NP1 Nursing Board Exam November 2008 Answer Key 'Foundation of Professional Nursing Practice' 100 Nursing Board

Exam test questions of November 2008 Nurse Licensure Examination (NLE) Nursing Practice 1 Foundation of Professional Nursing Practice Fundamentals of Nursing PART 1 Board Exam test questions 1 - 50

Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today. 1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and population. This is the most accepted definition of nursing as defined by the: A. PNA B. ANA C. Nightingale D. Henderson 2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT expanded career role for nurse? A. Nurse practitioner B. Clinical Nurse Specialist C. Nurse Researcher D. Nurse anaesthesiologist 3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following EXCEPT: A. Issue, suspend revoke certificates of registration B. Issue subpoena duces tecum, ad testificandum C. Open and close colleges of nursing D. Supervise and regulate the practice 4. A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make judgments about them is in what stage of Nursing Expertise? A. Novice B. Newbie C. Advanced Beginner D. Competent 5. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of having: A. The ability to organize and plan activities B. Having attained an advanced level of education C. A holistic understanding and perception of the client D. Intuitive and analytic ability in new situations

Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer this.

6. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is to be administered to the client. Which of the following site will you choose? A. Deltoid B. Rectus Femoris C. Ventrogluteal D. Vastus lateralis 7. In infants 1 year old and below, which of the following is the site of choice in intramuscular injection? A. Deltoid B. Rectus Femoris C. Ventrogluteal D. Vastus lateralis 8. In order to decrease discomfort in Z track administration, which of the A. Pierce the skin quickly and smoothly at 90 degree angle B. Inject the medication at around 10 minutes per millilitre C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel D. Pierce the skin slowly and carefully at a 90 degree angle 9. After injection using the Z track technique, the nurse should know that she needs to wait for few second before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus decreasing the clients discomfort. How many seconds should the nurse wait before withdrawing the needle? A. 2 second B. 5 seconds C. 10 seconds D. 15 seconds 10. The rationale in using the Z track technique in an intramuscular injection is: A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissue. B. It will allow a faster absorption of the medication C. The Z track technique prevent irritation of the muscle D. It is much more convenient for the nurse Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment: 11. All of the following are correct methods in assessment of the blood pressure EXCEPT: A. Take the blood pressure reading on both arms for comparison B. Listen to and identify the phases of Korotkoff sound C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated D. Observe procedures for infection control 12. You attached a pulse oximeter to the client. You know that the purpose id to: A. Determine if the clients hemoglobin level is low and if he needs blood transfusion B. Check level of clients tissue perfusion C. Measure the efficacy of the clients anti-hypertension medications

D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops 13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: A. Inconsistent B. Low systolic and high diastolic C. Higher than what the reading should be D. Lower than what the reading should be 14. Through the clients health history, you gather that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the clients blood pressure for accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes 15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximiter is. Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours 16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of: A. 15 seconds B. 1 to 2 minutes C. 30 minutes D. 15 minutes 17. If the arm is said to be elevated when taking the blood pressure. It will create a: A. False high reading B. False low reading C. True False reading D. Indeterminate 18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the clients oral temperature? A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes 19. When auscultating the clients blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down to 80 mmHg and then silence. What is the clients pressure? A. 130/80 B. 150/100 C. 100/80

D. 150/100 20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? A. 10 20 seconds B. 30 45 seconds C. 1 - 1.5 minutes D. 3 3.5 minutes Situation 4 Oral care is an important part of hygienic practices and promoting client comfort. 21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution 22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and an orderly progression 23. The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves clients appearance and self-confidence D. improves appetite and taste of food 24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums D. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse.

26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure: A. Clenching his fist every 2 minutes B. Breathing in and out through the nose with his mouth open C. Tensing the shoulder muscles while lying on his back D. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: A. Nausea and vomiting B. Shortness of breath and laryngeal stridor C. Blood tinged sputum and coughing D. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instructed Fernan to: A. Exercise the neck muscles B. Breathe deeply C. Refrain from coughing and talking D. Clear his throat 29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: A. Keep the sterile equipment from contamination B. Assist the physician C. Open and close the three-way stopcock D. Observe the patients vital signs 30. Right after thoracentesis, which of the following is most appropriate intervention? A. Instruct the patient not to cough or deep breathe for two hours B. Observe for symptoms of tightness of chest or bleeding C. Place an ice pack to the puncture site D. Remove the dressing to check for bleeding Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the involvement at which type of acid base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimen are drawn? A. Guthing test B. Allens test C. Rombergs test D. Webers test 34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 35. Allens test checks the patency of the: A. Ulnar artery B. Radial artery C. Carotid artery D. Brachial artery 37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. empty a sample urine from the collecting bag into the specimen container C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 38. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation? A. to the patients inner thigh B. to the patients lower thigh C. to the patients buttocks D. to the patient lower abdomen 39. Which of the following menu is appropriate for one with low sodium diet? A. instant noodles, fresh fruits and ice tea B. ham and cheese sandwich, fresh fruits and vegetables C. white chicken sandwich, vegetable salad and tea D. canned soup, potato salad, and diet soda 40. Howe will you prevent ascending infection to Eileen who has an indwelling catheter? A. see to it that the drainage tubing touches the level of the urine B. change he catheter every eight hours C. see to it that the drainage tubing does not touch the level of the urine D. clean catheter may be used since urethral meatus is not a sterile area

A. B. C. D.

Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland: A. Hypothalamus B. Anterior pituitary gland C. Posterior pituitary gland D. Thyroid gland 42. All of the following are secreted by the anterior pituitary gland except: A. Somatotropin/Growth hormone B. Follicle stimulating hormone C. Thyroid stimulating hormone D. Gonadotropin hormone releasing hormone 43. All of the following hormones are hormones secreted by the Posterior pituitary gland except: A. Vasopressin B. Oxytocin C. Anti-diuretic hormone D. Growth hormone 44. Calcitonin, a hormone necessary for calcium regulation is secreted in the: A. Thyroid gland B. Hypothalamus C. Parathyroid gland D. Anterior pituitary gland 45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the: A. Thyroid gland B. Hypothalamus C. Parathyroid gland D. Anterior pituitary gland Situation 8 The staff nurse supervisor requests all the staff nurses to brainstorm and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 46. The plan of the nurse supervisor is an example of A. in service education process B. efficient management of human resources C. increasing human resources D. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra A. makes the assignment to teach the staff member B. is assigning the responsibility to the aide but not the accountability for those tasks C. does not have to supervise or evaluate the aide D. most know how to perform task delegated

48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should A. empathize with the nurse and listen to her B. tell her to take the day off C. discuss how she is adjusting to her new job D. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is A. grievance B. arbitration C. collective bargaining D. strike 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is A. professional course towards credits B. inservice education C. advance training D. continuing education Situation 9: As a nurse, you are aware that proper documentation in the patient chart is your responsibility. 51. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting? A. Bill of rights as provided in the Philippine Constitution B. Scope of nursing practice as defined in R.A. 9173 C. Board of Nursing resolution adopting the Code of Ethics D. Patients Bill of Rights 52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication? A. Incident Report B. Oral report C. Nursing kardex D. Complain report 53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges? A. Fraud B. Assault and Battery C. Harassment D. Breach of confidentiality 54. Which of the following is the essence of informed consent? A. It should have a durable power of attorney B. It should have coverage from an insurance company C. It should respect the clients freedom from coercion D. It should discloses previous diagnosis, prognosis and alternative treatments available for the client.

55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation? A. The RN must supervise all delegated tasks B. After a task has been delegated. It is no longer a responsibility of the RN. C. The RN is responsible and accountable for the delegated task in a adjunct with the delegate. D. Follow up with a delegated task necessary only if the assistive personnel is not trustworthy.

Situation 10 When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 56. The most important risk factor is: A. Cigarette smoking B. Hypertension C. binge drinking D. heredity 57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: A. Embolic stroke B. Hemorrhagic stroke C. diabetic stroke D. thrombotic stroke 58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: A. phlebitis B. trauma C. damage to blood vessel D. aneurysm 59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? A. Amphetamines B. Cocaine C. shabu D. Demerol 60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: A. More red blood cells thicken blood and make clots more possible. B. Increased RBC count is linked to high cholesterol. C. More red blood cell increases hemoglobin content. D. High RBC count increases blood pressure. Situation 11: Recognition of normal values is vital in assessment of clients with various disorders.

