FUNDAMENTALS OF NURSING

SITUATION: There are different nursing theories and health theories to help us explain the phenomena we are experiencing in health.

1.Virginia Henderson, a nursing pioneer, conceptualized the nurses role in assisting the client to achieve independence. Hendersons defined
nursing as it focused on which of the following fundamental needs:

A. Providing self-care B. Breathing normally C. Behaving as a totality D. Adapt to changes

Rationale: Answer is Letter B. Henderson conceptualizes the nurses role as assisting sick or healthy individuals to gain independence in meeting 14
fundamental needs: Since there is much similarity, Hendersons 14 components can be applied or compared to Abraham Maslows Hierarchy of
Needs. Components 1 to 9 are under Maslows Physiological Needs, whereas the 9th component is under the Safety Needs. The 10th and 11th
components are under the Love and Belongingness category and 12th, 13th and 14th components are under the Self-Esteem Needs.
Physiological Components
1. Breathe normally
2. Eat and drink adequately
3. Eliminate body wastes
4. Move and maintain desirable postures
5. Sleep and rest
6. Select suitable clothes
7. Maintain body temperature within normal range by adjusting clothing and modifying environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others
Psychological Aspects of Communicating and Learning
10. Communicate with others in expressing emotions, needs, fears, or opinions.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.
Spiritual and Moral
11. Worship according to ones faith
Sociologically Oriented to Occupation and Recreation
12. Work in such a way that there is sense of accomplishment
13. Play or participate in various forms of recreation

2. Which intervention would the nurse use to implement Imogene Kings theory of goal of attainment?
A. Listing self care deficits
B. Purposeful transactions
C. Interactions with the environment
D. Nursing intervention is a conservation activity

Rationale: Correct answer is letter B. Kings framework shows the relationship of operational systems (individuals), interpersonal systems (groups
such as nurse-patient), and social systems (groups such as nurse-patient). Transaction is a process of interactions in which human beings
communicate with the environment to achieve goals that are valued; transactions are goal-directed human behaviors.
Perception is each persons representation of reality. Process of Interaction: Action Reaction Interaction Transaction (goal outcome)

Letter A is incorrect. Dorothea Orem developed the self-care deficit theory. She conceptualized 3 systems as follows: Wholly Compensatory (nurse
accomplishes all the patients therapeutic self-care), Partially Compensatory (when both nurse patient engage in meeting self care needs), and
Supportive-Educative (assistance in decision making, behavior control and acquisition of knowledge and skills)
Letter C is incorrect. Nightingale focused on changing and manipulating the environment in order to put the patient in the best possible conditions for
nature to act. She believed in that in the nurturing of the environment, the body could repair itself.
Letter D is incorrect. Myra Levine believed nursing intervention is a conservation activity. She described the four conservation principles.
Conservation of energy (food, oxygen, fluids), Conservation of Structural Integrity (skin and mucous membrane; to prevent harmful agents from
entering the body) Conservation of Personal Integrity (sense of identity, self worth and self esteem) and Conservation of Social Integrity (reflects how
the client reflects the family and community in which the client functions).
3. When utilizing MadeleineLeiningers cultural theory, it would be important for the nurse to remember what concept of human caring?
A. It is universal and same in all cultures.
B. It is absent in some cultures.
C. It varies among cultures and is largely culturally derived.
D. It is common in different cultures.

Rationale: Letter C is the correct answer.Leininger emphasizes that human caring, although a universal phenomenon, varies among cultures in its
expressions, processes, and patterns; it is largely culturally derived. She produced the Sunrise Model to depict her theory of cultural care diversity
and universality. This model emphasizes that health and care are influenced by elements of the social structure, such as technology, cultural values,
religious and philosophical factors, political and legal factors, economic factors, and educational factors.
4. Which statement would the nurse include in a report on Jean Watsons theory of human caring?
A. There should be guidelines for including the family in client care.
B. There are ten adaptive mechanisms commonly used by clients.
C. There are environmental factors related to client care.
D. There are ten creative factors related to human care.
5. In which phase of the nurse-patient relationship, the client utilize all available resources to move toward a goal of maximum functionality?
A. Orientation B. Identification C. Exploitation D. Resolution

Rationale: Letter C is the correct answer. In exploitation phase, (use of professional assistance) the client derives full value from what the nurse
offers through the relationship.
Letter A is incorrect. In Orientation phase, (client seeks assistance) (will identify needs/problems) the nurse and the client initially do not know each
others goals and testing the role each will assume. The client attempts to identify difficulties and the amount of nursing help that is needed.
Letter B is incorrect. In Identification phase, the client responds to the help of the nurse to meet the identified needs. Both the nurse and client plan
together and appropriate program to foster health. (feeling of belongingness and decrease helplessness)
Letter D is incorrect. Resolution phase, refers to the termination phase of the nurse-client relationship. It occurs when the clients needs are met and
he/she can move toward a new goal.

SITUATION: You are assigned to do physical assessment on several clients while working in a female medical ward. Your basic
knowledge in Anatomy and Physiology as well as scientific basis for certain nursing procedures is important.
6. Mrs. Princess, 51 years old is your client. During physical assessment, you asked the client to make her chin touch the chest. As Mrs. Princess
performs the movements as instructed, you assess the function of which muscle?
A. Trapezius
B. Deltoid muscle
C. Supraspinatus muscle
D. Sternocleidomastoid

Rationale: Letter D is the correct answer. Moving the chin to the chest, determines the function of the sternocleidomastoid muscle. Head flexes at 45
degree. Deviations from normal: Limited range of motion, painful movements; involuntary movements (eg up and down nodding movements
associated with Parkinsons disease)
Letter A is incorrect. To determine the function of the trapezius muscle, move the head back (head hyperextends 60 degrees).
Letter B is incorrect. The deltoid muscle, acts as the main abductor of the shoulder joint.
Letter C is incorrect. Supraspinatus muscle helps the deltoid muscle initiate the abduction of the arm at the shoulder.

7. You are to examine Mrs. Princess abdomen. The correct sequence is as follows:
A. Inspection, Auscultation, Palpation, Percussion
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Inspection, Palpation, Auscultation, Percussion

Rationale: Letter C is the correct answer. When assessing the abdomen, the nurse performs inspection first, followed by auscultation, percussion,
and/or palpation. Auscultation is done before palpation and percussion, and/or palpation. Auscultation is done before palpation and percussion
because it causes movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.
For bowel sounds use the flast disc diaphragm of the stethoscope. Normal irregular gurgling noise occurs every 5-20 seconds or 3-12 bowel sounds
per minute. Hyperactive is every 3 seconds or >20/min (borborygmi/diarrhea). Hypoactive, 1 per minute, decrease motility, assoc with surgery and
inflammation. Absence of sounds (none head in 3-5 minutes, indicates cessation of intestinal motility. For percussion begin in RLQ-RUQ-LUQ-LLQ.

8. When you auscultated the abdomen of Mrs. Princess for vascular sounds such from the aorta. Which of the following regions, of the abdomen
will you consider?
A. Epigastric area B.Umbilical area C. Left hypochondriac area D. Right lumbar area
Rationale: Letter A is the correct answer. For vascular sounds use the bell of the stethoscope over the aorta, renal arteries, iliac arteries, and femoral
arteries. Listen for bruits.

