a sitting position. The head does not stay in line with the body when being pulled forward. Which of the following statements best represents the significance of this finding? A. Head lag should not be tested until the child is over 1 year of age B. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations C. The nurse has not conducted the test correctly and must do it again using proper technique D. This is a normal finding, as the infant’s head will stay 11. Which statement is correct regarding the use of cervical cap? A. B. C. D.

It may affect Pap smear results It does not need to be fitted by a physician It does not require the use of a spermicide It must be removed within 24 hours

12. The major components of communication process are: A. B. C. D.

Verbal, written, and nonverbal Speaker, listener and reply Facial expression, tone of voice, and gestures Message, sender, channel, receiver, and feedback

13. The extent of burns in children are normally assessed and expressed in terms of:

A. The amount of body surface that is unburned B. Percentages of total body surface area (TBSA) C. How deep the deepest burns are D. The severity of the burns on a 1 to 5 scale 14. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is: A. B. C. D.

Being raised by a parent of low intelligence quotient (IQ) An orphan A victim of child neglect A victim of poverty

15. Which of the following indicates the type(s) of acute renal failure? A. Four types: hemorrhagic with or without clotting, and nonhemorrhagic with or with clotting B. One type: acute C. Three types: prerenal, intrarenal and postrenal D. Two types: acute and subacute 16. A means of facilitating professional staff development is by building upon skills, abilities, and experience of each practitioner is called: A. B. C. D.

The novice to expert model Situational leadership model Career enhancement Clinical ladder

17. Which of the following questions by the nurse would best fit the philosophy of the nursing mutual participation of care (NMPMC)? A. B. C. D.

“have you brushed your child’s teeth today”?\ “how does your child look to you today”? “where have you been all morning”? “do you think your child’s color is worse”?

18. There are numerous definitions of the word “health”. Which definition below is from Florence Nightingale? A. B. C. D.

A state or a process of being and becoming an integrated and whole person The state of being free from illness or injury Being well and using every power the individual possesses to the fullest extent A state of complete and physical, social, and mental well-being and not merely the absence of disease and infirmity

19. Informal communication takes place when an individuals talk and is best described by saying the participants:

A. B. C. D.

Are involve in a preexisting informal relationships Talk with slang words Have no particular agenda or protocol Are relaxed

20. Tertiary care by home health nurse is directed towards children with: A. B. C. D.

Problems in mobility Short-term needs Minor problems Clinically apparent disease

21. The endometrium thickness during which phase of the menstrual cycle? A. B. C. D.

Secretory phase Menstrual phase Proliferative phase Ischemic phase

22. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over a specific period of time is called: A. B. C. D.

Staffing pattern Skill mix Benchmarking Patient classification

23. 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 of the nurse is: A. “these circumference normally are the same, but in some babies this just differs” B. “perhaps your baby was small for gestational age or premature” C. “this is normal until the age of 1 year, when the chest will be greater” D. “let me ask you a few questions, and perhaps we can figure out the cause of this difference” 24. Which of the following approaches would work best when the nurse is communicating with an infant? A. B. C. D.

Use an adult voice just you would for anyone. Communicate through the caregivers Allow the child time to warm up to the nurse Respond only after the child cries for a little while

25. Evidence-based care started in medicine as a way to: A. Promote technological advances in medicine

B. Incorporate collaboration within all health care disciplines C. Integrate individual experience with clinical research D. Teach medical students the art and science of medicine 26. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as primary manifestation of Hirschsprung;s disease? A. B. C. D.

A fine rash over the trunk Failure to pass meconium during the first 24 to 48 hours after birth The skin turns yellow and then brown over the first 48 hours of life High-grade fever

27. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable has minimal spotting and is being sent home. Which of these instruction to the client may indicate a need further teaching? A. B. C. D.

Maintain bed rest with bathroom privileges Avoid intercourse for three days Call if contractions occur Stay on left side as much as possible when lying down

28. Which of the following groups of people in the world disproportionately represents the homeless population? A. Hispanics B. Asians

C. African Americans D. Caucasians

29. The nurse assessing a child or adolescent with a diagnosis of dysrythmic disorder would find which of the following symptoms? A. B. C. D.

Avoid covering the area of the topical medication with the diaper Avoid the use of clothing on top of the diaper Put the diaper on as usual Apply an icepack for 5 minutes to the outside of the diaper

30. The nurse assessing a child or adolescent with a diagnosis of dysrythmic disorder would find which of the following symptoms? A. Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones and associated symptoms B. Severe shaking of the hands when trying to hold a glass of water or other object C. A depression that is deeper, more acute, and more likely to lead to suicide than major depressive disorder D. A depressed or irritable mood for most of the day, on most days, for 2 or more years and low energy fatigue

31. You were the nurse assigned to work with a child who has had whole brain radiation. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea, parents in w/c of the following areas? A. B. C. D.

Accepting a reoccurrence of the tumor Dealing with the side effects of the radiation therapy Caring for the dying child Accepting the imminent death of their child

32. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis “Nutrition: Less than body requirements.” Which of the following interventions will be the most helpful in resolving this nursing problem? A. B. C. D.

Two large meals a day instead of several minimeals and snacks Special IBD diet (diet that has been proven effective for treating IBD) Salt-free diet high in potassuim, vitamins, and minerals Diet as tolerated with lactose hydrolyzed milk instead of milk products, and omission of highly seasoned foods, and reduction of fiber

33. Emotional intelligence consists of a number of competencies. Some of these are listed below. Which is NOT a characteristic of emotional intelligence? A. Self-esteem B. Self-awareness

C. Empathy D. Self-regulation

34. Data collection for driving and restraining forces, including costs, desirability, and feasibility, is a: A. People issue B. Structural issue

C. Political issue D. Technology issue

35. One of four factors describing the experience of sexually abused children and effect it has on their growth and development is stigmatization that occurs when: A. A child blames him-or herself for the sexual abuse and begins to withdraw and isolate B. Newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser stop D. The child is shared by other members of the family or friends when sexual abuse becomes public knowledge 36. The painful phenomenon known as “black labor” occurs in a client whose fetus in what position? A. Brow position B. Right occipito-anterior position

C. Breech position D. Left occipito-posterior position

37. FOCUS methodology stand for A. B. C. D.

Focus, Organize, Clarify, Understand, Solution Focus, Opportunity, Continuous, Utilize, Substantiate Focus, Organize, Clarify, Understand, Substantiate Focus, Opportunity, Continuous (process), Understand, Solution

38. While community health nurses focus on the individual or the family, which of the following do they have as their final objective? A. B. C. D.

The well-being of the chronically ill The financial well-being of the family The well-being of the extended family The well-being of the community

39. Which of the following is the best example of the ethical principle of fidelity? A. B. C. D.

Doing whatever the client or the client’s physician asks of you Keeping a promise to return to the client’s room at a given time Being good friend to the client by sharing secrets Saving the client time and money y not wasting supplies

40. Which of the following factors is most important in determining the success of the relationships used in delivering nursing care? A. B. C. D.

Type of illness of the client Transference and countertransference Effective communication Personality of the participants

41. Which of the following statements best describes the term glove type burs? A. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot scalding water B. The parents have dipped the child into the hot liquid while he or she was asleep C. The child was wearing a glove when immersed in hot liquid D. The burn has the look of a glove immersed in hot scalding water 42. The school nurse keeps a list of enrolled students who have medical or religious objections to immunizations and those who are likely to have decreased immunity. The nurse likely keeps this list to: A. B. C. D.

Provide statistics for the department of health Reassure the family that the nurse will respect the family’s wishes at all times Meet national government requirements Facilitate exclusion in case of an outbreak of highly communicable disease in the school

43. Preschoolers are able to see things from which of the following perspectives? A. B. C. D.

Their peers’ Their own and their caregivers’ Their own and their mother’s Only their own

44. In conflict management, the win-win approach occurs when: A. B. C. D.

There are conflicts and the parties agree toe each win one Each party gives in on 50% of the disagreements making up the conflict Both parties involved are committed to solving the conflict The conflict is settled out of court so the legal system and the parties win

45. According to the social-interactional systematic perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are thee family itself, the caregiver, the child and: A. The presence of a family crisis B. Genetics

C. the nationa emphasis on sex D. Chronic poverty

46. When a person is discussing the strong influences that child-rearing methods have on the development of the child, this person is most probably coming from which of the following viewpoints or theories? A. Naturalistic B. Nature

C. Neocalssic D. Nurture

47. In working with the caregivers of a child with an acute or chronic illness, the nurse would: A. Teach care daily and let the caregivers do a return demonstration just before discharge B. Delegate care of the child to a nurse’s aide and make certain he or she understands the care delegated and completes it C. Teach care early and allow caregivers to provide daily care for as many aspects of the child’s care as possible D. Take responsibility for the child’s care until the day before discharge, and then give caregivers instructions 48. Which of the following signs and symptoms would you most likely find when assessing an infant with Arnold-Chiari malformation? A. B. C. D.

Weakness of the leg muscles, loss of sensation in the legs and restlessness Difficulty swallowing, diminished or absent gag reflex, and respiratory distress Difficulty sleeping, hypervigilant and an arching of the back Paradoxical irritability, diarrhea, and vomiting

49. A parent calls you frantically reports that her child has gotten into her ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell her mother to: A. B. C. D.

Call emergency medical services (EMS) and get the child to the emergency room Relax because these symptoms will pass the child will be fine Administer syrup of ipecac Call the poison control center

50. …………………………………….. you are on “the pill”. The most appropriate response would be: A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or skipped occasionally” B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible” C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly” D. “Missed periods can be very dangerous and may lead to the formation of precancerous cells” 51. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening? A. Elevated temperature, cough, sore throat, changing complete blood count(CBC) with differential B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinuria plus edema C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face D. A temperature of 37.8 degrees C(100degrees F), flank pain, burning, frequency, urgency on voiding. And cloudy urine. 52. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times, yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following area? A. B. C. D.

Isolation Loneliness Lack of fulfillment Identity

53. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of.

A. B. C. D.

Delegation Supervision Responsibility Competence

54. A child suffers a head injury in a tumbling accident in gym class. The nurse’s best course of action is to: A. B. C. D.

Get the child up walking and make sure he or she stays awake Leave the child and go get help Leave the child in the care of an older child and go get help Stay with the child, keep assessing, and have someone call the care givers

55. The American academy of pediatrics suggests that caregivers do which of the following things in regard to physical activities for preschoolers? A. B. C. D.

Push the child to practice sports activities while they are more flexible Encourage a variety of physical activities in a noncompetitive environment Have the child engage in competitive sports to see where they excel Keep physical activities to a minimum until the child is in grade school

56. Which of the following arrangements is generally considered to be the best or the parents of a hospitalized infant or young child? A. B. C. D.

Rooming-in Separate caregiver sleeping room to the unit Day visits and sleeping at home Staying at a nearby hotel or motel

57. When one person allows the conflict to be resolves at his or her own expense, this is referred to in conflict management as: A. Losing B. Winning while losing

C. The win-lose approach D. The lose-win approach

58. Which of the following statements best describes acquaintance rape? A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. When two people don’t love each other and engage in sexual activities C. When someone on a date tricks the other person into having sexual intercourse D. Sexual intercourse committed with force or the threat of force without person’s consent 59. The school nurse is teaching a health education and hygiene course to a group of high schools males, which includes a number of young men who are competitive sports team. Which of the following health practices would the nurse most stress in preventing the transmission of human immunodeficiency virus (HIV) virus in case any team member has HIV or acquired immunodeficiency syndrome (AIDS)

A. B. C. D.

No sharing of underarm deodorant or shower soap No sharing or razors or toothbrushes Making certain towels have been washed in boiling water Avoiding physical contact such as sports hug or swats

60. At 17 weeks’ gestation, a type 1 diabetic undergoes an ultrasound examination. What information about the fetus at this time in pregnancy would results of this examination provide? A. Placental maturity B. Estimated fetal weight

C. Gestational age D. Fetal lung maturity

61. Which of the following best describes a difference in communicating with school-age children versus toddlers? A. Toddlers require more empathy and more touching and holding B. For toddlers, preparation for procedures is just before the procedure and much earlier for school-aged children C. Caregivers need less information when care involves a school-aged child D. The number of words is more when communicating with a toddler than it is with a school-aged children 62. Genetic testing should be performed on a child only if: A. B. C. D.