61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following? A. 60% B. 47% C. 45% D. 32% 62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? A. ST depression B. Inverted t wave C. Prominent U wave D. Tall peaked T waves 63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? A. U waves B. Absent P waves C. Elevated T waves D. Elevated ST segment 64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? A. Neutrophils 60% B. White blood cells (WBC) 9000/mm C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr D. Iron 75 mg/100 ml 65. Which of the following laboratory test result indicate presence of an infectious process? A. Erythrocyte sedimentation rate (ESR) 12 mm/hr B. White blood cells (WBC) 18,000/mm3 C. Iron 90 g/100ml D. Neutrophils 67% Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Question to 66 to 70 refer to this? 66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion? A. Reduced or absent breath sound at the base of the lungs, dyspnea, tachypnea and shortness of breath. B. Hypoxemia C. Noisy respiration, crackles, stridor and wheezing D. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds 67. Thoracentesis is performed to the client with effusion. The nurse knows that he removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause: A. Pneumothorax B. Pleurisy or Pleuritis C. Cardiovascular collapse

D. Hypertension 68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that the pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to: A. Restore positive intrathoracic pressure B. Restore negative intrathoracic pressure C. To visualize the intrathoracic content D. As a method of air administration 69. The chest tube is functioning properly if: A. There is an oscillation B. There is no bubbling in the drainage bottle C. There is a continuous bubbling in the water seal. D. The suction control bottle has a continuous bubbling 70. In a client with pleural effusion, the nurse is instructing a appropriate breathing technique. Which of the following is included in the teaching? A. Breath normally B. Hold the breath after each inspiration for 1 full minute C. Practice abdominal breathing D. Inhale slowly and hold the breath for 3-5 seconds after each inhalation. Situation 13: Health care delivery system affects the health status of every Filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life. 71. When should rehabilitation commence? A. The day before discharge B. When the patient desires C. Upon admission D. 24hours after discharge 72. What exemplified the preventive and promotive programs in the hospital? A. Hospitals as a center to prevent and control infection B. Program for smokers C. Program for alcoholics and drug addicts D. Wellness Center 73. Which makes nursing dynamic? A. Every patient is a unique physical, emotional, social and spiritual being B. The patient participate in the over all nursing care plan C. Nursing practice is expanding in the light of modern development that takes place D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes. 74. Prevention is an important responsibility of the nurse in: A. Hospitals B. Community C. Workplace D. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a periodic payment. A. Health Maintenance Organization B. Medicare C. Philippine Health Insurance Act D. Hospital Maintenance Organization 91. Health care reports have different purposes. The availability of patients record to all health ream members demonstrates which of the following purposes: A. Legal documentation B. Education C. Research D. Vehicle for communication 92. When a nurse commits medication error she should accurately document clients response and her corresponding action. This is very important for which of the following purposes: A. Research B. Nursing Audit C. Legal documentation D. Vehicle for communication 93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should include: A. Prescription of the doctor to the patients illness B. Plan of care for patient C. Patients perception of ones illness D. Nursing Problem and Nursing Diagnosis 94. The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording? A. POMR B. SOAPIE C. Modified POMR D. SOMR 95. Which of the following is the advantage of SOMR or Traditional Recording? A. Increase efficiency of Data gathering B. Reinforces the use of the nursing process C. The caregiver can easily locate proper section for making charting entries D. Enhances effective communication among health care team members Situation 17: June is 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest X-ray revealed pleural effusion. The physician will perform thoracentesis 96. Thoracentesis is useful in treating which of the following pulmonary disorders except: A. Hemothorax B. Tuberculosis C. Hydrothorax D. Empyema 97. Which of the following psychological preparation is not relevant for him?

A. Telling him that the gauge of the needle and anesthesia to be used B. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place. C. Allow June to express his feeling and concerns D. Physicians explanation on the purpose of the procedure and how it will be done. 98. Before thoracentesis, the legal consideration you must check is: A. Consent is signed by the client B. Medicine preparation is correct C. Position of the client is correct D. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: A. Orthopneic B. Knee-chest C. Low fowlers D. Sidelying position on the affected side 100. Which of the following anesthetic drug is used for thoracentecis? A. Procaine 2 % B. Valium 250 mg C. Demerol 75 mg D. Phenobarbital

Situation Accurate computation prior to drug administration is a basic skill all nurses must have.

1. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will received per oral administration? A. 1,000 mg tid B. 500 mg tid C. 1,500 mg tid D. 50 mg tid 2. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose? A. 0.5 ml B. 1.5 ml C. 2.5 ml D. 10 ml 3. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug? A. Check the pump setting every 2 hours B. Teach the client how the infusion pump operates C. Have another nurse check the infusion pump setting

D. Set the alarm of the pump loud enough to be heard 4. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: give 3.00 cc of Lanoxin today for 1 dose only. Which of the following is the most appropriate action by the nurse? A. Clarify order with the attending physician B. Discuss the order with the pediatric heart specialist in the unit C. Administer Lanoxin intravenously as it is the usual route of administration D. Refer to the medication administration record for previous administration of Lanoxin 5. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse? A. Hold the nurse administration of the clients medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the clients medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurses station and prepare accordingly

Situation You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. 6. Using Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an: A. competent nurse B. novice nurse C. proficient nurse D. advanced beginner 7. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of having: A. the ability to organize and plan activities B. having attained an advanced level of education C. a holistic understanding and perception of the client D. intuitive and analytic ability in new situations 8. As you become socialized into the nursing culture you become a patient advocate. Advocacy is explained by the following EXCEPT: A. respecting a persons right to be autonomous B. demonstrating loyalty to the institutions rights C. shared respect, trust and collaboration in meeting health needs D. protecting and supporting another persons rights 9. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. Clinical nurse specialist B. Critical care nurse C. community health nurse D. staff nurse

10. You join a continuing education program to help you: A. Earn credits for license renewal B. Get in touch with colleagues in nursing C. Enhance your basic knowledge D. Update your knowledge and skills related to field of interest Situation Mr. Joses chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data. 11. Mr. Joses chart contains all information about his health care. The functions of records include all except: A. means of communication that health team members use to communicate their contributions to the clients health care B. the clients record also shows a document of how much health care agencies will be reimbursed for their services C. educational resource for student of nursing and medicine D. recording of actions in advance to save time 12. An advantage of automated or computerized client care system is: A. The nursing diagnoses for a clients data can be accurately determined B. Cost of confinement will be reduced C. Information concerning the client can b easily updated D. The number of people to take care of the client will be reduced 13. Information in the patients chart is inadmissible in court as evidence when: A. The clients family refuses to have it used B. The client objects to its use C. The handwriting is not legible D. It has too many abbreviations that are unofficial 14. Nursing audit aims to: A. provide research data to hospital personnel B. study clients illness and treatment regimen closely C. compare actual nursing done to established standards D. provide information to health-care providers 15. A telephone order is given for a client in your ward. What is your most appropriate action? A. Copy the order on to the chart and sign the physicians name as close to his original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the clients chart and have the head nurse co-sign it D. Tell the physician that you can not take the order but you will call the nurse supervisor Situation Errors while providing nursing care to patients must be avoided and minimized at all time. Effective management of available resources enables the nurse to provide safe, quality patient care. 16. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing

service department, probable causes were identified. Which of the following is process related? A. interruptions B. use of unofficial abbreviations C. lack of knowledge D. failure to identify client 17. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Method C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications. 18. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. The nurses check clients identification band before giving medications B. The nurse reports adverse reaction to drugs C. Average waiting time for medication administration is measured D. The unit has well ventilated medication room 19. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. Interviews nurses for comments regarding staffing B. Measures waiting time for clients per nurses call C. Checks equipment for its calibration schedule D. Determines whether nurses perform skin assessment every shift 20. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor? A. Assign another nurse to perform the procedure B. Ask the nurse to find way to learn the procedure C. Tell the nurse to read the procedure manual D. Do the procedure with the nurse Situation Oral care is an important part of hygienic practices and promoting client comfort. 21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution 22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control

D. Clean mouth with oral swabs in a careful and an orderly progression 23. The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves clients appearance and self-confidence D. improves appetite and taste of food 24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums D. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment Situation - Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU. 26. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case his condition becomes severe to a point that he will be unable to make decisions for himself. This document is: A. living will B. informed consent C. last will and testament D. power of attorney 27. After one day, the patients condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should: A. follow the patient because it is his right to die gracefully B. follow the patient as it is his right to determine the medical regimen he needs C. refuse the patient and encourage him to verbalize hid feelings D. refuse the patient since euthanasia is not accepted in the Philippines 28. Euthanasia is an ethical dilemma which confronts nurses in the ICU because: A. the choices involved do not appear to be clearly right or wrong B. a clients legal right co-exist with the nurses professional obligation C. decisions has to be made based on societal norms. D. decisions has to be mad quickly, often under stressful conditions 29. A nurse who supports a patient and familys need to make decisions that is right for them is practicing which of the following ethical principles?

A. Autonomy B. confidentiality C. privacy D. truthfulness 30. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as: A. power f attorney B. living will C. informed consent D. medical records Situation - Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education. 31. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration? A. planning B. controlling C. directing d. organizing 32. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of administration: A. monitoring B. evaluation C. organizing D. planning 33. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration: A. monitoring B. organizing C. evaluation D. planning 34. Revaluation and administrative process is BEST described as: A. a continuing process of seeing that performance meets goals and targets B. obtaining commitment of members to do better C. informing personnel how well and how much improvement has been made D. follow-up of activities that have been studied 35. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro? 1. Decision making skills 2. Forecasting skills 3. Auditing skills 4. Communications skills A. 2 & 3

B. 1 & 4 C. 1 & 2 D. 2 & 4 Situation - Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people. 36. How does a nurse promote ones well being? A. periodic travels for rest and recreation B. faithful and observance of healthy simple lifestyle C. run away from polluted, stressful areas D. avoid sleepless, over fatigue nights 37. The nurse can be involved with health promotion as a significant person in helping the family:

A. become a better family B. prevent disease C. control their symptoms D. modify health promotive behaviors 38. The nurse should NOT leave medication at the bedside because: a. the bedside table is not sterile b. it is convenient for the nurse c. the nurse will not be able to accurately document that the patient actually took the medication d. the patient may forget to take it. 39. Non-pharmacologic pain management includes all the following EXCEPT: a. relaxation techniques b. massage c. use of herbal medicines d. body movement 40. When assessing a clients blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. 10 b. 30 c. 45 d. 60 Situation The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials. 41. Martha wants to do a study on this topic: Effects of massage and meditation on stress and pain. The type of research that best suits this topic is: A. Applied research B. Qualitative research C. Basic research D. Quantitative research

42. The type of research design that does not manipulate independent variable is: A. Experimental design B. Quasi-experimental design C. Non-experimental design D. Quantitative design 43. This research topic has the potential to contribute to nursing because it seeks to A. include new modalities of care B. resolve a clinical problem C. clarify an ambiguous modality of care D. enhance client care 44. Martha does review of related literature for the purpose of A. determine statistical treatment of data research B. gathering data about what is already known or unknown about the problem C. to identify if problem can be replicated D. answering the research question 45. Clients rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT: A. right of self-determination B. right to compensation C. right of privacy D. right not to be harmed Situation Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen and remove excessive secretions in the airway. 46. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be: A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position 47. When documenting outcome of Richards treatment Mario should include the following in his recording EXCEPT: A. Color, amount and consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of client before and after the procedure D. Significant changes in vital signs 48. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT: A. Amount of food and fluid taken during the last meal before treatment B. Respiratory rate, breath sounds and location of congestion C. Teaching the clients relatives to perform the procedure D. Doctors order regarding position restrictions and clients tolerance for lying flat

49. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 50. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. In both percussion and vibration the hands are on top of each other and hand action is in tune with clients breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air.