9. You are to perform breast palpation on a client without a history of breast masses. Which of the following is the most appropriate position of the
client?
A. Sitting and supine position C. Supine position
B. Sitting position D. Semi-Fowlers position

Rationale: Letter C is the correct answer. Palpation of the breast is generally performed while the client is supine. In the supine position, the breasts
flatten evenly against the chest wall, facilitating palpation. For clients who have a past of history of breast masses, who are at high risk for breast
cancer, or who have pendulous breasts, examination in both supine and sitting position is recommended. To enhance flattening of the breast,
instruct the client to abduct the arm and place her hand behind her head. Then place a small pillow or rolled towel under the clients shoulder. For
palpation use the palmar surface of the middle three fingertips (held together) and make a gentle rotary motion on the breast.

10. While inspecting the jugular veins of Mrs. Princess for distention, you should place her in which BEST position?
A. Semi-Fowlers C. High-Fowlers
B. Low-Fowlers D.Turn the clients head slightly away from the side being examined
Rationale: Letter A is the correct answer. Inspect the jugular veins for distention while the client is placed in a semi-fowlers position (30-45 deg
angle) with the head supported on a small pillow. Normal findings, veins not visible, indicating the right side of the heart is functioning normally.
Deviations from normal, veins visibly distended (indicating advanced cardiopulmonary disease).
Letter D is incorrect. This is for auscultation of the carotid artery. To facilitate the placement of the stethoscope. Normal findings no sound should be
heard. Presence of bruit in one or both arteries (suggests occlusive artery disease).

SITUATION: Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.

11.You are about to perform Rombergs test to an elderly client. To ensure safety, which of the following intervention should you implement?
A. Instruct the client to keep both of his eyes open
B. Stand close to provide support
C. Have the client hold onto you
D. Instruct the client to spread his feet apart

Rationale: Romberg's test,is used in an exam of neurological function for balance, and also as a test for drunken driving. Ask the client to stand with
feet together and arms resting at the sides, first with eyes open, then closed. Stand close during this test to prevent the client from falling. Normal
findings, negative Romberg: may sway slightly but is able to maintain upright posture and foot stance. Abnormal finding (+) Romberg: cant maintain
foot stance, moves feet apart. Sensory ataxia, cant maintain balance with eyes shut (lack of coordination of the voluntary muscles. Cerebellar
ataxia, if balance cant be maintained whether the eyes are open or shut.

12. To adequately inspect the external ear canal of an adult client, the nurse should do which of the following prior to inserting the otoscope?
A. Pull the pinna up and back.
B. Use an applicator to remove cerumen.
C. Have the client lie down to promote comfort.
D. Pull the pinna down and back.
Rationale: A is the correct answer. To straighten the ear canal to facilitate vision of the ear canal and the tympanic membrane.Adults ear canal is
more shorter, wider, and straighter compared to a child below 3 years old.In children, the eustachian tube is horizontal. In adults, it's angled more
vertically. If the tube is horizontal, it's harder for fluid to drain.

13. The nurse is preparing to palpate the abdomen as a part of the physical examination. Which of the following steps is appropriate?
A. Depress the abdominal wall 6 to 10 cm during deep palpation.
B. Palpate with the palms of the hands rather than the fingers.
C. Begin palpation in the right upper quadrant.
D. Palpate sensitive areas of the abdomen last.

Rationale: Letter D is the correct answer. Perform light palpation first to detect areas of tenderness. Depress the abdominal wall lightly, about 1 cm
or to the depth of the subcutaneous tissue, with the pads of your fingers. Then perform deep palpation over all 4 quadrants. Palpate sensitive areas
last. Depress the abdominal wall about 4-5 cm (1 to 2 inches).

14. You are to perform a physical assessment to a 22-year-old client. Which assessment examination would require you to wear gloves?
A. Breast B. Integumentary C. Oral D. Opthalmic

Rationale: Letter C is the correct answer. Gloves should be worn any time there is a risk of exposure to the clients blood or body fluids. Oral, rectal,
and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally
do not involve contact with the clients body fluids and do not require the nurse to wear gloves for protection. However, if there are areas of skin
breakdown or drainage, gloves should be used.

15. In which of the following position would it be best to place the client so the nurse can inspect and palpate the bartholins glands?
A. Sims B. Prone C. Supine D. Lithotomy

Rationale: Letter D is the correct answer. Bartholin glands or greater vestibular glands are two pea sized located slightly posterior and to the left and
right of the opening of the vagina. They secrete mucus to lubricate the vagina and are homologous to bulbourethral glands in males.

16. The nurse would use which of the following methods of examination to assess for the presence of a bruit in the abdomen:
A. Inspection B. Palpation C. Auscultation D. Percussion

Rationale: Bruit, or vascular murmur, is the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial
obstruction; or a localized high rate of blood flow through an unobstructed artery.

SITUATION: The nursing process is a goal-oriented method of caring that provides a framework to nursing care. It involves major steps.

17. Which of the following is a correctly written nursing diagnosis that should be added to a clients plan of care?
A. Impaired skin integrity related to ulceration of the sacral area.
B. Fluid replacement related to fever.
C. Risk for ineffective airway clearance related to emphysema.
D. Impaired gas exchange related to aspiration of foreign matter.
Rationale: Letter D is the correct answer. Use nursing terminology rather than medical terminology to describethe probable cause of the clients
response. The basic 2 part nursing diagnosis statement includes the following: Problem (P): statement of the clients response (NANDA label).
Etiology (E): Factors contributing to or probable causes of the response. And the basic 3 part nursing diagnosis statement is called the PES format:
Problem, Etiology +Signs and Symptoms (S): defining the characteristics manifested by the client.
Letter A is incorrect. Response and probable cause are the same. Correct statement is: Risk for Impaired skin integrity related to immobility.
Letter B is incorrect. Fluid replacement is a need. State in terms of a problem, not a need. Correct statement is: Deficient fluid volume (problem)
related to fever.
Letter C is incorrect. Emphysema is a medical terminology.

18. The client states, My chest hurts and my left arm feels numb. What is the type and source of this data?
A. Subjective data from a secondary source.
B. Subjective data from a primary source.
C. Objective data from a secondary source.
D. Objective data from a primary source.

Rationale: Letter B is the correct answer. Subjective data, also referred to as symptoms or covert data, are apparent only to the person affected and
can be described or verified only by that person. Itching, pain and feelings of worry are examples of subjective data. Objective data, also referred to
as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or
smelled and are obtained by observation or physical examination. Sources of data are either primary or secondary. The client is the primary source
of data. Family members, health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary
sources.

19. Which nurse is demonstrating the assessment phase of the nursing process?
A. The nurse who asks the client how much lunch was eaten.
B. The nurse who works with the client to set desired outcome goal.
C. The nurse who changes the bed linens after the client is incontinent of feces.
D. The nurse who observes that the clients pain was relieved with pain medication.