The parents both want it performed It is in best interest of the child It is necessary for the child to survive No one objects

63. Infant head control is judged by the: A. B. C. D.

Ability to hold head w/o support Presence or absence of head lag Rigidity of the neck and head Amount of beck wrinkling

64. Which o the following roles BEST exemplifies the expanded role of the nurse? A. B. C. D.

Circulating nurse in surgery Medication nurse Obstetrical nurse Pediatric nurse practitioner

65. The tone ant pitch of the voice, volume, inflection, speed, grunts and other vocalizations are referred to by which of the following terms? A. Paraverbel clues B. Ancillary speech

C. Third element D. Enhancements

66. The plan-do-study cycle begins with A. Four stages B. Five agendas

C. Three questions D. Two concepts

67. During your shift, you noted one of your pregnant clients considered as “waiting case” manifest morning sickness and which later progresses. Which assessment finding may indicate a possible developing complication? A. Maternal pulse 90 B. Trace glucose in the urine

C. FHT 155 D. 1+ ketones in the urine

68. The nurse is working with a child who is going to have a bone marrow aspiration. The physician orders TAC (tetracaine, adrenaline, and cocaine). Which of the following is the route of administration? A. B. C. D.

Application to the skin, covered with a dressing prior to the procedure Subcutaneous IV using a very slow drip over approximately 4 hours prior to procedure Nasal inhalation

69. According to DeRosa and Kochura’s (2006) article enttled “Implement Culturally Competent Health Care in you Workplace,” cultures have different patterns of verbal and nonverbal communication. Which differences does NOT necessarily belong? A. Personal behavior B. Eye contact

C. Subject matter D. Conversational style

70. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in such a way to expose the cord. The major purpose of exposing the cord is to: A. B. C. D.

Remind the caregivers to do cord care Keep the diaper from rubbing the cord Provide air circulation for the cord Allow visualization at all times

71. The level of health of an individual, family, group, population, or community is called: A. Health assets B. Health status

C. Quality of life D. health needs

72. The nurse is teaching a group of expectant mothers about the prevention of diaper dermatitis. The nurse explains that one preventive measures Is the use of: A. Absorbent disposable diapers B. Baby powder or cornstarch 73. The Code of Nurses

C. Plastic panties over diapers D. Cloth diaper

A. B. C. D.

delineates all obligation and responsibilities of the nurse is a binding oath, which tells nurses how to make ethical decisions assists the nurse in formulating a personal belief system supports the concepts of respect

74. The obligation to correctly perform one’s assigned duties is: A. Delegation B. Assignment

C. Responsibility D. Accountability

75. During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus to be slightly boggy. Which action should the nurse take to decrease the risk of uterine inversion during uterine massage? A. B. C. D.

Massage only until cramping begins Place one hand on the abdomen above the symphysis pubis Ask the client to ambulate to the bathroom to empty her bladder Position the client in a slight Trendelenburg position

Situational Situation 1 – Nurse Lisa manages her own reproductive Children’s Nursing Clinic in Sorsogon and necessarily she attends to health conditions of mothers and children. The following conditions pertain to the GROWING FETUS. 76. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo. What would your best explanation? A. B. C. D.

Her baby will be a fetus as soon as placenta forms From the time of implantation until 5 to 8 weeks, the baby is in embryo After the 20th week of pregnancy, the baby is called a zygote This term is used during the time before fertilization

77. Marichu is worried that her baby will be born with a congenital heart disease. What assessment of a fetus at birth is important to help detect congenital heart defect? A. B. C. D.

Determining that the color of the umbilical cord is not green Assessing whether the umbilical cord has two arteries and one vein Assessing whether the Wharton’s jelly of the cord has a pH higher than 7.2 Measuring the length of the cord to be certain that it is longer than 3 feet

78. Additionally, Nurse Lisa would gather more information about Marichu’s worry about what may threaten the health of her baby. What would Nurse Lisa hope to find? A. Has Marichu been overly anxious about something B. Has Marichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy

C. Has Marichu engaged in sexual activity during the fetal development state of her child D. Has Marichu engaged in any detrimental activities during the fetal development stage e.g. smoking, drinking, taking, drugs, a bad fall, or attempts to terminate pregnancy 79. Marichu is scheduled to have an ultrasound examination. What instruction would you give before here examination? A. B. C. D.

You can have medicines for pain for any contractions caused by the test Drink at least 3 glasses of fluid before the procedure The intravenous fluid infused to dilate your uterus does not hurt the fetus Void immediately before the procedure to reduce your bladder size

80. Marichu is scheduled to have an amniocentesis to test for fetal maturity. What instruction would you give her before this procedure? A. The X-ray used to reveal your fetus’ position has no longer term effects B. The intravenous fluid infused to dilate your uterus does not hurt the fetus C. No more amniotic fluid forms afterward, which is why only a small amount is removed D. Void immediately before the procedure to reduce your bladder size Situation 2- health instruction s are essentially given to pregnant mothers 81. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy? A. B. C. D.

Presence of dark color in the neck Increased vaginal discharge Swelling of face Breast tenderness

82. A woman who is 9 weeks pregnant comes to the health center with moderate bright red vaginal bleeding. On physical examination, the physician finds the client’s cervix 2 cm dilated. Which term best describes the client’s condition? A. B. C. D.

Missed abortion inevitable abortion Incomplete abortion Inevitable abortion Threatened abortion

83. In a big government hospital Nurse Pura is taking care of a woman with a diagnosis of abruption placenta. What complication of this condition is of most concern to Nurse Pura? A. Urinary tract infection B. Pulmonary embolism C. Hypocalcaemia

D. Disseminated intra vascular coagulation 84. Which of the following findings on a newly delivered woman’s chart would indicate she is at risk for developing postpartum hemorrhage? A. B. C. D.

Post-term delivery Epidural anesthesia Grand multiparty Premature rupture of membrane

85. Mrs. Hacienda Garcia 35 y.o. postpartum client is at risk of thrombophlebitis. Which of the following nursing interventions decreases her chance of developing postpartum thrombophelebitis A. B. C. D.

Breastfeeding the new born Early ambulation Administration of anticoagulant postpartum Immobilization and elevation of the lower extremities

Situation 3- with the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. The following conditions apply. 86. Which among the following is the primary focus of prevention of cancer? A. B. C. D.

Elimination of conditions causing cancer Diagnosis and treatment Treatment at early stage Early detection

87. In the prevention and control of cancer which of the following activities is the most important function of the community health nurse? A. Conduct of community assemblies B. Referral to cancer specialist those clients with symptoms of cancer C. Use the nine warning signs of cancer as parameters in our process of detection, control, and treatment modalities D. Teach women about correct/proper nutrition 88. Who among the following are recipients of the secondary level of care for cancer cases? A. B. C. D.

Those under early case detection Those under post care treatment Those scheduled for surgery Those undergoing treatment

89. Who among the following are recipients of the tertiary level of care for cancer cases? A. Those under early treatment B. Those under supportive care

C. Those under early detection D. Those scheduled for surgery 90. 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: A. B. C. D.

Nursing diagnosis Nursing protocol Nursing research Nursing process

Situation 4 – Dengue hemorrhagic fever is common health concern in Philippine society. It does not only pose a threat to health but more so to the lives of both young and old, and well rich and marginalized of society. The following conditions apply. 91. An important role of the community health nurse in the prevention and control Dengue H-fever includes: A. Advising the elimination of vectors by keeping water containers covered B. Conducting strong health education drives/campaign directed towards proper garbage disposal C. Explaining to the individuals, families, groups and community the nature of the disease and its causation D. Practicing residual spraying with insecticides 92. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for hospitalization of H-fever suspects. A. B. C. D.

Marked anorexia, abdominal pain and vomiting Increasing hematorit count Fever for more than 2 days Persistent headache

93. The community health nurses’ primary concern in the immediate control of hemorrhage among patients with dengue is: A. B. C. D.

Advising low fiber and non-fat diet Providing warmth through light weight covers Observing closely the patient for vital signs leading to shock Keeping the patient at rest

94. Which of these signs mat NOT be REGARDED as a truly positive signs indicative of Dengue H-Fever? A. Prolonged bleeding time B. Appearance of at least 5 petechiae C. Steadily increasing hematocrit count

D. Fall in platelet count 95. Which of the following is the most important treatment of patients with Dengue HFever? A. B. C. D.

Give aspirin for fever Replacement of body fluids Avoid unnecessary movement of patient Ice cap over the abdomen in case of melena

Situation 5 – Two children were broughtto you. One with chest in-drawing and the other had diarrhea. The following questions apply. 96. Using the Integrated Management & Childhood Illness (IMCI) approach, how would you classify the 1st child? A. Bronchopneumonia B. No pneumonia: cough or cold

C. Severe pneumonia D. Pneumonia

97. The 1st child who s 13 month has fast breathing using IMCI parameters he has: A. B. C. D.

40 breaths per minute or more 50 breaths per minute 30 breaths per minute or more 60 breaths per minute

98. Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is irritable, and her eyes are sunken. The nurse offered fluids and the child drinks eagerly. How would you classify Nina’s illness? A. B. C. D.

Some dehydration Dysentery Severe dehydration No dehydration

99. Nina’s treatment should include the following EXCEPT: A. Reassess the child and classify him for dehydration B. For infants under 6 months old who are not breastfeed, give 100-200 ml clean water as well during this period C. Give in the health center the recommended amount of ORS for 4 hours D. Do not give any other foods to the child for home treatment 100. While on treatment, Nina, 18 months old weighed 28 kilograms and her temperature registered at 37 C. her mother says she developed cough 3 days ago. Nina has no general danger signs. She has 45 breaths/minute, no chest in-drawing, no stridor. How would you classify Nina’s manifestation? A. No pneumonia

B. Severe pneumonia C. Pneumonia D. Bronchopneumonia *** END *** NURSING PRACTICE III – Care of Clients with Physiology and Psychosocial Alterations (Part A) SITUATIONAL Situation 1 – Rita just retired from government service and was admitted for pnuemonectomy. 1. As the nurse on duty, you should check for the medical clearance of your client for surgery among other pre op requirements. This clearance primarily covers: A. B. C. D.

Stress-coping mechanism of the client Socio-economic status of the client Smoking and eating habits of the client Cardio-pulmonary system

2. A battery of preoperative tests was done. Particularly, the nurse should assess the lung capacity by checking the: A. B. C. D.

Serum creatinine level Chest x-ray Serum protein levels Arterial blood gas

3. The major objective in postoperative pnuemonectomy is to: A. B. C. D.

Maintain a patent airway Provide maximum remaining lung capacity Provide early rehabilitation Recognize early symptoms of complication

4. There is an order of Central Venus Pressure (CVP) reading. As a nurse, you should know that this is a measure of observing signs of: A. B. C. D.

Hypoxia Hypovolemia Hypothermia Hypoxemia

5. Pulmonary edema is a potential danger that we nurses should monitor in post pnuemonectomy. This is usually due to:

A. B. C. D.

Extreme temperature Liberal fluid intake Rapid infusion of IV fluids Fluid retention due to prolonged bed rest

Situation 2 – The PRC regulates the practice of 42 professions in the Philippines 6. What is the basic requirement of the state for a nurse to practice her profession? A. B. C. D.

Willingness to practice the profession A BSN degree A nursing license An NCLEX and CGFNS passer

7. The Code of Good Government for the profession in the Philippines shall be adapted by: A. B. C. D.

All registered professionals All Filipino professionals All professionals All registered nurses

8. The standardized guidelines and procedures for the implementation of Continuing Professional Education (CPE) for all professional. Resolution number 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be: A. B. C. D.

