Sunteți pe pagina 1din 20

c c





a. Hemothorax
b. Flail chest
c. Atelectasis
d. Pleural effusion






a. Dullness to percussion in the third to 5th intercostals space, midclavicular line

b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases



a. Observe for intermittent bubbli ng in the water seal chamber

b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client



a. Notify the physician

b. Insert a new chest tube
c. Ñover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives

½ c
%      &ë £ 

a. Establishing limits on activity

b. Fostering a relaxed environment
c. Identifying goals for self care
d. Destricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.

 ( % ½ 
   )   cc 

     ( %        

% '    " 

a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity

 ( %        



a. ºixes room air with oxygen

b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract

  !  ( %    


a. "I was feeling fine so I removed my nasal prongs."

b. "I've increased my fluids to six glasses of water daily."
c. "Don¶t forget to come back quickly w hen you get me out of the bed; I don't want
to be without my oxygen for too long."
d. ·ºy family was angry when I told them they could not smoke in my room.·

ü %


a. Anticipate the need for humidification

b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Œchedule nursing care to allow frequent observations of the cli ent

Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol
abuse for the past 15 years. His wife brings him to the emergency department
because he is increasingly confused and is coughing blood. His medical diagnosis is
cirrhosis of the liver. He has ascites and esophageal varices.

c+    ( %



a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. luish discoloration of the umbilicus

cc ! 


a. Decreased serum creatinine

b. Decreased sodium
c. Increased ammonia
d. Restricted sodium

c3 #      


a. High protein
b. Increased potassium
c. Restricted fluids
d. Destricted sodium

cë % ),-)          


a. Deflate the esophageal balloon

b. Encourage him to take the deep breath
c. ºonitor his vital signs
d. Notify the physician

c£ ,       

    ( %

a. Liver
b. Kidneys
c. Adrenals
d. Pancreas

Situation 4 - Rape is one of the most tragic things that could happen to anyone
especially with young girls. Incidence such as these could develop into a crisis
situation involving not only the rape victims but also their families.




a. Combination of developmental and situational

b. Œituational
c. Emotional
d. Developmental
c .      

a. Since this is a legal case, call the press about the incidence of rape
b. erform thorough physical assessment and documenting objectively all the
evidences of rape
c. Ask the patient to stay in one isolated room first to provide privacy while
attending to other patients
d. Provide emotional support first and postponed physical assessment when patient
is already calm

c !  



a. Attitude therapy
b. Psychotherapy
c. Ñrisis intervention
d. Re-motivation technique

c  !  


a. Ñrisis is self-limiting
b. After crisis, the individual always return to a pre -crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help

cü -





a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. £-6 weeks

Situation 6 - One Important fact that will guide the nurse in the practice of the
profession is her knowledge of the nursing law.

3+    cüüc



a. This Act delineates the practice of nursing and midwifery

b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. The Act defines the practice of nursing in the Philippines
3c !    ) -  


a. She's not bound to perform according to the standards of nursing practice

b. rovides nursing care within the acceptable standards of nursing practice
c. She's not obligated to provide professional service
d. The employer does not hold the nurse responsible for her action

33  / $½    #  ë   



a. Misrepresentation
b. Êssault and attery
c. Malpractice
d. Negligence

3ë    -12 3) 

 30       3!   



a. Only medication will be given

b. All ordinary measure will be stopped
c. asic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped

3£ ! 




a. Report to the head nurse and calls someone to help

b. ¦etermine any injury or harm
c. Refer to the resident on duty
d. Put back patient to bed

Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the
office and he remains conscious. Police officers brought her to the hospital.

3½ 4         




a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness

3 !  



a. Scopalamine
b. Lanoxin
c. Coumadin
d. ºannitol

3 %           


a. Encourage her to observe bed rest

b. Check blood pressure every shift
c. Observe complete best rest
d. ºeasure intake and output

3  - 

a. Observe how he talks

b. Instruct her to squeeze her hands
c. Allowing him to stand alone
d. Pricking her skin with pin

3ü !  


a. Ñoughing
b. Reading
c. Turning
d. Sleeping

Situation 8 - Basic Psychiatric concepts a nurse should be aware of...