Letter A is the correct answer. Assessing is the systematic and continuous collection, organization, validation, and documentation of data (COVD). It
is to establish a database about the clients response to health concerns: nursing health history, physical assessment, review client records, consult
support persons.
Letter B is incorrect. It is part of the Planning phase. This is where you prioritize problems/diagnoses, formulate goals/desired outcomes, select
nursing interventions and write nursing interventions. Eg, nurse and patient collaborate to establish a goal (restore effective breathing) and develops
a care plan that includes but is not limited to coughing and deep breathing exercises every 3 hours, fluid intake of 3000ml and daily postural
drainage.
Letter C is incorrect. It is part of the Implementation phase. Carrying out (or delegating) and documenting the planned nursing interventions.
Letter D is incorrect. It is part of the Evaluation phase. To determine whether to continue, modify, or terminate the plan of care.

22. After establishing priorities, the nurse and client set goals for each nursing diagnosis. In the planning phase, the goals and desired outcomes are
described. Which of the following is/are an example(s) of desired outcomes?
1. Improved nutritional status.
2. Stand without assistance by the end of month.
3. Ability to bear weight on affected leg.
4. Within 24 hours after surgery, demonstrate good cough effort.

A. 1 B. 2 C. 1,3 D. 2,4

Rationale: The correct answer is letter D. Goals are stated broadly and desired outcomes as the more specific. Eg Goal (broad) Improved nutritional
status. Desired outcome (specific) Gain 5 lbs by July 20.

20. The nurse is measuring the clients urine output and straining the urine to assess the stones. Which of the following should the nurse record as
objective data?
A. The clients urine output was 450ml.
B. The client is complaining of abdominal pain.
C. The client stated, I feel like I have passed a stone.
D. The client stated, I did not see any stones in my urine.

Rationale: Letter A is the correct answer. Referred to as signs or overt data.

Letters B, C, D are all subjective data.

21. This type of assessment is an ongoing process integrated with nursing care:
A. Initial Assessment
B. Problem-Focused Assessment
C. Emergency Assessment
D. Time-Lapsed Assessment

Rationale: Letter B is the correct answer. To determine the status of a specific problem identified in an earlier assessment. Eg. Hourly assessment of
fluid intake and urinary output.There are 4 different types of assessments: Initial, Problem focused, Emergency, and Time-lapsed assessment.
Letter A is incorrect. Initial Assessment: Performed within specified time after admission to a health care agency. Eg nursing admission assessment
Letter C is incorrect. Emergency Assessment: During any physiologic or psychologic crisis of the client. To identify life-threatening problems.To
identify new or overlooked problems.Eg Rapid assessment of a persons airway, breathing status and circulation during a cardiac arrest or
assessment of suicidal tendencies or potential for violence
Letter D is incorrect. Time-lapsed reassessment: Done several months after initial assessment. To compare the clients current status to baseline
data previously obtained. Eg. Reassessment of a clients functional health patterns in a home care or outpatient setting, or in a hospital, at shift
change

SITUATION: Nursing practice act requires nurses to maintain a safe environment to clients. Nurses must act to identify and minimize
risks to clients.

23. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons
sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in
preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to:

A. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
B. Congratulate the nurse on the use of good technique.
C. Interrupt the procedure to inform the nurse that sterile gloves are not needed to remove the old dressing.
D. Discuss dressing change technique with the nurse at a later date.

Rationale:The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile
gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the
soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to
the immediate attention of the nurse.

24. You are to operate a fire extinguisher. Arrange the following steps in the correct order.
1. Sweep from side-to-side at the base of the flame.
2. Aim the extinguisher at the base of the fire.
3. Pull the pin
4. Squeeze the handle of the fire of extinguisher.

A. 2, 3, 4, 1 B. 3, 4, 2, 1 C. 3, 2, 4, 1 D. 3, 2, 1, 4

Rationale: Letter C is the correct answer. P-A-S-S Technique.

25. While doing her rounds, the nurse passed through a private room and saw flames and smelled smoke. Which of the following should be the initial
action of the nurse?
A. Get the fire extinguisher to put out the fire.
B. Alert others and emergency services.
C. Evacuate the clients out of the burning room.
D. Close the windows of the room.

Rationale: Letter C is the correct answer. Upon discovery of fire do the following in order: Rescue, Alarm, Contain, Extinguish (RACE).
Rescue: anyone in immediate danger of the fire.
Alarm: Activate the nearest fire alarm.
Contain: Contain fire by closing all doors/windows in the area.
Extinguish: Extinguish small fires (small trash basket). If the fire cannot be extinguished leave the area and close the door.

26. A toddler with meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
A. Administering antipyretic.
B. Instituting droplet precaution.
C. Instituting airborne precaution.
D. Orienting the parents to pediatric unit.

Rationale: Droplet isolation precautionsused for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples:
pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should: Wear a surgical mask while in the room.

27. A teenager has third-degree burns of the arms, face and chest. Which nursing diagnosis takes priority?
A. Disturbed body image related to physical appearance.
B. Ineffective airway clearance related to edema.
C. Risk for infection related to impaired skin integrity.
D. Impaired urinary elimination.

Rationale: Letter B is the correct answer. The primary focus is on assessing and managing an effective airway. Body image disturbance, impaired
urinary elimination, and infection are all integral parts of burn management but arent the first priority.

SITUATION: Primary Prevention involves health promotion as protection against diseases. Activities of this type generally apply to the
healthy individuals before and disease or dysfunction occurs.

28.Nurses play a big role in the primary level of prevention. Examples of nurse activities showing primary prevention are the following, EXCEPT:
A. Referrals to client support groups
 B. Teaching parents of toddlers about prevention of poisoning accidents at home
C. Family planning to newlyweds
D. Giving immunizations to children

Rationale: Letter A is the correct answer. Letters B, C, D are all primary prevention. Primary prevention aims to prevent disease or injury before it
ever occurs.Eg: education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) and immunization against infectious
diseases.

29. Secondary prevention includes health maintenance activities which involves the following, EXCEPT:
A. Yearly mammography
B. Smoking cessation program
C. Chronic disease management program
D. Laboratory analysis

Rationale: Letter C is the correct answer. Tertiary Prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is
done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to
improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include:cardiac or stroke rehabilitation
programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.)support groups that allow members to share
strategies for living wellvocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.

30. A nurse conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic
complications is emphasized. This is considered which level of preventive care?
A. Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Illness Prevention

Rationale: Letter B is the correct answer. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is
done by detecting and treating disease or injury as soon as possible to halt or slow its progress. Ex: regular exams and screening tests to detect
disease in its earliest stages (e.g. mammograms to detect breast cancer), daily low-dose aspirins and/or diet and exercise programs to prevent
further heart attacks or strokessuitably modified work so injured or ill workers can return safely to their jobs.

SITUATION: Proper nutrition and elimination are important to health and the nurse has an important role to play in assisting people from
various age groups to obtain proper information.

31. A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes
which food on the item list?
A. Chocolate milk
B. Brocolli
C. Salmon
D. Apple

Rationale: Chocolate milk is a high-fat food. Options B and C: Fruits and vegetables are low in fat because they do not come from animal sources.
Option D: Salmon is naturally lower in fat.