Situation A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client. 51. When doing an initial assessment, the best way for you to identify the clients priority problem is to: A. Interview the client for chief complaints and other symptoms B. Talk to the relatives to gather data about history of illness C. Do auscultation to check for chest congestion D. Do a physical examination while asking the client relevant questions 52. Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to: A. Introduce the client to the ward staff to put the client and family at ease B. Give client and relatives a brief tour of the physical set up the unit C. Take his vital signs for a baseline assessment D. Establish priority needs and implement appropriate interventions 53. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will: A. Observe his sleeping patterns in the next few days B. Ask him what he means by this statement C. Check his physical environment to decrease noise level D. Take his blood pressure before sleeping and upon waking up 54. Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach? A. Moisturize lower extremities to prevent skin irritation B. Measure fluid intake and output to decrease edema C. Elevate lower extremities for postural drainage D. Provide the client a list of food low in sodium 55. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: A. Making a final physical assessment before client leaves the hospital

B. Giving instructions about his medication regimen C. Walking the client to the hospital exit to ensure his safety D. Proper recording of pertinent data

Situation Using Maslows need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurses knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. 56. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues: A. Carol with tumor in the brain B. Theresa with anemia C. Sonnyboy with a fracture in the femur D. Brigitte with diarrhea 57. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called: A. Cyanosis B. Hypoxia C. Hypoxemia D. Anemia 58. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be: A. tip of the nose to the base of the neck B. the distance from the tip of the nose to the middle of the neck C. the distance from the tip of the nose to the tip of the ear lobe D. eight to ten inches 59. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed B. Using gloves to prevent introduction of pathogens to the respiratory system C. Applying no suction while inserting the catheter D. Rotating catheter as it is inserter with gentle suction 60. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band? A. Ask the client if she is Mrs. Santos B. Ask the client his name C. Ask the room mate if the client is Mrs. Santos D. Compare the ID band with the bed tag Situation During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno, shows increased interest. 61. Mr. Bruno asks what the normal allowable salt intake is. Your best response to Mr. Bruno is: A. 1 tsp of salt/day with iodine and sprinkle of MSG B. 5 gms per day or 1 tsp of table salt/day

C. 1 tbsp of salt/day with some patis and toyo D. 1 tsp of salt/day but no patis and toyo 62. Your instructions to reduce or limit salt intake include all the following EXCEPT: A. eat natural food with little or no salt added B. limit use of table salt and use condiments instead C. use herbs and spices D. limit intake of preserved or processed food 63. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate concerns of the group. Your presentation for a group of young mothers would be best if you focus on: A. diets limited in salt and fat B. harmful effects of drugs and alcohol intake C. commercial preparation of dishes D. cooking demonstration and meal planning 64. Cancer cure is dependent on A. use of alternative methods of healing B. watching out for warning signs of cancer C. proficiency in doing breast self-examination D. early detection and prompt treatment 65. The role of the health worker in health education is to A. report incidence of non-communicable diseases to community health center B. educate as many people about warning signs of non-communicable diseases C. focus on smoking cessation projects D. monitor clients with hypertension Situation As you begin to work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them. 66. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote rest and sleep B. Instructing the client about the use of call system C. Raising the side rails D. Placing the bed in high position

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

68. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. Encourage the client to log roll when turning B. Encourage the client to do self-care C. Instruct the client to do deep breathing exercises D. Ambulate the client in ward premises every twenty minutes 69. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozanos hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? A. Involving family members in meeting clients personal needs B. Meeting his needs till he is ready to perform self-care C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care 70. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. Provide support to the family members by teaching ways to care for their loved one C. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family Situation Myrna, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 71. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursings body of knowledge B. Organizes the development of study and links the findings to nursings body of knowledge C. Provides logical structure of the research findings D. Identifies concepts and relationships between concepts 72. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. locating and identifying resources B. reading and recording notes C. clarifying a research topic D. using the library 73. The primary purpose for reviewing literature is to: A. organize materials related to the problem of interest B. generate broad background and understanding of information related to the research problem of interest C. select topics related to the problem of interest D. gather current knowledge of the problem of interest

74. In formulating the research hypotheses, researcher Myrna should state the research question as: A. What is the response of the staff nurses to the health values? B. How is variable health value perceived in a population? C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 75. The proposed study shows the relationship between the variables. Which of the following is the independent variable? A. Staff nurses in a selected college of nursing B. Health values C. Health promotion activities D. Relationship between health values and health promotion activities Situation While working in a tertiary hospital, you are assigned to the medical ward. 76. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a: A. Nurse supervisor B. Social worker C. bookkeeping department D. physician 77. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. receive emotional support B. to be a part of a research study C. provide financial assistance D. assist with chemotherapy 78. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a: A. nutritionist B. dietitian C. physician D. medical pathologist 79. When collaborating with other health team members, the best description of Nurse Ritas role is: A. encourages the clients involvement in his care B. shares and implements orders of the health team to ensure quality care C. she listens to the individual views of the team members D. helps client set goals of care and discharge 80. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies: A. Communication, trust, and decision making B. Conflict management, trust, negotiation C. Negotiation, decision making D. Mutual respect, negotiation and trust

Situation The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to provide safe nursing to your clients? 81. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is: A. critical thinking to decide appropriate nursing actions B. understanding of various nursing diagnoses C. observation skills for data collection D. possession of in scientific knowledge about client needs 82. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. creating plans of care for particular clientele B. identifying the correct nursing diagnoses for clients C. making a thorough assessment of client needs and problems D. using standards of nursing care as your criteria for evaluation 83. The effectiveness of your nursing care plan for your clients is determined by A. the number of nursing procedures performed to comfort the client B. the amount of medications administered to the client as ordered C. the number of times the client calls the nurse D. the outcome of nursing interventions based on plan of care 84. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue? A. Blood pressure measurement of 170/100 B. Complaint of hot flashes C. Report of pain after ingestion of fatty food D. Complaint of frequent bouts of dizziness 85. While talking with Mrs. Amado, it is most important for the nurse to: A. schedule the laboratory exams ordered for her B. do an assessment of the client to determine priority needs C. tell the client that your shift ends after eight hours D. have the client sign an informed consent Situation - Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 86. Given the above assessment data, the most immediate goal of the nurse would be which of the following?

A. Prevent urinary complication B. maintains fluid and electrolytes C. Alleviate pain D. Alleviating nausea

87. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. empty a sample urine from the collecting bag into the specimen container C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int the specimen container. D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 88. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation? A. to the patients inner thigh B. to the patients lower thigh C. to the patient D. to the patient lower abdomen 89. Which of the following menu is appropriate for one with low sodium diet? A. instant noodles, fresh fruits and ice tea B. ham and cheese sandwich, fresh fruits and vegetables C. white chicken sandwich, vegetable salad and tea D. canned soup, potato salad, and diet soda 90. How will you prevent ascending infection to Eileen who has an indwelling catheter? A. see to it that the drainage tubing touches the level of the urine B. change he catheter every eight hours C. see to it that the drainage tubing does not touch the level of the urine D. clean catheter may be used since urethral meatus is not a sterile area Situation You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications for these clients. 91. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what rate should the IV fluid be flowing hourly? A. 100 ml per hour B. 210 ml per hour C. 150 ml per hour D. 190 ml per hour 92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of 1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he receive at 11 am? A. 350 ml/hour B. 275 ml/hour C. 400 ml/hour D. 200 ml/hour 93. You are to apply a transdermal patch of nitoglycerin to your client. The following are important guidelines to observe EXCEPT: A. Apply to hairless clean area of the skin not subject to much wrinkling

