NURSING PRACTICE I- SET A

1. 6.

2. 7. C. Use the bell of the stethoscope to

listen for bruits (low-pitched, murmur-like
sound, pronounced BROO-ee) over the
abdominal aorta and renal, iliac and
femoral arteries.

A. It is use when observing the size,

shape and color of abdomen.
3.
B. palpate for any enlargement.

D. percuss for tone.

8. A. Ask the client to stand erect with

arms at side and feet together. Note any
4. unsteadiness or swaying. Then with the
client in the same body position, ask the
client to close the eyes for 20 seconds.
Again note any imbalance.

B.
5.
C.
D. it is use to test ROM of the thoracic
and lumbar spine.
12. C. Previously, the initial steps were
Airway, Breathing, and Chest
compression. The literature indicates
9. A. unless the client is extremely thin
that starting compressions early in the
with a long neck, the thyroid gland is
process will increase survival rates.
usually not palpable. If the thyroid can be
Therefore, the steps have been changed
palpated, the lobes are smooth, firm and
to Chest compression, Airway,
non-tender. The right lobe is often 25 %
Breathing.
larger than the left lobe.
A. cricoid pressure is no longer routinely
B. parathyroid gland is not usually
performed.
palpated
B. for infants, use a manual defibrillator if
C. it is not slightly deviated.
available. If not available, an AED with
D. no nodules should be palpated. pediatric dose attenuator should be used
for an infant

10. D. the importance of high quality chest

compressions was confirmed, with
enhanced recommendations for
maximum rates and depths.

13. D. chest compression should be

delivered to adults at a depth between 2
11. B. the change from the traditional
to 2.4 inches or 5 to 6 cm because
ABC sequence in 2010 was confirmed in
compressions at greater depths may
the 2015 guidelines.
result in injury to vital organs without
A. it should be CAB.
increasing odds of survival.
C. it should be CAB.
A. It should be 5 to 6 cm
D. it should be CAB. B. It should be 5 to 6 cm
C. it should be 2 to 2.4 inches
14. C. 5 cm- chest compression should
be about 5 cm
A. too deep
B. too low
C. the same with letter A.
15. D. keep chest compression depth
about 1.5 inches or 4 cm for infants.
A. too deep
B. too low
C. too deep
16. B. daylight and darkness- darkness
and preparing for sleep causes decrease
in stimulation of RAS.
A. Although bedtime rituals and routines
induce comfort and relaxation but the
most influence on an individual’s sleep-
wake cycle is darkness.
C. the amount of sleep and individual’s
needs varies with lifestyle, health and
age.
D.
17. A. Melatonin- during the night the
pineal gland in the brain begins to
secrete the natural hormone melatonin,
and the person feels less alert. During
sleep, the growth hormone is secreted
and the cortisol is inhibited.
B. serotonin- is thought to lessen the
response to sensory stimulation
C. Dopamine- increase in dopamine
causes wakefulness.
D. Endorphins- is a happy
neurotransmitter
18. B. A snack containing carbohydrates
and protein contains tryptophan, a
precursor of serotonin, which is thought
to induce and maintain sleep.
A. it should be carbohydrates and protein
not fats.
C. Snack can be offer as long as it is high
in carbohydrates and protein.
D. Carbohydrates and protein not fats.
19. A. Regular use of any sleep
medication can lead to tolerance over
time and rebound insomnia, this may
lead clients to increase the dosage. diminished sensation, excessive body
Clients must be cautioned about heat, advanced age, and the presence of
developing a pattern of drug chronic conditions.
dependency.
A. friction is a force acting parallel to the
B. some of sedative- hypnotic last many skin surface. Ex. Sheets rubbing the skin
hours beyond the time that the client’s create friction.
perception of daytime drowsiness and
B. shearing force is defined as
impaired psychomotor skills have
combination of friction and pressure
disappeared after administration.
occurs commonly when a client assumes
C. The client is already laying on bed a fowler’s position in bed.
which is the position that people normally
D. A pressure ulcer is any lesion caused
assume to sleep.
by unrelieved pressure that results in
D. Carbohydrates can induce sleep with damage to underlying tissue.
this, it is not the reason why the client
cannot sleep at night.
22. C. Pressure is defined as a
compressing downward force on a body
20. D. this is in the stage I of NREM which area.
is describe as very light sleep and last
A. friction is a force acting parallel to the
only a few minutes.
skin surface.
A. the individual is difficult to arouse.
B. Shearing force is a combination of
B. friction and pressure.