32. Nurse Daniel is giving dietary instructions on a client who is on a vegan diet. The nurse provides dietary teaching focus on foods high in which
vitamin that may be lacking in a vegan diet?
A. Vitamin C
B. Vitamin E
C. Vitamin A
D. Vitamin D

Rationale: Letter D is the correct answer. Deficiencies in vegetarian diets include vitamin B12 (Cobalamin, water soluble) which are found in animal
products and vitamin D (if limited exposure to sunlight). Options A, C, and D are found in fruits and vegetables, which are eaten by a vegetarian.

33. A client who is recovering from a surgery has been ordered a change from a clear liquid diet to a full liquid diet. The nurse would offer which full
liquid item to the client?
A. Popsicle B. Carbonated beverages C. Gelatin D. Pudding

Rationale: Letter D is the correct answer. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding, and
custard, soups that are strained, refined cooked cereals, and strained vegetable juices. Options A, B, and C are clear liquid diet.

34. The nurse recognizes that urinary elimination changes may occur even in healthy elders because:
A. The bladder distends and its capacity increases.
B. Elders ignore the need to void.
C. Urine becomes more concentrated.
D. The amount of urine retained after voiding increases.

Rationale: The correct answer is letter D. The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be
retained.
Letter B is incorrect. Older adults dont ignore the urge to void and may have difficulty getting to the toilet in time.
Letter C is incorrect. The kidney becomes less able to concentrate urine with age.

35. You are to perform straight catheterization on a pregnant client. As you were performing the procedure, the catheter slips into the vagina. What is
the appropriate nursing action?
A. Remove the catheter and redirects it to the urinary meatus.
B. Remove the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
C. Leave the catheter in place and get a new sterile catheter.
D. Leave the catheter in place and ask another nurse to assist you with the procedure.

Rationale: The catheter in the vagina is contaminated and cant be reused.If left in place, it may help avoid mistaking the vaginal opening for the
urinary meatus. A single failure to catheterize the meatus doesnt indicate that another nurse is needed although sometimes a second nurse can
assist in visualization of the meatus.

36. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
1. Voids each time there is an urge.
2. Practices slow, deep breating until the urge decreases.
3. Uses adult diapers, for just in case
4. Drinks citrus juices and carbonated beverages
5. Performs pelvic muscle exercises

A. 2, 5 B. 1, 5 C. 1, 2, 5 D. All of the above

Rationale: Letter A is the correct answer. It is important for the client to inhibit the urge to void sensation when a premature urge is experienced.
Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated
beverages increase diuresis and the risk of incontinence (opt4). Pelvic muscle exercises is beneficial in helping improve bladder an bowel control.

SITUATION: Vital signs are an important component of patient care. They determine which treatment protocols to follow, provide critical
information needed to make life-saving decisions, and confirm feedback on treatments performed.
37. Short febrile periods of a few days that are interspersed with periods of 1 or 2 days of normal temperature is known as:
A. Remittent Fever B. Relapsing Fever C. Constant Fever D. Intermittent Fever

Rationale: Letter B is the correct answer. Relapsing fever occurs when there are short febrile periods of a few days interspersed with periods of 1 or
2 days of normal temperature
Letter A is incorrect. The temperature remains above normal throughout the day and fluctuates more than 2 Celsius in 24 hours. Never
reachers normal.
Letter C is incorrect. Constant fever aka sustained fever. Minimal fluctuations in temp all of which are above normal.
Letter D is incorrect. Intermittent fever is on and off within the day.

38. Placing the newborn on cold surfaces like the weighing scale is an example of what type of heat loss?

A. Radiation B. Conduction C. Convection D. Vaporization

Rationale: Heat is lost from the body through radiation, conduction, convection, and vaporization.
Letter B is the correct answer. Conduction is transfer of heat with contact. Loss of body heat in direct contact with cool surfaces eg. a
spoon in hot tea and touching a hot cup of coffee.
Letter A is incorrect. The transfer of heat from the surface of one object to the surface of another without contact. Mostly in the form of
infrared rays; eg sun warming your face
Letter C is incorrect. Convection is loss of heat due to cool air. Eg. wrap the NB immediately with blanket & promote flexion to minimize
body surface exposed to cool air/using a fan to cool off the body and heating a room during the cold season
Letter D is incorrect. Vaporization loss of heat through conversion of a liquid to a vapor. Eg. Loss of heat as water evaporates from the
infants body; dry the NB immediately after birth to prevent heat loss/ boiling water turning into steam is a perfect example of vaporization.

39. If a client has been taking cold fluids, the nurse should wait ___ minutes before taking the temperature orally:
A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes

Rationale: Letter B is the correct answer. If the patient has smoked, eaten hot or cold food, drank hot or cold beverage, or chewed gum within the
last 30 minutes. It will probably result in an oral temperature reading that is higher than the actual oral temperature. Cold foods and cold drinks will
probably cause the oral temperature reading to be lower than the actual oral temperature. Rectal is most reliable and accurate. Axilla is safest and
noninvasive (5-9 mins, avg 7 mins). Tympanic membrane is fast, accessible and core.

40. If a bladder cuff is too narrow, the blood pressure reading will be:
A. Erroneously Low B. Erroneously High C. Low Diastolic D. No change

Rationale: Letter B is the correct answer. Bladder cuff too narrow, insufficient rest deflating cuff too slowly could have false high readings or higher
than what the reading should be.
Deflating cuff too quickly, bladder cuff too wide, and arm is above the level of the heart could have false low readings.

41. Because the blood pressure is a low-frequency sound, it is best heard by which part of the stethoscope?
A. Bell B. Diaphragm C. Both D. None

Rationale: Letter A is the correct answer. Because the blood pressure is a low-frequency sound, it is best heard with the bell-shaped diaphragm.
(belLow frequency sound)
42. After taking the blood pressure of your client, you must wait ___ minute(s) before making further measurements:
A. 1-2 minutes B. 5-10 minutes C. 15-20 minutes D. 30 minutes

Rationale: A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur.

43. A pulse may be measured in nine sites. Which site is routinely used for infants and children up to 3 years of age?
A. Brachial B. Carotid C. Apical D. Popliteal

Rationale: Letter C is the correct answer.

Letter A is incorrect. Brachial is used to measure blood pressure and used during cardiac arrest for infants.
Letter B is incorrect. Carotid is used during cardiac arrest/shock in adults and used to determine circulation to the brain.
Letter D is incorrect. Popliteal is used to determine circulation to the lower leg.

44. Temporal, where the temporal artery passes over the temporal bone of the head. The site is:
A. Inferior and lateral to the eye.
B. Superior and lateral to the eye.
C. Inferior and superior to the eye.
D. Superior and inferior and lateral to the eye.

Rationale: Letter B is the correct answer. Temporal, where the temporal artery passes over the temporal bone of the head. The site is superior
(above) and lateral to (away from the midline of) the eye.

45. MAP, or mean arterial pressure, is defined as the average pressure in a patient's arteries during one cardiac cycle. What is the MAP of systolic
and diastolic pressure values of 150/100 mmHg?
A. 100 B. 110 C.120 D. 130

Rationale: The correct answer is letter C. MAP = [ (2 x diastolic) + systolic ] divided by 3. The mean arterial pressure (MAP) is a term used in
medicine to describe an average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle. MAP
gives you an indication of the mean (average) perfusion pressure across the entire cardiac cycle. A normal range for mean arterial blood pressure is
70 to 110. A minimum of 60 is required to supply enough blood to nourish the coronary arteries, brain and kidneys. If mean arterial pressure falls
below 60 for an appreciable length of time, vital organs can be deprived of oxygen.

