300-Item NLE Practice Exam Situation Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions

s and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen and re ove excessive secretions in the airway. !. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs. "he appropriate position to drain the anterior and posterior apical seg ents of the lungs when Mario does percussion would be# $. %lient lying on his back then flat on his abdo en on "rendelenburg position &. %lient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdo en %. %lient lying flat on his back and then flat on his abdo en '. %lient lying on his right then left side on "rendelenburg position (. )hen docu enting outco e of Richards treat ent Mario should include the following in his recording *+%*P"# $. %olor, a ount and consistency of sputu &. %haracter of breath sounds and respiratory rate before and after procedure %. $ ount of fluid intake of client before and after the procedure '. Significant changes in vital signs -. )hen assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following *+%*P"# $. $ ount of food and fluid taken during the last eal before treat ent &. Respiratory rate, breath sounds and location of congestion %. "eaching the clients relatives to perfor the procedure '. 'octors order regarding position restrictions and clients tolerance for lying flat .. Mario prepares Richard for postural drainage and percussion. )hich of the following is a special consideration when doing the procedure/ $. Respiratory rate of !0 to (1 per inute &. %lient can tolerate sitting and lying positions %. %lient has no signs of infection '. "i e of last food and fluid intake of the client 2. "he purpose of chest percussion and vibration is to loosen secretions in the lungs. "he difference between the procedures is# $. Percussion uses only one hand while vibration uses both hands &. Percussion delivers cushioned blows to the chest with cupped pal s while vibration gently shakes secretion loose on the exhalation cycle %. 3n both percussion and vibration the hands are on top of each other and hand action is in tune with clients breath rhyth '. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air Situation $ 0! year old an, Mr. Regalado, is ad itted to the private ward for observation after co plaints of severe chest pain. 4ou are assigned to take care of the client. 0. )hen doing an initial assess ent, the best way for you to identify the clients priority proble to# $. 3nterview the client for chief co plaints and other sy pto s &. "alk to the relatives to gather data about history of illness %. 'o auscultation to check for chest congestion '. 'o a physical exa ination while asking the client relevant 5uestions is

6. Nancy bla es 7od for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her fa ily. $ religious person before, she now refuses to pray or go to church stating that 7od has abandoned her. "he nurse understands that Nancy is grieving for her self and is in the stage of#

$. bargaining &. denial %. anger '. acceptance 8. )hich of the following ethical principles refers to the duty to do good/ $. &eneficence &. 9idelity %. :eracity '. Non aleficence ;. 'uring which step of the nursing process does the nurse analy<e data related to the patient=s health status/ $. $ssess ent &. 3 ple entation %. 'iagnosis '. *valuation

!1. "he basic difference between nursing diagnoses and collaborative proble s is that $. nurses anage collaborative proble s using physician>prescribed interventions. &. collaborative proble s can be anaged by independent nursing interventions. %. nursing diagnoses incorporate physician>prescribed interventions. '. nursing diagnoses incorporate physiologic co plications that nurses onitor to detect change in status. Situation Mrs. Seva, 2( years old, asks you about possible proble s regarding her eli ination now that she is in the enopausal stage. !!. 3nstruction on health pro otion regarding urinary eli ination is i portant. )hich would you include/ $. ?old urine as long as she can before e ptying the bladder to strengthen her sphincter uscles &. 3f burning sensation is experienced while voiding, drink pineapple @uice %. $fter urination, wipe fro anal area up towards the pubis '. "ell client to e pty the bladder at each voiding !(. Mrs. Seva also tells the nurse that she is often constipated. &ecause she is aging, what physical changes predispose her to constipation/ $. inhibition of the parasy pathetic reflex &. weakness of sphincter uscles of anus %. loss of tone of the s ooth uscles of the colon '. decreased ability to absorb fluids in the lower intestines !-. "he nurse understands that one of these factors contributes to constipation# $. excessive exercise &. high fiber diet %. no regular ti e for defecation daily '. prolonged use of laxatives !.. 4ou will do nasopharyngeal suctioning on Mr. $bad. 4our guide for the length of insertion of the tubing for an adult would be# $. tip of the nose to the base of the neck &. the distance fro the tip of the nose to the iddle of the neck %. the distance fro the tip of the nose to the tip of the ear lobe '. eight to ten inches Situation Mr. 'i<on, 8. years old, brought to the * ergency Roo for co plaint of hypertension, flushed face, severe headache, and nausea. 4ou are doing the initial assess ent of vital signs. !2. 4ou are to *+%*P"# easure the clients initial blood pressure reading by doing all of the following

$. "ake the blood pressure reading on both ar s for co parison &. Aisten to and identify the phases of Borotkoffs sound %. Pu p the cuff to around 21 ?g above the point where the pulse is obliterated '. Cbserve procedures for infection control !0. $ pulse oxi eter is attached to Mr. 'i<ons finger to# $. 'eter ine if the clients he oglobin level is low and if he needs blood transfusion &. %heck level of clients tissue perfusion %. Measure the efficacy of the clients anti>hypertensive edications '. 'etect oxygen saturation of arterial blood before sy pto s of hypoxe ia develops !6. 3n which type of shock does the patient experiences a is atch of blood flow to the cells/ $. 'istributive %. ?ypovole ic &. %ardiogenic '. Septic !8. "he preferred route of ad inistration of the following routes/ $. 3ntravenous &. *pidural edication in the ost acute care situations is which of

%. Subcutaneous '. 3ntra uscular

!;. $fter a few hours in the * ergency Roo , Mr. 'i<on is ad itted to the ward with an order of hourly onitoring of blood pressure. "he nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be# $. inconsistent &. low systolic and high diastolic %. higher than what the reading should be '. lower than what the reading should be (1. "hrough the clients health history, you gather that Mr. 'i<on s okes and drinks coffee. )hen taking the blood pressure of a client who recently s oked or drank coffee, how long should the nurse wait before taking the clients blood pressure for accurate reading/ $. !2 inutes &. -1 inutes %. ! hour '. 2 inutes (!. )hile the client has pulse oxi eter on his fingertip, you notice that the sunlight is shining on the area where the oxi eter is. 4our action will be to# $. Set and turn on the alar of the oxi eter &. 'o nothing since there is no identified proble %. %over the fingertip sensor with a towel or bedsheet '. %hange the location of the sensor every four hours ((. )hen taking blood pressure reading the cuff should be# $. deflated fully then i ediately start second reading for sa e client &. deflated 5uickly after inflating up to !81 ?g %. large enough to wrap around upper ar of the adult client ! c above brachial artery '. inflated to -1 ?g above the esti ated systolic &P based on palpation of radial or brachial artery (-. "o ensure client safety before starting blood transfusions the following are needed before the procedure can be done *+%*P"# $. take baseline vital signs &. blood should be war ed to roo te perature for -1 inutes before blood transfusions is ad inistered %. have two nurses verify client identification, blood type, unit nu ber and expiration date of blood '. get consent signed for blood transfusion (.. Mr. &runo asks what the Dnor alE allowable salt intake is. 4our best response to Mr. &runo is# $. ! tsp of saltFday with iodine and sprinkle of MS7 &. 2 g s per day or ! tsp of table saltFday

%. ! tbsp of saltFday with so e patis and toyo '. ! tsp of saltFday but no patis and toyo (2. )hich of the following ethods is the best ethod for deter ining nasogastric tube place ent in the sto ach/ $. +>ray &. Cbservation of gastric aspirate %. "esting of p? of gastric aspirate '. Place ent of external end of tube under water (0. )hich of the following is the Pul onary 'isease/ $. %igarette s oking &. Cccupational exposure %. $ir pollution '. 7enetic abnor alities ost i portant risk factor for develop ent of %hronic Cbstructive

(6. )hen perfor ing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter -01 degrees for which of the following ti e periods/ $. !1>!2 seconds %. (1>(2 seconds &. -1>-2 seconds '. 1>2 seconds (8. "he nurse auscultates the apex beat at which of the following anato ical locations/ $. 9ifth intercostal space, idclavicular line &. Mid>sternu %. (E to the left of the lower end of the sternu '. !E to the left of the xiphoid process (;. )hich of the following ter s describes the a ount of blood e@ected per heartbeat/ $. Stroke volu e &. %ardiac output %. *@ection fraction '. $fterload -1. 4ou are to apply a transder al patch of nitoglycerin to your client. "he following are i portant guidelines to observe *+%*P"# $. $pply to hairless clean area of the skin not sub@ect to uch wrinkling &. Patches ay be applied to distal part of the extre ities like forear %. %hange application and site regularly to prevent irritation of the skin '. )ear gloves to avoid any edication on your hand -!. "he 7$G7* si<e in *" tubes deter ines# $. "he external circu ference of the tube &. "he internal dia eter of the tube %. "he length of the tube '. "he tubes volu etric capacity -(. "he nurse is correct in perfor ing suctioning when she applies the suction inter ittently during# $. 3nsertion of the suction catheter &. )ithdrawing of the suction catheter %. both insertion and withdrawing of the suction catheter '. )hen the suction catheter tip reaches the bifurcation of the trachea

--. "he purpose of the cuff in "racheosto y tube is to# $. Separate the upper and lower airway &. Separate trachea fro the esophagus %. Separate the larynx fro the nasopharynx '. Secure the place ent of the tube

-.. )hich priority nursing diagnosis is applicable for a patient with indwelling urinary catheter/ $. Self estee disturbance &. 3 paired urinary eli ination %. 3 paired skin integrity '. Risk for infection -2. $n incontinent elderly client fre5uently wets his bed and eventually develop redness and skin excoriation at the perianal area. "he best nursing goal for this client is to# $. Make sure that the bed linen is always dry &. 9re5uently check the bed for wetness and always keep it dry %. Place a rubber sheet under the clients buttocks '. Beep the patient clean and dry -0. $s a Nurse Manager, 'MAM en@oys her staff of talented and self otivated individuals. She knew that the leadership style to suit the needs of this kind of people is called# $. $utocratic &. Participative %. 'e ocratic '. Aaisse< 9aire -6. $ fire has broken in the unit of 'MAM R.N. "he best leadership style suited in cases of e ergencies like this is# $. $utocratic &. Participative %. 'e ocratic '. Aaisse< 9aire -8. )hich step of the anage ent process is concerned with Policy and ob@ective of the institution/ $. Planning &. Crgani<ing %. 'irecting '. %ontrolling aking and Stating the goals

-;. 3n the anage ent process, the periodic checking of the results of action to coincides with the goal of the institution is ter ed as# $. Planning &. *valuating %. 'irecting '. Crgani<ing

ake sure that it

.1. "he :ision of a certain agency is usually based on their beliefs, 3deals and :alues that directs the organi<ation. 3t gives the organi<ation a sense of purpose. "he belief, 3deals and :alues of this $gency is called# $. Philosophy &. Mission %. :ision '. 7oals and Cb@ectives .!. Mr. %BB is unconscious and was brought to the *.R. )ho a ong the following can give consent for %BBs Cperation/ $. 'octor &. Nurse %. Next of Bin '. "he Patient .(. Mang %arlos has been ter inally ill for 2 years. ?e asked his wife to decide for hi longer capable to do so. $s a Nurse, 4ou know that this is called# $. Aast will and testa ent &. 'NR %. Aiving will when he is no