20 credit units per year 30 credit units for 3 years 60 credit units for 3 years 10 credit units required

9. The Board of Nursing is vested with power to issue, suspend, or revoke for cause, the A. B. C. D.

Certificate of Good Moral Character Certificate of Practice Certificate of Registration Certificate of Employment

10. RA 7193 stipulates the removal examination of the nurse licensure examination be taken: A. B. C. D.

Within 3 years after the last failed examination Anytime the examinee want to take the examination Within 2 years after the last failed Within the same year after the last failed examination

Situation 3 – Pain is always associated to surgery 11. As a surgical nurse, which of the following nursing intervention will allay anxiety and pain among surgical patients?

A. B. C. D.

Assess the client for concerns especially those that can potentially cause pain Verify that the operative permit is signed Discourage the client from discussing the details of the surgical procedure Ensure safety of client while in surgery

12. Rhizotomy is a condition surgical procedure to manage those that can potentially cause pain. Which is the crucial in determining a good candidate for rhizotomy? A. B. C. D.

Pain which is resistant to non-pharmacologic for 6 months Pain which is resistant to pharmacologic protocol for 12 months Local pain with no radiating pain or signs of nervous compassion Deep pain with obvious signs of peripheral nerve damage

13. Which of the following would be the nurse’s appropriate response to a crying female client scheduled for emergency surgery who is verbalizing fear of pain but afraid to go to sleep? A. Let her cry and tell significant to stand by B. Squeeze her hand and assure her that there will be no pain at all because she will be given anesthesia C. Stand by her side and quietly ask her to describe her feelings D. Check her name tag and request anesthesiologist to sedate client 14. Which of the following client’s statement indicates that he understands nurse’s instruction about postoperative wound pain? A. B. C. D.

“I shall call the nurse when my wound itches and smells: “I shall expect slight pain and discomfort from the surgical incision” “I should call my doctor if my wound has no drainage and intact” “I should not touch my surgical wound”

15. What do you think is an important responsibility relates to pain that is subjective in nature? A. B. C. D.

Divert attention of client in pain Leave the patient alone while in pain Believe what the patient says about the pain Assume responsibility to eliminate pain as described

Situation 4 – Nurses’ attitudes toward pain influence the way they perceive and interact with clients in pain 16. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and management of pan should address the following beliefs EXCEPT A. Older patients seldom tend to report pain than the younger ones B. Pain is a sign of weakness C. Older patients do not believe in analgesic; they are tolerant

D. Complaining of pain will lead to being labeled a ‘bad’ patient 17. Nurses should understand that when a client responds favorably to a placebo, it is known as the ‘placebo effect’. Placebos do not indicate whether or not a client has: A. B. C. D.

Conscience Real pain Disease Drug tolerance

18. You are the nurse in the pain clinic where you have a client who has difficulty specifying the location of pain. How can you assist such client? A. B. C. D.

The pan is vague By charting-it hurts all over Identify the absence and presence of pain Ask the client to point to the painful area by just one finger

19. What symptom, more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain: A. Forgetfulness B. Constipation

C. Drowsiness D. Allergic reactions like pruritis

20. Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice? A. B. C. D.

Start another drug and slowly lessen the opioid dosage Indulge in recreational outdoor activities Isolate opioid dependent to a restful resort Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms

Situation 5 – As a preoperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for the patient use to prevent infection 21. Items that enter sterile tissue or vascular system are categorized as critical items and should be: A. Clean B. Decontaminated

C. Sterilized D. Disinfected

22. As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection? A. B. C. D.

Material compatibility and efficiency Odor and availability Cost and duration of disinfection process Duration of disinfection and efficiency

23. Before you use a disinfected instrument, it is essential that you: A. B. C. D.

Rinse with tap water followed by alcohol Wrap the instrument with sterile towel Dry the instrument thoroughly Rinse with sterile water

24. You have a critical heart labile instrument to sterilize and are considering to use a high level disinfectant. What should you do? a) b) c) d)

Cover the soaking vessel to contain the vapor Double the amount of high level disinfectant Test the potency of the high level disinfectant Prolong the exposure time accordingly to manufacturer’s direction

25. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin should be: A. Disinfected B. Sterile

C. Clean D. Alcoholized

Situation 6 – The OR is divided into three zones to control traffic flow and contamination. 26. What OR attires are worn in the restricted are? A. B. C. D.

Scrub suit, OR shoes, head cap Head cap, scrub suit, mask, OR shoes Mask, OR shoes, scrub suit Cap, mask, gloves, shoes

27. Which of the following nursing intervensions should be given the highest priority when receiving a client in the OR? A. B. C. D.

Check for the presence of dentures, jewelry, nail polish, and other accessories Receive the client at the semi-restricted area and change his gown Assess level of consciousness Verify the identification and informed consent

28. Conversation while in the operation is ongoing is minimized because: A. B. C. D.

Fell concentration is demanded during the entire procedure It annoys the surgeon It is unethical to talk about the client It enhances the spread of microorganism to the incision site

29. Spaulding categorized instrument according to use. Where do you classify endoscopic instrument?

A. B. C. D.

Decontaminated instruments High level disinfected instruments High technology instruments Sterile instruments

30. In the OR, “Surgical Conscience” means: A. B. C. D.

Observance of Operating Room Protocol at all times Use of prescribed OR attire in all areas of the OR Honest adherence to surgical aseptic techniques all the times Strict implementation of “Standard Precaution”

Situation 7 – Nurses have the responsibility to assist the diabetic clients with insulin administration. It is essential that both nurse and client learn how to measure insulin dosage accurately 31. Insulin concentration is labeled and measured in: A. Units/ml B. Gm/ml

C. Grain D. mg/ml

32. Each unit of insulin provides the client with the same dose and effect regardless of its concentration per 1 ml of solution. Is insulin of 500 “u” per ml more potent that insulin of 100 ”u” per ml? A. B. C. D.

Moderate potency Less potent More potent Same potency

33. Nursing intervention for a parient on low dose IV insulin therapy includes the following, EXCEPT A. B. C. D.

Elevation of serum to monitor ketosis Vital signs including BP Estimate serum potassium Elevation of blood glucose levels

34. The doctor ordered to incorporate 1000 “u” insulin to the remaining on going IV. The strength is 500 u/ml. how much should you incorporate into the IV solution? A. 10 ml B. 2 ml

C. 0.5 ml D. 5 ml

35. Multiple vial-dose-insulin when in use should be: A. Kept at room temperature B. Kept in the refrigerator

C. Kept in the narcotic cabinet D. Stored in the freezer Situation 8 – Collaborative planning is essential if nursing and health care are to be made available to all people 36. Perioperative examples of collaboration are the following EXCEPT: A. Communicate with other members of the health profession to improve the integrity B. Communicate with health officials the incidence of Hepatitis B among OR personnel C. Collaboration with other Or personnel regarding the practices of surgeons collecting exorbitant professional fees D. Collaborate with DOH regarding disposal or specimens 37. The nurses collaborate with other members of the health profession to improve the integrity of the hospital working environment through the following ways EXCEPT A. Joining barangay health club projects B. Joining the Mayo Uno Labor Union C. Joining labor day rally to increase wages of healthcare workers and improve dilapidated health centers D. Affiliating with The All Healthcare Alliance 38. An example of a collaborating effort on public service particularly during summer is: A. B. C. D.

Boto mo, Ipatrol mo Operation Linis Clean and Green Operation Tuli

39. When does a nurse reject the interdependence f providers and patients in achieving access to health care? A. “Our hospital does not honor visiting doctors” B. When the nurse replies to a client’s relative “You have the best doctor in town” C. When the nurse communicates to the attending physician the desire of the patient to be seen by a urologist D. “the doctor is not on duty today” 40. Individual patients and society as a whole benefit from nursing participation in decisions made about health care. This is exemplified in: A. B. C. D.

Supporting political candidates that advance nursing care health care issues Bringing the NCLEX in the Philippines Supporting the proliferation of colleges of nursing in the country Following the decision of CGFNS to retake. Test III and V to validate the visa screen for the U.S.

Situation 9 – Pain management is not limited to pharmacological means 41. Ronald, one of your clients who is being worked out for AIDS, tells you that he has been using acupuncture to help with his pain. You questioned his treatment because A. B. C. D.

Acupuncture uses needles to stimulate certain points on the body to treat pain. Acupuncture uses a variety of herbs and oils from wild plants Acupuncture uses manipulation of the skeletal muscles to relieve stress and pain Acupuncture uses pressure from the fingers and to stimulate body responses

42. Your younger brother came home with a right black eye. He asked for an eye ointment to relieve the pain and swelling. You should offer: A. B. C. D.

Ice pack over the right eye Tetracycline ophthalmic ointment Hot compress over right eye Ice cold drinks

43. Menstrual pain and discomfort account for absences in schools and offices. An nonpharmacological remedy for menstrual pain is: A. Regular bowel movement B. Knee-chest exercises before menstruation and hot water bag application over lower abdomen during onset C. Warm shower during onset of menstrual period D. Diet restriction on fatty foods and liberal fluid intake 44. Among burn clients, especially 1st and 2nd degree, one of the primary nursing functions is to alleviate pain. The following are appropriate nursing interventions, EXCEPT A. B. C. D.

Using cold water for dehydration Avoiding exposure to draft Administering morphine SO4 as prescribed Using of bed cradle to relive pain 45. Nurses taking care of post skin-graft patients know that the post-op pain is at the A. Buttocks B. Donor site

C. Recipient site D. Injection site

Situation 10 – one learns by doing especially when you practice the best methods. 46. Which action by a new nurse signifies a need of further teaching in infection control? A. B. C. D.

The nurse places the side rails the time to an unconscious patient The nurse elevates the head of the bed to check the BP The nurse uses her bare hands to change the dressing The nurse applies oxygen catheter to the mouth

47. You are on PM shift and about 5 patients are for discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue? A. B. C. D.

Call the attention of the orderly in private Ignore this situation because you are busy Report the behavior of the nurse in charge Monitor the situation and note whether any other items are reported missing

48. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? A. B. C. D.

Try to explore the interaction with the nursing attendant concerned Change the attendant’s assignment Initiate a group discussion with all the other nursing attendants Discuss the matter with the patient’s family

49. You have been in the surgical ward for almost a year and have cared for a number of patients with CVP. Which observation from a colleague would indicate a need further teaching? A. The colleague turns the stop-cock to the off position from the IV fluid to the patient B. The nurse colleague notes the level at the top of the meniscus C. The colleague instructs the client to perform valsalva maneuver during the CVP reading D. The nurse colleague charting medication administration that she has not yet given 50. You saw one colleague charting medication administration that she has not yet administered. After talking to her, you also report the incident to the charge nurse should: A. B. C. D.

Require the staff to submit an incident report Terminate the nurse Change the erring nurse with dishonesty Report to the board of nursing

Situation 11- You are assigned to the PACU. 9:30 am, post-op clients started to be wheeled in from the OR. 51. Which nursing diagnosis has priority among client in the PACU? A. B. C. D.

Acute pain related to discomfort of wound and immobility Body image disturbance because of wound dressing and drains. Ineffective airway clearance related to general anesthesia Knowledge deficit related to lack of information because patients are all sedated

52. Which of the following clients at the PACU will demonstrate the effectiveness of preoperative teaching?

A. B. C. D.

The client demonstrates deep breathing, coughing, splintering and leg exercises The client manifests normal temperature The client sleeps well The client has good balance I and O

53. Which of the following remark indicates that the client’s relative understood the discharge instruction for wound care? A. B. C. D.

“If the wound is painful, I will say it is normal” “It is alright to use adhesive tape over the wound to keep it intact” “It is ok for his pet to remain at his bedside to keep him company” “I will report ant redness or swelling of the wound”

54. You just transferred out a post-op client to her room. What would your instruction to the family include to prevent accidents? A. B. C. D.

Report when IV infusion is almost finished Test the call system if functioning Keep the room lights on for 24 hours Make sure the side rails are up

55. One of your post-op patients has a temperature of 37.9 C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9 C. The nursing student asked you to explain the absence of shivering even if the temperature was higher A. B. C. D.