B. Patches may be applied to distal part of the extremities like forearm C. Change application and site regularly to prevent irritation of the skin D. Wear gloves to avoid any medication on your hand 94. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops: A. directly onto the cornea B. pressing the lacrimal duct C. into the outer third of the lower conjunctival sac D. from the inner canthus going towards the side of the eye 95. When applying eye ointment, the following guidelines apply EXCEPT: A. squeeze about 2 cm of ointment and gently close but not squeeze the eye B. apply the ointment from the inner canthus going outward of the affected eye C. discard the first bead of the eye ointment before application because the tube is likely to expel more than desired amount of ointment D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva Situation The staff nurse supervisor requests all the staff nurses to brainstorm and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 96. The plan of the nurse supervisor is an example of A. in service education process B. efficient management of human resources C. increasing human resources D. primary prevention 97. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra A. makes the assignment to teach the staff member B. is assigning the responsibility to the aide but not the accountability for those tasks C. does not have to supervise or evaluate the aide D. most know how to perform task delegated 98. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should A. empathize with the nurse and listen to her B. tell her to take the day off C. discuss how she is adjusting to her new job D. ask about her family life 99. Process of formal negotiations of working conditions between a group of registered nurses and employer is A. grievance B. arbitration C. collective bargaining D. strike 100. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is

A. professional course towards credits B. inservice education C. advance training D. continuing education NURSING PRACTICE I SET A NURSING PRACTICE I Foundation of PROFESSIONAL Nursing Practice

MULTIPLE CHOICE 1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band? A. Ask the client if she is Mrs. Santos B. Ask the client his name C. Ask the room mate if the client is Mrs. Santos D. Compare the ID band with the bed tag 2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide the staff nurse in the use of touch, which of the following would be BEST response of Lizette? A. Use touch when the situation calls for it. B. Touch serves as a connection between the nurse and the patient. C. Use touch with discretion. D. Touch is used in physical assessment. 3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly? A. The cane and one foot or both feet are on the floor at all times B. He advances the cane followed by the left leg C. Client keeps the cane on the right side along the weak leg D. Client leans to the left side which is stronger 4. George, a 43 year old executive is scheduled for cardiac bypass surgery. While being prepared for the surgery, he says to the nurse I am not going to have the surgery. I may die because of the risk. Which response by the nurse is most appropriate? A. Without the surgery you will most likely die sooner. B. There are always risks involved with surgery. C. There is a client in the other room who had successful surgery and you can talk to him. D. This must be very frightening for you. Tel me how you feel about the surgery. 5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? A. Report to the physician the effects of the medication on urination. B. Take the medicine early in the morning C. Take a full glass of water with the medicine D. Measure frequency of urination in 24 hours

6. Nurse Glenda gets a call from the neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? A. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood. B. Recommend to bring the child immediately to the hospital C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital. D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to the hospital. 7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular accident. While being transported to the X-ray department, the straps accidentally broke and the client fell to the floor hitting to his head. In this situation, the nurse is: A. not responsible because of the doctrine of respondent superior B. free from any negligence that caused harm to the patient C. liable along with the employer for the use of a defective equipment that harms the client D. totally responsible for the negligence 8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna? A. Ignore the incidence B. Report the incidence to the head nurse C. Respect the clients actions as this provides structure and support to the client D. Call her attention so she can go to sleep 9. A client asks for advice on low cholesterol food. You advise the client to eat the following: A. Chicken liver, cow liver, eggs B. Lean beef and pork, egg ewhite, fish C. Balut, salted eggs, duck and chicken egg D. Pork liempo, cow brain, lungs and kidney 10. The code of ethics for nurses has an interpretative statement that provides: A. continuity of care for the improvement of the client B. guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the profession C. standards of care in carrying out nursing responsibilities D. identical care to all clients in any setting 11. Which of the following situations would possibly cause a nurse to be sued due to negligence? A. Nurse gave a client wrong medication, and an hour later, client complained of dyspnea B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the clients medicine cup C. As the nurse was about to administer medication, the client questioned why the medication is still given when in fact the physician discontinued it. D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error and complained.

12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital? A. Diabetic client type2 B. Client with chronic obstructive pulmonary disease (COPD) C. Client with second degree burns D. Client with psoriasis 13. Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has observed her to be too involved in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse? A. Dont worry. I will call the attention of your wife. B. Your wife is just trying to help because she is worried about you. C. What are your thoughts about your wifes involvement in your care? D. Your wife can assist you well in your care and recovery. 14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take? A. Approach the two nurses and tell them that their actions are inappropriate especially in a public place B. Wait till the nurses finish the discussion and report the situation to the supervisor C. Say nothing to avoid embarrassing the staff nurses D. Remain quiet and ignore the discussion 15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father has been getting out of bed at night and walks around the house in the early hours of the morning causing him to fall and injure himself. Which instruction would you give? A. Apply restraints during night hours only B. Advise hospitalization to prevent future accidents C. Keep a radio or TV for company and to orient the client D. Have someone check on the client frequently at night

Situation 1 Preparation and administration of medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save patients lives. 16. You are to administer an intramuscular injection to Dulce, 1 year old girl. The most appropriate site to administer the drug is: A. dorso gluteal region B. ventral forearm C. vastus lateralis D. gluteal region 17. An infant is ordered to receive 500ml of D5NSS for 24 hours. The intravenous drip is running at 60 drops/minute. How many drops per minute should the flow rate be? A. 60 drops per minute B. 21 drops per minute C. 30 drops per minute D. 15 drops per minute

18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? A. 42 drops B. 20 drops C. 60 drops D. 32 drops 19. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drop per minutes should the IV be regulated? A. 13-14 drops C. 10-12 drops B. 17-18 drops D. 15-16 drops 20. The physician ordered Nembutal Na gr XX. The bottle contains 100mg/capsule. How many capsule will be administered to the client? A. 1 capsule B. 1 capsule C. 2 capsule D. capsule Situation 2 The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved. 21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should: A. tell the nurse how to give bed baths correctly B. ask another staff nurse to do bed baths instead C. provide a manual to be read on giving bed baths D. bring the staff nurse to a clients room and demonstrate 22. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client. Together, they observe how well the dressings absorb the drainage. In what step of the decision making process are they? A. Testing options B. Considering effects on results C. Defining the problem D. Making final decisions 23. To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act responsibly when at work. Which of the following actions of the nurse demonstrates the attitude of responsibility? A. Thinking of alternative methods of nursing care B. Sharing ideas regarding patient care C. Following standards of practice D. Planning other approaches for patient care 24. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. Roman, a client who is ambulatory and for surgery tomorrow

B. A post operative client, Rey, who has a blood pressure of 90/50 mmHg C. Mr. Abad, a client who needs instructions for home medications D. Fred, a client who received pain medications 5 minutes ago 25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a clients problem and its possible cause. The following is an example of a well written nursing diagnosis: A. Acute pain related to altered skin integrity secondary to hysterectomy B. Electrolyte imbalance related to hypocalcemia C. Altered nutrition related to high fat intake secondary to obesity D. Knowledge deficit related to proctosigmoidoscopy Situation 3 You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV. 26. When caring for a dying client, you will perform which of the following activities? A. Encourage the client to reach optimal health B. Assist client perform activities of daily living C. Assist the client towards a peaceful death D. Motivate client to gain independence 27. The client prepares for her eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of: A. acceptance B. resolution C. denial D. bargaining 28. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a multidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. You are to give the both medications in one injection. You will: A. withdraw the medication from the vial first then from the ampule B. inject air into the vial, then into the ampule C. inject air into the ampule, aspirate the desired dose, then into the vial D. withdraw medication from the ampule then from the vial 29. When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml, what is the total volume that you will inject to the client? A. 2 ml B. 1 ml C. 1.5 ml D. 1.75 ml 30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity? A. Blisters B. Reddening of the skin C. Pressure sores D. Pustules Situation 4 You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility.

31. Ramils right leg is injured and Nurse Karen has to move him from the bed to wheel chair. Which of the following is the appropriate nursing action of Nurse Karen? A. Put the client on the edge of the bed and place the wheelchair at her back B. Face the client and place the wheelchair on her left side C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. Put the client on the edge of the bed and place the wheelchair on the clients left side 32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented? A. adduction of the shoulder B. Lateral flexion of the sternocleidomastoid muscle C. Hyperextension of the knees D. Anterior flexion of the lumbar curvature 33. Joseph prefers to be in high fowlers position most of the time. The nurse should prevent which of the following? A. Posterior flexion of the lumbar curvature B. Internal rotation of the shoulder C. External rotation of the hip D. Adduction of the shoulder 34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first? A. Move the patient to the edge of the bed near the nurse B. Adjust the bed to flat position C. Lock the wheels of the bed D. Raise the bed rails opposite the nurse 35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Sandbags C. Pillow B. Firm mattress D. High foot board Situation 5 As you begin to work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them. 36. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote rest and sleep B. Instructing the client about the use of call system C. Raising the side rails D. Placing the bed in high position

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

B. Impaired movements related to pain due to surgery C. Impaired mobility related to surgery D. Severe pain related to surgery 38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. Encourage the client to log roll when turning B. Encourage the client to do self-care C. Instruct the client to do deep breathing exercises D. Ambulate the client in ward premises every twenty minutes 39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozanos hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? A. Involving family members in meeting clients personal needs B. Meeting his needs till he is ready to perform self-care C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care 40. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. Provide support to the family members by teaching ways to care for their loved one C. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family Situation 6 Myrna, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 41. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursings body of knowledge B. Organizes the development of study and links the findings to nursings body of knowledge C. Provides logical structure of the research findings D. Identifies concepts and relationships between concepts 42. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. locating and identifying resources B. reading and recording notes C. clarifying a research topic D. using the library 43. The primary purpose for reviewing literature is to: A. organize materials related to the problem of interest B. generate broad background and understanding of information related to the research problem of interest