'. 'urable Power of $ttorney .-. Mang %arlos has a standing 'NR order. ?e then suddenly stopped breathing and you are at his bedside. 4ou would# $. 7ive extraordinary easures to save Mang %arlos &. Stay with Mang %arlos and 'o nothing %. %all the physician '. $ctivate %ode &lue ... 3t is not a legally binding docu ent but nevertheless, :ery i portant in caring for the patients. $. &CN Resolution No. ((1 Series of (11( &. Patients &ill of Rights %. Nurses %ode of *thics '. Philippine Nursing $ct of (11( .2. 3n onitoring the patient in P$%G, the nurse correctly identify that checking the patients vital signs is done every# $. ! hour &. 2 inutes %. !2 inutes '. -1 inutes Situation# 'ianne May 'ee, R.N., is conducting a research on her unit about the effects of effective nurse>patient co unication in decreasing anxiety of post operative patients. .0. )hich of the following step in nursing research should she do next/ $. Review of related literature &. $sk per ission fro the hospital ad inistrator %. 'eter ine the research proble '. 9or ulate ways on collecting the data .6. &efore 'ianne perfor s the for al research study, what do you call the pre testing, s all scale trial run to deter ine the effectiveness of data collection and ethodological proble that ight be encountered/ $. Sa pling &. Pre>testing %. Pre>Study '. Pilot Study .8. Cn the study Deffects of effective nurse>patient co unication in decreasing anxiety of post operative patientsE )hat is the 3ndependent variable/ $. *ffective Nurse>patient co unication &. %o unication %. 'ecreasing $nxiety '. Post operative patient .;. Cn the study Deffects of effective nurse>patient co unication in decreasing anxiety of post operative patientsE )hat is the 'ependent variable/ $. *ffective Nurse>patient co unication &. %o unication %. $nxiety level '. Post operative patient 21. 3n the recent technological innovations, which of the following describe researches that are to i prove and ake hu an life easier/ $. Pure research &. &asic research %. $pplied research '. *xperi ental research ade

2!. )hich of the following is not true about a Pure *xperi ental research/ $. "here is a control group &. "here is an experi ental group %. Selection of sub@ects in the control group is rando i<ed '. "here is a careful selection of sub@ects in the experi ental group 2(. )hen Mrs. 7uevarra, a nurse, delegates aspects of the clients care to the nurse>aide who is an unlicensed staff, Mrs. 7uevarra $. akes the assign ent to teach the staff e ber &. is assigning the responsibility to the aide but not the accountability for those tasks %. does not have to supervise or evaluate the aide '. ost know how to perfor task delegated 2-. Process of for al negotiations of working conditions between a group of registered nurses and e ployer is $. grievance &. arbitration %. collective bargaining '. strike 2.. 4ou are attending a certification on cardiopul onary resuscitation H%PRI offered and re5uired by the hospital e ploying you. "his is $. professional course towards credits &. inservice education %. advance training '. continuing education 22. "he law which regulated the practice of nursing profession in the Philippines is# $. R.$ ;!6&. AC3 ;.; %. Patients &ill of Rights '. %ode of *thics for Nurses 20. "his 5uality is being de onstrated by a Nurse who raise the side rails of a confused and disoriented patient/ $. $utono y &. Responsibility %. Prudence '. Resourcefulness 26. Nurse Joel and $na is helping a !0 year old Nursing Student in a case filed against the student. "he case was frustrated ho icide. Nurse Joel and $na are aware of the different circu stances of cri es. "hey are correct in identifying which of the following %ircu stances that will be best applied in this case/ $. Justifying &. $ggravating %. Mitigating '. *xe pting 28. 3n signing the consent for , the nurse is aware that what is being observed as an ethical consideration is the patients $. $utono y &. Justice %. $ccountability '. &eneficence 2;. )hy is there an ethical dile a/ $. &ecause the law do not clearly state what is right fro what is wrong &. &ecause orality is sub@ective and it differs fro each individual %. &ecause the patients right coincide with the nurses responsibility '. &ecause the nurse lacks ethical knowledge to deter ine what action is correct and what action

is unethical 01. )ho a ong the following can work as a practicing nurse in the Philippines without taking the Aicensure exa ination/ $. 3nternationally well known experts which services are for a fee &. "hose that are hired by local hospitals in the country %. *xpert nurse clinicians hired by prestigious hospitals '. "hose involved in edical ission whos services are for free 0!. 3n signing the consent for , the nurse is aware that what is being observed as an ethical consideration is the patients $. $utono y &. Justice %. $ccountability '. &eneficence 0(. Nurse &uddy gave 3napsine instead of 3nsulin to a patient in severe hyperglyce ia. ?e reported the incident as soon as he knew there was an error. $ nurse that is always ready to answer for all his actions and decision is said to be# $. $ccountable %. %ritical thinker &. Responsible '. $ssertive 0-. )hich of the following best describes Pri ary Nursing/ $. 3s a for of assigning a nurse to lead a tea of registered nurses in care of patient fro ad ission to discharge &. $ nurse is responsible in doing certain tasks for the patient %. $ registered nurse is responsible for a group of patients fro ad ission to discharge '. $ registered nurse provides care for the patient with the assistant of nursing aides 0.. "he best and ost effective $. 9unctional Method &. Pri ary Nursing ethod in ti es of staff and financial shortage is# %. "ea Nursing '. Modular Method

02. 4ou are doing bed bath to the client when suddenly, "he nursing assistant rushed to the roo and tell you that the client fro the other roo was in Pain. "he best intervention in such case is# $. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the PRN edication &. "ell the nursing assistant to give the pain edication to the client co plaining of pain %. "ell the nursing assistant to go the clients roo and tell the client to wait '. 9inish the bed bath 5uickly then rush to the client in Pain 00. $ngie is a disoriented client who fre5uently falls fro the bed. $s her nurse, which of the following is the best nursing intervention to prevent future falls/ $. "ell $ngie not to get up fro bed unassisted &. Put the call bell within her reach %. Put bedside co ode at the bedside to prevent $ngie fro getting up '. Put the bed in the lowest position ever 06. )hen in@ecting subcutaneous in@ection in an obese patient, 3t should be angled at around# $. .2 K &. ;1 K %. !81 K '. Parallel to the skin 08. "he following state ents are all true about L>"rack techni5ue except# $. L track in@ection prevent irritation of the subcutaneous tissues &. "he techni5ue involve creating a Lig Lag like pattern of edication %. 3t forces the edication to be contained at the subcutaneous tissues '. 3t is used when ad inistering Parenteral 3ron

0;. %o unication is best undertaken if barriers are first re oved. %onsidering this state ent, which of the following is considered as deterrent factor in co unication/ $. Not universally accepted abbreviations &. )rong 7ra ar %. Poor Pen anship '. Cld age of the client 61. Nurse 'MAM is correct in identifying the correct se5uence of events during abdo inal assess ent if she identifies which of the following/ $. 3nspection, $uscultation, Percussion, Palpation &. 3nspection, Percussion, Palpation, $uscultation %. 3nspection, Palpation, Percussion, $uscultation '. 3nspection, $uscultation, Palpation, Percussion 6!. "o prevent in@ury and strain on the uscles, the nurse should observe proper body $ ong the following, which is a principle of proper body echanics/ $. &roaden the space between the feet &. Push instead of pull %. Move the ob@ect away fro the body when lifting '. &end at the waist, not on the knees 6(. 3n taking the clients blood pressure, the nurse should position the clients ar # $. $t the level of the heart &. Slightly above the level of the heart %. $t the 2th intercostals space idclavicular line '. &elow the level of the heart 6-. )hat principle is used when the client with fever loses heat through giving cooling bed bath to lower body te perature/ $. Radiation %. *vaporation &. %onvection '. %onduction 6.. "he ost effective way in li iting the nu ber of icroorganis in the hospital is# $. Gsing strict aseptic techni5ue in all procedures &. )earing ask and gown in care of all patients with co unicable diseases %. Sterili<ation of all instru ents '. ?andwashing 62. "he i unoglobulin of the other that crosses the placenta to protect the child is an exa ple of# $. Natural active i unity %. $rtificial active i unity &. Natural passive i unity '. $rtificial passive i unity 60. Richard is a sub@ect of a research lead by his doctor. "he nurse knows that all of the following is a correct understanding as his right as a research sub@ect except# $. 3 can withdraw with this research even after the research has been started &. My confidentiality will not be co pro ised in this research %. 3 ust choose another doctor if 3 withdrew fro this research '. 3 can withdraw with this research before the research has been started 66. )hich of the following is a nor al finding during assess ent of a %hest tube in a - way bottle syste / $. "here is a continuous bubbling in the drainage bottle &. "here is an inter ittent bubbling in the suction control bottle %. "he water fluctuates during inhalation of the patient '. "here is - c of water left in the water seal bottle 68. 3n obtaining a urine speci en for culture and sensitivity on a catheteri<ed patient, the nurse is correct if# $. %la p the catheter for -1 inutes, $lcoholi<e the tube above the cla p site, Cbtain a sterile syringe and draw the speci en on the tube above the cla p &. $lcoholi<e the self sealing port, obtain a sterile syringe and draw the speci en on the self sealing port echanics.

%. 'isconnect the drainage bag, obtain a sterile syringe and draw the speci en fro the drainage bag '. 'isconnect the tube, obtain a sterile syringe and draw the speci en fro the tube 6;. )hich of the following is an exa ple of secondary prevention/ $. "eaching the diabetic client on obtaining his blood sugar level using a gluco eter &. Screening patients for hypertension %. 3 uni<ing infants with &%7 '. Providing PP' on a construction site 81. )hich of the following is a for $. Regular %heck ups &. Regular Screening %. Self Medication '. 3 uni<ation of pri ary prevention/

8!. $n abnor al condition in which a person is# $. Crthopnea &. 'yspnea %. *upnea '. $pnea

ust sit, stand or use

ultiple pillows when lying down

8(. $s a nurse assigned for care for geriatric patients, you need to fre5uently assess your patient using the nursing process. )hich of the following needs be considered with the highest priority/ $. Patients own feeling about his illness &. Safety of the client especially those elderly clients who fre5uently falls %. Nutritional status of the elderly client '. Physiologic needs that are life threatening 8-. "he co ponent that should receive the highest priority before physical exa ination is the# $. Psychological preparation of the client &. Physical Preparation of the client %. Preparation of the *nviron ent '. Preparation of the *5uip ents 8.. Aegally, Patients chart are# $. Cwned by the govern ent since it is a legal docu ent &. Cwned by the doctor in charge and should be kept fro the ad inistrator for whatever reason %. Cwned by the hospital and should not be given to anyone who re5uest it other than the doctor in charge '. Cwned by the patient and should be given by the nurse to the client as re5uested 82. )hich of the following categories identifies the focus of co unityFpublic health nursing practice/ $. Pro oting and aintaining the health of populations and preventing and ini i<ing the progress of disease &. Rehabilitation and restorative services %. $daptation of hospital care to the ho e environ ent '. ?ospice care delivery 80. $ a@or goal for ho e care nurses is $. restoring axi u health function. &. pro oting the health of populations. %. ini i<ing the progress of disease. '. aintaining the health of populations. 86. $ written nursing care plan is a tool that# $. %heck whether nursing care goals were achieved &. 7ives 5uality nursing care %. Select the appropriate nursing intervention