SITUATION: Respiration is the process of gas exchange between the individual and environment. Effective breathing, requires clear
airways, an intact central nervous system and respiratory center, an intact thoracic cavity and musculature, and adequate pulmonary
compliance and recoil.
46. Which of the following client statement informs the nurse that the teaching about the proper use of an incentive spirometer was effective?
A. I should inhale slow and steadily to keep the yellow balls up.
B. I should exhale slow and steadily to keep the yellow balls up.
C. I should breathe out as hard as I can into the device.
D. I should clean the whole device with soapy water after each use for hygienic purposes.

Rationale: Letter B is the correct answer. Also referred to as sustained maximal inspiration devices (SMIs), measure the flow of air inhaled through
the mouthpiece and are used to improve pulmonary ventilation/loosen respiratory secretions. Using an incentive spirometer: Hold the device in an
upright position. Exhale normally. Seal the lips tightly around the mouthpiece. Take in slow, deep breath to elevate the balls, and then hold the
breath for 2 seconds initially, increasing to 6 seconds, to keep the balls or cylinder if possible. Cough after incentive effort. Repeat the procedure
several times and then four or five times hourly. Clean the mouthpiece with water and shake it dry.

47. Which of the following conditions has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues:
A. Anemia B. Flail chest C. Fever D. Infection

Rationale: Letter A is the correct answer. Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the
oxygen molecules are transported to the tissues.
Letter B. A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Letter D would depend on where the infection is
located.

48. The term that best describes shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in
a chair is:
A. Dyspnea B. Orthopnea C. Apnea D. Eupnea

Rationale: Letter B is the correct answer. Orthopnea is difficulty in breathing while lying down. Apnea is temporary cessation of breathing, especially
during sleep. Eupnea is normal, unlabored breathing.

49. A client with acute bronchitis is prescribed corticosteroid therapy on a short-term basis. The client asks the nurse how the steroids will help him.
The nurse responds correctly by saying that the corticosteroids will do which of the following?
A. Prevent respiratory infection B. Decrease inflammation C. Promote bronchodilation D. Liquify secretions

Rationale: Corticosteroids (cortisone-like medicines) are used to provide relief for inflamed areas of the body. They lessen swelling, redness, itching,
and allergic reactions. They are often used as part of the treatment for a number of different diseases, such as severe allergies or skin problems,
asthma, or arthritis. Eg. Inhaled corticosteroids Fluticasone (Flovent HFA), Budesonide (Pulmicort), Mometasone (Asmanex Twisthaler)

50. You as a nurse is to perform postural drainage. Which of the following statements is incorrect:
A. A good time to perform this procedure is after having breakfast and after lunch.
 B. To percuss a clients chest you should cover the area with a towel or gown to reduce discomfort.
C. When done correctly, the percussion action should produce a hollow popping sound.
D. After each vibration, encourage the client to cough and expectorate secretions into the sputum container.

Rationale is the correct answer. Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion.
The best times include before breakfast, before lunch, in the late afternoon, and before bedtime. It is best to avoid hours shortly after meals because
postural drainage at these times can be tiring and can induce vomiting.

51. Your patient is having trouble on how to use a metered-dose inhaler. You are correct by saying that it should be used through the:
A. Nose B. Nose and mouth C. Mouth D. Close to the face

Rationale: The correct answer is letter C. Remove the mouthpiece cap. Holding the inhaler upright, shake the inhaler vigorously for 3 to 5 seconds to
mix the medication evenly. Hold the canister upside down. Hold the MDI 2 to 4 cm (1 to 2 in) from the open mouth or put the mouthpiece far enough
into the mouth with its opening toward the throat such that lips can tightly close around the mouthpiece. An MDI with a spacer or extender is always
placed in the mouth.

52. A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the
specimen?
A. Limiting fluid
B. Having the client take deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating

Rationale: Letter C is the correct answer. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply,
and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be
thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in
the morning.

53.The nonrebreather mask delivers the highest oxygen concentration possible. All are true, except:
A. To prevent carbon dioxide build-up, the nonrebreather bag must totally deflate during inspiration.
B. It delivers 95-100% oxygen.
C. One-way valves on the mask prevent the room air and the clients exhaled air from entering the bag.
D. Liter flows of 10-15L per minute.

Rationale: The correct answer is letter A. To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. The
nonrebreather mask delivers the highest oxygen concentration possible 95-100% at 10-15L per minute. One way valve on the mask and between
the reservoir bag and the mask prevent the room air and the clients exhaled air from entering the bag so only the oxygen in the bag is inspired.

54. What should Nurse Glen do first if a patient is choking on food?

A. Apply sharp thrusts over the patients xiphoid process
B. Hit the middle of the patients back firmly
C. Determine if the patient can make any verbal sounds
D. Sweep the patients mouth with a finger

Rationale: Letter C is the correct answer. When a person is choking on food, the first intervention is to determine if the person can speak because
the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction, the person will be able to make
sounds because some air can pass from the lungs through the vocal chords. In this situation the persons own efforts open parentheses gagging and
coughing) should be allowed to clear the airway. With a total airway obstruction, the person will not be able to make a sound because the airway is
blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver). Thrusts to the xiphoid process may cause a
fracture that may result in a pneumothorax (Letter A).

55. Your patient is having difficulty breathing. The client is lying in bed and is receiving oxygen therapy. Which is the nursing priority?
A. Increase the oxygen flow.
B. Encourage coughing and deep breathing exercises.
C. Assist the client to Fowlers position.
D. Count his respirations for 1 full minute.

Rationale: The correct answer is letter C. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to
care delivery is to relieve the client's dyspnea (difficulty breathing). Fowler's position facilitates maximal lung expansion and thus optimizes breathing.
With the client in this position, the nurse can better assess and determine the cause of the client's dyspnea.

SITUATION: Mariah is a 30 year old woman admitted with exacerbation of her ulcerative colitis. The nurse on duty is to perform an
admission assessment.
56. The nurse is assessing patient teaching needs regarding appropriate diet and lifestyle modifications for Ms. Mariah. To develop an effective
teaching plan, the nurse must solicit which of the following input from Ms. Mariah?
A. Details about her childhood fears
B. Her feelings, beliefs, and attitudes about her chronic illness.
C. Information about her financial status.
D. Information about his relationship with his wife
57. Which choice best describes the phase of nurse-patient relationship the nurse is currently engaged in with Ms. Mariah?
A. Evaluation phase
 B. Orientation phase
C. Termination phase
D. Working phase

SITUATION: Leanne Coats is a 45 year old woman who has been diagnosed with terminal breast cancer.
58. Techniques that would be useful in eliciting information about how this patient is coping with her diagnosis include:
A. Asking closed questions.
B. Asking open-ended questions.
C. Obtaining information from the patients family.
D. By showing sympathy.