C. D.

21. C. several factors contribute to the 23. D. transparent dressing is used to

formation of pressure ulcers: immobility, provide protection against contamination
inadequate nutrition, fecal and urinary and friction; to provide insulation by
incontinence, decreased mental status,
preventing fluid evaporation and facilitate 25. D. redness that does not go away is
wound assessment. the first or early sign of pressure ulcer. It
involves the epidermis layer of the skin
A. dry to wet
A. Pressure is the compressing
B. dry sterile gauze
downward force on a body area.
C. hydrocolloid dressing is used to
B. Blister formation is in the Stage II of
absorb exudate; to produce moist
Pressure ulcers. The epidermis and
environment that facilitates healing but
dermis layer of the skin are involved in
does not cause maceration of
this stage
surrounding skin. To protect from
bacterial contamination, foreign debris C. a sore the does not heal is in the stage
and urine or feces. III or IV of pressure ulcer in which the
epidermis, dermis, subcutaneous or and
muscle are involved.
24. D. Hydrocolloid dressing is used for
Pressure ulcers Stage II- IV. It is used to
absorb exudate; to produce moist 26.
environment that facilitates healing but
does not cause maceration of
surrounding skin. To protect from
bacterial contamination, foreign debris
and urine or feces.
27. C. One of the purpose of nursing
A. dry sterile gauze theories in practice is to help establish

B. Dry to wet gauze criteria to measure the quality of nursing

care.
C. transparent dressing is used for
Pressure ulcers Stage I. A. help build a common nursing
terminology to use in communicating with
other health professionals. Ideas are
developed and words are defines
B. Nursing theories is not a basis to C. Florence Nightingale- Interactions
promote enhanced salaries and benefits with the environment
for nurses.
D. Betty Neuman- neuman model
D. This is one of the purpose of theories focuses on the impact on health and
in research. addresses stress and the reduction of
stress.

30.
28. A. The culture care needs of people
in the world will be met by nurses
prepared in transcultural nursing.

B.

C. transcultural nursing’s goal is to

31. A.
provide culture- specific and universal
nursing care practices for health and C. Working phase

well-being of people. D. Working phase

D. Human caring is a universal

phenomenon, but the expression,
32.
process and patterns vary among
cultures. A.

29. B. Imogene king- Systems framework D.

and theory of goal attainment. Nursing as
a helping profession that assist
individuals and groups in society to
attain, maintain and restore health. 33.

A. Dorothea Orem- Self-care deficit

nursing
 D.

34

39. C. reticular Activating System

40. D. Milk- it contains tryptophan, a

precursor of serotonin, which is thought
to induce and maintain sleep.
35.
A. It contains caffeine which is a
stimulant that should be avoided.

B. It contains caffeine which is a

stimulant that should be avoided.

36. C. very light sleep. C. It contains caffeine which is a

stimulant that should be avoided.

41. C. when you assess the

37. D. Brain is highly active and dreaming
supraspinatus muscle you ask the patient
occurs this situation occur during REM
to make her chin touches her chest.
stage.
A. when assessing the trapezius muscle
A.
you ask the patient to shrug the
B. shoulders against the resistance

C. B. when you assess the deltoid muscle

you ask the patient to

D. when you assess the

38. A. Histamine
Sternocleidomastoid muscle you ask the
B.
patient to turn the head against
C. resistance, first to the right then to the
left.
42. A. the region

46.

43. C. the position of the client should

be forward- leaning position.

A.