C. select topics related to the problem of interest D. gather current knowledge of the problem of interest 44. In formulating the research hypotheses, researcher Myrna should state the research question as: A. What is the response of the staff nurses to the health values? B. How is variable health value perceived in a population? C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 45. The proposed study shows the relationship between the variables. Which of the following is the independent variable? A. Staff nurses in a selected college of nursing B. Health values C. Health promotion activities D. Relationship between health values and health promotion activities Situation 7 While working in a tertiary hospital, you are assigned to the medical ward. 46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a: A. Nurse supervisor B. Social worker C. bookkeeping department D. physician 47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. receive emotional support C. provide financial assistance B. to be a part of a research study D. assist with chemotherapy 48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a: A. nutritionist B. dietitian C. physician D. medical pathologist 49. When collaborating with other health team members, the best description of Nurse Ritas role is: A. encourages the clients involvement in his care B. shares and implements orders of the health team to ensure quality care C. she listens to the individual views of the team members D. helps client set goals of care and discharge 50. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies: A. Communication, trust, and decision making B. Conflict management, trust, negotiation C. Negotiation, decision making D. Mutual respect, negotiation and trust

Situation 8 The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to provide safe nursing to your clients? 51. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is: A. critical thinking to decide appropriate nursing actions B. understanding of various nursing diagnoses C. observation skills for data collection D. possession of in scientific knowledge about client needs 52. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. creating plans of care for particular clientele B. identifying the correct nursing diagnoses for clients C. making a thorough assessment of client needs and problems D. using standards of nursing care as your criteria for evaluation 53. The effectiveness of your nursing care plan for your clients is determined by A. the number of nursing procedures performed to comfort the client B. the amount of medications administered to the client as ordered C. the number of times the client calls the nurse D. the outcome of nursing interventions based on plan of care 54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue? A. Blood pressure measurement of 170/100 B. Complaint of hot flashes C. Report of pain after ingestion of fatty food D. Complaint of frequent bouts of dizziness 55. While talking with Mrs. Amado, it is most important for the nurse to: A. schedule the laboratory exams ordered for her B. do an assessment of the client to determine priority needs C. tell the client that your shift ends after eight hours D. have the client sign an informed consent

Situation 9 Oral care is an important part of hygienic practices and promoting client comfort. 56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution 57. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?

A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and an orderly progression 58. The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves clients appearance and self-confidence D. improves appetite and taste of food 59. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums D. suctioning as needed while cleaning the buccal cavity 60. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment Situation 10 Errors while providing nursing care to patients must be avoided and minimized at all time. Effective management of available resources enables the nurse to provide safe, quality patient care. 61. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related? A. interruptions B. use of unofficial abbreviations C. lack of knowledge D. failure to identify client 62. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Method C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications. 63. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. The nurses check clients identification band before giving medications

B. The nurse reports adverse reaction to drugs C. Average waiting time for medication administration is measured D. The unit has well ventilated medication room 64. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. Interviews nurses for comments regarding staffing B. Measures waiting time for clients per nurses call C. Checks equipment for its calibration schedule D. Determines whether nurses perform skin assessment every shift 65. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor? A. Assign another nurse to perform the procedure B. Ask the nurse to find way to learn the procedure C. Tell the nurse to read the procedure manual D. Do the procedure with the nurse Situation 11 Mr. Joses chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data. 66. Mr. Joses chart contains all information about his health care. The functions of records include all except: A. means of communication that health team members use to communicate their contributions to the clients health care B. the clients record also shows a document of how much health care agencies will be reimbursed for their services C. educational resource for student of nursing and medicine D. recording of actions in advance to save time 67. An advantage of automated or computerized client care system is: A. The nursing diagnoses for a clients data can be accurately determined B. Cost of confinement will be reduced C. Information concerning the client can b easily updated D. The number of people to take care of the client will be reduced 68. Information in the patients chart is inadmissible in court as evidence when: A. The clients family refuses to have it used B. The client objects to its use C. The handwriting is not legible D. It has too many abbreviations that are unofficial 69. Nursing audit aims to: A. provide research data to hospital personnel B. study clients illness and treatment regimen closely C. compare actual nursing done to established standards D. provide information to health-care providers 70. A telephone order is given for a client in your ward. What is your most appropriate action?

A. Copy the order on to the chart and sign the physicians name as close to his original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the clients chart and have the head nurse co-sign it D. Tell the physician that you can not take the order but you will call the nurse supervisor Situation 12 Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of clients with various conditions. 71. Which of the following client conditions should be Miss Roques priority in the pediatric unit? A. The baby whose fantanelle is bulging and firm while asleep B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. A baby who is wailing after being awakened by the banging door D. A baby boy whose circumcision has yellowish exudate 72. When suctioning the endotracheal tube, the nurse should: A. Explain procedure to patient; insert catheter gently applying suction. Withdrawn using twisting motion B. Insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter is withdrawn C. Hyperoxygenate client insert catheter using back and forth motion D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn 73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. While Doris is doing spone bath, what action of Doris needs correction? A. Answering the phone while wearing gloves used for sponge bath B. Rolling the patient like a log to do back rub C. Lining the rubber mat with bed sheet as incontinence pad for the patient D. Turning the patient on the left side with head slightly elevated 74. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application is most important for Nurse Roque to do? A. Use baby powder to reduce irritation under the cast B. Assess sensation of each arm C. Evaluate skin temperature in the area D. Check radial pulses bilaterally and compare 75. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? A. Upon waking up, cough deeply and expectorate into container B. Cough after pursed lip breathing C. Save sputum for two days in covered container D. After respiratory treatment, expectorate into a container Situation 13 Infections are quite commonly the reasons for a clients hospitalization. Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care.

76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? A. Neutrophils 60% B. White blood cells (WBC) 9000/mm C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr D. Iron 75 mg/100 ml 77. Surgical sepsis is observed when: A. inserting an intravenous catheter B. disposing of syringes and needles in puncture proof containers C. washing hands before changing wound dressing D. placing dirty soiled linen in moisture resistant bags 78. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. Client was exposed to the infection 2 days ago but without any symptoms B. Oral temperature shows fever C. Acute symptoms are no longer visible D. Client feels sick but can do normal activities 79. Which of the following laboratory test result indicate presence of an infectious process? A. Erythrocyte sedimentation rate (ESR) 12 mm/hr B. White blood cells (WBC) 18,000/mm3 C. Iron 90 g/100ml D. Neutrophils 67% 80. Among the clients you are assigned to take care of, who is the most susceptible to infection? A. Diabetic client B. Client with burns C. client with pulmonary emphysema D. client with myocardial infarction Situation 14 You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. 81. Using Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an: A. competent nurse B. novice nurse C. proficient nurse D. advanced beginner 82. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of having: A. the ability to organize and plan activities B. having attained an advanced level of education C. a holistic understanding and perception of the client D. intuitive and analytic ability in new situations 83. As you become socialized into the nursing culture you become a patient advocate. Advocacy is explained by the following EXCEPT:

A. respecting a persons right to be autonomous B. demonstrating loyalty to the institutions rights C. shared respect, trust and collaboration in meeting health needs D. protecting and supporting another persons rights 84. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. Clinical nurse specialist C. community health nurse B. Critical care nurse D. staff nurse 85. You join a continuing education program to help you: A. Earn credits for license renewal B. Get in touch with colleagues in nursing C. Enhance your basic knowledge D. Update your knowledge and skills related to field of interest Situation 15 When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 86. The most important risk factor is: A. Cigarette smoking B. Hypertension C. binge drinking D. heredity 87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: A. Embolic stroke B. Hemorrhagic stroke C. diabetic stroke D. thrombotic stroke 88. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: A. phlebitis B. trauma C. damage to blood vessel D. aneurysm 89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? A. Amphetamines B. Cocaine C. shabu D. Demerol 90. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: A. More red blood cells thicken blood and make clots more possible. B. Increased RBC count is linked to high cholesterol. C. More red blood cell increases hemoglobin content. D. High RBC count increases blood pressure.

Situation 16 Accurate computation prior to drug administration is a basic skill all nurses must have. 91. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will received per oral administration? A. 1,000 mg tid B. 500 mg tid C. 1,500 mg tid D. 50 mg tid 92. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose? A. 0.5 ml B. 1.5 ml C. 2.5 ml D. 10 ml 93. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug? A. Check the pump setting every 2 hours B. Teach the client how the infusion pump operates C. Have another nurse check the infusion pump setting D. Set the alarm of the pump loud enough to be heard 94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: give 3.00 cc of Lanoxin today for 1 dose only. Which of the following is the most appropriate action by the nurse? A. Clarify order with the attending physician B. Discuss the order with the pediatric heart specialist in the unit C. Administer Lanoxin intravenously as it is the usual route of administration D. Refer to the medication administration record for previous administration of Lanoxin 95. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse? A. Hold the nurse administration of the clients medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the clients medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurses station and prepare accordingly Situation 17 You are taking care of Mrs. Santillan a 48 year old woman who is unconscious after a cerebrovascular accident. You are aware that there are many physical complications due to immobility. 96. You should be alert for the following complications she may experience EXCEPT: A. Impaired mobility B. Contractures and muscle atrophy