The patient is no longer febrile thus he is no longer chilling Shivering normally disappears as temperature becomes higher The body has reached its new set point thus the absence of shivering The patient is felling better

Situation 12 – Patients with chest tubes can be very challenging to new nurses 56. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. After an hour you noticed that the bubbling stops. Which of the following condition is the possible cause of the malfunctioning sealed drainage? A. B. C. D.

A suction being too high An air leak A tube too small A tension pneumothroax

57. While you were making your endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action? A. B. C. D.

Assist the client back to his bed and place him on the affected side Cover the end of the chest tube with sterile gauze Reconnect the tube to the chest tube system Put the end of the chest tube into a cup of sterile normal saline

58. Dr. Reyes asked you to assist him with the removal of Tirso’s chest tube. You would instruct the client to: A. B. C. D.

Continuously breathe normally during the normal of the chest tube Take a deep breath, exhale, and bear down Exhale upon actual removal of the tube Hold breath until the chest is pulled out

59. Chest tube diameter is measured or expressed in A. French B. Gauge

C. Milliliters D. Inches

60. When transporting clients with chest tube, the system should be: A. B. C. D.

Disconnected Closed Placed lower than the patient’s chest Placed between the legs of the client to prevent breakage

Situation 13 – The perioperative nurse collaborates with the client, significant others, and healthcare providers 61. Patient outcomes reflect collaborative interdisciplinary effort and independent nursing activities. Who is the primary partner of the nurse in health care? A. The family B. The doctor

C. The client D. The significant other

62. The control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT A. B. C. D.

Biomedical division Chaplaincy services Infection control committee Pathology department

63. Waste disposal poses a big problem for the hospital. Biological wastes (i.e. amputated limbs) disposal should be coordinated with the following agencies EXCEPT A. Crematorium B. DOH

C. MMDA D. DILG

64. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs prior to surgery, is in severe pain 3 hrs after cholecystectomy. Upon checking chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with A. Nurse supervisor B. Anesthesiologist

C. Surgeon D. Intern in duty 65. Rosie, 57, who is a diabetic, is for debridement of incision wound. When circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do? A. B. C. D.

Double check the doctor’s order and call the attending MD Communicate with the ward nurse to verify if insulin was incorporated or not Communicate with the client to verify if insulin was incorporated Incorporate insulin as ordered

Situation 14 – Technology and patient’s education has dramatically improved the management of the diabetic client. 66. The current insulin pumps available in the market have the following capability, EXCEPT: A. B. C. D.

Prevent unexpected saving in blood glucose measurements Detect signs and symptoms of hypoglycemia and hypercalcemia Deliver a pre-meal bolus dose of insulin before each meal Deliver a continuous basal rate of insulin at 0.5 units to 2.0 units per hour

67. Discharge plan of diabetic clients include injection-site-rotation. You should emphasize that the space between sites should be A. 6 cm B. 5 cm

C. 2.5 cm D. 4 cm

68. It is critical also that a diabetic client should be educated in the possible site if regular insulin injection. The fastest absorption rate happens at the tissue areas of: A. B. C. D.

Gluteal area Deltoid area Anterior thigh Abdominal area

69. Self-monitoring of blood glucose (SMBG) is recommended for patient’s use. You will recommend this technology in the following diabetic patients, EXCEPT A. B. C. D.

Client with proliferative retinopathy Unstable diabetes Hypoglycemia without warning Abdominal renal glucose threshold

70. It is necessary for a diabetic client to exercise regularly, what is the effect of regular exercise to a diabetic client? A. It burns excess glucose

B. It improves insulin utilization and lowers blood glucose C. It lowers glucose, improves insulin utilization, decrease total triglyceride levels D. It will make you fit and energized Situation 15 – RN’s should always be conscious that the contents in charting are admissible in court as evidence 71. If there is any deviation from normal practice or procedure e.g. streptomycin was given by IV not IM, this should documented in the: A. B. C. D.

Progress notes Incident report Nurse’s note Patient’s chart

72. Documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patient’s chart? A. B. C. D.

Presence of prosthetic devices such as dentutes, artificial limbs, hearing aid, etc. Baseline physical, emotional, and psychosocial data Arguments between nurses and residents regarding treatments Observed untoward signs and symptoms and interventions including concomitant intervening factors

73. 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 to show: A. B. C. D.

Document the incident Be apart of the patient’s chart Present confidential report Evidence of the quality of care

74. Erasures, alterations, and additions in medical records and the nurse’s notes can be avoided. The following are some tips on how to do correction EXCEPT: A. Cross out blank spaces B. Cross out word or phrase with one or two lines making the crossed out word discernible C. Insert additions or corrections D. State the for any deviation from procedure/practice 75. Kathy is one of your patient’s. her uncle, who is a doctor, wants to read her chart. Your appropriate action would be A. Instruct Kathy’s uncle to present a written authorization signed by the patient B. Refer to the hospital C. Instruct Kathy’s uncle to present a written request to the Medical Records Section of the hospital

D. Refer to the attending physician Situation 16 – During the month July, you noticed that there is an incidence of upper respiratory disorders 76. One of your cases is with acute pharingitis. Your nursing management includes the following EXEPT: A. B. C. D.

Suggest a soft or liquid diet during acute stage Encourage liberal amount of cold fruit juices Encourage bed rest during febrile stage Apply ice collar for symptomatic relief f severe sore throat

77. For a nurse to assess an upper respiratory tract infection, you should palpate the following: A. B. C. D.

The ears, eyes, nose, and throat Adenoids, tonsils and nose Nose and throat only The tracheal and nasal mucosa including the frontal sinuses

78. Among patients with upper airway infection, airway clearance can be facilitated by the following EXEPT: A. B. C. D.

Regularly administering prescribed vasoconstrictive medications Decreasing systemic hydration Positional drainage Humidifying inspired room air

79. A friend asked you some nursing measures of uncomplicated common colds. You will include the following measures EXEPT: A. B. C. D.

Instruct client about symptoms of secondary infections Administer prescribed antibiotics Teach that the causative virus is contagious even before symptoms appear Suggest adequate of fluids and rest

80. The following are your nursing suggestions for a patient with acute or chronic sinusitis EXEPT: A. B. C. D.

Local heat application to promote drainage Consult an ENT surgeon Increase humidity Advice adequate fluid intake

Situation 17- a specimen is a piece of tissue or body fluid taken from the disease body organ or tissue to aid the health care team diagnosis and effective treatment. Necessarily, the nurse assume responsibility in the care of the specimen.

81. Carmen is suspected to have left CA. She is scheduled in your room on 5 for frozen section. How will you prepare the specimen for laboratory? A. B. C. D.

Refrigerate and send it along with the day’s specimen Send it pathology immediately without soaking Soak in NSS Soak in formalin

82. How will you label this specimen? What information was essential in the label? A. B. C. D.

Name of client, age, sex, hospital number Name of client, age, sex Name, age, site, type of specimen, hospital number, doctor Name, doctor, type of specimen, hospital number

83. Foreign body the extracted from the body like pins, needles, seeds or bullets are also considered as specimen. You assisted in the multiple gun-shot wound exploration. During the surgery 3 bullets were recovered. You should specimen to: A. B. C. D.

The department of pathology The national bureau of investigation The OR head nurse Client’s family.

84. A post dilation and curettage (D and C) client is for discharge. Follow-up of lab results should be part of the discharge plan. You will instruct the client to follow up result at the: A. B. C. D.

Medical record Laboratory Doctor’s clinic Nurse’s station

85. You are the circulating nurse in OR 2. You have 4 thyroidectomy cases for the day. How do you prevent switching of specimens? A. B. C. D.

Send specimens to laboratory right away after the operation with the proper labels Collect all specimens and send to laboratory at the end of the day Label specimen at once Prepare 4 specimen vials first thing in the morning

Situation 18 – Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scanty urination, hermaturia and dysuria. 86. You are the nurse in charge of Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as follows: A. Uretera, kidney, bladder urethra B. Urethra, bladder wall, trigone, uteral opening

C. Bladder wall, uterine wall and urethral opening D. Urethral opening, ureteral opening, bladder 87. In the OR, you will position Mr. Santos who is cystoscopy in: A. Supine B. Lithotomy

C. Semi-Fowler D. Trendelenburg

88. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him? A. B. C. D.

“Cystoscopy is direct visualization and examination by urologist” “Cystoscopy is done by x-ray visualization of the urinary tract” “Cystoscopy is done by using lasers on the urinary tracts” “Cystoscopy is an endoscopic procedure of the urinary tract”

89. Within 24-48 hours post cystoscopy, it is normal to observe one the following: A. B. C. D.

Pink-tinged urine Distended bladder Signs of infection Prolonged hematuria

90. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes: A. Bed rest B. Warm moist soak

C. Early ambulation D. Hot sitz bath

Situation 19 – During the surgical procedure, contamination should be confined and contained within the immediate vicinity of the surgical field to prevent the spread of pathogenic microorganisms. 91. The following technique illustrates the concept “concine and contain”, EXCEPT: A. Contaminated items like sponges are handled using gloves B. All blood, tissue, and body fluid specimens should be placed in leak-proof containers C. Surgeons conduct their patient’s rounds in scrub suit D. Prompt clean up of accidental spills of contaminated debris e.g. blood, body fluids 92. The OR is a ‘restricted are’ where OR attire worn, temperature and humidity are set for patient and personnel safety and reduce bacterial contamination. During surgery, movement of personnel including the circulating nurse is: A. B. C. D.

Kept to a minimum Eliminated when possible Restricted Monitored

93. ‘Sterile’ is the condition of almost all items, devices or supplies used in the OR for any surgical procedure. Shelf-life packaged sterile item is event related and depends on the following, EXCEPT: A. B. C. D.

Type of sterilizer used to sterile items Amount of handling The quality of packaging material used Storage conditions

94. Precaution recommends that the use of standard personal protective equipment (PPE) to prevent cross contamination. Which is NOT considered a piece of PPE? A. Cover gown B. Eyewear

C. Gloves D. Face shields

95. Traffic patterns in the OR suite should: A. B. C. D.

Prevent unauthorized personnel from entering the OR Prevent transmission of pathogenic microorganisms Assure that personnel walk in the same direction Allow personnel t move freely between restricted and unrestricted areas

Situation 20 – Nokia is powerful to “connect people” from continent, all trough communication via the cellphone. Other ways of communication to relay information or instructions exist even in the healthcare setting. 96. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb, 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as standby. What gauge spinal sets will you make available in the OR suite? A. B. C. D.

Gauge 16 and 22 Gauge 18 and 16 Gauge 16 and 20 Gauge 25 and 22

97. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains ‘laughing gas’? A. Yellow B. Green

C. Black D. Blue

98. On the traffic light, yellow means “proceed with caution”. In the field of healthcare, where do you discard your used tissue papers? A. B. C. D.

Yellow bin Orange bin Green bin Black bin

99. An instrument tray with black stripes autoclave/steam chemical indicator tape communicates that the instrument tray…. A. B. C. D.

Is clean Is ready to use in surgery Is sterile Has undergone the sterilization process

100. In health care, when lead apron is required in any procedure like orthosurgery, there is danger of exposure to: A. B. C. D.

Water and blood splashes Pseudomona Radiation Bone fragments

*** END ***

NURSING PRACTICE III – Care of Clients with Physiology and Psychosocial Alterations (Part B) 1. 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 A. B. C. D.

Battery Assault Negligence Malpractice

2. Jake is in the Post Anesthesia Car Unit following a colorectal resection. H has an IV of dextrose 5% Lactated Ringers Solution. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs, moist respiration and tachypnea. Which of the following will you do first? A. B. C. D.

Notify anesthesiologist Increase O2 flow rate Place on fowler’s position Reduce IV rate

3. As a head nurse of the unit, which of the following sources should you take into consideration when making effective assignments for the next shift? A. B. C. D.

Seniority preferences Recent performance evaluation Personally traits Client classification data

4. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. As the triage nurse, you would assign the HIGHEST priority to the client with the: A. B. C. D.