B.
D.
44. C. inspect the jugular venous pulse
by standing on the right side of the
client. The clients should be in supine
position with the torso elevated 30-45
degrees.
A. the head is low so with that you
cannot get the accurate assessment.
B. it is not used since the head part
should be elevated at 30-45 degrees.
47. B. Environmental theory- nursing
ought to signify the proper use of fresh
air, light, warmth, cleanliness, quit and
the proper selection and administration
of diet- all at the least expense of vital
power to the patient.
A. Unitary human beings is theory of
Martha Rogers
C. Hildegard Peplau- Interpersonal
Relations in Nursing Model
D. Imogene King- systems framework
and theory of goal attainment

D. it is not used since the head part

should be elevated at 30-45 degrees. 48. B. nursing identified its domain in a
paradigm that includes four linkages: the
person, health, environment/ situation,
45. and nursing.
A. A metaparadigm is a set of theories or
ideas that provide structure for how a
discipline should function.
C. Conceptual model are set of
concepts and the propositions that
integrate them into a meaningful
configuration.
D. grand theories are intended to
provide structural framework for broad,
abstract ideas about nursing.
49.
50.
51.
52. A. Handwashing is the best way to
prevent transmission of microorganism.
B. Although this can provide protection
but the most effective infection control
procedure is handwashing.
C. same with letter B.
D. not necessary unless the patients
has airborne transmitted disease or is
immunocompromised.
53. C. the best way to prevent
transmission of microorganism is
handwashing that’s why advice visitor to
wash hands before and after contact
with the patient.
A. not necessary since TB cannot be
transmitted through contact.
B. patient will feel more isolated and
different from other people.
D. after 2 weeks of treatment
mycobacterium tuberculosis is cannot
be transmitted through air as long as the
patient is compliance with the treatment.
54. D. this can provide our client enough
time to think and to comprehend the
situation and to control his emotion.
A. although this is right but the client is D. transparent film can provide easy
still angry. You cannot explain the assessment because the wound can be
procedure to the client unless he’s assessed through them.
already in stable emotion.

B. this does not respond to the problem

57. D.
of the patient.
A.
C. the client is still angry that’s why we
need to respect our client’s emotion. B.

C.

55. C.

A. 58.

B.

D.

56. A. hydrocolloids dressing can be

molded to uneven body surfaces. It 59. B. it is not advisable to put lotion in
consist of two layers. The inner wet skin. Air dry only.
adhesive has particles that absorb
A. it can help to
exudates while the outer layer provides
an occlusive seal.

B. since it contains waterproof adhesive

wafers, pastes, or powders the client
can take a bathe nor shower.

C. this type of dressing is designed to

60. D. inadequate intake of protein
be worn for up 3 to 7 days only.
contributes to pressure ulcer formation,
lengthy surgical procedure makes the
client to stay in one position (immobility
or inactivity), excessive body heat
increases the metabolic rate, thus
increasing cells need of oxygen.
A. People with insomnia might do
activities that will help them sleep.
Water bed support surface filled with
water. Water temperature can be
controlled.
B. Water bed support surface filled with
water. Water temperature can be
controlled.
C. People with insomnia might do
activities that will help them sleep.
61. C.
A.
B.
D.
62. C. evaluating is a planned, ongoing,
purposeful activity in which clients and
health care professionals determine the
client’s progress toward achievement of
goal’s/outcomes and the effectiveness
of the nursing care plan.
A. in planning, the nurse plans how to
solve the problem, what are the
intervention that should be done.
B. the client is already in pain, and there
is already intervention done.
D. the intervention is already
implemented.
63. A. It should be specific and time-
bounded.
B. it is measurable because there is
pain scale that should be met.
C. goal is written but it’s not complete.
D. although objective cues is needed
but it is not measurable.
64.
65. C. Delegation is the act of assigning
to someone else a portion of work to be
done with corresponding authority,
responsibility and accountability.
Delegated task must be based on
policies, job description and capabilities
of workers. In delegation of D. no intervention is done, since it is still
responsibility to a nursing assistant in the planning stage.
choose procedure that is simple and
non-invasive.
68.
A. evaluation is the responsibility of the
nurse. To check if the goal was achieve
after the shift.

B. the rate of the infusion pump is one of

the responsibility of the nurse. Since
69.
nurses always make sure to prevent
fluid overload.