'. Make a nursing diagnosis 88. 7ina, $ client in prolong labor said she cannot go on any ore. "he health care tea decided that both the child and the other cannot any ore endure the process. "he baby is pre ature and has a little chance of surviving. %aesarian section is not possible because 7ina already lost enough blood during labor and additional losses would tend to be fatal. "he husband decided that 7ina should survive and gave his consent to ter inate the fetus. "he principle that will be used by the health care tea is# $. &eneficence &. Non alfeasance %. Justice '. 'ouble effect Situation "here are various develop ents in health education that the nurse should know about# 8;. "he provision of health infor ation in the rural areas nationwide through television and radio progra s and video conferencing is referred to as# $. %o unity health progra &. "elehealth progra %. )ellness progra '. Red %ross progra ;1. 3n teaching the sister of a diabetic client about the proper use of a gluco eter in deter ining the blood sugar level of the client, "he nurse is focusing in which do ain of learning according to bloo / $. %ognitive &. $ffective %. Psycho otor '. $ffiliative ;!. $ nearby co unity provides blood pressure screening, height and weight easure ent, s oking cessation classes and aerobics class services. "his type of progra is referred to as $. outreach progra &. hospital extension progra %. barangay health progra '. wellness progra ;(. $fter cleaning the abrasions and applying antiseptic, the nurse applies cold co press to the swollen ankle as ordered by the physician. "his state ent shows that the nurse has correct understanding of the use of cold co press# $. %old co press reduces blood viscosity in the affected area &. 3t is safer to apply than hot co press %. %old co press prevents ede a and reduces pain '. 3t eli inates toxic waste products due to vasodilation ;-. $fter receiving prescription for pain edication, Ronnie is instructed to continue applying -1 inute cold at ho e and start -1 inute hot co press the next day. 4ou explain that the use of hot co press# $. Produces anesthetic effect &. 3ncreases nutrition in the blood to pro ote wound healing %. 3ncrease oxygenation to the in@ured tissues for better healing '. 3nduces vasoconstriction to prevent infection Situation $ nursing professor assigns a group of students to do data gathering by interviewing their class ates as sub@ects. ;.. She instructed the interviewees not to tell the interviewees that the data gathered are for her own research pro@ect for publication. "his teacher has violated the students right to# $. Not be har ed &. 'isclosure %. Privacy

'. Self>deter ination ;2. &efore the nurse researcher starts her study, she analy<es how uch ti e, oney, aterials and people she will need to co plete the research pro@ect. "his analysis prior to beginning the study is called# $. :alidity &. 9easibility %. Reliability '. Researchability ;0. 'ata analysis is to be done and the nurse researcher wants to include variability. "hese include the following *+%*P"# $. :ariance %. Standards of 'eviation &. Range '. Mean ;6. Nurse Minette needs to schedule a first ho e visit to C& client Aeah. )hen is a first ho e>care visit typically ade/ $. )ithin . days after discharge &. )ithin (. hours after discharge %. )ithin ! hour after discharge '. )ithin ! week of discharge ;8. &y force of law, therefore, the PR%>&oard of Nursing released Resolution No. !. Series of !;;; entitled# D$doption of a Nursing Specialty %ertification Progra and %reation of Nursing Specialty %ertification %ouncil.E "his rule> aking power is called# $. Muasi>Judicial Power &. Regulatory Power %. Muasi>Aegislative Power '. *xecutiveFPro ulgating Power ;;. $nita is perfor ing &S* and she stands in front of the Mirror. "he rationale for standing in front of the irror is to check for# $. Gnusual discharges co ing out fro the breast &. $ny obvious alignancy %. "he Si<e and %ontour of the breast '. "hickness and lu ps in the breast

!11. $n e erging techni5ue in screening for &reast %ancer in developing countries like the Philippines is# $. Ma ography once a year starting at the age of 21 &. %linical &S* Cnce a year %. &S* Cnce a onth '. Pap s ear starting at the age of !8 or earlier if sexually active !1!. "rans ission of ?3: fro an infected individual to another person occurs# $. Most fre5uently in nurses with needlesticks &. Cnly if there is a large viral load in the blood %. Most co only as a result of sexual contact '. 3n all infants born to wo en with ?3: infection !1(. $fter a vaginal exa ination, the nurse deter ines that the clients fetus is in an occiput posterior position. "he nurse would anticipate that the client will have# $. $ precipitous birth &. 3ntense back pain %. 9re5uent leg cra ps '. Nausea and vo iting !1-. "he rationales for using a prostaglandin gel for a client prior to the induction of labor is to# $. Soften and efface the cervix &. Nu b cervical pain receptors

%. Prevent cervical lacerations '. Sti ulate uterine contractions Situation# Nurse Aorena is a 9a ily Planning and 3nfertility Nurse Specialist and currently attends to 9$M3A4 PA$NN3N7 %A3*N"S $N' 3N9*R"3A* %CGPA*S. "he following conditions pertain to eeting the nursing needs of this particular population group. !1.. 'ina, !6 years old, asks you how a tubal ligation prevents pregnancy. )hich would be the best answer/ $. Prostaglandins released fro the cut fallopian tubes can kill sper &. Sper cannot enter the uterus because the cervical entrance is blocked. %. Sper can no longer reach the ova, because the fallopian tubes are blocked '. "he ovary no longer releases ova as there is no where for the to go. !12. "he 'ators are a couple undergoing testing for infertility. 3nfertility is said to exist when# $. a wo an has no uterus &. a wo an has no children %. a couple has been trying to conceive for ! year '. a couple has wanted a child for 0 onths !10. "he correct te perature to store vaccines in a refrigerator is# $. between >. deg % and N8 deg % &. between ( deg % and N8 deg % %. between >8 deg % and 1 deg % '. between >8 deg % and N. deg % !16. )hich of the following vaccines is not done by intra uscular H3MI in@ection/ $. Measles vaccine %. ?epa>& vaccine &. 'P" '. "etanus toxoids !18. "his vaccine content is derived fro $. Measles &. "etanus toxoids RN$ reco binants. %. ?epatitis & vaccines '. 'P"

!1;. "his special for is used when the patient is ad itted to the unit. "he nurse co pletes the infor ation in this record particularly hisFher basic personal data, current illness, previous health history, health history of the fa ily, e otional profile, environ ental history as well as physical assess ent together with nursing diagnosis on ad ission. )hat do you call this record/ $. Nursing Bardex &. Nursing ?ealth ?istory and $ssess ent )orksheet %. Medicine and "reat ent Record '. 'ischarge Su ary !!1. "hese are sheetsFfor s which provide an efficient and ti e saving way to record infor ation that ust be obtained repeatedly at regular andFor short intervals of ti e. "his does not replace the progress notesO instead this record of infor ation on vital signs, intake and output, treat ent, postoperative care, post partu care, and diabetic regi en, etc. "his is used whenever specific easure ents or observations are needed to be docu ented repeatedly. )hat is this/ $. Nursing Bardex &. 7raphic 9low Sheets %. 'ischarge Su ary '. Medicine and "reat ent Record !!!. "hese records show all edications and treat ent provided on a repeated basis. )hat do you call this record/ $. Nursing ?ealth ?istory and $ssess ent )orksheet &. 'ischarge Su ary %. Nursing Bardex '. Medicine and "reat ent Record

!!(. "his flip>over card is usually kept in a portable file at the Nurses Station. 3t has (>parts# the activity and treat ent section and a nursing care plan section. "his carries infor ation about basic de ographic data, pri ary edical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in patient care and factors related to daily living activities. "his record is used in the charge>of>shift reports or during the bedside rounds or walking rounds. )hat record is this/ $. 'ischarge Su ary &. Medicine and "reat ent Record %. Nursing ?ealth ?istory and $ssess ent )orksheet '. Nursing Bardex !!-. Most nurses regard this conventional recording of the date, ti e, and ode by which the patient leaves a healthcare unit but this record includes i portantly, directs of planning for discharge that starts soon after the person is ad itted to a healthcare institution. 3t is accepted that collaboration or ultidisciplinary involve ent Hof all e bers of the health tea I in discharge results in co prehensive care. )hat do you call this/ $. 'ischarge Su ary &. Nursing Bardex %. Medicine and "reat ent Record '. Nursing ?ealth ?istory and $ssess ent )orksheet !!.. &ased on the %ode of *thics for 9ilipino Nurses, what is regarded as the hall ark of nursing responsibility and accountability/ $. ?u an rights of clients, regardless of creed and gender &. "he privilege of being a registered professional nurses %. ?ealth, being a funda ental right of every individual '. $ccurate docu entation of actions and outco es !!2. $ nurse should be cogni<ant that professional progra s for specialty certification by the &oard of Nursing accredited through the# $. Professional Regulation %o ission &. Nursing Specialty %ertification %ouncil %. $ssociation of 'eans of Philippine %olleges of Nursing '. Philippine Nurse $ssociation !!0. 3ntegrated anage ent for childhood illness is the universal protocol of care endorsed by )?C and is use by different countries of the world including the Philippines. 3n any case that the nurse classifies the child and categori<ed the signs and sy pto s in P3NB category, 4ou know that this eans# $. Grgent referral &. $ntibiotic Manage ent %. ?o e treat ent '. Cut>patient treat ent facility is needed !!6. 4ou know that fast breathing of a child age !$. .1 &. 21 %. 01 '. -1 onths is observed if the RR is ore than#

!!8. $ngelo, $n 8 onth old child is brought to the health care facility with sunken eyes. 4ou pinch his skin and it goes back very slowly. 3n what classification of dehydration will you categori<e $ngelo/ $. No 'ehydration &. So e 'ehydration %. Severe 'ehydration '. 'iarrhea !!;. 3n responding to the care concerns of children with severe disease, referral to the hospital is of the essence especially if the child anifests which of the following/ $. )hee<ing &. Stop feeding well

%. 9ast breathing '. 'ifficulty to awaken !(1. $ child with ear proble should be assessed for the following, *+%*P"# $. is there any fever/ &. *ar discharge %. 3f discharge is present for how long/ '. *ar pain !(!. 3f the child does not have ear proble , using 3M%3, what should you as the nurse do/ $. %heck for ear discharge &. %heck for tender swellings behind the ear %. %heck for ear pain '. 7o to the next 5uestion, check for alnutrition !((. $ll of the following are treat ent for a child classified with no dehydration except# $. !,111 l to !,.11 l be given within . hours &. %ontinue feeding %. ?ave the child takes as uch fluid as he wants '. Return the child to the doctor if condition worsens !(-. $n ear infection that persists but still less than !. days is classified as# $. Mastoiditis &. %hronic *ar 3nfection %. $cute *ar 3nfection '. Ctitis Media !(.. 3f a child has two or ore pink signs, you would classify the child as having# $. No disease &. Mild for of disease %. Grgent Referral '. :ery severe disease !(2. "he nurse knows that the ost co $ Pneu onia and larynigotracheitis &. *ncephalitis %. Ctitis Media '. &ronchiectasis on co plication of Measles is#

!(0. $ client scheduled for hysterosalpingography needs health teaching before the procedure. "he nurse is correct in telling the patient that# $. She needs to void prior to the procedure &. $ full bladder is needed prior to the procedure %. Painful sensation is felt as the needle is inserted '. 9lushing sensation is felt as the dye in in@ected !(6. 3n a population of ;,211. )hat is your esti ate of the population of pregnant wo an needing tetanus toxoid vaccination/ $. 0-(.2 %. .21.2 &. 2!(.2 '. --(.2 !(8. $ll of the following are seen in a child with easles. )hich one is not/ $. Reddened eyes %. Pustule &. %ory<a '. %ough !(;. Mobili<ing the people to beco e aware of their own proble called# $. %o unity Crgani<ing &. 9a ily Nursing %are Plan %. Nursing 3ntervention and to do actions to solve it is