Severe head injury and no blood pressure Maxillofacial injury and gurling respirations Second trimester pregnancy with premature labor Lumbar spinal cord injury and lower extremity paralysis

5. When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible?

A. B. C. D.

Volunteer nurse, hospital and the nurse in charge The professional organization w/c the volunteer nurse represents Hospital Volunteer nurse because there is no employer employee relationship

6. Daniel with multiple myeloma complains of deep bone pain. As his care, w/c of the following will you do FIRST? A. B. C. D.

Assess bone pain Administer prescribed analgesic Teach pain relief strategies Support position with pillow

7. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory results should you expect to find? A. B. C. D.

Increased platelet count Altered blood urea nitrogen (BUN) and creatinine levels Electrolyte imbalance Elevated erythrocyte sedimentation rate (ESR)

8. Mrs. Paras is receiving the total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of the following indicators will let you that TPN was effective? A. B. C. D.

Laboratory work up Adequate hydration Weight gain Diminish episode of nausea and vomiting

9. While jayvee, a burn patient being transferred from the burn unit to the operating room, the IV bottle fell on Jayvee’s head. He sustained a location on his forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do? A. B. C. D.

Hold the IV bottle Check the IV stand Place the IV stand on the foot part of the stretcher Restrain Jayvee

10. While Mrs. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs? A. B. C. D.

Administer Compazine before meals Enrich diet with red meats Serve hot soup and food Increase the amount of spice in the diet

11. Nurses working in the 35 bed Female Medical Unit were noted to implement new and innovative client care activities long before other units in the hospital. Which of the

following leadership characteristics exhibited by the nurse manager best describes this strength? A. B. C. D.

Communication skills Knowledge and skills Vision and passion Interpersonal abilities

12. Olga is receiving D5W 1 liter regulated at 30 drops/min to be continued in 8 hours. It was started at 8am. At 10am her relative informed you that the bottles is empty. Which of the following will you do first? A. B. C. D.

Refer to the nurse manager Assess Olga and check level of fluid left in the bottle Discontinue IV and assess Olga Replace the IV fluid with prescribed follow-up

13. A research study found out that 60% of the patients complaints were due to delayed responses of nurses in the emergency department. Which of the following measurement of data was used in this study? A. B. C. D.

Measures of variability Measures of central tendency Frequency distribution Inferential statistics

14. During a meal, a client with Hepatitis B dislodges her I.V. 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 A. Alcohol B. Acetone

C. Ammonia D. Bleach

15. Nino is being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy? A. B. C. D.

Cover the areas with thick clothing materials Apply a heating pad to the site Wash skin with water after the therapy Avoid applying creams and powders to the area

16. You are assigned to the following patients. Which of the following patients is most at risk for the metabolic alkalosis? A. Grace 30 year old post surgical who has continuous nasogastric suction B. Rachel a 55 year old who has just experienced a stroke C. Helen 70 year old with altered level of consciousness who is unable to access water freely D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution

17. Studies have shown that the highest incidence of Hodgkin’s disease is common among young adults. Juana 20 years old approaches you and tells you “I am worried about the mass on y neck”. What should you do as a nurse? A. B. C. D.

Tell her there is nothing to worry if it does not bother her Palpate Juana’s neck and explain the possible cause Tell her Hodgkin’s disease is common among young adults like her Tell her to see a doctor

18. As a nurse, you accidentally administer 40 mg of Propranolol (Indernal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to a large dose, you should: A. B. C. D.

Complete an incident report Call the hospital attorney Inform the client’s family Do nothing because the client’s condition is stable

19. 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 a group of clients utilizing evidence-based practice? A. Client’s care is planned based on the nurse’s clinical expertise and latest research findings B. Standardized care plans are used on all of the nurse’s clients. C. Standards of care are developed by the hospital nursing service and should be followed D. Client’s needs are assessed and individualized care plan are developed for each client 20. 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? A. B. C. D.

Correct errors in the physician medication order Eliminate drug interaction Provide a list of drugs with their generic name Document drug administration

SITUATIONAL Situation 1 – P. Cruz, 65 year old, was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. You are expected to recognize electrocardiographic readings on the cardiac monitor. 21. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium?

A. B. C. D.

QRS interval ST segment and T wave P wave PR interval

22. From an ECG reading, a QRS represents A. B. C. D.

Ventricular depolarization Ventricular repolarization End of the Ventricular depolarization Atrial depolarization

23. Which of the following represents Ventricular repolarization? A. B. C. D.

T wave St segment RS complex PR interval

24. It is important that the nurse measures intervals of QRS complex. Which of the following represents the normal interval of the QRS complex? A. B. C. D.

Greater than .20 sec .20 sec .10 sec .12 sec to .20 sec

25. Later in the acute phase of Myocardial Infarction, which of the following typically appears as the first sign of tissue death? A. B. C. D.

ST segment suppression Short T wave Prolonged PR interval Pathologic Q wave

Situation 2 – To be able to help our clients with their psychological concerns we have to explore how they view themselves and their body image 26. When assessing patient’s body image, which of the following would be most important to ask? A. B. C. D.

What are your hobbies? What kind of work did you do prior to all this illness? Are your living accommodation all on one level? What kind of food do you like?

27. The most appropriate nursing intervention to facilitate client’s acceptance of a change in body image would be to:

A. B. C. D.

Encourage dependence Establish a therapeutic relationship Joke with the client Establish a social relationship

28. Which of the following responses would indicate that the client is beginning to accept change in his/her body image? A. B. C. D.

Feeling of the dressing over the incisional site Stating he/she is too tired to have visitors Discussing his/her stamp collection with the nurse Showing no interest in the dressing change

29. It is important for you to remember, that a sudden change in body image would occur from: A. B. C. D.

Weight gain Side effects of medication on skin Radiation treatment of the breast Surgical removal of an eyeball

30. Before you can help Lorna accept a change in body image you must FIRST: A. B. C. D.

Be in agreement with the philosophy of therapy for the client Become aware of her own attitude toward mutilation and disfigurement Be aware of the attitudes and feelings of the client and her family Accept the fact that a person can live with a body part missing

Situation 3 – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as a nurse. 31. Albert is recovering external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert? A. B. C. D.

Tell him that sometimes these feelings can be psychogenic Refer him to a physician Reassure him that these feelings are normal Help him plan his activities and test period

32. Immediately following the radiation teletherapy, Albert is A. B. C. D.

Considered radioactive for 24 hours Given a complete bath Placed on isolation for 6 hours Free from radiation

33. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms.

A. B. C. D.

Petechiae, ecchymosis, epistaxis Weakness, easy fatigability, pallor Headache, dizziness, blurred vision Severe sore throat, bacteremia, hepatomegaly

34. What nursing diagnosis should be of highest priority? A. B. C. D.

Knowledge deficit regarding thrombocytopenia precautions Activity intolerance Impaired tissue integrity Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal

35. What intervention should you include in your care plan? A. B. C. D.

Inspect his skin to petechiae, bruising, Gl bleeding regularly Place Albert on strict isolation precaution Provide rest in between activities Administer antipyretics if his temperature exceeds 38 C

Situation 4 – Andrea is admitted to the ER following an assault where was hit in the face and head. She was brought to the ER by a police woman. Emergency measures were started 36. As Andrea’s nurse, what will be your priority intervention? A. B. C. D.

Insert an intravenous catheter Insert an oral or nasopharyngeal airway Obtain arterial blood gases Give 100% oxygen by mask

37. Andrea’s arterial blood gases reflect acidosis. This is most likely related to: A. B. C. D.

Partially obstructed airway Ineffective breathing pattern Head injury Pain

38. Andrea loses consciousness. You should prepare for which of the following FIRST? A. B. C. D.

Placement of a nasogastric tube Placement of second IV line Endotracheal intubation or surgical airway placement CT scan of the head

39. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to: A. Promote cerebral-tissue fluid movement B. Promote renal perfusion

C. Correct acid-base imbalances D. Enhance renal excretion of drugs 40. As Andrea’s nurse your goal is to prevent increased intracranial pressure (ICP). Which of the following independent nursing interventions is NOT suited for her? A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration B. Keep head of bed 30-45 degrees elevated C. Maintain Andrea’s head in straight alignment and prevent hip flexion D. Prevent constipation and increases in intra abdominal pressure Situation 5- specific interventions may be done with lung cancer is detected early. You have important peri-operative respon cibilities in caring for patients with lung cancer. 41. Horace underwent lobectomy. Which of the following I the purpose of horace’s closed chest drainage post lobectomy. A. B. C. D.

Facilitation of coughing Promotion of wound healing Expansion of remaining lung Prevention of mediastinal shift

42. Which of the following observations indicates that the closed chest drainage is functioning properly? A. B. C. D.

Absence of bubbling in the suction-control bottle The fluctuating movement fluid in the water-seal bottle during inspiration Intermittent bubbling through the long tube of the suction control bottle Less then 25 ml. drainage in the drainage bottle

43. following lobectomy, you can best make Horace to reduce to reduce pain during deep breathing and coughing exercises by: A. B. C. D.

Placing him on his operative side during exercises Splinting his chest with both hands during exercises Administering the prescribed analgesic immediately prior to exercise Providing rest for six hours before exercises

44. Peter underwent pneumonectomy. During the immediate postoperative period, deep tracheal suction should be done with extreme caution because: A. B. C. D.

Peter will not be able to tolerate coughing. The trcheobracial trees are dry The remaining normal lung needs minimal stimulation The bronchial suture line may be traumatized

45. On which of the following positions should you place Peter who just underwent pneunoctomy?

A. B. C. D.

Prone position On his abdomen or on the side of opposite surgery On his back or on the side of surgery Any position is acceptable

Situation 6- As a nurse you should be able to address problems and discomforts experienced by the acutely ill older persons. 46. Pain in the older persons require as careful assessment because they: A. B. C. D.

Are expected to experience chronic pain Experienced reduce sensory perception Have increased sensory perception Have a decreased pain threshold

47. Administration of analgesics to the older persons requires careful patients assessment because older people: A. B. C. D.

Have increased hepatic, renal, and gastrointestinal function Mobilize drug more rapidly Have increased sensory perception Are more sensitive to drugs

48. The older person is at higher risk for incontinence because of A. B. C. D.

Increased glomerular filtration Decreased bladder capacity Diuretic use Dilated urethra

49. The most dependable caused of infection in the older person is A. B. C. D.

Change in mental status Fever Decreased breath sounds with crackles Pain

50. Your priorities when caring for the older person who sustained traumatic injuries include: A. B. C. D.

Circulation: air way: breathing Air way, breathing , disability (neurologic) Air ways, breathing, circulation Disability (neurologic), airway, breathing

Situation 7 – Mang Felix, a 79 year old man is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling urinary catheter for continuous fast drip bladder irrigation w/c is connected to a straight drainage

51. Immediately after surgery, what would you expect his urine to be? A. B. C. D.

Light yellow Amber Bright red Pinkish to red

52. The purpose of the continuous bladder is to: A. B. C. D.

Allow continuous monitoring of the fluid output status Provide continuous flushing of clots and debris from the bladder Allow for proper exchange of electrolytes and fluid Ensure accurate monitoring of intake and output

53. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action? A. B. C. D.

Remove his catheter then allow him to void on his own Irrigate the catheter Tell him to “go ahead and void” “you have a catheter” Assess color and rate of outflow; if there is a change refer to urologist for possible irrigation

54. You decided to check on Mang Felix’s IV fluid infusion. You noted a change in flow rate, pallor and coldness around the insertion site. What is your assessment finding? A. B. C. D.

Phlebitis Infiltration to subcutaneous tissue Pyrogenic reaction Air embolism

55. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during the first post operative day, which of the following is the LEAST relevant to document in the case of Mang Felix? A. B. C. D.

Chest pain and vital signs Intravenous infusion rate Amount, color, and consistency of bladder irrigation drainage Activities of daily living started

Situation 8 – Many 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. 56. Which of the following is the purpose of the ethical committee? A. Promote implementation of general standards B. Enhance health care provider’s liability C. Increase individuals responsibility of decision making

D. Decrease public scrutiny of health care provider’s action 57. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20,000/aeL develops epistaxis and melena. Treatment will corticosteroids and immunoglobulin has not been successful. Her physician recommended splenectomy. Daria states “I don’t need surgery. This will go away on its own”. In considering your response to Daria you must depend on the ethical principle of: A. B. C. D.