ë+ (



a. Ñonscious
b. Unconscious
c. Preconscious
d. Foreconscious


a. Id
b. -go
c. Superego
d. Unconscious

ë3 -    


a. Affective reactions
b. Ritualistic behavior
c. Withdrawal patterns
d. ¦efense mechanisms

ëë %

a. Act out in a reverse something already one or thought

b. Return to an earlier, less mature stage of development
c. Exclude fro the conscious things th at are psychologically disturbing
d. Ñhannel an acceptable sexual desire into socially approved behavior


a. Imaginative activity to escape reality

b. Ignoring unpleasant aspects of reality
c. Resisting any demands mad e by others
d. ent-up emotion directed to other than the primary source

Situation 9 - Joan, age 34, is hospitalized because of alcoholism.

ë½ 5       



a. !o reduce her feelings of guilt

b. To iive up to others' expectation
c. To make her seem more independent
d. To make her look better in the eyes of others

ë 5           




a. In telling the truth

b. ºeeting an ego ideal
c. With dependence and independence
d. In identifying who is creating the problem

ë ! )  


a. ºost polydrug abusers also abuse alcohol

b. Most alcoholics become polydrug abusers
c. Addictive individuals tend to use hostile abusive behavior
d. An unhappy childhood is a causative factor in many addictions




a. The availability of community resources

b. The accepting attitude of the client¶s family
c. !he client's emotional or motivational readiness
d. The qualitative level of the client's physical state

ëü 5  )    

     6  !  



a. "You'll find you need their support."

b. ·¦o you have feelings about going t o these meetings?·
c. "No its best to wait until you feet you really need them."
d. "Yes, because you will learn how to cope with your problem."

Situation 10 - Nurse Medie has been encountering schizophrenic and different

psychotic disorders. .




3  3  

a. ¦issociation
b. Transference
c. Displacement
d. Reaction formation


a. Autism
b. -cholalia
c. Neologism
d. Echopraxia

£3 $ #  




a. Logic
b. Association
c. Deality testing
d. The thought process

£ë #        


a. Reduce the neurotic syndrome

b. Prevent secondary complication
c. Prevent destructiveness by the client
d. ºake the client more amenable to psychotherapy

££    *    

* '  

a. Aggressive acting out behavior

b. Periodic remissions and exacerbations
c. Hypoxia of selected areas of brain tissue
d. Êreas of brain destruction called senile plaques

Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in
the clinic.

£½ -   )     


a. Cold, clammy skin

b. Increased pulse rate
c. Elevated blood pressure
d. Cyanosis of the nail beds

£ !  


a. An inflammation of the inner ear

b. Insufficient cerebral oxygenation
c. A sudden drop in blood pressure
d. Decreased level of serum glucose

6     !  

      '  " 

a. Administer this at least an hour before meals

b. Explain that loose stools are common with iron
c. áave Êisa take the diluted iron preparation through a straw
d. Avoid giving Aisa orange or other citric juices with the iron preparation



a. Œerum hepatitis
b. Allergic response
c. Pulmonary edema
d. Hemolytic reaction

Situation 12 - Eric Pineda is admitted to hospital to have his urethra dilated by the
physician. A urinary retention catheter is inserted following the procedure.

      ( $   -   

a. Take no special action

b. Defrigerate the specimen
c. Store on dry side of utility room
d. Discard and collect a new specimen later




a. Epididymis
b. rostate gland
c. Seminal vesicle
d. Bulbourethral gland

½c       ( $  ' 


a. Perineal cleansing
b. Encouraging fluids
c. Irrigating the catheter
d. Ñleansing around the meatus periodically

½3 !( $       


a. Notify the physician

b. Milk the tubing gently
c. Ñheck the patency of the catheter
d. Irrigate the catheter with prescribed solutions

½ë ( $      




a. Fluid imbalance
b. Mr. Pineda's recent sedentary lifestyle
c. Ên interruption in normal voiding habits
d. Nervous tension following the p rocedure

Situation 13 - Helen Alcantara is admitted to hospital with complaints of hematuria,

frequency, urgency, and dysuria.

½£ ( 

a. Pyelitis
b. Cystitis
c. Nephrosis
d. Pyelonephritis

½½ ( 

a. Altered urinary pH
b. Hormonal secretions
c. Position of the bladder
d. roximity of the urethra and anus





a. A catheter inserted for the client's benefit

b. Ê treatment that does not need a separate consent form
c. Treatment without consent of the client, which is an invasion of rights
d. Inability to obtain consent for treatment because the client was aphasic

½ !  


a. Monitor urinary specific gravity

b. Record urinary output every hour
c. Œubtract irrigant from output to determine urine volume
d. Include irrigating solution in any 24 hour urine tests order

½  !    



a. Carbachol injection
b. Neosporin GU irrigant
c. ethanecol (Urecholine)
d. Pilocarpine hydrochloride (Pilocar)
Situation 14 - Arman Adriatico is admitted to hospital with extensive c arcinoma of
the descending portion of the colon with metastasis to the lymph nodes.