'. Nursing Process !-1. Prevention of work related accidents in factories and industries are responsibilities of which field of nursing/ $. School health nursing &. Private duty nursing %. Cccupational health nursing '. 3nstitutional nursing !-!. 3n one of your ho e visit to Mr. JGN, you found out that his son is sick with cholera. "here is a great possibility that other e ber of the fa ily will also get cholera. "his possibility is aFan# $. 9oreseeable crisis &. ?ealth threat %. ?ealth deficit '. %risis !-(. )hy is bleeding in the leg of a pregnant wo an considered as an e ergency/ $. &lood volu e is greater in pregnant wo anO therefore, blood loss is increased &. "here is an increase blood pressure during pregnancy increasing the likelihood of he orrhage %. Pregnant wo an are ane ic, all for s of blood loss should be considered as an e ergency especially if it is in the lower extre ity '. "he pressure of the gravid uterus will exert additional force thus, increasing the blood loss in the lower extre ities

!--. $ling Maria is nearing enopause. She is habitually taking cola and coffee for the past (1 years. 4ou should tell $ling Maria to avoid taking caffeinated beverages because# $. 3t is sti ulating &. 3t will cause nervousness and inso nia %. 3t will contribute to additional bone de inerali<ation '. 3t will cause tachycardia and arrhyth ias !-.. $ll of the following are contraindication when giving 3 uni<ation except# $. &%7 :accines can be given to a child with $3'S &. &%7 :accine can be given to a child with ?epatitis & %. 'P" %an be given to a child that had convulsion - days after being given the first 'P" 'ose '. 'P" %an be given to a child with active convulsion or other neurological disease !-2. "heresa, a other with a ( year old daughter asks, Dat what age can 3 be able to take the blood pressure of y daughter as a routine procedure since hypertension is co on in the fa ily/E 4our answer to this is# $. $t ( years you ay &. $s early as ! year old %. )hen shes - years old '. )hen shes 0 years old !-0. &aby John develops hyperbilirubine ia. )hat is a newborn/ $. Beeping infants in a war and dark environ ent &. $d inistration of cardiovascular sti ulant %. 7entle exercise to stop uscle breakdown '. *arly feeding to speed passage of econiu ethod used to treat hyperbilirubine ia in a

!-6. "he co unityFPublic ?ealth &ag is# $. a re5uire ent for ho e visits &. an essential and indispensable e5uip ent of the co unity health nurse %. contains basic edications and articles used by the co unity health nurse '. a tool used by the %o unity health nurse is rendering effective nursing procedures during a ho e visit

!-8. )hat is the rationale in the use of bag techni5ue during ho e visits/ $. 3t helps render effective nursing care to clients or other e bers of the fa ily &. 3t saves ti e and effort of the nurse in the perfor ance of nursing procedures %. 3t should ini i<e or prevent the spread of infection fro individuals to fa ilies '. 3t should not overshadow concerns for the patient !-;. 3n consideration of the steps in applying the bag techni5ue, which side of the paper lining of the %?N bag is considered clean to ake a non>conta inated work area/ $. "he lower lip &. "he outer surface %. "he upper tip '. "he inside surface !.1. ?ow any words does a typical !(> onth>old infant use/ $. $bout !( words &. "wenty or ore words %. $bout 21 words '. "wo, plus D a aE and DpapaE !.!. . 'uring operation, "he CR suites lighting, noise, te perature and other factors that affects the operation are anaged by who / $. Nurse Supervisor %. %irculating nurse &. Surgeon '. Scrub nurse !.(. &efore and after the operation, the operating suite is anaged by the# $. Surgeon %. Nurse Manager &. Nurse Supervisor '. %hief Nurse !.-. "he counting of sponges is done by the Surgeon together with the# $. %irculating nurse &. Scrub nurse %. $ssistant surgeon '. Nurse supervisor !... "he CR tea perfor s distinct roles for one surgical procedure to be acco plished within a prescribed ti e fra e and deliver a standard patient outco e. )hile the surgeon perfor s the surgical procedure, who onitors the status of the client like urine output, blood loss/ $. Scrub Nurse &. Surgeon %. $naesthesiologist '. %irculating Nurse !.2. Surgery schedules are co unicated to the CR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. 9or orthopedic cases, what depart ent is usually infor ed to be present in the CR/ $. Rehabilitation depart ent &. Aaboratory depart ent %. Maintenance depart ent '. Radiology depart ent !.0. 3n so e hip surgeries, an epidural catheter for 9entanyl epidural analgesia is given. )hat is your nursing priority care in such a case/ $. 3nstruct client to observe strict bed rest &. %heck for epidural catheter drainage %. $d inister analgesia through epidural catheter as prescribed '. $ssess respiratory rate carefully !.6. "he patients edical record can work as a double edged sword. )hen can the beco e the doctorsFnurses worst ene y/ $. )hen the record is volu inous &. )hen a edical record is subpoenaed in court edical record

%. )hen it is issing '. )hen the edical record is inaccurate, inco plete, and inade5uate !.8. 'isposal of edical records in govern ent hospitalsFinstitutions coordination with what agency/ $. 'epart ent of 3nterior and Aocal 7overn ent H'3A7I &. Metro Manila 'evelop ent $uthority HMM'$I %. Records Manage ent $rchives Cffice HRM$CI '. 'epart ent of ?ealth H'C?I !.;. 3n the hospital, when you need the re5uest per ission through# $. 'octor in charge &. "he hospital director %. "he nursing service '. Medical records section ust be done in close

edical record of a discharged patient for research you will

!21. 4ou will give health instructions to %arlo, a case of bronchial asth a. "he health instruction will include the following, *+%*P"# $. $void e otional stress and extre e te perature &. $void pollution like s oking %. $void pollens, dust, seafood '. Practice respiratory isolation !2!. $s the head nurse in the CR, how can you i prove the effectiveness of clinical alar syste s/ $. Ai it suppliers to a few so that 5uality is aintained &. 3 ple ent a regular inventory of supplies and e5uip ent %. $dherence to anufacturers reco endation '. 3 ple ent a regular aintenance and testing of alar syste s !2(. Cverdosage of edication or anesthetic can happen even with the aid of technology like infusion pu ps, sphyg o ano eter and si ilar devicesF achines. $s a staff, how can you i prove the safety of using infusion pu ps/ $. %heck the functionality of the pu p before use &. Select your brand of infusion pu p like you do with your cellphone %. $llow the technician to set the infusion pu p before use '. :erify the flow rate against your co putation !2-. )hile tea effort is needed in the CR for efficient and 5uality patient care delivery, we should li it the nu ber of people in the roo for infection control. )ho co prise this tea / $. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly &. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist %. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist '. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse !2.. )hen surgery is on>going, who coordinates the activities outside, including the fa ily/ $. CrderlyFclerk %. %irculating Nurse &. Nurse Supervisor '. $nesthesiologist !22. "he breakdown in tea work is often ti es a failure in# $. *lectricity &. 3nade5uate supply %. Aeg work '. %o unication !20. "o prevent recurrent attacks on client with glo erulonephritis, the nurse instructs the client to# $. "ake a shower instead of tub baths &. $void situations that involve physical activity %. %ontinue the sa e restriction on fluid intake '. Seek early treat ent for respiratory infection

!26. )hen ad inistering "apa<ole, "he nurse should adverse effect/ $. ?yperthyroidis &. ?ypothyroidis %. 'rowsiness '. Sei<ure

onitor the client for which of the following

!28. Post bronchoscopy, the nurse priority is to check which of the following before feeding/ $. 7ag reflex &. )earing off of anesthesia %. Swallowing reflex '. Peristalsis !2;. %hanges nor ally occur in the elderly. $ ong the following, which is a nor al change in an elderly client/ $. 3ncreased sense of taste &. 3ncreased appetite %. Grinary fre5uency '. "hinning of the lens Situation# %olosto y is a surgically created anus. 3t can be te porary or per anent, depending on the disease condition. !01. Skin care around the sto a is critical. )hich of the following is not indicated as a skin care barriers/ $. $pply liberal a ount of ineral oil to the area &. Gse karaya paste and rings around the sto a %. %lean the area daily with soap and water before applying bag '. $pply talcu powder twice a day !0!. )hat health instruction will enhance regulation of a colosto y HdefecationI of clients/ $. 3rrigate after lunch everyday &. *at fruits and vegetables in all three eals %. *at balanced eals at regular intervals '. Restrict exercise to walking only !0(. $fter ileosto y, which of the following condition is NC" expected/ $. 3ncreased weight &. 3rritation of skin around the sto a %. Ai5uid stool '. *stablish ent of regular bowel ove ent !0-. "he following are appropriate nursing interventions during colosto y irrigation, *+%*P"# $. 3ncrease the irrigating solution flow rate when abdo inal cra ps is felt &. 3nsert (>. inches of an ade5uately lubricated catheter to the sto a %. Position client in se i>9owler '. ?ang the solution !8 inches above the sto a !0.. )hat sensation is used as a gauge so that patients with ileosto y can deter ine how often their pouch should be drained/ $. Sensation of taste %. Sensation of s ell &. Sensation of pressure '. Grge to defecate !02. 3n perfor ing a cleansing ene a, the nurse perfor s the procedure by positioning the client in# $. Right lateral position &. Aeft lateral position %. Right Si s position '. Aeft Si s position !00. Mang %aloy is scheduled to have a he orrhoidecto y, after the operation, you would expect that the clients position post operatively will be#

$. Bnee chest position &. Side lying position %. Si s position '. 7enopectoral position !06. 4ou would expect that after an abdo inal perineal resection, the type of colosto y that will be use is/ $. 'ouble barrel colosto y &. "e porary colosto y %. Per anent colosto y '. $n 3leosto y !08. 4ou are an osto y nurse and you know that colosto y is defined as# $. 3t is an incision into the colon to create an artificial opening to the exterior of the abdo en &. 3t is end to end anasto osis of the gastric stu p to the duodenu %. 3t is end to end anasto osis of the gastric stu p to the @e@unu '. 3t is an incision into the ileu to create an artificial opening to the exterior of the abdo en !0;. Aarry, 22 years old, who is suspected of having colorectal cancer, is ad itted to the %3. $fter taking the history and vital signs the physician does which test as a screening test for colorectal cancer. $. &ariu ene a &. %arcinoe bryonic antigen %. $nnual digital rectal exa ination '. Proctosig oidoscopy !61. Sy pto s associated with cancer of the colon include# $. constipation, ascites and ucus in the stool &. diarrhea, heart burn and eructation %. blood in the stools, ane ia, and Dpencil shapedE stools '. anorexia, he ate esis, and increased peristalasis !6!. (. ?ours after creation of colosto y, Nurse :ioly is correct if she identify that the nor al appearance of the sto a is # $. Pink, oist and slightly protruding fro the abdo en &. 7ray, oist and slightly protruding fro the the abdo en %. Pink, dry and slightly protruding fro the abdo en '. Red, oist and slightly protruding fro the abdo en !6(. 3n cleaning the sto a, the nurse would use which of the following cleaning $. ?ydrogen Peroxide, water and ild soap &. Providone 3odine, water and ild soap %. $lcohol, water and ild soap '. Mild soap and water ediu s/