C. hypostatic pneumonia D. pressure sores 97. Proper positioning of an immobilized unconsciousness client is important for the following reasons EXCEPT: A. Maintain skin integrity B. Promotes optimal lung expansion C. Prevent injuries and deformities of the musculo-skeletal system D. Facilitates rest and sleep 98. When positioning your client, you should observe good body mechanics for yourself and the client. This means that the nurse: A. Uses back muscles B. Assumes correct body alignment and efficient use of muscles to avoid injury C. Observes rhythmic movements when moving about D. Uses large muscles only 99. You are going to move Mrs. Santillan, a 150 lbs unconscious woman. Some principles to use when moving the client include the following EXCEPT: A. prepare to move client by taking deep breath and tightening abdominal and gluteal muscles B. maintain wide base of support with feet and with knees flexed C. push and pull using arms and legs instead of lifting D. move close to the object to be moved leaning or bending at the waist 100. After moving Mrs. Santillan to the desired position, which action will you avoid? A. Avoid friction between bony prominences B. Place pillows to position clients extremeties C. Apply restraints D. Raise bed rails

Situation 1 Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg subcutaneously. 1. The indication for epinephrine injection for Mrs. Simon is to: A. Reduce anaphylaxis B. Relieve hypersensitivity to allergen C. Relieve respiratory distress due to bronchial spasm D. Restore clients cardiac rhythm 2. When preparing the epinephrine injection from an ampule, the nurse initially: A. Taps the ampule at the top to allow fluid to flow to the base of the ampule B. Checks expiration date of the medication ampule C. Removes needle cap of syringe and pulls plunger to expel air D. Breaks the neck of the ampule with a gauze wrapped around it 3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to: A. Inject needle at a 15 degree angle over the stretched skin of the client

B. Pinch skin at the injection site and use airlock technique C. Pull skin of patient down to administer the drug in a Z track D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: A. Syringe 3-5 ml and needle gauge 21 to 23 B. Tuberculin syringe 1 ml with needle gauge 26 or 27 C. Syringe 2 ml and needle gauge 22 D. Syringe 1-3 ml and needle gauge 25 to 27 5. The rationale for giving medications through the subcutaneous route is: A. There are many alternative sites for subcutaneous injection B. Absorption time of the medicine is slower C. There are less pain receptors in this area D. The medication can be injected while the client is in any position

Situation 2 The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials. 6. Martha wants to do a study on this topic: Effects of massage and meditation on stress and pain. The type of research that best suits this topic is: A. Applied research B. Qualitative research C. Basic research D. Quantitative research 7. The type of research design that does not manipulate independent variable is: A. Experimental design B. Quasi-experimental design C. Non-experimental design D. Quantitative design 8. This research topic has the potential to contribute to nursing because it seeks to A. include new modalities of care B. resolve a clinical problem C. clarify an ambiguous modality of care D. enhance client care 9. Martha does review of related literature for the purpose of A. determine statistical treatment of data research B. gathering data about what is already known or unknown about the problem C. to identify if problem can be replicated D. answering the research question 10. Clients rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT: A. right of self-determination B. right to compensation C. right of privacy

D. right not to be harmed Situation 3 Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen and remove excessive secretions in the airway. 11. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be: A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position 12. When documenting outcome of Richards treatment Mario should include the following in his recording EXCEPT: A. Color, amount and consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of client before and after the procedure D. Significant changes in vital signs 13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT: A. Amount of food and fluid taken during the last meal before treatment B. Respiratory rate, breath sounds and location of congestion C. Teaching the clients relatives to perform the procedure D. Doctors order regarding position restrictions and clients tolerance for lying flat 14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. In both percussion and vibration the hands are on top of each other and hand action is in tune with clients breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air Situation 4 A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client. 16. When doing an initial assessment, the best way for you to identify the clients priority problem is to: A. Interview the client for chief complaints and other symptoms

B. Talk to the relatives to gather data about history of illness C. Do auscultation to check for chest congestion D. Do a physical examination while asking the client relevant questions 17. Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to: A. Introduce the client to the ward staff to put the client and family at ease B. Give client and relatives a brief tour of the physical set up the unit C. Take his vital signs for a baseline assessment D. Establish priority needs and implement appropriate interventions 18. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will: A. Observe his sleeping patterns in the next few days B. Ask him what he means by this statement C. Check his physical environment to decrease noise level D. Take his blood pressure before sleeping and upon waking up 19. Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach? A. Moisturize lower extremities to prevent skin irritation B. Measure fluid intake and output to decrease edema C. Elevate lower extremities for postural drainage D. Provide the client a list of food low in sodium 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: A. Making a final physical assessment before client leaves the hospital B. Giving instructions about his medication regimen C. Walking the client to the hospital exit to ensure his safety D. Proper recording of pertinent data

Situation 5 Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension. 21. Considering her level of anxiety, the nurse can best assist Nancy by: A. Giving her activities to divert her attention B. Giving detailed explanations about the treatments she will undergo C. Preparing her and her family in case surgery is not successful D. Giving her clear but brief information at the level of her understanding 22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of: A. bargaining B. denial C. anger D. acceptance

23. The nurse visits Nancy and prods her to eat her food. Nancy replies whats the use? My time is running out. The nurses best response would be: A. The doctor ordered full diet for you so that you will be strong for surgery B. I understand how you feel but you have to try for your childrens sake C. Have you told your doctor how you feel? Are you changing your mind about your surgery? D. You sound like you are giving up. 24. The nurse feels sad about Nancys illness and tells her head nurse during the end of shift endorsement that its unfair for Nancy to have cancer when she is still so young and with two kids. The best response of the head nurse would be: A. Advise the nurse to be strong and learn to control her feelings B. Assign the nurse to another client to avoid sympathy for the client C. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her D. Ask the other nurses what they feel about the patient to find out if they share the same feelings 25. Realizing that she feels angry about Nancys condition, the nurse learns that being selfaware is a conscious process that she should do in any situation like this because: A. This is a necessary part of the nurse client relationship process B. The nurse is a role model for the client and should be strong C. How the nurse thinks and feels affect her actions towards her client and her work D. The nurse has to be therapeutic at all times and should not be affected Situation 6 Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. 26. Instruction on health promotion regarding urinary elimination is important. Which would you include? A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles B. If burning sensation is experienced while voiding, drink pineapple juice C. After urination, wipe from anal area up towards the pubis D. Tell client to empty the bladder at each voiding 27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation? A. inhibition of the parasympathetic reflex B. weakness of sphincter muscles of anus C. loss of tone of the smooth muscles of the colon D. decreased ability to absorb fluids in the lower intestines 28. The nurse understands that one of these factors contributes to constipation: A. excessive exercise B. high fiber diet C. no regular time for defecation daily D. prolonged use of laxatives 29. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would be to:

A. tell client to drink less fluids to avoid accidents B. instruct client to start wearing thin adult diapers C. ask the client to bring change of underwear just in case D. teach client pelvic exercise to strengthen perineal muscles 30. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by: A. Using thick diapers to absorb urine well B. Drying the skin with baby powder to prevent or mask the smell of ammonia C. Thorough washing, rising and drying of skin area that get wet with urine D. Making sure that linen are smooth and dry at all times Situation 7 Using Maslows need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurses knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. 31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues: A. Carol with tumor in the brain B. Theresa with anemia C. Sonnyboy with a fracture in the femur D. Brigitte with diarrhea 32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called: A. Cyanosis B. Hypoxia C. Hypoxemia D. Anemia 33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be: A. tip of the nose to the base of the neck B. the distance from the tip of the nose to the middle of the neck C. the distance from the tip of the nose to the tip of the ear lobe D. eight to ten inches 34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed B. Using gloves to prevent introduction of pathogens to the respiratory system C. Applying no suction while inserting the catheter D. Rotating catheter as it is inserter with gentle suction 35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. The nurse documents this condition as: A. Apnea B. Orthopnea C. Dyspnea D. Tachypnea

Situation 8 You are assigned to screen for hypertension. Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood pressure readings. 36. When taking blood pressure reading the cuff should be: A. deflated fully then immediately start second reading for same client B. deflated quickly after inflating up to 180 mmHg C. large enough to wrap around upper arm of the adult client 1 cm above brachial artery D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery 37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death world wide and is a preventable disease. The primary cause of COPD is A. tobacco hack B. bronchitis C. asthma D. cigarette smoking 38. In your health education class for clients with diabetes you teach them the areas for Control of Diabetes which include all EXCEPT A. regular physical activity B. thorough knowledge of foot care C. prevention nutrition D. proper nutrition 39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following is true? A. both types diabetes mellitus clients are all prone to developing ketosis B. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology C. Type I (IIDM) is characterized by fasting hyperglycemia D. Type II (NIDDM) is characterized by abnormal immune response 40. Lifestyle-related diseases in general share areas common risk factors. These are the following except: A. physical activity B. smoking C. genetics D. nutrition Situation 9 Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident 41. Her priority nursing action would be to: A. Assess damage to property B. Assist in the police investigation since she is a witness C. Report the incident immediately to the local police authorities D. Assess the extent of injuries incurred by the victims of the accident 42. Priority attention should be given to which of these clients? A. Linda who shows severe anxiety due to trauma of the accident B. Ryan who has chest injury, is pale and with difficulty breathing