a. lleostomy
b. Ñolectomy
c. Colostomy
d. Cecostomy


 (     ' 


a. Mastery of techniques of ostomy care

b. Deadiness to accept an altered body function
c. Awareness of available community resources
d. Knowledge of the necessary dietary modifications

c ! (            



a. Be appropriate hour before breakfast

b. rovide ample uninterrupted bathroom use at hom e
c. Approximate Mr. Adratico's usual daily time for elimination
d. Be about halfway between the two largest meals of the day

3 !  

a. ½cm

ë (       


a. Rich in protein
b. Low in fiber content
c. High in carbohydrate
d. As close to normal possible

Situation 15 - Richard Gabatan, a 32 -year-old car salesman, suffered a spinal cord

injury in a motor vehicle accident resulting to paraplegia.
£    ( / )   

a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek
additional help
b. Gently raise Mr. Gabatan to a sitting position to see if the pain either
c. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover
him with any material available
d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available
transportation, rush him to the nearest medical institution

½ 8      
     ( / 


a. Upper extremities are paralyzed

b. Lower extremities are paralyzed
c. One side of the body is paralyzed
d. Both lower and upper extremities are paralyzed

    * # 

 ( /

a. ladder control
b. Client education
c. Quadriceps setting
d. Use of aids for ambulation

( /       




a. Active exercise
b. Deep massage
c. Use of tilt board
d. roper positioning

  ( /:

a. Should be left up to Mr. Gabatan and his family

b. Œhould be considered and planned for early in his care
c. Are not necessary, because he will return to former activities
d. Are not necessary, because he will probably not able to work again

Situation 16- Karen Boltron, age 16, is withdrawn and non commu nicative. She
most of her time lying on her bed.

ü !     




a. Êssist her to care for personal hygiene needs

b. Encourage her to keep up with school studies
c. Encourage her to join the other clients in group singing
d. Leave her alone when these appears to be a disinterest in the activities at hand

+ !   



a. Try to get her discuss feelings

b. Focus oh non threatening subjects
c. Ask simple questions that require answers
d. Sit and look magazines with her

c !  



a. Help keep her oriented to reality

b. Involve her in activities throughout the day
c. Encourage her to discuss why mixing with other people is avoided
d. Help her understand that it is harmful to withdraw from situations

3 8 ;  

)        34  )
 '       )   )3!    

a. "You seem angry with me."

b. ·Œtink? I don't understand.·
c. "Boy, you're in a bad mood."
d. "I can't be all that bad, can I?"

ë 8   



a. Ao back to regular activities

b. Call the unit whenever upset
c. Continue in an after care situation
d. Find a group that has similar problem

Situation 17 - Danny Dasigao, age 63, has an obsessive -compulsive behavior

disorder. He believes that the doorknobs are contaminated and refuses to touch
them except with the tissue.
£ !     
  )  "

a. Œupply rim with paper tissue to help him function until his anxiety is reduced
b. Explain to him that this idea about doorknob is part of his illness and is not
c. Encourage him to scrub the doorknobs with a strong antiseptic so he does not
need to use tissues
d. Encourage him to touch doorknobs by removing all available paper tissue until he
learns to deal with the situation

½ !   

a. He is using the method to pu nish himself

b. He is listening to voices telling him that the doorknobs are unclean
c. áe wants to unconsciously control unacceptable impulses or feelings
d. He has a need to punish others by carrying out an annoying procedure


  0'  "

a. Explore with him the nature of his anxiety

b. Œtimulate him to express his ritualistic actions regularly
c. Encourage him to participate in his therapeutic plan of care
d. Provide him with an environm ent that is both supportive and non -opinionated




a. Deny his time for the ritualistic behavior

b. Give a schedule for the ritualistic behavior
c. ¦etermine the purpose of the ritualistic behavior
d. Suggest a symptom substitution technique to refocus the behavior



a. Avoiding unpleasant objects and events

b. Prolonged exposure to fearful situation
c. Êcquiring skills with which to face stressful events
d. Introducing an element of pleasure into fearful situations

Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis of anorexia
nervosa. She has lost 10 kg in 5 weeks. She is very thin but exces sively concerned
about being overweight. Her daily intake is 10 cups of coffee.

ü !      