!6-. )hen observing a return de onstration of a colosto y irrigation, you know that is re5uired if pt# $. Aubricates the tip of the catheter prior to inserting into the sto a &. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion %. 'iscontinues the insertion of fluid after only 211 l of fluid has been instilled '. %la ps of the flow of fluid when felling unco fortable !6.. )hat does a sa ple group represent/ $. %ontrol group &. Study sub@ects %. 7eneral population '. Gniverse

ore teaching

!62. $s a nurse, you can help i prove the effectiveness of co unication a ong healthcare givers by# $. Gse of re inders of Pwhat to do &. Gsing standardi<ed list of abbreviations, acrony s, and sy bols %. Cne>on>one oral endorse ent

'. "ext

essaging and e> ail

!60. Myxede a co a is a life threatening co plication of long standing and untreated hypothyroidis with one of the following characteristics. $. ?yperglyce ia %. ?yperther ia &. ?ypother ia '. ?ypoglyce ia !66. Mang *dgardo has a chest tube inserted in place after a Aobecto y. "he nurse knows that that %hest tube after this procedure will# $. Prevents ediastinal shift &. Pro ote chest expansion of the re aining lung %. 'rain fluids and blood accu ulated post operatively '. Re ove the air in the lungs to pro ote lung expansion !68. Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions, *+%*P"# $. straddling a chair with ar s and head resting on the back of the chair &. lying on the unaffected side with the bed elevated -1>.1 degrees %. lying prone with the head of the bed lowered !2>-1 degrees '. sitting on the edge of the bed with her feet supported and ar s and head on a padded overhead table !6;. %hest x>ray was ordered after thoracentesis. )hen your client asks what is the reason for another chest x>ray, you will explain# $. to rule out pneu othorax &. to rule out any possible perforation %. to decongest '. to rule out any foreign body !81. "he RR nurse should onitor for the $. he orrhage &. endotracheal tube perforation %. osopharyngeal ede a '. epiglottis ost co on postoperative co plication of#

!8!. "he P$%G nurse will aintain postoperative " and $ client in what position/ $. Supine with neck hyperextended and supported with pillow &. Prone with the head on pillow and turned to the side %. Se i>fowlers with neck flexed '. Reverse trendelenburg with extended neck !8(. "ony is to be discharged in the afternoon of the sa e day after tonsillecto y and adenoidecto y. 4ou as the RN will ake sure that the fa ily knows to# $. offer osteri<ed feeding &. offer soft foods for a week to ini i<e disco fort while swallowing %. supple ent his diet with :ita in % rich @uices to enhance healing '. offer clear li5uid for - days to prevent irritation Situation Rudy was diagnosed to have chronic renal failure. ?e odialysis is ordered so that an $>: shunt was surgically created. !8-. )hich of the following action would be of highest priority with regards to the external shunt/ $. $void taking &P or blood sa ple fro the ar with the shunt &. 3nstruct the client not to exercise the ar with the shunt %. ?eparini<e the shunt daily '. %hange dressing of the shunt daily !8.. 'iet therapy for Rudy, who has acute renal failure is low>protein, low potassiu sodiu . "he nutrition instructions should include# $. Reco end protein of high biologic value like eggs, poultry and lean eats &. *ncourage client to include raw cucu bers, carrot, cabbage, and to atoes and low

%. $llowing the client cheese, canned foods and other processed food '. &ananas, cantaloupe, orange and other fresh fruits can be included in the diet !82. "he ost co on causative agent of Pyelonephritis in hospitali<ed patient attributed to prolonged catheteri<ation is said to be# $. *. %oli %. Pseudo onas &. Blebsiella '. Staphylococcus !80. "he 3:P reveals that 9e has s all renal calculus that can be passed out spontaneously. "o increase the chance of passing the stones, you instructed her to force fluids and do which of the following/ $. &alanced diet %. Strain all urine &. $ bulate ore '. &ed rest !86. Sergio is brought to * ergency Roo after the barbecue grill accident. &ased on the assess ent of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extre ities and right lower extre ities. ?is wife asks what that eans/ 4our ost accurate response would be# $. Structures beneath the skin are da age &. 'er is is partially da aged %. *pider is and der is are both da aged '. *pider is is da aged !88. 'uring the first (. hours after the ther al in@ury, you should asses Sergio for# $. hypokale ia and hypernatre ia &. hypokale ia and hyponatre ia %. hyperkale ia and hyponatre ia '. hyperkale ia and hypernatre ia !8;. $ll of the following are instruction for proper foot care to be given to a client with peripheral vascular disease caused by 'iabetes. )hich is not/ $. "ri nail using nail clipper &. $pply cornstarch to the foot %. $lways check for the te perature of the water before bathing '. Gse %anvas shoes !;1. 4ou are on orning duty in the edical ward. 4ou have !1 patients assigned to you. 'uring your endorse ent rounds, you found out that one of your patients was not in bed. "he patient next to hi infor ed you that he went ho e without notifying the nurses. )hich a ong the following will you do first/ $. Make an incident report &. %all security to report the incident %. )ait for ( hours before reporting '. Report the incident to your supervisor !;!. 4ou are on duty in the edical ward. 4ou were asked to check the narcotics cabinet. 4ou found out that what is on record does not tally with the drugs used. )hich a ong the following will you do first/ $. )rite an incident report and refer the atter to the nursing director &. Beep your findings to yourself %. Report the atter to your supervisor '. 9ind out fro the endorse ent any patient who ight have been given narcotics !;(. 4ou are on duty in the edical ward. "he other of your patient who is also a nurse, ca e running to the nurses station and infor ed you that 9iolo went into cardiopul onary arrest. $. Start basic life support easures &. %all for the %ode %. &ring the crash cart to the roo '. 7o to see 9iolo and assess for airway patency and breathing proble s

!;-. )hen observing a return de onstration of a colosto y irrigation, you know that is re5uired if pt# $. Aubricates the tip of the catheter prior to inserting into the sto a &. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion %. 'iscontinues the insertion of fluid after only 211 l of fluid has been instilled '. %la ps of the flow of fluid when felling unco fortable

ore teaching

!;.. )hich of the four phases of e ergency anage ent is defined as Dsustained action that reduces or eli inates long>ter risk to people and property fro natural ha<ards and their effects.E/ $. Recovery &. Mitigation %. Response '. Preparedness !;2. )hich of the following ter s refer to a process by which the individual receives education about recognition of stress reaction and anage ent strategies for handling stress which ay be instituted after a disaster/ $. %linical incident stress anage ent &. 9ollow>up %. 'efriefing '. 'efusion !;0. 9ires are approached using the $. Run &. Race %. Rescue '. Re ove ne onic R$%*, in which, R stands for#

!;6. 4ou are caring for %onrad who has a brain tu or and increased 3ntracranial Pressure H3%PI. )hich intervention should you include in your plan to reduce 3%P/ $. $d inister bowel softener &. Position %onrad with his head turned toward the side of the tu or %. Provide sensory sti ulation '. *ncourage coughing and deep breathing !;8. Beeping %onrads head and neck align ent results in# $. increased intrathoracic pressure &. increased venous outflow %. decreased venous outflow '. increased intraabdo inal pressure !;;. *arliest sign of skin reaction to radiation therapy is# $. des5ua ation &. erythe a %. atrophy '. pig entation (11. $ guideline that is utili<ed in deter ining priorities is to assess the status of the following, *+%*P"# $. perfusion %. respiration &. loco otion '. entation (1!. Miss Bate is a bread vendor and you are buying a bread fro her. 4ou noticed that she receives and changes oney and then hold the bread without washing her hand. $s a nurse, )hat will you say to Miss Bate/ $. Miss, 'ont touch the bread 3ll be the one to pick it up &. Miss, Please wash your hands before you pick up those breads %. Miss, Gse a pick up forceps when picking up those breads '. Miss, 4our hands are dirty 3 guess 3ll try another bread shop

(1(. 3n ad inistering blood transfusion, what needle gauge is used/ $. !8 %. (&. (( '. (. (1-. &efore ad inistration of blood and blood products, the nurse should first# $. %heck with another R.N the clients na e, 3dentification nu ber, $&C and R? type. &. *xplain the procedure to the client %. $ssess baseline vital signs of the client '. %heck for the &" order (1.. "he only 3: fluid co patible with blood products is# $. '2AR %. NSS &. '2NSS '. Plain AR (12. 3n any event of an adverse he olytic reaction during blood transfusion, Nursing intervention should focus on# $. Slow the infusion, %all the physician and assess the patient &. Stop the infusion, $ssess the client, Send the re aining blood to the laboratory and call the physician %. Stop the infusion, %all the physician and assess the client '. Slow the confusion and keep a patent 3: line open for ad inistration of edication (10. "he nurse knows that after receiving the blood fro the blood bank, it should be ad inistered within# $. ! hour %. . hours &. ( hours '. 0 hours (16. 'uring blood ad inistration, the nurse should carefully onitor adverse reaction. "o this, it is essential for the nurse to# $. Stay with the client for the first !2 inutes of blood ad inistration &. Stay with the client for the entire period of blood ad inistration %. Run the infusion at a faster rate during the first !2 inutes '. "ell the client to notify the staff i ediately for any adverse reaction (18. $s Aedas nurse, you plan to set up an e ergency e5uip ent at her beside following thyroidecto y. 4ou should include# $. $n airway and rebreathing tube &. $ tracheosto y set and oxygen %. $ crush cart with bed board '. "wo a pules of sodiu bicarbonate (1;. )hich of the following nursing interventions is appropriate after a total thyroidecto y/ $. Place pillows under your patients shoulders. &. Raise the knee>gatch to -1 degrees %. Beep you patient in a high>fowlers position. '. Support the patients head and neck with pillows and sandbags. (!1. 3f there is an accidental in@ury to the parathyroid gland during a thyroidecto y which of the following ight Aeda develop postoperatively/ $. %ardiac arrest %. Respiratory failure &. 'yspnea '. "etany (!!. $fter surgery Aeda develops peripheral nu bness, tingling and )hat would you anticipate to ad inister/ $. Magnesiu sulfate %. Potassiu iodide &. %alciu gluconate '. Potassiu chloride Situation# NGRS*S are involved in care anage ent. uscle twitching and spas . onitor

aintaining a safe and healthy environ ent. "his is part of 5uality

(!(. "he first step in deconta ination is# $. to i ediately apply a che ical deconta ination foa to the area of conta ination &. a through soap and water wash and rinse of the patient %. to i ediately apply personal protective e5uip ent '. re oval of the patients clothing and @ewelry and then rinsing the patient with water (!-. 9or a patient experiencing pruritus, you reco end which type of bath. $. water %. saline &. colloidal Hoat ealI '. sodiu bicarbonate (!.. 3nduction of vo iting is indicated for the accidental poisoning patient who has ingested. $. Rust re over %. toilet bowl cleaner &. 7asoline '. aspirin Situation# &ecause severe burn can affect the persons totality it is i portant that>you apply interventions focusing on the various di ensions of an. 4ou also have to understand the rationale of the treat ent. (!2. $ client was rushed in the *.R showing a whitish, leathery and painless burned area on his skin. "he nurse is correct in classifying this burn as# $. 9irst degree burn %. "hird degree burn &. Second degree burn '. Partial thickness burn (!0. 'uring the first (. hours of burn, nursing $. 3 and C hourly &. Strict aseptic techni5ue %. 9orced oral fluids '. 3solate the patient easures should focus on which of the following/