Beneficence Justice Autonomy Advocacy

58. Zorayda is terminally ill and is experiencing severe pain. She has bone and liver metastasis. She has been on morphine for several months now. Zorayda is aware that they are having financial problems. She decides to sign a DNR form. What ethical principle did Zorayda and her family utilize as basis for their decision to sign a DNR. A. B. C. D.

Justice Autonomy Beneficence Advocacy

59. Tricia, a staff nurse working 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? A. B. C. D.

Beneficence Autonomy Advocacy Justice

60. You are commuting to work riding the LRT. An older person collapsed and nobody seem 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 diabetes clinic to have her fasting blood sugar tested. She developed hypoglycemia. You were able to save a life. You felt good. What principle was applied? A. B. C. D.

Advocacy Beneficence Justice Autonomy

Situation 9 – ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse

61. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure. A. B. C. D.

Clenching his fist every 2 minutes Breathing in and out through the nose with his mouth open Tensing the shoulder muscle while lying in his back Holding his breath periodically for 30 seconds

62. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication. A. B. C. D.

Nausea and vomiting Shortness of breath and laryngeal stridor Blood tinged sputum and coughing Sore throat and hoarseness

63. Immediately after bronchoscopy, you instructed Fernan to A. B. C. D.

Exercise the neck muscles Breathe deeply Refrain coughing and talking Clear is throat

64. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your important function during the procedure is to: A. B. C. D.

Keep the sterile equipment from contamination Assist the physician Open and close the three-way stopcock Observe the patient’s vital signs

65. Right after thoracentesis, which of the following is most appropriate intervention? A. B. C. D.

Instruct the patient not to cough or deep breathe for two hours Observe for symptoms of tightness of chest for bleeding Place an ice pack to the puncture site Remove the dressing to check for bleeding

Situation 10 – As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients. 66. Getty is receiving chemotherapy for cancer. You review Getty’s laboratory report and note that he has anemia. To which nursing diagnosis should you give the highest priority A. B. C. D.

Activity intolerance Impaired oral mucous membrane Impaired tissue perfusion, cerebral, cardiovascular, gastrointestinal Impaired tissue integrity

67. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease A. B. C. D.

Hypertension Pain Hematuria Weight

68. A difficult problem to deal with when caring for a patient with partial-thickness burns sustained 3 days ago is: A. B. C. D.

Alteration in body image Maintenance of sterility Frequent dressing change Severe pain

69. Which outcome criterion would be most appropriate for a client with a nursing diagnosis of ineffective airway clearance A. B. C. D.

Continued use of oxygen when necessary Breath sounds clear on auscultation Respiratory rate of 24/min Presence of congestion

70. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related to purulent wound drainage A. B. C. D.

Heart rate of 88 beats/min Dry and intact wound dressing Oral temperature of 38.8 deg C Wound healing by first intention

Situation 11 – Nurses have important responsibilities when caring for hospitalized acutely ill patients 71. Domingo, 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. His physician was considering dementia. Side rails were placed to ensure that he will not fall from bed. At 2:00 am, the call light at his room was on. You came in and saw Domingo slumped on the floor moaning. His daughter told you that he got out of the bed to go to the toilet. He climbed over the side rail but his foot got caught in the beddings. He has opened wound on his forehead. Which among the following will you do FIRST? A. B. C. D.

Transfer him to bed Apply restraints Ensure airway, breathing, circulation Call his physician

72. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Based on the ECG obtained on administration at the ER and clinical findings, the physician gave a diagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain. A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI. as Aimee’s nurse, you have to anticipate occurrence of complications. Take note that the major cause of death after an MI is: A. B. C. D.

Cardiac arrhythmias Heart failure Cardiogenic shock Pulmonary embolism

73. The cardiac monitor indicates that Cedric’s heart rate has increased to 150 beats per minute. Shortly after this increase, you notice Cedric is in Ventricular tachycardia. After reporting this to the physician. You anticipate that the physician will order: A. B. C. D.

Intracardiac epinephrine Insertion of a peacemaker Bolus of Lidocaine Manual cardiopulmonary resuscitation (CPR)

74. Hermie with a left-sided hert failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. You should recognize this as signs and symptoms of A. B. C. D.

Cardiogenic shock Right-sided heart failure Acute pulmonary edema Pneumonia

75. You are caring for Lulu who has acute pulmonary edema. To immediate promote oxygenation and relief of dyspnea, you should first A. B. C. D.

Perform chest physiotherapy Have her take deep breaths and cough Place Lulu on high fowler’s position Administer oxygen

Situation 12 – Acute respiratory distress is life threatening. Your presence and critical decision making as a nurse are important 76. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. When assessing Frank you would expect to find A. B. C. D.

An altered mental status Hypertension A slowed rate of breathing Tenacious secretion

77. Frank’s respiratory status necessitates endotracheal intubation and positive pressure ventilation. Your most immediate nursing intervention for Frank at this time would be to: A. B. C. D.

Facilitate Frank’s verbal communication Maintain sterility of the ventilation system Assess his response to the equipment Prepare him for emergency surgery

78. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, you should A. B. C. D.

Apply suction while inserting the catheter Use short and jabbing movements of the catheter to loosen secretion Hyperoxygenate with 100% oxygen before and after suctioning Suction two or three times quick succession to remove all secretion

79. As a nurse you should observe Bernard, who has a restrictive airway disease, for early indications of respiratory acidosis, which include: A. B. C. D.

Light-headedness Bradypnea Bradycardia Restlessness

80. The physician orders low concentration oxygen to be given continuously for Kenneth who has a chronic obstructive pulmonary disease to prevent: A. B. C. D.

An excessive drying of the respiratory mucosa Depression of the respiratory center Rupture of emphysematous bullae A decrease in red blood cell formation

Situation 13 – As a nurse you have to be prepared to care for patients receiving blood transfusion. The physician has ordered 3 units of whole blood to be transfused to Diego following a repair of dissecting aneurysm of the aorta. 81. You are preparing a unit of whole blood for transfusion. From the time you obtain it from the blood bank how long should you infuse it? A. B. C. D.

4 hours 1 hour 2 hours 6 hours

82. What should you do FIRST before you administer blood transfusion? A. Check IV site and use appropriate BT set and needle B. Verify physician’s order

C. Verify client identity and blood product, serial number, blood type, cross matching results, expiration date with another nurse D. Verify client identity and blood product, serial number, blood type, cross matching results, expiration date 83. As Diego’s nurse what will you do after transfusion has been started? A. B. C. D.

Discontinue the primary IV of Dextrose 5% water Stay with Diego for 15 minutes to note for any possible BT reaction Check his vital signs every 15 minutes Add total amount of the blood to be transfused to the intake and output

84. Diego is undergoing transfusion of the first unit. The earliest signs of transfusion reactions are A. B. C. D.

Oliguria and jaundice Urticaria and wheezing Hypertension and flushing Headache, chills, fever

85. In case of Diego 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 physician B. Slow the blood transfusion and monitor the patient closely C. Immediately stop the blood transfusion, notify the blood bank and administer antihistaminics D. Immediately stop the blood transfusion, infuse normal saline, solution, call the physician, notify the blood bank Situation 14 – Based on studies of nurses working in special units like the intensive care unit and coronary unit, it is important for nurses to gather as much information to be able to address their needs for nursing care 86. Critically ill patients frequently complain about which of the following when hospitalized? A. B. C. D.

Hospital food Lack of blankets Lack of privacy Inadequate nursing staff

87. Who of the following is at greatest risk of developing sensory problem? A. B. C. D.

Female patient Adolescent patient Transplant patient Unresponsive patient

88. Which of the following factors may inhibit learning in critically il patients? A. B. C. D.

Gender Medication Educational level Previous knowledge of illness

89. Which of the following statements does not apply to critically ill patients? A. B. C. D.

Majority need extensive rehabilitation All have been hospitalized previously Are physically unstable Most have chronic illness

90. Families of critically ill patients desire which of the following needs to be met first by the nurse? A. B. C. D.

Provision of comfortable space Emotional support Updated information on client’s status Spiritual counseling

Situation 15 – Pain is one of the most common reasons why people consult their physicians. It is regarded as the 5th Vital Sign. This strategy is used to give emphasis on how pain should be managed. You have collaborative as well as independent nursing intervention of pain 91. The Who analgesic ladder provides the health professional with A. B. C. D.

Pharmacologic and non pharmacologic pain management choices General pain management choices based on level of pain Non pharmacologic interventions based on level of pain Specific pain management choices based on severity of pain

92. As a nurse caring for patients pain you should evaluate for opioid side effects which include the following EXCEPT: A. B. C. D.

Physical dependence Pruritus Respiratory depression Constipation

93. Which of the following statements about cancer pain is NOT TRUE? A. Undertreatment of pain is often due to a clinician’s failure to evaluate the severity of the client’s problem B. Adjuvant medication such as steroids, anticonvulsants, nonsteriodal antiinflammatory drug enhance pain perception C. Opioids are drugs choice for severe pain

D. Pain associated with cancer and the terminal phase of the disease occurs in majority of patients 94. Jack has been on morphine on a regular basis several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that Jack is A. B. C. D.

Becoming psycologiclly dependent Needing to have the morphine discontinued Developing tolerance to the morphine Exaggerating his level of pain

95. The guidelines for choosing appropriate non pharmacologic interventions for pain include all of the following EXCEPT: A. B. C. D.

Pain problem identification Type of opoid being used Skill of the health professional Effectiveness for patient

Situation 16 – ? 96. ? 97. ? 98. ? 99. ? 100. You are caring for Lenard who sustained burn injury and he is in the emergent phase of burn injury. As his nurse, you gathered the following: Hemoglobin 13.5 g/100 ml, hematocrit 50%, serum Na 130 mEq/L. how will you explain the laboratory results? A. B. C. D.

These are due to hemodilution from rapid IV fluid replacement All the laboratory tests are within normal range They are slightly abnormal but will normalize once IV fluids have been started These are due to a loss of serum and interstitial fluid through the burn wound

*** END ***

NURSING PRACTICE V – Care of Clients with Physiology and Psychosocial Alterations (Part C) SITUATIONAL Situation 1 – The following wuestions refer to a nurse’s efforts to do collaboration and teamwork. Select the best answer. 1. The most important role of the nurse as a member of the team is to a) b) c) d)

Carry out medical orders Meet the needs for the physical well being of patients Coordinate the psychological care and management of clients Keep a 24 hour watch for the patients

2. A biological/medical approach to the patient care utilizes which of the following? A. B. C. D.

Million therapy Somaticc therapy Behavioral therapy Psychotherapy

3. Which of these nursing actions belong to the secondary level of preventive intervention? A. B. C. D.

Providing mental health consultation to health care providers Providing emergency psychiatric services Being politically active in relation to mental health care issues Providing mental health education to members of the community

4. When a nurse identifies a client who has attempt to commit suicide the nurse should: A. B. C. D.

Call a priest Counsel the client Refer the client to the psychiatrist Refer the matter to the police

5. The community health nurse was invited by the principal of an elementary school and was asked to give talk to parents. As appropriate topic would be:

A. B. C. D.

The legal aspects of drug abuse Disciplining children at home and school Marital crises The problems of out of school youth

Situation 2 – The nurse visited the Reyes family to check on their two growing children, aged 7 and 4 years. Upon her visit she observed common areas of arguments between Mr. and Mrs. Reyes are about conflicting ways of bringing up their children. Mrs. Reyes is lax of tolerant while Mr. Reyes often insists strict ways to a point of over protectiveness from what he perceives as unsafe i.e. community and neighbors that cannot be trusted. 6. Mrs. Reyes remarked “I am wary about people visiting – with all the media news about child kidnapping and robberies” – The nurse’s BEST response would be: A. “Would you rather wish that I don’t come and visit you may regard me as a stranger?” B. “I get that.” The nurse diverts the attention to talk about non-threatening topics C. “It must be distressing to think and feel the way you do” D. I acknowledge what you are saying. My concern is the health care of your family and information are strictly confidential” 7. 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? A. B. C. D.