C. Noel who has lacerations on the arms with mild bleeding D. Andy whose left ankle swelled and has some abrasions 43. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms. While assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to: A. Apply antiseptic to prevent infection B. Clean the wound vigorously of contaminants C. Control and reduce bleeding of the wound D. Bandage the wound and elevate the arm 44. The nurse applies dressing on the bleeding site. This intervention is done to: A. Reduce the need to change dressing frequently B. Allow the pus to surface faster C. Protect the wound from microorganisms in the air D. Promote hemostasis 45. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be discharged include the following EXCEPT: A. Encouraging the client to go to the outpatient clinic for follow up care B. Accurate recording of treatment done and instructions given to client C. Instructing the client to see you after discharge for further assistance D. Providing instructions regarding wound care Situation 10 While working in the clinic, a new client, Geline, 35 years old, arrives for her doctors appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment. 46. The purpose of your initial nursing interview is to: A. Record pertinent information in the clients chart for health team to read B. Assist the client find solutions to he her health concerns C. Understand her lifestyle, health needs and possible problems to develop a plan of care D. Make nursing diagnoses for identified health problems 47. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this pain occurs about an hour after taking black coffee without breakfast for three weeks now. You will record this as follows: A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics B. After drinking coffee, the client experienced severe abdominal pain C. Client complained of intermittent abdominal pain an hour after drinking coffee D. Client reported abdominal pain an hour after drinking black coffee for three weeks now. 48. Geline tells you that she drinks black coffee frequently within the day to have energy and be wide awake and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning a healthy balanced diet with Geline, you will: A. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet and drink plenty of fluids B. Plan a high protein diet, low carbohydrate diet for her considering her favorite food. C. Instruct her to attend classes in nutrition to find food rich in complex

carbohydrates to maintain daily high energy level. D. Discuss with her the importance of eating a variety of food from major food groups with plenty of fluids. 49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following? A. Caffeine products affect the central nervous system and may cause the mother to have a nervous breakdown B. Malnutrition and its possible effects on growth and development problems in the unborn fetus C. Caffeine causes a stimulant effect on both mother and the baby D. Studies show conclusively that caffeine causes mental retardation 50. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of non-communicable diseases that are influenced by her lifestyle. These include the following EXCEPT: A. Cardiovascular diseases B. Cancer C. Diabetes Mellitus D. Osteoporosis

Situation 11 Management of nurse practitioners is done by qualified nursing leaders who had clinical experience and management experience. 51. An example of a management function of a nurse is: A. Teaching patient do breathing and coughing exercises B. Preparing for a surprise party for a client C. Performing nursing procedures for clients D. Directing and evaluating the staff nurses 52. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone without consulting anybody. This type of leadership is: A. Laissez faire leadership B. Democratic leadership C. Autocratic leadership D. Managerial leadership 53. When the head nurse in your ward plots and approves your work schedules and directs your work, she is demonstrating: A. Responsibility B. Delegation C. Accountability D. Authority 54. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT: A. Transfer a client from bed to chair B. Change IV infusions C. Irrigation of a nasogastric tube

D. Take vital signs 55. You made a mistake in giving the medicine to the wrong client. You notify the clients doctor and write an incident report. You are demonstrating: A. Responsibility B. Accountability C. Authority D. Autocracy

Situation 12 Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.

56. You are to measure the clients initial blood pressure reading by doing all of the following EXCEPT: A. Take the blood pressure reading on both arms for comparison B. Listen to and identify the phases of Korotkoffs sound C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated D. Observe procedures for infection control 57. A pulse oximeter is attached to Mr. Dizons finger to: A. Determine if the clients hemoglobin level is low and if he needs blood transfusion B. Check level of clients tissue perfusion C. Measure the efficacy of the clients anti-hypertensive medications D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops 58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: A. inconsistent B. low systolic and high diastolic C. higher than what the reading should be D. lower than what the reading should be 59. Through the clients health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the clients blood pressure for accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes 60. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours

Situation 13 The nurses understanding of ethico-legal responsibilities will guide his/her nursing practice. 61. The principles that govern right and proper conduct of a person regarding life, biology and the health professionals is referred to as: A. Morality B. Religion C. Values D. Bioethics 62. The purpose of having a nurses code of ethics is: A. Delineate the scope and areas of nursing practice B. Identify nursing action recommended for specific health care situations C. To help the public understand professional conduct expected of nurses D. To define the roles and functions of the health care givers, nurses, clients 63. The most important nursing responsibility where ethical situations emerge in patient care is to: A. Act only when advised that the action is ethically sound B. Not takes sides, remain neutral and fair C. Assume that ethical questions are the responsibility of the health team D. Be accountable for his or her own actions 64. You inform the patient about his rights which include the following EXCEPT: A. Right to expect reasonable continuity of care B. Right to consent to or decline to participate in research studies or experiments C. Right to obtain information about another patient D. Right to expect that the records about his care will be treated as confidential 65. This principle states that a person has unconditional worth and has the capacity to determine his own destiny: A. Bioethics B. Justice C. Fidelity D. Autonomy Situation 14 Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you know that this entails quality assurance programs. 66. The following mechanisms can be utilized as part of the quality assurance program of your hospital EXCEPT: A. Patient satisfaction surveys B. Peer review to assess care provided C. Review of clinical records of care of client D. Use of Nursing Interventions Classification 67. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is? A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice B. It refers to the scope of nursing practice as defined in Republic Act 9173 C. It is a license issued by the Professional Regulation Commission to protect the

public from substandard nursing practice D. The Standards of Care includes the various steps of the nursing process and the standards of professional performance 68. you are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone? A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours C. Have the registered nurse, family and doctor sign the order D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours 69. To ensure client safety before starting blood transfusions the following are needed before the procedure can be done EXCEPT: A. take baseline vital signs B. blood should be warmed to room temperature for 30 minutes before blood transfusions is administered C. have two nurses verify client identification, blood type, unit number and expiration date of blood D. get consent signed for blood transfusion 70. Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true? A. Doctors order for restraints should be signed within 24 hours B. Remove and reapply restraints every 2 hours C. Check clients pulse, blood pressure and circulation every 4 hours D. Offer food and toileting every 2 hours Situation 15 During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno, shows increased interest. 71. Mr. Bruno asks what the normal allowable salt intake is. Your best response to Mr. Bruno is: A. 1 tsp of salt/day with iodine and sprinkle of MSG B. 5 gms per day or 1 tsp of table salt/day C. 1 tbsp of salt/day with some patis and toyo D. 1 tsp of salt/day but no patis and toyo 72. Your instructions to reduce or limit salt intake include all the following EXCEPT: A. eat natural food with little or no salt added B. limit use of table salt and use condiments instead C. use herbs and spices D. limit intake of preserved or processed food 73. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate concerns of the group. Your presentation for a group of young mothers would be best if you focus on: A. diets limited in salt and fat B. harmful effects of drugs and alcohol intake C. commercial preparation of dishes

D. cooking demonstration and meal planning 74. Cancer cure is dependent on A. use of alternative methods of healing B. watching out for warning signs of cancer C. proficiency in doing breast self-examination D. early detection and prompt treatment 75. The role of the health worker in health education is to A. report incidence of non-communicable diseases to community health center B. educate as many people about warning signs of non-communicable diseases C. focus on smoking cessation projects D. monitor clients with hypertension Situation 16 You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications for these clients. 76. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what rate should the IV fluid be flowing hourly? A. 100 ml per hour B. 210 ml per hour C. 150 ml per hour D. 190 ml per hour 77. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of 1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he receive at 11 am? A. 350 ml/hour B. 275 ml/hour C. 400 ml/hour D. 200 ml/hour 78. You are to apply a transdermal patch of nitoglycerin to your client. The following are important guidelines to observe EXCEPT: A. Apply to hairless clean area of the skin not subject to much wrinkling B. Patches may be applied to distal part of the extremities like forearm C. Change application and site regularly to prevent irritation of the skin D. Wear gloves to avoid any medication on your hand 79. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops: A. directly onto the cornea B. pressing the lacrimal duct C. into the outer third of the lower conjunctival sac D. from the inner canthus going towards the side of the eye 80. When applying eye ointment, the following guidelines apply EXCEPT: A. squeeze about 2 cm of ointment and gently close but not squeeze the eye B. apply the ointment from the inner canthus going outward of the affected eye C. discard the first bead of the eye ointment before application because the

tube is likely to expel more than desired amount of ointment D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva Situation 17 The staff nurse supervisor requests all the staff nurses to brainstorm and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 81. The plan of the nurse supervisor is an example of A. in service education process B. efficient management of human resources C. increasing human resources D. primary prevention 82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra A. makes the assignment to teach the staff member B. is assigning the responsibility to the aide but not the accountability for those tasks C. does not have to supervise or evaluate the aide D. most know how to perform task delegated 83. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should A. empathize with the nurse and listen to her B. tell her to take the day off C. discuss how she is adjusting to her new job D. ask about her family life 84. Process of formal negotiations of working conditions between a group of registered nurses and employer is A. grievance B. arbitration C. collective bargaining D. strike 85. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is A. professional course towards credits B. inservice education C. advance training D. continuing education Situation 18 There are various developments in health education that the nurse should know about: 86. The provision of health information in the rural areas nationwide through television and radio programs and video conferencing is referred to as: A. Community health program B. Telehealth program C. Wellness program D. Red Cross program