(!6. 'uring the $cute phase of burn, the priority nursing intervention in caring for this client is# $. Prevention of infection &. Pain anage ent %. Prevention of &leeding '. 9luid Resuscitation (!8. "he nurse knows that the phase of burn is# $. ?ypokale ia &. ?yperkale ia %. ?ypernatre ia '. ?yponatre ia ost fatal electrolyte i balance in burned client during the * ergent

(!;. ?ypokale ia is reflected in the *%7 by which of the following/ $. "all " waves %. Pathologic M wave &. )idening MRS %o plex '. G wave ((1. Pain $. 3: &. 3M edications given to the burn clients are best given via what route/ %. Cral '. SM

((!. )hat type of debride ent involves proteolytic en<y es/ $. 3nterventional %. Surgical &. Mechanical '. %he ical (((. )hich topical anti icrobial is $. Neosporin &. Silver nitrate %. Silver sulfadia<ine '. Sulfa ylon ost fre5uently used in burn wound care/

((-. ?ypertrophic burn scars are caused by# $. exaggerated contraction &. rando layering of collagen %. wound ische ia '. delayed epitheliali<ation ((.. "his study which is an in depth study of one boy is a# $. case study &. longitudinal study %. cross>sectional study '. evaluative study ((2. "he process recording was the principal tool for data collection. )hich of the following is NC" a part of a process recording/ $. Non verbal narrative account &. $nalysis and interpretation %. $udio>visual recording '. :erbal narrative account ((0. "he ost significant factor that ight affect the nurses care for the psychiatric patient is# $. Nurses own beliefs and attitude about the entally ill &. $ ount of experience he has with psychiatric clients %. ?er abilities and skill to care for the psychiatric clients '. ?er knowledge in dealing with the psychiatric clients ((6. 3n order to establish a therapeutic relationship with the client, the nurse $. Self awareness %. Self acceptance &. Self understanding '. Self otivation ust first have#

((8. Nurse *dna thinks that the patient is so ewhat like his father. She then identifies positive feeling for the patient that affects the ob@ectivity of her nursing care. "his e otional reaction is called# $. "ransference &. %ounter "ransference %. Reaction for ation '. Sy pathy

((;. "he ost i portant 5uality of a nurse during a Nurse>Patient interaction is# $. Gnderstanding &. $cceptance %. Aistening '. "eaching (-1. Selective inattention is seen in what level of anxiety/ $. Mild &. Moderate %. Severe '. Panic (-!. Cbsessive co pulsive disorder is characteri<ed by# $. Gncontrollable i pulse to perfor an act or ritual repeatedly &. Persistent thoughts and behavior %. Recurring unwanted and disturbing thoughts '. Pathological persistence of unwilled thoughts (-(. Ms. Maria Salvacion says that she is the incarnation of the holy :irgin Mary. She said that she is the child of the covenant that would save this world fro the evil forces of Satan. Cne orning, while caring for her, she stood in front of you and said D&ow down before eQ 3 a the holy other of %hristQ 3 a the blessed :irgin MaryQE "he best response by the Nurse is#

$. "ell e ore about being the :irgin Mary &. So, 4ou are the :irgin Mary/ %. *xcuse e but, you are not any ore a :irgin so you cannot be the &lessed :irgin Mary. '. 4ou are Maria Salvacion (--. Marias state ent D&ow down before :irgin MaryQE is an exa ple of# $. 'elusion of grandeur &. :isual ?allucination %. Religious delusion '. $uditory ?allcucination eQ 3 a the holy other of %hristQ 3 a the blessed

(-.. "he nurse interprets the state ent D&ow down before eQ 3 a the holy other of %hristQ 3 a the blessed :irgin MaryQE as i portant in docu enting in which of the following areas of ental status exa ination/ $. "hought content &. Mood %. $ffect '. $ttitude (-2. Mang 'avid, $ (6 year old psychiatric client was ad itted with a diagnosis of schi<ophrenia. 'uring the orning assess ent, Mang 'avid shouted D'id you know that 3 a the top sales an in the world/ 'ifferent co panies want eQE $s a nurse, you know that this is an exa ple of# $. ?allucination &. 'elusion %. %onfabulation '. 9light of 3deas (-0. "he reco ended treat ent $. Psychotherapy &. &ehavior therapy %. $version therapy '. Psychoanalysis odality in clients with obsessive co pulsive disorder is#

(-6. $ state of dise5uilibriu wherein a person cannot readily solve a proble using his usual coping echanis s is called# $. Mental illness %. %risis &. Mental health '. Stress (-8. Cbsessive co pulsive disorder is classified under# $. Psychotic disorders &. Neurotic disorders %. Ma@or depressive disorder '. &ipolar disorder

or situation even by

(-;. )hich nursing diagnosis is a priority for clients with &orderline personality disorder/ $. Risk for in@ury &. 3neffective individual coping %. $ltered thought process '. Sensory perceptual alteration

(.1. $n appropriate nursing diagnosis for clients in the acute $. Risk for in@ury directed to self &. Risk for in@ury directed to others %. 3 paired nutrition less than body re5uire ents '. 3neffective individual coping

anic phase of bipolar disorder is#

(.!. $ paranoid client refuses to eat telling you that you poisoned his food. "he best intervention to this client is#

$. "aste the food in front of hi and tell hi that the food is not poisoned &. Cffer other types of food until the client eats %. Si ply state that the food is not poisoned '. Cffer sealed foods (.(. "oilet training occurs in the anal stage of 9reuds psychosexual task. "his is e5uivalent to *riksons# $. "rust vs. Mistrust &. $utono y vs. Sha e and 'oubt %. 3nitiative vs. 7uilt '. 3ndustry vs. 3nferiority (.-. 'uring the phallic stage, the child ust identify with the parent of# $. "he sa e sex &. "he opposite sex %. "he other or the pri ary caregiver '. &oth sexes (... Ms. $N$ had a car accident where he lost her boyfriend. $s a result, she beca e passive and sub issive. "he nurse knows that the type of crisis Ms. $N$ is experiencing is# $. 'evelop ental crisis &. Maturational crisis %. Situational crisis '. Social %risis (.2. Persons experiencing crisis beco es passive and sub issive. $s a nurse, you know that the best approach in crisis intervention is to be# $. $ctive and 'irective &. Passive friendliness %. $ctive friendliness '. 9ir kindness (.0. "he psychosocial task of a 22 year old adult client is# $. 3ndustry vs. 3nferiority &. 3nti acy vs. 3solation %. 3ntegrity vs. 'espair '. 7enerativity vs. Stagnation (.6. "he stages of grieving identified by *li<abeth Bubler>Ross are# $. Nu bness, anger, resolution and reorgani<ation &. 'enial, anger, identification, depression and acceptance %. $nger, loneliness, depression and resolution '. 'enial, anger, bargaining, depression and acceptance (.8. )hich physiologic effect should the nurse expect in a client addicted to hallucinogens/ $. 'ilated pupils &. %onstricted pupils %. &radycardia '. &radypnea (.;. Miss %** is ad itted for treat ent of a@or depression. She is withdrawn, disheveled and states DNobody wants eE "he nurse ost likely expects that Miss %** is to be placed on# $. Neuroleptics edication &. Special diet %. Suicide precaution '. $nxiolytics edication (21. 3n alcoholic patient, the nurse knows that the vita in deficient to these types of clients that leads to psychoses is# $. "hia ine %. Niacin &. :ita in % '. :ita in $

(2!. )hich of the following ter s refers to weakness of both legs and the lower part of the trunk/ $. Paraparesis &. ?e iplegia %. Muadriparesis '. Paraplegia

(2(. Cf the following neurotrans itters, which de onstrates inhibitory action, helps control and sleep, and inhibits pain pathways/ $. Serotonin &. *nkephalin %. Norepinephrine '. $cetylcholine

ood

(2-. "he lobe of the brain that contains the auditory receptive areas is the RRRRRRRRRRRR lobe. $. te poral &. frontal %. parietal '. occipital (2.. 3n preparation for *%", the nurse knows that it is al ost si ilar to that of# $. *%7 %. **7 &. 7eneral $nesthesia '. MR3 (22. "he expected side effect after *%" is co only associated with# $. "ransient loss of e ory, confusion and disorientation &. Nausea and vo iting %. 9ractures '. ?ypertension and increased in cardiac rate (20. "he purpose of *%" in clients with depression is to# $. Sti ulation in the brain to increase brain conduction and counteract depression &. Mainly &iologic, increasing the norepinephrine and serotonin level %. %reates a te porary brain da age that will increase blood flow to the brain '. 3nvolves the conduction of electrical current to the brain to charge the neurons and co bat depression (26. "he priority nursing diagnosis for a client with $. $ltered nutrition &. $ltered thought process %. Self care deficit '. Risk for in@ury a@or depression is#

(28. $ patient tells the nurse D3 a depressed to talk to you, leave response by the nurse is ost therapeutic/ $. 3ll be back in an hour &. )hy are you so depressed/ %. 3ll seat with you for a o ent '. %all e when you feel like talking to e

e aloneE )hich of the following

(2;. Cne of the following state ents is true with regards to the care of clients with depression# $. Cnly entally ill persons co it suicide &. $ll depressed clients are considered potentially suicidal %. Most suicidal person gives no warning '. "he chance of suicide lessens as depression lessens (01. $n adolescent client has bloodshot eyes, a voracious appetite and dry abuse would the nurse ost likely suspect/ $. Mari@uana &. $ pheta ines %. &arbiturates outh. )hich drug

'. $nxiolytics (0!. 'uring which phase of therapeutic relationship should the nurse infor ter ination of therapy/ $. Pre>orientation &. Crientation %. )orking '. "er ination the patient for

(0(. $ client says to the nurse D3 a worthless person, 3 should be deadE "he nurse best replies# $. D'ont say you are worthless, you are not a worthless personE &. D)e are going to help you with your feelingsE %. D)hat akes you feel youre worthless/E '. D)hat you say is not trueE (0-. "he nurses ost uni5ue tool in working with the e otionally ill client is hisFher $. theoretical knowledge &. personality ake up %. e otional reactions '. co unication skills (0.. "he entally ill person responds positively to the nurse who is war de onstration of the nurses role as# $. counselor &. other surrogate %. therapist '. sociali<ing agent (02. "he past history of %a ila would $. schi<oid &. extrovert %. a bivert '. cycloid and caring. "his is a

ost probably reveal that her pre orbid personality is#

(00. 3n an extre e situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within# $. (. hours &. -0 hours %. .8 hours '. !( hours (06. 3f it is established that the child is physically abused by a parent, the nurse could for ulate with the fa ily is that# $. %hild and any siblings will live in a safe environ ent &. 9a ily will feel co fortable in their relationship with the counselor %. 9a ily will gain understanding of their abusive behavior patterns '. Mother will be able to use verbal discipline with her children (08. %ocaine is derived fro $. Narcotic &. Sti ulant %. &arbiturate '. ?allucinogen ost i portant goal the

the leaves of coca plantO the nurse knows that cocaine is classified as#

(0;. "o successfully co plete the tasks of older adulthood, an 82 year old who has been a widow for (2 years should be encouraged to# $. 3nvest her creative energies in pro oting social welfare &. Redefine her role in the society and offer so ething and offer so ething of value %. 9eel a sense of satisfaction in reflecting on her productive life '. Aook to recapture the opportunities that were never started or co pleted