Keeping trust in the relationship Avoid relating with neighbors to minimize conflict Be assertive to express her individuality Ignore the husband and just be supportive

8. 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 care plan. She is applying of A. B. C. D.

Responsibility and accountability Consistency and predictability Honesty and integrity Empathy and compassion

9. Which of these symptoms if demonstrated by Mr. Reyes would necessitate referral to a doctor? A. B. C. D.

Hypervigilance Suspicious affect Hypertensive Loss of reality contract

10. The paranoid client utilizes which of the following defense mechanism?

A. B. C. D.

Sublimation Projection Rationalization Reaction formation

Situation 3 – Mr. Sison has been diagnosed as having early chronic glaucoma. He has been admitted to the hospital for treatment 11. The nurse identified a nursing problem of disturbed sensory perception: visual impairment characterized by: A. B. C. D.

Sudden loss of eyesight Loss of night vision Loss of peripheral vision Loss of central vision

12. In order to understand the rationale for drug therapy, it is important fot the nurse to know that glaucoma is usually caused by A. B. C. D.

Opacity in the lens Gradual diminution of the retina Damage to the proteins in the lens Increase production of aqueous fluid

13. Diamox is a drug used in the treatment of glaucoma. Which of the following effect of this drug? A. B. C. D.

Consists the pupil Acts as osmotic diuretic Reduces production of aqueous humor Facilitates outflow of aqueous humor

14. Public health nurses should identify which of these patients as a risk group for development of glaucoma, hence the need for annual eye examinations: A. B. C. D.

Patient with Parkinson’s disease Cancer patients Diabetic and hypertensive patients Patient with COPD

15. The appropriate method of instilling eye drops is: instilling into an opened eye, with the head back and with the eye looking A. B. C. D.

To the left Downward To the right Upward

Situation 4 – SEXUAL DISORDERS

16. A hospitalized male adolescent flirts with and is sexually provocative toward a female nurse. The nurse can respond MOST therapeutically by doing which of the following? A. B. C. D.

Telling him she is married and too old for him Introducing him to female clients his own age Encouraging him to watch TV in his room Ignoring his flirtations and provocative behaviors

17. The premorbid personality of a person with a non psychotic maladaptive response to anxiety may most accurately be described as A. B. C. D.

Unpredictable, impulsive and aggressive Rigid, insecure and conforming Dependent, passismistic and moody Anxious, insensitive and self-absorbed

18. An oral-dependent personality is characterized by which of the following? A. B. C. D.

Helplessness Hopelessness Aggressiveness Suspiciousness

19. The pedophile’s choice of a sex object is primary based on: A. B. C. D.

Difficulty relating with adults Feelings of tenderness toward children Fears of incestuous impulses Preferred for a passive sexual role

20. A young adult male unable to stay put in one job and has no commitment in his relationship is having difficulty in achieving a sense of: A. B. C. D.

Autonomy Trust Industry Intimacy

Situation 5 – Anita is experiencing rape-trauma syndrome in an acute phase. She had been invited to a fraternity party. She had too much drink and she was raped by her date. The day after, she was brought to the hospital. She has feelings of anger, humiliation, helplessness, nausea, vomiting, nightmare and muscle tension. 21. When the nurse approached Anita, initially she was just crying, felt she was in a nightmare and she was at a loss. The appropriate nursing diagnosis is A. Situational low self-esteem B. Sexual violence

C. Ineffective coping D. Sexual dysfunction 22. Anita expressed to the nurse that she douched, showered for half an hour and still did not feel clean. Anita is experiencing A. B. C. D.

Guilt Anger Denial Frustration

23. Which of these communicate unconditional acceptance of Anita and her situation? A. B. C. D.

“You are safe here and I am ready to listen” “Why did you date a guy you hardly knew” “Tell me when you are ready and I’ll come back to you” “I would be best of help if you stop crying”

24. Anita is experiencing: A. B. C. D.

Maturational crisis Developmental crisis Anticipated crisis Situational crisis

25. Which of these behaviors of Anita signal her readiness to proceed to the working phase of the nurse-patient relationship A. B. C. D.

She states she trusted the nurse She wants to talk to a lawyer She inquires persona information about the nurse She wants to be told what her rights are

Situation 6 – The psychiatric mental health nurse adheres to standards that ensure quality improvement. The following situations and behaviors are means to achieve this goal. 26. This is a process wherein the client’s chart is reviewed to compare criteria for quality care with actual practice A. B. C. D.

Psychiatric audit Nursing Care Process Interaction Process Analysis Algorithms

27. In order to assess “Reliability” as a behavioral characteristic, the nurse would ask herself which of the following questions regarding her recording A. Did the history of the present problem correlate with the review of growth and development?

B. How long did it take to complete the nursing data base? C. Is the nursing date base complete? D. Are the nursing history and psychosocial assessment accurate? 28. All of these are the advantages of peer review EXCEPT A. B. C. D.

Demads accountability for nursing actions Has the possibility of enhancing intra professional respect It requires the development of standards for quality care Provide an evaluation of the nurse’s abilities

29. 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 A. B. C. D.

follow the problem solving approach do not pass judgment on the ideas presented ideas must be feasible suggestions must be cost effective

30. “Did the nurse perform in the best possible manner without waste?” aims to describe the nurse’s A. B. C. D.

Thoroughness Reliability Efficiency Analytic sense

Situation 7 – A nurse was interested to study the research question; “What are the differences and similarities between aggressive and non-aggressive cognitively impaired, elderly, institutionalized people”. 31. Investigation of cognitively impaired individual presented some ethical dilemmas. Which of the following protocol would be considered unethical? A. B. C. D.

Recording interaction with the elderly with their permission Verbal permission from the subject is unnecessary Data coded and recorded solely by the investigation A written consent from the institution and a significant other

32. A semi-structured interview was conducted. This means that: A. B. C. D.

Interview is conducted precisely in the same manner Interviewer is not held to any specific question Subject is allowed to express without any suggestion from the interviewer Interviewer is free to probe beyond a number of specific major questions

33. The type of study conducted is:

A. B. C. D.

Descriptive Quasi-experimental Experimental Case study

34. The review of the literature included reference to retrospective studies. Such studies have the following advantages EXCEPT A. B. C. D.

Data are inexpensive to obtain Possibility memory bias and distortion of fact There is mush material available It s easy to get data

35. The average age of the respondents was 86. This represents: A. B. C. D.

The sum ages divided by the total number of participants The youngest participant is 86 years old The oldest participant is 86 years old Most of the number of participants is 86 years old

Situation 8 – Mr. David is brought to the hospital due to pain radiating to the hip and leg. He is diagnosed with a herniated lumbar disk. He is scheduled for myelogram. 36. After the procedure, the nurse must include which of the following nursing action in his care. A. B. C. D.

Assess for the movement and sensation of the lower extremity Place the client in most comfortable position Lying supine with heels flexed Bed rest with bead elevated at 45 degrees

37. Mr. David is scheduled for lumbar laminectomy. Post operatively the nurse should A. B. C. D.

Logroll the client with the help of another nurse Inform the client that he should be in supine position Asses for century loss in the legs Instruct the patient from side to side

38. Trimethobenzamide Hydrochloride (tigan) was administered post operatively. The action of this drug is effective when it: A. B. C. D.

Controls nausea Controls pain Controls muscle spasm Controls edema

39. Mr. David is to ambulate for the first time following surgery. What nursing action would be best when the client begins to fail?

A. B. C. D.

Get another nurse for help Maneuver the client to a sitting position Get back to his bed and place in sideline position Assist the client to form a wide base to help support and lean against the nurse

40. Mr. David has to wear back brace. Which position is recommended when the brace is applied? A. B. C. D.

Sitting position Standing position Lying on his side in bed Supine position in bed

Situation 9- through the nurse-patient relationship the nurse intervenes utilizing effective communication techniques the following are varied situations in a psychiatry ward. 41. The patient verbalizes “masama ang pakirmdam ko hindi ako nakatulog kagabi” a therapeutic response of the nurse is: A. B. C. D.

“Baka iniistorbo ka nanaman nang mga boses” “Sinabi mo sana sa nars para nabigyan ka nang sedative drug mo” “Relax lang! wag kang masyadong mag-iisip nang problema mo” “Maari mo bang sabihin sa akin ang mga naiisip at nararamdaman mo?”

42. Solidad is terminally ill of cancer looking sad she expresses, “wala na yata akong pagasang mabuhay pa) a response which fosters hope is: A. “mukhang napakabigat ang dinaramdam ninyo. Andito po ako at pwede tayong magusap” B. “Wag po niyo isipin an sakt ninyo. Bale wala yon. Andito naman ako. C. “lakasan ang loob ninyo. Lahat naman tayo doon ang patutunguhan D. “gagaling din po kayo.wag po kayong magalala” 43. Camilia verbalizes ,“pinaguusapan nila ako.ayaw nila ako .” A. B. C. D.

“nalulungkot ba ang pakiramdam mo? “hayaan mo sila. Ang mahalaga ay ang palagay mo sa sarili mo “sino ang ‘nila’ ang tinutokoy mo” “wag mong isipin yan.masama yan”

44. During socialization Nicanor was provoked ,became furious and started shouting “walang hiya kayo! Ako ang bida dito” the nurses action is: A. Take him away from the group until he manages to control with himself B. Immediately restrain him and put him on isolation to protect other patients C. Prevent him from becoming more furious by giving an extra PRN dose of sedative D. Respond with, “nicanor pare pareho lang kayo ng ibang pasyente dito”

45. Nicanor has becomes verbally assaultive to the nurse. He says, “ikaw,nurse wala kang alam! Marunong pa ako sayo,e. anu ba ang ipnag mamalaki mo!” the nurse responds theraputicaly by: A. Admonishing him with, “ako ang nurse dito. Dapat sumunod ka sa akin.” B. Acknowledging his behavior, however put him in his right senses; respond with, “oo nga, galit ka sa nurse pero hindi tama na naninigay ka.” C. Acknowledging his behavior and respond, “nagagalit ka sa nurse at nawawala ka sa sarili mo.” D. Ignoring the behavior of the patient Situation 10- Nicanor was discharge from the hospital and recovered from a manic episode of bipolar disorder Nicanor was re admitted with an entirely different behavior. He was very depressed 46. The defense mechanism utilized by manic patients to cover up depression is: A. B. C. D.

Reaction formation Compensation Displacement Denial

47. The psychodynamics of depression is: A. B. C. D.

Lax super-ego Weak super-ego Internalized hostility feelings Narcissistic personality

48. Which of these drugs is likely to indicate for Nicanor? A. B. C. D.

Serenace(haloperidol) Valium(diazepam) Tofranil(imipramine HCl) Trilafon(perfenazine)

49. Therapeutic use of self is essential in relating with psychiatric patients. This is best demonstrated in: A. B. C. D.

Sympathizing with he miserable feelings of Nicanor Engaging Nicanor in productive activity Engaging Nicanor in introspective thinking Suppressing her own feelings toward Nicanor

50. After three days of anti-depressant medication, Nicanor still manifest depression. The nurse evaluate this as: A. Unusual because action of anti-depressant drug in immediate B. Expected because it takes about two weeks for the medication to be effective

C. Unexpected because it takes within one week for the medication to be effective D. Ineffective because perhaps the drug’s dosage is inadequate Situation 11 – 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. 51. Which of these ethical principles can guide the nurse in her action? A. B. C. D.

Beneficence Fidelity Autonomy Non maleficence

52. Purita has six children who are already adults. They differ in their opinion whether or not to allow their mother to decide herself. The nurse would encourage family conference for: A. B. C. D.

The eldest child’s opinion to be given priority Majority of the children to decide Allowing the medical staff to decide in their behalf Consensus building

53. 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’s right must be regarded? A. B. C. D.

Right to refuse treatment Right to privacy Right to informed consent Right to habeas consent

54. Which of these would be the nurse’s priority following the treatment principle of least restrictive alternative? A. B. C. D.