5 "
a. Explain the value of good nutrition
b. Compliment her on her lovely figure
c. !ry to establish a relationship of trust
d. Explore the reasons why she does not eat

 + !   
  5 '   " 

a. Êllow self-esteem
b. Feelings of unworthiness
c. Anger directed at the parents
d. An unconscious fear of growing up




a. Remind frequently the client to eat all the food served on the tray
b. Increase phone calls allowed the client by or a per day for each pound gained
c. Include the family with the client in therapy sessions two times per week
d. Weigh the client each day at 6:00 A.M. in hospital gown and slippers after she

 3   ;c 

;    3(     - '   ' 3

a. "I do trust you, but S was assigned to be with you."

b. ·It sounds as if you are manipulating me.·
c. "OK. When S return, you should have eaten everything."
d. "Who is your primary nurse."

 ë !     


a. The client eats meals in the dining room

b. !he client gains one pound per week
c. The client attends group therapy sessions
d. The client has a more realistic self -control

Situation 19 - Mr. Pascua is pacing about the unit and wringing his hands. He is
breathing rapidly and complains of palpi tations and nausea and he has difficulty
focusing on what the nurse is saying. ‡

 £ ( $         -    


a. If the client is out of control, another person will help to decrease his anxiety
b. Being alone with an anxious client is dangerous
c. It will take another person to direct the client into activities to relieve anxiety
d. Hospital protocol for han dling anxious clients requires at least two people

 ½     )       



a. Mild
b. Moderate
c. Severe
d. anic

 ( $  

a. Ñalm reassurance, deep breathing and modication as ordered

b. Teach Mr. Pascua problem solving in relation to his anxiety
c. Expiam the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause of his anxiety

Situation 20 - Joel is a toddler who has classical hemophilia.



'   " 

a. Hemophilia is an autosomal dominant disorder in which the woman carries

the trait
b. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle
ceil anemia
c. This disorder can be carried by either male or female but occurs in the sex
opposite that of the carrier
d. áemophilia is an X-linked disorder in which the mother is usually the carrier of the
illness but is not affected by it




a. †oints
b. Intestines
c. Cerebrum
d. Ends of the log bones

 ü !  


a. Albumin
b. Fresh frozen plasma
c. Factor VIII concentrate
d. Factor II, Vll, IX, X complex

ü+ 5 
'   )   



a. All the girls will be normal and the other son a carrier
b. All the girls will be carriers and one half the boys will be affected
c. -ach son has a chance of being affected and each daughter a ½  chance of
being a carrier
d. Each son has 50% chance of being affected or a carrier, and the girls will be all




a. Call the physician

b. Slow the flow rate
c. Œtop the blood immediately
d. Relieved the symptoms with an ordered antihistamines

Situation 19 - Mr. Villa who was admitted to the respiratory floor with COPD. The
nurse finds him extremely restless, incoherent, and showing signs of acute
respiratory distress. He Is using accessory muscles for breathing and Is diaphoretic
and cyanotic.


a. Êdministered oxygen as ordered

b. Assess vital signs and neural vital signs
c. Administered medication which has been ordered for pain
d. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis



a. Respiratory rate
b. Color of mucus membranes
c. Pulmonary function tests
d. Êrterial blood gases

ü£ ( <






a. Encourage the client to cough an deep breath

b. Êpply pressure to the puncture site for ½ minutes
c. Shake the vial of blood before transporting it to the lab
d. Keep the client on bed rest for 2 hours



   ë½1+3 +1+ë ë½  
+3 + !     "

a. The client is in metabolic acidosis

b. The client is in compensated metabolic alkalosis
c. The client is in respiratory alkalosis
d. !he client is in compensated respiratory acidosis

Situation 20 - The nurse is assigned in a counseling clinic about preventive

measures for cancers.

ü 1    #        ! 


a. Increasing governmental control of potential carcinogens

b. Changing hab its and customs that predispose the individual to cancer
c. Conducting more mass screening programs
d. -ducating public and professional people about cancer

ü -    


a. Uterine cervix
b. Uterine body
c. Vagina
d. Fallopian tube


a. Wash the area with soap and warm water

b. Apply a cream or lotion to the area
c. Leave the skin alone until it is clear
d. Êvoid applying creams or lotion to the area


a. " There really is no reason your doctor just wrote the orders that way."
b. "This schedule will red uce the side effect of the drug."
c. ·¦ivided doses produce greater cytotoxic effects on the diseased cells.·
d. "Because these drugs prevent cell division, they are more effective in divided



a. Prevent infection postoperatively

b. Eliminate the need for preoperative enemas
c. Decreased and retard the growth of normal bacteria in the intestines
d. Treat cancer of the colon