Rationale: Letter B is the correct answer. Asking open-ended questions that require a complex response is the best way for nurses to elicit
information from patients. Closed questions that are answered with yes or no typically provide only limited information. Although seeking
information from the patients family may seem worthwhile; it isnt necessarily the best way to gain patient information because of confidentiality
issues.

59. Objective data that may indicate anxiety in Ms. Robinson includes?
A. Decreased independence in daily living activities
B. Increased distraction
C. Increased independence in daily living activities
D. Increased urinary frequency

Rationale: Letter D is the correct answer. Objective data is measurable. Increased urinary frequency is measurable data that is related to anxiety.
Independence of daily living and distraction arent measurable quantities.

SITUATION: Nurses are often intimidated by the math that occurs in everyday practice. Patient safety depends on the practitioner's ability
to calculate medications correctly and in a timely manner.
60. Your patient needs 12,000 units of heparin SC. You have on hand 5000 units/mL. How much will you inject?
A. 0.4ml B. 1 ml C. 2 ml D. 2.4 ml
61. The physician orders meperidine 75 mg IM every 4 to 6 hours prn for a patient admitted with acute cholecystitis. You have on hand meperidine
50 mg/mL. How much will you give?
A. 1ml B. 1.5 ml C. 2 ml D. 4 ml
62. The total volume to be given is 840 ml. The time over which this is to be given is 10 hours.
The drop factor is 20. How many drops per minute will be delivered?
A. 20 gtts/minute B. 21 gtts/minute C. 22 gtts/minute D. 23 gtts/minute
63. A patient is admitted to the emergency room with a fractured leg. The physician orders morphine 15 mg IM stat. You have on hand morphine 10
mg/mL. How many milliliters will you administer?
A. 0.7 ml B. 1 ml C. 1.5 ml D. 2 ml
64. Your order reads cortisone 15 mg PO every morning. You have on hand cortisone 10 mg tablets. How should you prepare the correct dose?
A. tablet B. 1 tablet C. 1 tablets D. 2 tablets
65. A patient is instructed to take acetaminophen (Tylenol) liquid (elixir) 650 mg qid. The elixir is 160 mg/5 mL. How many milliliters in total should
the patient take in 1 day?
A. 20 ml B. 40 ml C. 80 ml D. 5 ml

PROFESSIONAL ADJUSTMENT, LEADERSHIP & MANAGEMENT, NURSING RESEARCH

PROFESSIONAL ADJUSTMENT
66. Mia, daughter of the client, refuses to inform her father about his diagnosis. The nurse was concerned about whether or not she will tell the client
about his diagnosis. This is an example of an ethical:
A. Conflict B. Concern C. Dilemma D. Issue

Rationale: Letter C is the correct answer. Ethical dilemmas, also known as a moral dilemmas, are situations in which there is a choice to be made
between two options, neither of which resolves the situation in an ethically acceptable fashion.

67. When the nurse finished performing oral care on the patient, she was requested to come back to change the linen. The nurse changed the linen
as requested by the client:
A. Non-maleficence B. Veracity C. Justice D. Fidelity

Rationale: Letter D is the correct answer. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and
is based upon the virtue of caring.
Non-maleficence means to do no harm.
Veracity - is the principle of truth telling, and it is grounded in respect for persons and the concept of autonomy. In order for a person to make fully
rational choices, he or she must have the information relevant to his or her decision.
Justice- All clients must be treated fairly and equally. The distribution of nurses to areas of most need in the time of a nursing shortage .

68. A pharmaceutical company releasing a drug that has been governmentally approved with known side effects because the drug is able to help
more people than are bothered by the minor side effects. This is an example of:
A. Justice B. Utilitarianism C. Deontology D. Beneficence
Rationale: Letter B is the correct answer. Utilitarianism is an ethical theory that states that the best action is the one that maximizes utility. Act
utilitarianism often shows the end justifies the means mentality or the greatest good for the greatest number. Believes that only the consequences
of an act are important.
Letter C is incorrect. By contrast, deontology focuses on the moral aspects of any action, not its consequences. Deontology is defined as an ethical
theory that the morality of an action should be based on whether that action itself is right or wrong under a series of rules, rather than based on the
consequences of the action. An example of deontology is the belief that killing someone is wrong, even if it was in self-defense.

69. A nurse caring for a confused elderly client leaves the bedside without raising the side rails and the patient falls to the floor. What type of legal
action could be used against the nurse in a lawsuit?
A. Assault B. Battery C. Negligence D. Malpractice

Rationale: Letter C is the correct answer. Negligence is omission of an act that a prudent nurse would have performed; in this case, the act is failure
to raise the side rails. Malpractice is the proximate cause of injury or harm to a patient resulting from the failure to act using the professional
knowledge, experience or skill that can be expected of others in the profession. Battery is the unlawful use of force/touch on a person.

70. A nurse who administered a medication to a patient without prescription is an example of which type of liability?
A. Assault B. Battery C. Negligence D. Malpractice

Rationale: Letter D is the correct answer.

71. An error has been committed and a nurse alters a hospital record. The action of the nurse may be classified as:
A. Fraud B. Malpractice C. Libel D. Slander

Rationale: Letter A is the correct answer. Fraud is the act of intentionally misleading or deceiving another person by any means. Altering a chart fits
this definition. Malpractice is the proximate cause of injury or harm to a patient resulting from the failure to act using the professional knowledge,
experience or skill that can be expected of others in the profession. Libel is defined as false accusation- written, printed, or typed- that is made with
malicious intent. Slander is defined as any words spoken with malice that are untrue and prejudicial to another person.

72. Which of the following acts as a guide in making moral decisions related to nursing practice?
A. Philippine Nursing Act of 2002 C. Code of Good Governance for the Professions
B. Code of Ethics for Registered Nurses D. Standards of Nursing Practice

Rationale: Letter B is the correct answer. By BON, BR 220 Resolution Series 2004.

73. Violation of the Code of Ethics might equate to suspension and/or revocation of the nursing license. Who has the power to revoke the license?
A. PNA B. PRC C. BON D. DOH

Rationale: Letter C is the correct answer. The Board of Nursing shall have the power to issue, revoke or suspend the certificate of registration of a
nurse. BON is also the who prepares the exam and PRC sets the time and place of the exam.

74. Ms. Ruth wants her mother designated to make her health decisions. What documentation is needed?
A. Living Will B. Last Will and Testament C. Doctors Order D. Durable Power of Attorney

Rationale: A power of attorney (aka health care proxy) is a legal document that authorizes someone to act for you. You name someone known as an
agent or attorney-in-fact (though the person need not be an attorney) who steps into your shoes, legally speaking.
An advance directive is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes
unable to make those decisions. There are two main types of advance directive the Living Will and the Durable Power of Attorney for Health
Care.
Letter B is incorrect. A will or testament is a legal document by which a person, the testator, expresses his or her wishes as to how his or her
property is to be distributed at death, and names one or more persons, the executor, to manage the estate until its final distribution.

75. This is known as willful telling of a lie under oath; also known as false testimony:
A. Double jeopardy B. Misdemeanor C. Perjury D. Felony

Rationale: Letter C is the correct answer.