(61. 3n a therapeutic relationship, the nurse ust understand own values, beliefs, feelings, pre@udices S how these affect others. "his is called# $. "herapeutic use of self &. Psychotherapy %. "herapeutic co unication '. Self awareness (6!. )hile on &ryants traction, which of these observations of 7raciela and her traction apparatus would indicate a decrease in the effectiveness of her traction/ $. 7racielas buttocks are resting on the bed. &. "he traction weights are hanging !1 inches above the floor. %. 7racielas legs are suspended at a ;1 degree angle to her trunk. '. "he traction ropes ove freely through the pulley. (6(. "he nurse notes that the fall ight also cause a possible head in@ury. She will be observed for signs of increased intracranial pressure which include# $. Narrowing of the pulse pressure &. :o iting %. Periorbital ede a '. $ positive Bernigs sign (6-. "his is a tricyclic antidepressant drug# $. :enlafaxine H*ffexorI &. 9louxetine HPro<acI %. Sertraline HLoloftI '. 3 ipra ine H"ofranilI (6.. "he working phase in a therapy group is usually characteri<ed by which of the following/ $. %aution &. %ohesiveness %. %onfusion '. %o petition (62. Substance abuse is different fro substance dependence in that, substance dependence# $. includes characteristics of adverse conse5uences and repeated use &. re5uires long ter treat ent in a hospital based progra %. produces less severe sy pto s than that of abuse '. includes characteristics of tolerance and withdrawal (60. Rickys 3M falls within the range of 21>22. he can be expected to# $. Profit fro vocational training with oderate supervision &. Aive successfully in the co unity %. Perfor si ple tasks in closely supervised settings '. $c5uire acade ic skills of 0th grade level (66. "he other of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son ight @ust beco e worse while relating with other drug users. "he others behavior can be described as# $. Gnhelpful &. %odependent %. %aretaking '. Supportive (68. 4ou teach your clients the difference between, "ype 3 H3''MI and "ype 33 HN''MI diabetes. )hich of the following is true/ $. both types diabetes ellitus clients are all prone to developing ketosis &. "ype 33 HN3''MI is ore co on and is also preventable co pared to "ype 3 H3''MI diabetes which is genetic in etiology %. "ype 3 H33'MI is characteri<ed by fasting hyperglyce ia '. "ype 33 HN3''MI is characteri<ed by abnor al i une response

(6;. Aifestyle>related diseases in general share areas co except# $. physical activity &. s oking %. genetics '. nutrition

on risk factors. "hese are the following

(81. "he following echanis s can be utili<ed as part of the 5uality assurance progra hospital *+%*P"# $. Patient satisfaction surveys &. Peer review to assess care provided %. Review of clinical records of care of client '. Gse of Nursing 3nterventions %lassification

of your

(8!. "he use of the Standards of Nursing Practice is i portant in the hospital. )hich of the following state ents best describes what it is/ $. "hese are state ents that describe the axi u or highest level of acceptable perfor ance in nursing practice &. 3t refers to the scope of nursing practice as defined in Republic $ct ;!6%. 3t is a license issued by the Professional Regulation %o ission to protect the public fro substandard nursing practice '. "he Standards of %are includes the various steps of the nursing process and the standards of professional perfor ance (8(. 4ou are taking care of critically ill client and the doctor in charge calls to order a 'NR Hdo not resuscitateI for the client. )hich of the following is the appropriate action when getting 'NR order over the phone/ $. ?ave the registered nurse, fa ily spokesperson, nurse supervisor and doctor sign &. ?ave ( nurse validate the phone order, both nurses sign the order and the doctor should sign his order within (. hours %. ?ave the registered nurse, fa ily and doctor sign the order '. ?ave ! nurse take the order and sign it and have the doctor sign it within (. hours (8-. Gnder the PR%>&oard of Nursing Resolution pro ulgating the adoption of a Nursing Specialty %ertification Progra and %ouncil, which two H(I of the following serves as the strongest for its enforce ent/ HaI $dvances ade in Science and "echnology have provided the cli ate for speciali<ation in al ost all aspects of hu an endeavorO and HbI $s necessary conse5uence, there has e erged a new concept known as globali<ation which seeks to re ove barriers in trade, industry and services i posed by the national laws of countries all over the worldO and HcI $wareness of this develop ent should i pel the nursing sector to prepare our people in the services sector to eet the above challengeO and HdI %urrent trends of speciali<ation in nursing practice recogni<ed by the 3nternational %ouncil of Nurses H3%NI of which the Philippines is a e ber for the benefit of the 9ilipino in ter s of deepening and refining nursing practice and enhancing the 5uality of nursing care. $. b S c are strong @ustifications &. a S b are strong @ustifications %. a S c are strong @ustifications '. a S d are strong @ustifications

(8.. Bnowing that for a co atose patient hearing is the last sense to be lost, as Judys nurse, what should you do/ $. "ell her fa ily that probably she cant hear the &. "alk loudly so that )endy can hear you %. "ell her fa ily who are in the roo not to talk '. Speak softly then hold her hands gently (82. )hich a ong the following interventions should you consider as the highest priority when caring for June who has he iparesis secondary to stroke/

$. Place June on an upright lateral position &. Perfor range of otion exercises %. $pply antie bolic stockings '. Gse hand rolls or pillows for support (80. Salo e was fitted a hearing aid. She understood the proper use and wear of this device when she says that the battery should be functional, the device is turned on and ad@usted to a# $. therapeutic level &. co fortable level %. prescribed level '. audible level (86. Me bership dropout generally occurs in group therapy after a $. $cco plishes his goal in @oining the group &. 'iscovers that his feelings are shared by the group e bers %. *xperiences feelings of frustration in the group '. 'iscusses personal concerns with group e bers e ber#

(88. )hich of the following 5uestions illustrates the group role of encourager/ $. )hat were you saying/ &. )ho wants to respond next/ %. )here do you go fro here/ '. )hy havent we heard fro you/ (8;. "he goal of re otivation therapy is to facilitate# $. 3nsight %. Sociali<ation &. Productivity '. 3nti acy (;1. &eing in contact with reality and the environ ent is a function of the# $. conscience %. id &. ego '. super ego (;!. Substance abuse is different fro substance dependence in that, substance dependence# $. includes characteristics of adverse conse5uences and repeated use &. re5uires long ter treat ent in a hospital based progra %. produces less severe sy pto s than that of abuse '. includes characteristics of tolerance and withdrawal (;(. 'uring the detoxification stage, it is a priority for the nurse to# $. teach skills to recogni<e and respond to health threatening situations &. increase the clients awareness of unsatisfactory protective behaviors %. i ple ent behavior odification '. pro ote ho eostasis and ini i<e the clients withdrawal sy pto s (;-. %o only known as DshabuE is# $. %annabis Sativa &. Aysergic acid diethyla ide %. Methylenedioxy etha pheta ine '. Metha peta ine hydrochloride (;.. )hich of the following gauges should you prepare for spinal anesthesia if the anesthesiologist re5uires a pink spinal set and a blue spinal set as backup/ $. 7auges !0 and (( &. 7auges !8 and !0 %. 7auges !0 and (1 '. 7auges (2 and (( (;2. 'ischarge plans of diabetic clients include in@ection site rotation. 4ou should e phasi<e that the space between sites should be# $. 0.1 c . &. 2.1 c . %. (.2 c .

'. ..1 c . (;0. )hich of the ff. colors would you expect a tank containing nitrous oxide Hlaughing gasI to have, based on the universally>accepted color codes/ $. Red &. &lue %. 7reen D. Crange (;6. $. &. %. '. 9ro an *%7 reading, a MRS %o plex represents# $trial depolari<ation :entricular repolari<ation :entricular depolari<ation *nd of ventricular depolari<ation

(;8. 'iego is undergoing blood transfusion of the first unit. "he earliest signs of transfusion reactions are# $. Cliguria and @aundice &. Grticaria and whee<ing %. ?eadache, chills, S fever '. ?ypertension and flushing (;;. 4our alertness to both the physical and e otional needs of clients is based on which of the following philosophical fra eworks/ A. "here is a basic si ilarity a ong hu an beings. &. $ll behavior has eaning for co unicating a essage or need. %. ?u an beings are syste s of interdependent and interrelated parts. '. *ach individual has the potential for growth and change in the direction of positive ental health.
300.

Soledad is ter inally ill of cancer. Aooking sad, she expresses, Wala na yata akong pagasang mabuhay pa. $ response which fosters hope is# A. Gagaling din po kayo. Huwag po kayong mag-alala. B. Lakasan ang loob ninyo. Lahat naman po tayo ay doon ang patutunguhan. C. Mukhang napakabigat and dinadamdam ninyo. Andito po ako at puwede tayong mag-usap. . Huwag po ninyong isipin ang sakit ninyo. Bale wala yon. Andito naman ako pa!a makausap ninyo.

ANSWER KEY !. &. %lient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdo en (. %. $ ount of fluid intake of client before and after the procedure -. %. "eaching the clients relatives to perfor the procedure .. &. %lient can tolerate sitting and lying positions 2. &. Percussion delivers cushioned blows to the chest with cupped pal s while vibration gently shakes secretion loose on the exhalation cycle 0. '. 'o a physical exa ination while asking the client relevant 5uestions 6. %. anger 8. $. &eneficence ;. $. $ssess ent !1. $. nurses anage collaborative proble s using physician>prescribed interventions. !!. $. ?old urine as long as she can before e ptying the bladder to strengthen her sphincter uscles !(. %. loss of tone of the s ooth uscles of the colon !-. '. prolonged use of laxatives !.. %. the distance fro the tip of the nose to the tip of the ear lobe !2. %. Pu p the cuff to around 21 ?g above the point where the pulse is obliterated !0. '. 'etect oxygen saturation of arterial blood before sy pto s of hypoxe ia develops !6. $. 'istributive !8. $. 3ntravenous !;. %. higher than what the reading should be (1. &. -1 inutes (!. %. %over the fingertip sensor with a towel or bedsheet ((. '. inflated to -1 ?g above the esti ated systolic &P based on palpation of radial or brachial artery (-. &. blood should be war ed to roo te perature for -1 inutes before blood transfusions is ad inistered (.. '. ! tsp of saltFday but no patis and toyo (2. $. +>ray (0. $. %igarette s oking (6. $. !1>!2 seconds (8. $. 9ifth intercostal space, idclavicular line (;. $. Stroke volu e -1. &. Patches ay be applied to distal part of the extre ities like forear -!. &. "he internal dia eter of the tube -(. &. )ithdrawing of the suction catheter --. $. Separate the upper and lower airway -.. '. Risk for infection -2. '. Beep the patient clean and dry -0. '. Aaisse< 9aire