One to one staffing Use of on site guard/watcher Physician restraint Seclusion

55. Purita talks about her joy in having responsible and accomplished children and recalls challenging career as a lawyer. She is demonstrating a sense of A. B. C. D.

Ego integrity Industry Generativity Autonomy

Situation 12 – Marina, 26 years old, is aloof in relating with other patients and members of the staff. She claims that the medications being given her are meant to poison her. She is also suspicious about the food served to her. 56. Basically, Marina is suspicious because of her inability to develop a sense of: A. B. C. D.

Intimacy Generativity Trust Inactive

57. Marina utilizes projection by being suspicious. This means that she: A. Unconsciously refuses to accept a feeling, thought or impulse and attributes it to someone else B. Justifies behavior, attitudes and feelings with excuses C. Involuntarily refuses to acknowledge reality D. Involuntarily excludes wishes, impulses, memories and feelings from awareness 58. Which of these nursing approaches is MOST appropriate for the nurse to begin with? A. Engage Marina for at least one hour in one-to-one interaction daily B. Invite her to socialize with other patients C. Make self available while maintaining distance until patient shows readiness to interact D. Refer her activity therapy 59. When she resists to take her medication, it is best to: A. B. C. D.

Let her read the drug literature to convince her that it is therapeutic Force her to take the drug to maintain therapeutic effectiveness of the drug Have the same nurse, who she interacts with regularly, administer the drug Request the doctor to give her medication

60. Another reason why she refuses to take Thorazine is because she complains of robot like movement and slurred speech. The nurse’s action is: A. B. C. D.

Decrease the dosage of thorazine Explain the extrapymardial side effects and administer benadryl Avoid giving foods that are in rich in tyramine Withhold medication until referral is made to the doctor

Situation 13 – The supervising nurse received report that a staff nurse is displaying frequent irritation, anger, and even indifference toward clients and co-workers. 61. The initial action of the supervisor would be able to: A. Post guidelines on proper decorum of nurses in the bulletin board B. Write a memo of warning t the nurse

C. Request anecdotal report from nurse’s co-workers D. Call the nurse for a one on one conference 62. The nurse expressed increasing feelings of dissatisfaction. The supervising nurse intervenes therapeutically by taking on the role of: A. B. C. D.

Administrator by relieving her of responsibilities Therapist by delving into the nurse’s internal conflicts Counselor by actively listening Educator by reorienting her of her role as a nurse

63. 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: A. B. C. D.

Psychotic anxiety Staff burnout Personality maladjustment Neurotic depression

64. A priority in the nurse’s personal development program would be to: A. B. C. D.

Address her physical well being Boost her self-confidence Provide social support Help her find value and meaning in her work

65. The most relevant professional program for her would be: A. B. C. D.

Training Stress management Group dynamics and team building Behavior modification

Situation 14 – The purpose of the nursing care plan is to identify the care for an individual patient based on his problems. The nurse writes a nursing care plan for a patient based on nursing care standards. 66. Given this example problem: “Anxiety due to job interview”. The “due to” or the reason for the problem should be included if it is known. The initial step in identifying problem is: A. B. C. D.

Gather the data about the patient Determine if the problems are usual or unusual Analyze the data Analyze the problems as concisely as possible

67. Given this 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?

A. B. C. D.

An expected outcome is stated in terms of what the patient will do An expected outcome is stated in terms of what the nurse will do Every outcome must measurable Every outcome answers the question “How will you know when the problem is resolved?”

68. The following are reasons for setting deadlines within which to achieve outcomes of care EXCEPT: A. B. C. D.

Indicate specific times to review progress or lack of progress Does not allow plans to be changed Allow plans the need to be changed Set the time by which the expected outcome should be reached

69. Which of these is not a relevant nursing order? A. B. C. D.

Ask patient any outward side effects of medications he is taking Have patient role play interview situation Discuss with a patient specific means he might prepare for the job interview Ask the patient what he is feeling about the job interview

70. Which of these practices on evaluation support nursing care? Review of care plan is : A. B. C. D.

A nursing team responsibility The sole responsibility of the primary nurse The responsibility of peers The sole responsibility of the supervisor

Situation 15 – A nurse assigned in the neurologic unit is taking care of clients with varying degrees of degenerative disorders. 71. Mr. A with gravis is having difficulty speaking. What communication strategies should the nurse avoid when interacting with Mr. A? A. B. C. D.

Repeating what the client says for better understanding Using paper and pencil in communicating with the client Encouraging the client to speak slowly Encouraging the client to speak quickly

72. When planning fir nursing care for Mr. B who has Parkinson’s disease, which of the following goals would be MOST appropriate? A. B. C. D.

To improve muscle tone To start rehabilitation as much as possiblie To treat the disease To maintain optimal body function

73. For the past 10 years, Alma, 42 years old, has had multiple sclerosis. Clients with multiple sclerosis experience any different symptoms. As part of the rehabilitation planned for Alma, the nurse suggested therapy and hobbies to help her: A. B. C. D.

Strengthen muscle coordination Establish routine Develop perseverance and motivation Establish good health habits

74. On his second day of hospitalization, Mr. Santos was unable to stand and his having difficulty swallowing and talking. Which of the following is the priority of the nurse in assisting Mr. Santos? A. B. C. D.

To prevent bladder distention To prevent decubitus ulcer To prevent contracture To prevent aspiration pneumonia

75. The wife of a seventy two (72) year old male with a diagnosis of Alzheimer’s disease begins to cry and tells the nurse, “I could not understand my husband anymore. He has changed drastically”. Which of the following responses of the nurse is MOST appropriate? A. “The physician and the staff will make sure that your husband will be comfortable and safe here” B. “This has been a difficult time for you. Let us walk and find a quiet place where we can talk” C. “He will soon recover in his condition” D. “You need not worry, we are doing the best we could” Situation 16 – Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is: 76. The accurate information of the nurse of the goal of desensitization is: A. To help the clients relax and progressively work up a list anxiety provoking situations through imagery B. To provide corrective emotional experiences through a one-to-one intensive relationship C. To help clients in a group therapy setting to take on specific roles and reenact in front of the audience, situations in which interpersonal conflict is involved D. To help clients cope with their problems by learning behaviors that are more functional and be better equipped to face reality and make decisions 77. It is essential in desensitization for the patient to: A. Have rapport with the therapist B. Use deep breathing or another relaxation technique C. Assess one’s self for the need of an anxiolytic drug

D. Work trough unresolved unconscious conflicts 78. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences tunnel vision. Physical signs of anxiety become more pronounced. A. B. C. D.

Severe anxiety Panic Mild anxiety Moderate anxiety

79. Antianxiety medications should be used with extreme caution because long term use can lead to: A. B. C. D.

Parkinsonian like syndrome Hypertensive crisis Hepatic failure Risk of addiction

80. The nursing management of anxiety related with post traumatic stress disorders includes all of the following EXCEPT: A. B. C. D.

Encourage participation in recreation or sports activities Reassure client’s safety while touching client Speak in a calm soothing voce Remain with the client while fear level is high

Situation 17 – For personal and professional development program. “Self enhancement through Assertiveness. 81. An appropriate assessment tool to maximize gathering of needs of nurse is through: A. B. C. D.

Interview of nurses Survey Observation Brain storming sessions

82. A priority objective of the program is: A. B. C. D.

Develop the art project speaking Protect a positive image of the nursing profession Develop art and skills of therapeutic use of self Earn continuing education units

83. The most effective way to practice assertiveness skills is through: A. B. C. D.

Written evaluation form Process recording Descriptive report Role play

84. The least satisfactory method to evaluate the effectiveness of the program is through: A. B. C. D.

Group discussion and report Return demonstration Attendance Individual interview

85. Which of these feedback from individual participants indicate maximum gain from the staff development program is through: A. B. C. D.

“I will write a plan for personal development program” “I feel very good. The program inspired me a lot” “I learned a lot. I hope to have more seminars of it’s kinds” “I have a ‘do it now” project for my self. i.e to approach my clinical supervisor regularly to discuss nursing care of our clients”

Situation 18- A vehicle hit some pedestrians while waiting for a bus ride. Some of the victims suffered injuries in the different parts of their bodies. The victims were brought to a nearby hospital. One of the victims, Josephine was confirmed to have a fractured left arm. While waiting for the plaster cast to be applied, Josephine appears to be anxious. 86. To reduce the anxiety, the nurse teaches the procedure to the client. Which of the following topics should NOT be included in the teaching plan? A. Leave cast uncovered to promote drying B. Bear weight on the plaster cast for one hour. A stockinet will be placed over the left arm to be placed in cast. C. Handle hardening cast with palms on hand D. Trim and reshape finished cast with knife or cutter 87. Cast was applied on Josephine’s left arm. In assessing the neurovascular status of the client, which of the following assessment findings should be reported to the physician? A. B. C. D.

Pain in the left arm Swelling of the fingers Skin abrasions on the edge of the plaster cast Nail bed capillary refill time of ten seconds

88. One of the victims, a sixty years old woman sustained hip fracture. Prior to surgery a buck’s extension traction is to be applied. The rationale for the application of traction is primarily based on the understanding that buck’s extension fraction: A. B. C. D.

Reduces muscle spasms and helps to immobilized the fracture Allows reduction of the fracture site for bone healing Secures the fracture site to prevent damage to the muscle tissues Secures the fraction site for rigid immobilization

89. Philip was placed in skeletal leg traction with an overbed frame. He is not allowed to move from side to side. Which of the following nursing interventions is useful in maintaining effective fraction? A. Assist the client by holding the trapeze and raising the hips off the bed B. Check the apparatus, that weighs hang free and knots in the rope are tied securely C. Suspend a trapeze within easy reach of the client D. Support the affected extremity while the weights are removed 90. To prevent complications when a child is in buck’s traction, the nurse should: A. B. C. D.

Clean the extremity and keep the skin dry Assess any skin and circulatory disturbances Clean the pin sites as necessary Provide high fiber small meals

Situation 19 – It is the nurse’s primary responsibility to ensure a safe environment for the patients at the psychiatric ward. 91. All of the following concepts are true EXCEPT A. B. C. D.

Hostility is destructive Frustration develops in response to unmet needs, wants and desire Anger is incompatible with love Aggression can be expressed in a constructive as well as a destructive manner

92. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. The MOST effective way to deal with Carlo’s behavior is initially to: A. B. C. D.

Set limits on the behavior by verbal command Administer prn tranquilizer Remove chairs from the room Restrain the patient and place him in the “Isolation Room”

93. Mrs. Dizon was visiting her son at the psychiatric ward. Which of the following items will the nurse not allow to be brought inside the ward? A. B. C. D.

String rosary bracelet Box of cake Bottle of coke Rubber shoes

94. Which of the following will probably be most therapeutic for a patient on behavioral modification ward? A. If client is agitated discuss the feeling especially anger B. Insist to stop obscene language by verbal reprimand C. Give client support and positive feedback for controlling use of obscene language

D. Provide a punching bag as an alternative to express upset emotions 95. Which of the following must be considered while planning activities for the depressed patient? A. B. C. D.

Activities which require exertion of energy Challenging activities to get him out his depression Reading materials to divert his thoughts Variety of unstructured activities

Situation 20 – Jim, age 25, recalled that his problem began round age 15 or 16. he would count pencils in a mug over and over with the thought that stopping could result in something bad happening 96. There are many things Jim seems he has to do to keep himself from feeling: A. B. C. D.

Confused Suspicious Excited Anxious

97. He has to change clothes 20 times before work, chew each bite he eats 24 times and go up and down the stairs four to five times before it feels right. He is demonstrating A. B. C. D.

Ideas of reference Denial and projection Obsession and compulsion Rationalization and over reaction

98. The objective of nursing care for Jim is to develop or increase feelings of A. B. C. D.

Self-mastery Self worth Self-actualization Self-determination

99. All of these are therapeutic interventions EXCEPT: A. B. C. D.

Impose limits every time the behavior becomes repetitive Establish a routine for him Assign task that can be done repetitively Facilitate self-expression

100. Jim is aware of his behavior, yet realizes that it is very disturbing to him. This is a pattern of: A. Personality disorder B. Psychosis C. Neurosis

D. Habitual disorder

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