D. since it is invasive procedure it

should be the RN’s responsibility to
assist the physician.
70.

66. D.

A.

B.
71.
C.

67. A. the nurse identifies the goal of the

nursing care plan.

B.
72. A. use thumb and finger of your
C. the nurse already assessed the
opposite hand to grasp the client’s
patient and diagnose that the patient
auricle firmly but gently. Pull up and
has anxiety.
back to straighten the external auditory
canal.
B. no need to use an applicator to
remove cerumen.
C. the client is asked to sit comfortably
with the back straight and the head tilted
slightly away from the examiner toward
his/her opposite shoulder.
D. no need to remove earrings as long
as it does not alter the procedure.
73.
A. Using the palmar surface of the
fingers, compress to a maximum depth
(5-6cm) during deep palpation.
B. In palpation we use the fingertips not
the palms in palpating the abdomen.
74. B. in assessing the patient for
jugular vein distention, the nurse
position the patient in 30 degrees head
elevation.
A. this is not the proper way of
positioning pt. for jugular vein distention.
C. same with letter D.
D. the result will be altered since the
patient is not positioned properly.
75. D. the patient is position in lithotomy
position when assessing the Bartholin’s
glands. Since this position allows the
nurse to inspect the area to be
inspected in female genitalia.
A.Sims position the patient lies on the l
eft side with the left thigh slightly flexed
and the right thigh acutely flexed on the
abdomen; the left arm is behind the bod
y with the body inclined forward, and the
right arm is positioned according to the
patient's comfort.
B.prone position a position with the pat
ient lying face down with arms bent com
fortably at the elbow and added with the
arm boards positioned forward.
C. it will not allow the nurse to see and
assess the genital area well.
76. C.
A.
B.
D. medical diagnosis.
77. B. subjective data, also referred as
symptoms or covert data apparent only
to the person affected and can be
described or verbalized only by that
person. The client is the primary source
of data that’s why A is the best answer.
A. secondary source of data can be
taken from family members, or other
during lunch. The data that he’s trying to
get is subjective and primary source.
B. this belongs to planning phase.
C. this is in implementation phase.
D. it is in the evaluation phase.

support persons, other health

professionals, records and reports.
81.
C. objective data also known as signs or
overt data are describable by the
observer or can be measured or tested
against accepted standard.

D. it should be subjective and primary

82. C. the nurse is getting vital signs
source.
belongs to assessment phase since the
nurse is getting baseline data.

78. B. A.

A. B.

C D. it is not in diagnosis phase.

D.

83. A. objective data also known as

signs or overt data are describable by
79.
the observer or can be measured or
tested against accepted standard. The
only option that provide objective data is
the urine output.

B. it is a subjective data.
80. A. the nurse is assessing by asking
the client the amount of food that he ate C. it is a subjective data.
D. it is a subjective data.

84. D. 88. A. it is the only data taken during

observation.
A.
B. it is a subjective data.
B.
C. it is a subjective data.
C.
D. it is a subjective data.

85. A. since a goal should be SMART,

with this it should be time-bounded.
B. it is stated in the statement the
expected client behavior.
C. it is stated in the statement the
condition needed.
D. same with letter B.
89. A. the proper way to assess the
abdomen is to follow this sequence
Inspection- Auscultation- Percussion-
Palpation.
B. not necessary to wear sterile gloves
unless the patient has sores.
C. after auscultation percussion is next
lastly is the palpation.

86. A. D. the patient should lie flat on bed.

B.

C. 90. D. in gathering past health history

D. nurses should also include all aspect of

wellbeing of the patient not only physical
but also mental, social, emotional and
87. spiritual wellbeing.

C. it should be subjective data. A. although this can be gathered but the

information that provide the best answer
is option A.
B. focus in the past health history not in C.
the present.

C. focus in the past health history.

95.

91. B. health history is done to gather

information not only from the patient but
also from the family members.

A.

C. 96.

D.

92. D.

A.

B.

C. 97.

93.

94. D. establishing rapport is the first 98.

thing to do before starting anything this

helps to build trust of the patient.

A.

B.
99.

100.