-6. $. $utocratic -8. $. Planning -;. &. *valuating .1. $. Philosophy .!. %. Next of Bin .(. '. 'urable Power of $ttorney .-. &. Stay with Mang %arlos and do nothing ... &. Patients &ill of Rights .2. %. !2 inutes .0. $. Review of related literature .6. '. Pilot Study .8. $. *ffective Nurse>patient co unication .;. %. $nxiety level 21. %. $pplied research 2!. '. "here is a careful selection of sub@ects in the experi ental group 2(. &. is assigning the responsibility to the aide but not the accountability for those tasks 2-. %. collective bargaining 2.. &. 3n>service education 22. $. R.$ ;!620. %. Prudence 26. %. Mitigating 28. $. $utono y 2;. %. &ecause the patients right coincide with the nurses responsibility 01. '. "hose involved in edical ission whos services are for free 0!. $. $utono y 0(. $. $ccountable 0-. %. $ registered nurse is responsible for a group of patients fro ad ission to discharge 0.. $. 9unctional Method 02. $. Raise the side rails, cover, put the call bell within reach, and attend to the client in pain to give the PRN edication 00. '. Put the bed in the lowest position ever 06. &. ;1 K 08. %. 3t forces the edication to be contained at the subcutaneous tissues

0;. $. Not universally accepted abbreviations 61. $. 3nspection, $uscultation, Percussion, Palpation 6!. $. &roaden the space between the feet 6(. $. $t the level of the heart 6-. '. %onduction 6.. '. ?andwashing 62. &. Natural passive i unity 60. %. 3 ust choose another doctor if 3 withdrew fro this research 66. %. "he water fluctuates during inhalation of the patient 68. &. $lcoholi<e the self sealing port, obtain a sterile syringe and draw the speci en on the self sealing port 6;. &. Screening patients for hypertension 81. '. 3 uni<ation 8!. $. Crthopnea 8(. '. Physiologic needs that are life threatening 8-. $. Psychological preparation of the client 8.. %. Cwned by the hospital and should not be given to anyone who re5uest it other than the doctor in charge 82. $. Pro oting and aintaining the health of populations and preventing and ini i<ing the progress of disease 80. $. restoring axi u health function. 86. &. 7ives 5uality nursing care 88. '. 'ouble effect 8;. &. "elehealth progra ;1. %. Psycho otor ;!. '. wellness progra

;(. %. %old co press prevents ede a and reduces pain ;-. %. 3ncrease oxygenation to the in@ured tissues for better healing ;.. &. 'isclosure ;2. &. 9easibility ;0. '. Mean ;6. &. )ithin (. hours after discharge ;8. %. Muasi>Aegislative Power ;;. %. "he Si<e and %ontour of the breast !11. %. &S* Cnce a onth !1!. $. Most fre5uently in nurses with needlesticks !1(. &. 3ntense back pain !1-. $. Soften and efface the cervix !1.. %. Sper can no longer reach the ova, because the fallopian tubes are blocked !12. %. a couple has been trying to conceive for ! year !10. &. between ( deg % and N8 deg % !16. $. Measles vaccine !18. %. ?epatitis & vaccines !1;. &. Nursing ?ealth ?istory and $ssess ent )orksheet !!1. &. 7raphic 9low Sheets !!!. '. Medicine and "reat ent Record !!(. '. Nursing Bardex !!-. $. 'ischarge Su ary !!.. '. $ccurate docu entation of actions and outco es !!2. &. Nursing Specialty %ertification %ouncil !!0. $. Grgent referral !!6. $. .1 !!8. %. Severe 'ehydration !!;. '. 'ifficulty to awaken !(1. $. is there any fever/ !(!. '. 7o to the next 5uestion, check for alnutrition !((. $. !,111 l to !,.11 l be given within . hours !(-. %. $cute *ar 3nfection !(.. '. :ery severe disease !(2. $. Pneu onia and larynigotracheitis !(0. '. 9lushing sensation is felt as the dye in in@ected !(6. '. --(.2 !(8. %. Pustule !(;. $. %o unity Crgani<ing !-1. %. Cccupational health nursing !-!. &. ?ealth threat !-(. '. "he pressure of the gravid uterus will exert additional force thus, increasing the blood loss in the A*. !--. %. 3t will contribute to additional bone de inerali<ation !-.. &. &%7 :accine can be given to a child with ?epatitis & !-2. %. )hen shes - years old !-0. '. *arly feeding to speed passage of econiu !-6. &. an essential and indispensable e5uip ent of the co unity health nurse !-8. &. 3t saves ti e and effort of the nurse in the perfor ance of nursing procedures !-;. '. "he inside surface !.1. '. "wo, plus D a aE and DpapaE

!.!. !.(. !.-. !... !.2. !.0. !.6. !.8. !.;.

%. %irculating nurse %. Nurse Manager &. Scrub nurse %. $naesthesiologist '. Radiology depart ent '. $ssess respiratory rate carefully '. )hen the edical record is inaccurate, inco plete, and inade5uate '. 'epart ent of ?ealth H'C?I '. Medical records section

!21. '. Practice respiratory isolation !2!. '. 3 ple ent a regular aintenance and testing of alar syste s !2(. $. %heck the functionality of the pu p before use !2-. &. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist !2.. &. Nurse Supervisor !22. '. %o unication !20. '. Seek early treat ent for respiratory infection !26. &. ?ypothyroidis !28. $. 7ag reflex !2;. %. Grinary fre5uency !01. $. $pply liberal a ount of ineral oil to the area !0!. %. *at balanced eals at regular intervals !0(. $. 3ncreased weight !0-. $. 3ncrease the irrigating solution flow rate when abdo inal cra ps is felt !0.. &. Sensation of pressure !02. '. Aeft Si s position !00. &. Side>lying position !06. %. Per anent colosto y !08. $. 3t is an incision into the colon to create an artificial opening to the exterior of the abdo en !0;. '. Proctosig oidoscopy !61. %. blood in the stools, ane ia, and Dpencil shapedE stools !6!. '. Red, oist and slightly protruding fro the abdo en !6(. '. Mild soap and water !6-. &. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion !6.. %. 7eneral population !62. &. Gsing standardi<ed list of abbreviations, acrony s, and sy bols !60. &. ?ypother ia !66. %. 'rain fluids and blood accu ulated post operatively !68. %. lying prone with the head of the bed lowered !2>-1 degrees !6;. $. to rule out pneu othorax !81. $. he orrhage !8!. &. Prone with the head on pillow and turned to the side !8(. &. offer soft foods for a week to ini i<e disco fort while swallowing !8-. $. $void taking &P or blood sa ple fro the ar with the shunt !8.. $. Reco end protein of high biologic value like eggs, poultry and lean eats !82. $. *. %oli !80. &. a bulate ore !86. %. *pider is and der is are both da aged !88. %. hyperkale ia and hyponatre ia !8;. '. Gse %anvas shoes !;1. '. Report the incident to your supervisor !;!. %. Report the atter to your supervisor !;(. %. &ring the crash cart to the roo !;-. &. ?angs the irrigating bag on the bathroo door cloth hook during fluid insertion !;.. &. Mitigation !;2. '. 'efusion !;0. %. Rescue !;6. $. $d inister bowel softener !;8. &. increased venous outflow !;;. &. *rythe a (11. '. Mentation (1!. %. Miss, Gse a pick up forceps when picking up those breads (1(. $. !8 (1-. $. %heck with another R.N the clients na e, 3dentification nu ber, $&C and R? type. (1.. %. NSS (12. &. Stop the infusion, $ssess the client, Send the re aining blood to the laboratory and call the physician (10. %. . hours (16. $. Stay with the client for the first !2 inutes of blood ad inistration (18. &. $ tracheosto y set and oxygen (1;. '. Support the patients head and neck with pillows and sandbags. (!1. '. "etany

(!!. (!(. (!-. (!.. (!2. (!0. (!6. (!8. (!;. ((1. ((!. (((. ((-. ((.. ((2. ((0. ((6. ((8. ((;. (-1. (-!. (-(. (--. (-.. (-2. (-0. (-6. (-8. (-;. (.1. (.!. (.(. (.-. (... (.2. (.0. (.6. (.8. (.;. (21. (2!. (2(. (2-. (2.. (22. (20. (26. (28. (2;. (01. (0!. (0(. (0-. (0.. (02. (00. (06. (08. (0;. (61.

&. %alciu gluconate '. re oval of the patients clothing and @ewelry and then rinsing the patient with water &. colloidal Hoat ealI '. aspirin %. "hird degree burn $. 3 and C hourly '. 9luid Resuscitation &. ?yperkale ia '. G wave $. 3: '. %he ical '. Sulfa ylon &. rando layering of collagen $. case study %. $udio>visual recording $. Nurses own beliefs and attitude about the entally ill $. Self>awareness &. %ounter "ransference %. Aistening &. Moderate &. Persistent thoughts and behavior '. 4ou are Maria Salvacion %. Religious delusion $. "hought content &. 'elusion $. Psychotherapy %. %risis &. Neurotic disorders $. Risk for in@ury &. Risk for in@ury directed to others '. Cffer sealed foods &. $utono y vs. Sha e and 'oubt $. "he sa e sex %. Situational crisis $. $ctive and 'irective '. 7enerativity vs. Stagnation $. Nu bness, anger, resolution and reorgani<ation $. 'ilated pupils %. Suicide precaution $. "hia ine $. Paraparesis $. Serotonin $. te poral &. 7eneral $nesthesia $. "ransient loss of e ory, confusion and disorientation &. Mainly &iologic, increasing the norepinephrine and serotonin level '. Risk for in@ury $. 3ll be back in an hour &. $ll depressed clients are considered potentially suicidal $. Mari@uana &. Crientation %. D)hat akes you feel youre worthless/E '. co unication skills &. other surrogate $. schi<oid $. (. hours $. %hild and any siblings will live in a safe environ ent $. Narcotic %. 9eel a sense of satisfaction in reflecting on her productive life '. Self>awareness

(6!. $. 7racielas buttocks are resting on the bed. (6(. &. :o iting (6-. '. 3 ipra ine H"ofranilI (6.. &. %ohesiveness (62. '. includes characteristics of tolerance and withdrawal (60. '. $c5uire acade ic skills of 0th grade level (66. &. %odependent (68. &. "ype 33 is ore co on and is also preventable co pared to "ype 3 diabetes which is genetic in etiology (6;. %. genetics (81. '. Gse of Nursing 3nterventions %lassification (8!. '. "he Standards of %are includes the various steps of the NP and the standards of professional perfor ance (8(. &. ?ave ( nurse validate the order, both nurses sign the order and the doctor should sign his order within (. hrs (8-. &. a S b are strong @ustifications (8.. '. Speak softly then hold her hands gently (82. &. Perfor range of otion exercises (80. '. audible level (86. %. *xperiences feelings of frustration in the group (88. &. )ho wants to respond next/ (8;. $. 3nsight (;1. &. ego (;!. '. includes characteristics of tolerance and withdrawal (;(. '. pro ote ho eostasis and ini i<e the clients withdrawal sy pto s (;-. '. Metha peta ine hydrochloride (;.. $ccording to the universally accepted color codes, gauge !0 is white, gauge !8 is pink, gauge (1 is yellow, gauge (( is black, and gauge (2 is orange. Since the PR% did not follow the codes, the closest answer is &. 7auges !8S!0. (;2. %. (.2 c . (;0. &. &lue (;6. %. :entricular depolari<ation (;8. %. ?eadache, chills, S fever 299. $. "here is a basic si ilarity a ong hu an beings. "##. C. Mukhang napakabigat and dinadamdam ninyo. Andito po ako at puwede tayong magusap.