Letter A is incorrect. Double jeopardy is a procedural defense that prevents an accused person from being tried again on the same (or similar)
charges and on the same facts, following a valid acquittal or conviction (cant be tried for the same case)
Letter B is incorrect. Misdemeanor is a minor wrong doing. Lesser criminal act that is less severe than a felony. Eg. Disturbing the peace, petty theft,
drunk driving with no injury to others, public drunkenness, simple assault and battery, and traffic violations.
LEADERSHIP AND MANAGEMENT
76. Mr. Daniel has been newly appointed to a patient care manager position. He has moderate concern for both of his staff and production. Which
management style is this?
A. Impoverished Management C. Organization Man
B. Country Club D. Team Management

Rationale: Letter C is the correct answer. Organization man has moderate concern for both people and production. The managerial grid model
(1964) is a style leadership model developed by Robert R. Blake and Jane Mouton.
Letter A is incorrect. Impoverished management has low concern for both people and production.
Letter B is incorrect. Country club management style puts concern for the staff as number one priority at the expense of the delivery of
services. He/she runs the department just like a country club where every one is happy including the manager.
Letter D is incorrect. Team management is the most effective leadership style. It reflects a leader who is passionate about his work and
who does the best he can for the people he works with.
77. One leadership theory states that to achieve the common goal, which refers to which of the following theories?
A. Charismatic C. Path Goal
B. Contingency D. Transformational

Rationale: Letter C is the correct answer. The goal is to increase your employees' motivation, empowerment, and satisfaction so they become
productive members of the organization. To clarify the path or remove obstacles. Give positive reinforcements and citations.
Letter A is incorrect. With charm and grace. Obtaining emotional commitment from members.
Letter D is incorrect. In transformational, the goal is change- the leader inspires change. Uses visioning as essence of leadership.
Transformational leaders work to enhance the motivation and engagement of followers by directing their behavior toward a shared vision.

78. Mr. Daniel displays a transactional type of leadership. Which of the following behaviors is manifested by the leader who uses this theory?
A. He inspires change C. With a back up plan
B. Use of rewards and punishment D. Displays charm and grace

Rationale: Letter B is the correct answer. If a subordinate does what is desired, a reward will follow, and if he does not go as per the wishes of the
leader, a punishment will follow.
Letter A is transformational type of leadership. Letter C is contingency theory with back up plan/flexibility. Letter D is charismatic- charm
and grace.

79. Which of the following is/are true about an autocratic type of leadership?
1. Workers are given responsibility, accountability and feedback.
2. Works perfectly in emergency or chaotic situations.
3. Ideal influence refers to the values and morals observed and emphasized by the leader.
4. Subordinates are not involved in decision making.
A. 1 and 4 B. 2 and 4 C.2, 3, 4 D. All of the above

Rationale: Letter B is the correct answer. Options 2 and 4 is Autocratic/Bureaucratic/Traditional/Dictatorial type of leadership. characterized by
individual control over all decisions and little input from group members. Autocratic leaders typically make choices based on their ideas and
judgments and rarely accept advice from followers.
Options 1 and 4 is democratic/consultative/participative type of leadership. Subordinates are totally involved in decision making. The most
desirable style that leads to increase productivity.

80. Nurse Ruth, a manager, decided to conduct a strategic planning workshop. Which of the following tasks is not a characteristic of this activity?
A. Focuses on day to day tasks
B. Extends to 3-5 years in into the future
C. Requires focus on mission and vision
D. Long-term goal setting

Rationale: Letter A is the correct answer. Strategic planning (long range) involves options A, B and D except C which is attributed to operational
planning. Strategic planning focuses on mission and vision and are those established to meet organizations' extensive goals. On the other hand,
operational plans are those that contain fine points for executing or implementing, those strategic plans in everyday activities. Strategic plans cover a
large span of time that is several years or decades. For instance, in an organization, a strategic plan for latest information delivery would capture five
years of accomplishment. On the other hand, an operational plan covers one year. For instance, an organization may have a procedure for stock
replacement, which addresses what happens today, tomorrow and next week.

81. Decentralized organizations have some advantages. Which of the following reflects the advantages of decentralized management?
1. Faster communication
2. Faster response or decision making
3. Highly cost-effective
4. Shared governance
A. 1 and 4 B. 2 and 3 C. 3 and 4 D. 1, 2, and 4

Rationale: The correct answer is letter B. The two forms of an organizational structure is centralized (aka tall org/vertical) and decentralized (flat
org/horizontal). Decentralization is a type of organizational structure in which daily operations and decision-making responsibilities are delegated by
top management to middle and lower-level mangers within the organization, allowing top management to focus more on major decisions/ transferring
decision making to lower positions Eg. The head nurse does the scheduling of the nursing staff.
Centralized organization can be defined as a hierarchy decision-making structure where all decisions and processes are handled strictly at
the top or the executive level Eg. The nursing director does the scheduling of the nursing stff.

82. Nurse Ruth assigns responsibilities and duties to her staff. Which of the following principles refer to this?
A. Span of control C. Scalar chain
B. Unity of direction D. Division of work

Rationale: The correct answer is letter D. Henry Fayol is the Father of Modern Operational Management and he came up with 14 Principles of
Management. Division of work is assigning responsibilities/duties to different individuals.
Letter B is incorrect. Unity of direction is achieving same goals and objectives.
Letter C is incorrect. Scalar chain is line of authority from top level management to lowest rank; keeping the chain of communication
within the chain of command.
83. The model of care that provides 24 hour care coverage from admission to discharge is called:
A. Functional Nursing B. Total Care Nursing C. Primary Nursing D. Modular Nursing
Rationale: Letter C is the correct answer. The distribution of nursing care in which care of one patient is managed for the entire 24-hour day by one
nurse who directs and coordinates nurses and other personnel (5-6 patients)
Letter A is incorrect. Functional nursing is task oriented. Divides nursing care into tasks: medication administration, dressing changes
and other treatments, baths and beds, vital signs. Separate tasks are assigned to each nurse based on: the difficulty of the task or skill to be
performed.
Letter D is incorrect. Modular nursing (Paraprofessional) is a modification of team nursing and focuses on the patient's geographic location
for staff assignments. Consists of non nursing members; will undergo training to do nursing tasks.
The other nursing care delivery system are team nursing, case nursing/method, and case management. Team nursing consists of group of
RNs with a leader. Case nursing/case method is 1:1 per shift eg PDN, student nurse, ICU nurse. In case management, nurse is assigned to a group
of patients with same disease.

84. You are to assign the best people to accomplish tasks to gain the goals of the organization. Which process refers to this?
A. Staffing B. Screening C. Recruitment D. Induction

The correct answer is letter A. Staffing is assigning competent people to fill the roles. The selection process are in this order: Recruitment (through
recommendation; media), Screening (qualified person), Interview (test for IQ, personality, how they interact), Orientation (has already been
accepted), Induction (Part of the payroll, completing of requirements).

85. Which of the following is the first phase of the staffing process:
A. Orientation C. Recruitment
B. Screening D. Interview

The correct answer is letter C. Recruitment is the first phase of the staffing process followed by screening, interview, and orientation.

NURSING RESEARCH
SITUATION: Queenie, a now registered nurse, applied for work as a research assistant. A thorough understanding of the steps in the
research process is important when doing a study.
86.Nurse Queenie knows that defining the purpose of the research project serves which function?
A. States the focus of the research study.
B. Identifies population group to be used.
C. Determines statistical treatment needed.
D. Explains why the problem is significant to the study.

Rationale: Letter D is the correct answer. Purpose of the research project is to know why the study is being made. The two purposes of the study is
Basic and Applied. Basic: Basic/fundamental, aims to gain new knowledge and understanding. Applied: aims to solve a practical problem.

87. This research is used to find solutions to everyday problems, cure illness, and develop innovative technologies. The research type used of this
nature is:
A. Applied B. Basic C. Quantitative D. Qualitative

Rationale: Letter A is the correct answer. Eg. (with interventions) Warm water therapy and improvement among knee injured patients
Letter B is incorrect. Basic research, also called pure research or fundamental research, is scientific research aimed to improve scientific
theories for improved understanding or prediction of natural or other phenomena. Eg (no intervention) Coping mechanism of patients with chronic
disease

88. During her job interview, Nurse Queenie was asked which type of research is intended to gain insight by discovering meaning? Her best reply
is:
A. Phenomenological
B. Ethnographic
C. Historical Studies
D. Case Study

Rationale: The correct answer is letter A. Phenomenological Study is what people experience in regard to some phenomenon or other and how they
interpret those experiences. A phenomenological research study is a study that attempts to understand people's perceptions, perspectives and
understandings of a particular situation (or phenomenon) eg amputees, yolanda victims
Letter B is incorrect. Ethnographic is the systematic study of people and cultures.
Letter C is incorrect. Historical studies involve examining past events to draw conclusions and make predictions about the future.
Letter D is incorrect. Case study is an in-depth study of a subject (of a person or 1 institution) eg. in CHN=family

89. A nurse did a research on zika virus. Its transmission, causative agent and factors, treatment, sign and symptoms and all the other in depth
information about zika. This study is best suited for which research design?
A. Survey B. Methodological C. Case study D. Comparative study

Rationale: Letter B is the correct answer. Case study is an in-depth study of a subject (of a person or 1 institution)

90. Nurse Queenie decided to conduct a study on the effect of cholesterol on blood pressure among obese patients. Which is the independent
variable?
A. Cholesterol B. Blood pressure C. Cholesterol on blood pressure D. Obese Patients

Rationale: Letter A is the correct answer. The independent variable (cause) is the value which is manipulated in an experiment. The dependent
variable (effect, result) is the value observed by the researcher during an experiment.
Letter B is incorrect. Blood pressure is the dependent variable.
 Letter D is incorrect. Obese patients is the population.

91. Queenie is interested to evaluate data from the past. Which of the following designs is appropriate for this study?
A.Grounded theory B. Ethnography C.Historical Studies D. Phenomenology

Rationale: Letter D is the correct answer. Identifies, evaluates data from the past.
Letter A is incorrect. Grounded theory is to develop new theories.
92. A nurse is conducting a research study on how Yolanda victims coped after the devastating effects of the typhoon. A design suited for this is:
A. Ethnography B. Phenomenological C. Case study D. Grounded theory

Rationale: Letter B is the correct answer.

93. You are interested to develop a new theory. The design appropriate for this study is:

A. Ethnography B. Phenomenological C. Case study D. Grounded theory

Rationale: Letter D is the correct answer.

94. Quantitative research designs are either descriptive or experimental. Its main general characteristics are:
1. Large sample size 2. Focused on experiences 3. Requires hard, replicable data 4. Small sample size
A. 1, 2 B. 2, and 4 C.1, 2, and 3 D.1, 3

Rationale: Letter D is the correct answer. The general characteristics of a quantitative research is that it requires, hard, replicable and reliable data,
large sample size (minimum of 30 because data needs to be proved replicable), and may or may not manipulate variables.
Letter B is incorrect. Options 2 and 4 are characteristics of a qualitative research.

95. Which of the following is not true about a True Experimental Research?
A. There is a control group.
B. There is an experimental group.
C. Randomized selection of subjects in the control group.
D. Careful selection of subjects in the experimental group.

Rationale: Letter D is the correct answer. In true experimental research the symbols used are: R, O, and X. R (random assignment;by chance), O
(test or measurement), X (Experiment, treatment, intervention).
96. The researcher implemented a new exercise regimen to obese patients while another group of obese patients received the usual routine
exercises. The researcher handpicked the experimental group. The researcher utilized which research design?
A. Pretest-Post test B. Quasi-experimental C. Solomon Four D. Non-experimental

Rationale: Letter B is the correct answer. In quasi-experimental there is no randomization.

Letters A and C are both true experimental designs.
Letter D is incorrect. Non-experimental research is the label given to a study when a researcher cannot control, manipulate or alter the
predictor variable or subjects, but instead, relies on interpretation, observation or interactions to come to a conclusion. CoCoMeSu.

97. A non-probability sample that is selected based on chosen criteria by the researcher is called:
A. Simple random B.Stratified random C. Judgmental D. Snowball

Rationale: Letter C is the correct answer. Judgmental and snowball are both non-probability sampling. Judgmental/Purposive sampling is according
to criteria or based on the subjective judgment of researcher.
Letter D is incorrect. Snowball is by referral (networking); it is a non-probability sampling technique where existing study subjects recruit
future subjects from among their acquaintances.
Letters A and B are both probability sampling/random. In a simple random sample is a subset of a statistical population in which each
member of the subset has an equal probability of being chosen; fishbowl technique. Stratified sampling is a probability sampling technique wherein
the researcher divides the entire population into different subgroups or strata, then randomly selects the final subjects proportionally from the
different strata; eg. OLFU students according to year level.

98. You are to study the effects of medication on pain experienced by post-op patients. What is the dependent variable?
A. The effects of B. Post-op patients C. Pain D. Medication

Rationale: Letter C is the correct answer. The dependent variable (effect, result) is the value observed by the researcher during an experiment.
Letter D is incorrect. Medication is the independent variable.
Letter B is incorrect. Post-op patients is the population.

99. You want to research on a development of a new way to measure IQ by creating a 50 item questionnaire that will assess the cognitive abilities of
an individual. The design best suited for this study is:
A. Survey B. Methodological C. Correlational D. Comparative study

Rationale: Letter B is the correct answer. Non-experimental research (CoCoMeSu) is the label given to a study when a researcher cannot control,
manipulate or alter the predictor variable or subjects, but instead, relies on interpretation, observation or interactions to come to a conclusion. Eg
race, gender.
Methodological Testing and evaluation of research instruments if useful eg Wong Baker scale
Correlational Relationship between two variables; if theres cause and effect Eg. Increase in age, Increase in BP
Comparative Differences between groups Eg. Is there a difference in birthweight of infants of marijuana addicted mothers and those of infant of
non addicted mothers?
Survey Studies IV and DV not required; no cause and effect; describes population; only 1 variable Eg. Social/school survey

100. Which of the following sampling methods allows the use of readily available research subjects?
A. Quota B. Simple random C. Convenience D. Judgmental

Letter C is the correct answer. A convenience sample (accidental/incidental) is one of the main types of non-probability sampling methods. A
convenience sample is made up of people who are easy to reach/readily available based on the convenience of the researcher.