87. A nearby community provides blood pressure screening, height and weight measurement, smoking cessation classes and aerobics class services. This type of program is referred to as A. outreach program B. hospital extension program C. barangay health program D. wellness program 88. Part of teaching client in health promotion is responsibility for ones health. When Danica states she needs to improve her nutritional status this means: A. Goals and interventions to be followed by client are based on nurses priorities B. Goals and intervention developed by the nurse and client should be approved by the doctor C. Nurse will decide goals and interventions needed to meet client goals D. Client will decide the goals and interventions required to meet her goals 89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary provision is A. Marriage counseling B. Self-examination for breast cancer C. Identifying complication of diabetes D. Poison Control 90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical cancer. This is an example of A. tertiary prevention B. secondary prevention C. health screening D. primary prevention Situation 19 Ronnie was in a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you notice how anxious he looks. 91. You establish rapport with him and to reduce his anxiety you initially: A. Take him to the radiology section for X-ray of affected extremity B. Identify yourself and state your purpose in being with the client C. Talk to the physician for an order of Valium D. Do inspection and palpation to check extent of his injuries 92. While doing your assessment, Ronnie asks you Do I have a fracture? I dont want to have a cast. The most appropriate nursing response would be: A. You have to have an x ray first to know if you have a fracture. B. Why do you sound so scared? It is just a cast and its not painful. C. You seem to be concerned about being in a cast. D. Based on my assessment, there doesnt seem to be a fracture. 93. Ronnie is very anxious and is unaware of the extent of his injury. The nurse can best assist him by: A. Asking the doctor to give an order for a sedative to call him down B. Informing him that he is being treated by a very competent health team so he has nothing to worry about C. Identifying his level of anxiety to determine how much information he can understand

D. Allaying his anxiety by telling him that he only sustained a minor injury 94. After cleaning the abrasions and applying antiseptic, the nurse applies cold compress to the swollen ankle as ordered by the physician. This statement shows that the nurse has correct understanding of the use of cold compress: A. Cold compress reduces blood viscosity in the affected area B. It is safer to apply than hot compress C. Cold compress prevents edema and reduces pain D. It eliminates toxic waste products due to vasodilation 95. After receiving prescription for pain medication, Ronnie is instructed to continue applying 30 minute cold at home and start 30 minute hot compress the next day. You explain that the use of hot compress: A. Produces anesthetic effect B. Increases nutrition in the blood to promote wound healing C. Increase oxygenation to the injured tissues for better healing D. Induces vasoconstriction to prevent infection Situation 20 A nursing professor assigns a group of students to do data gathering by interviewing their classmates as subjects. 96. She instructed the interviewees not to tell the interviewees that the data gathered are for her own research project for publication. This teacher has violated the students right to: A. Not be harmed B. Disclosure C. Privacy D. Self-determination 97. A nurse preceptor observes that many clients are being readmitted in the ward for postoperative infections. She suggests to the students that they do a research on this topic. What research activity is this? A. Sharing research results with colleagues B. Identifying clinical problem C. Developing guidelines for patient care D. Data collection 98. Quantitative research involves numerical data. Which of the following is based on quantitative research? A. A study on the effects of the white uniform of hospital personnel on pediatric patients B. The effects of regular nurse visits to clients bedside on the number of clients calls to the nurse C. A study on benefits of pre-operative health instructions to clients feeling of anxiety D. A study on the effects of touch on the clients feelings of isolation 99. Before the nurse researcher starts her study, she analyzes how much time, money, materials and people she will need to complete the research project. This analysis prior to beginning the study is called: A. Validity B. Feasibility C. Reliability D. Researchability

100. Data analysis is to be done and the nurse researcher wants to include variability. These include the following EXCEPT: A. Variance B. Range C. Standards of Deviation D. Mean Situation 1: Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU. 1. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case his condition becomes severe to a point that he will be unable to make decisions for himself. This document is: A. living will C. last will and testament B. informed consent D. power of attorney 2. After one day, the patient s condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should: A. follow the patient because it is his right to die gracefully B. follow the patient as it is his right to determine the medical regimen he needs C. refuse the patient and encourage him to verbalize hid feelings D. refuse the patient since euthanasia is not accepted in the Philippines 3. Euthanasia is an ethical dilemma which confronts nurses in the ICU because: A. the choices involved do not appear to be clearly right or wrong B. a clients legal right co-exist with the nurse s professional obligation C. decisions has to be made based on societal norms. D. decisions has to be mad quickly, often under stressful conditions 4. A nurse who supports a patient and family s need to make decisions that is right for them is practicing which of the following ethical principles? A. Autonomy B. confidentiality C. privacy d. truthfulness 5. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as: A. power f attorney C. informed consent B. living will D. medical records Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education. 6. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration? A. planning B. controlling C. directing d. organizing 7. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of administration: A. monitoring B. evaluation C. organizing d. planning

8. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration: A. monitoring B. organizing C. evaluation d. planning 9. Revaluation and administrative process is BEST described as: A. a continuing process of seeing that performance meets goals and targets B. obtaining commitment of members to do better C. informing personnel how well and how much improvement has been made D. follow-up of activities that have been studied 10. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro? 1. Decision making skills 2. Forecasting skills 3. Auditing skills 4. Communications skills A. 2 & 3 &4 Situation 3: Meldy. 40 years old. is waiting for her doctor s appointment at the clinic where you work. 11. You are to interview her as an initial nursing action so that you can. A. Document important data in her client records for health team to read. B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop plan of care C. provide solutions to her immediate health concern D. identify the most appropriate nurse diagnosis for her heath problem 12. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as: A. Client complains of intermittent abdominal pain an hour alter eating fatty foods B. After eating fatty food the client experienced severe abdominal pain C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods. 13. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will: A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids. B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates. C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise. D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet. 14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her premenopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation because: A. these products increase calcium loss from the bones B. These products have stimulant effect n the body B. 1 & 4 C. 1 & 2 D. 2

C. these products encourage increase in sugar consumption D. these products are addicting 15. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT: A. Cancer B. DM C. Osteoporosis D. Cardiovascular diseases Situation 4: Changes in technology, the nation s economy and the increasing number of population have brought about changes in the Health Care System. 16. At present, government hospitals are expected to offer comprehensive health services to include illness prevention and health promotion. In which of the following unit of services are these services integrated? A. Wellness center C. Rehabilitation Center C. Intensive Care unit D. newborn screening unit 17. Which of the following is the MOST recent government initiative to help subsidize the cost of health services for both the employed and the unemployed? A. National Health Insurance Act C. Medicare Act B. Worker s Compensation Act D. Magna Carta for Public Health Workers 18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of these conditions are preventable and have implications are preventable and have implications in the development of which nursing competencies? A. Execution of nsg. procedure and technique B. Therapeutic use of self C. Administration of treatment and medication D. Health education 19. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These facts will MOST LIKELY bring about development in which of the following? A. acute services C. home care services B. managed care services D. advance practice nursing 20. Which of the following latest trend has expanded health services based on prepaid fees with emphasis on health promotion and illness prevention? A. Government Insurance Plan C. Health Maintenance Organization B. Preferred Provider Organization D. Private Insurance Plan Situation 5: It is Safety Awareness Week in the Community and the nurse checks on the presence of hazards at home. The nurse plan is to have the residents themselves identify the physical hazards in their own homes. 21. Which of the following is NOT a physical hazard in the home? A. unstable and slippery stairway B. large windows that allow good ventilation C. obstacle people cam trip over like door mats, rugs, electric cords D. inadequate lighting in and out of the house 22. Risk factors exist for each of the different developmental levels. From infancy to preschool age, the most common cause of death is injury rather than disease. To protect children from harm, that parents should be aware that MOST injuries for this age group are due to:

A. Accidents at home caused by the swallowed poisonous materials, small objects, exploring electrical sockets B. Accidents from self inflicted wounds C. accidents from sports related activities at school or the neighborhood D. accidents in the Playground Park, school and presence of strangers who may abduct of molest the child. 23. To promote safety at home, the nurse identifies ways and means of child proofing the house. Which of the following is NOT safe? A. apply child proof caps and medicine bottles and chemicals B. covering electrical outlets, tying up long and loose electrical and telephone cords, securing cabinets or doors within reach o the child C. giving colorful grocery bags to play with or to store toys and materials D. removing objects that the child could easily dismantle and swallow like small parts of a mechanical toy, buttons, materials inside, stuffed animals, liquid chemicals. 24. The nurse knows that a person s hygienic practices are influenced family customs and traditions. Which of the following is NOT part of Basic Hygienic Practices? A. bathing practices, frequency and time, care of eyes, ear and nose B. oral hygiene practices such as brushing and flossing teeth, gum care C. care of skin with lesions, cuts with infection D. hair and skin such as washing hair and face, feet, hand and nail care 25. Falls are the common home accident among elderly and these are due to physical limitations imposed by aging and some hazards in the home setting. The nurse reduces the risk of falling through the following EXCEPT: A. rearranging furniture frequently B. having the bed or mattress close to the floor C. providing a nonskid and well fitted shoes or slippers D. having a call bell within the persons reach and answering call bells immediately Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 26. Given the above assessment data, the most immediate goal of the nurse would be which of the following?

A. Prevent urinary complication B. maintains fluid and electrolytes C. Alleviate pain D. Alleviating nausea

27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. empty a sample urine from the collecting bag into the specimen container C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 28. Where would the nurse tape Eileen s indwelling catheter in order to reduce urethral irritation? A. to the patient s inner thigh C. to the patient B. to the patient s lower thigh D. to the patient lower abdomen 29. Which of the following menu is appropriate for one with low sodium diet? A. instant noodles, fresh fruits and ice tea B. ham and cheese sandwich, fresh fruits and vegetables C. white chicken sandwich, vegetable salad and tea D. canned soup, potato salad, and diet soda 30. Howe will you prevent ascending infection to Eileen who has an indwelling catheter? A. see to it that the drainage tubing touches the level of the urine B. change he catheter every eight hours C. see to it that the drainage tubing does not touch the level of the urine D. clean catheter may be used since urethral meatus is not a sterile area Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed diabetic patient. She is beginning to write objectives of her teaching plan. 31. Which of the following objectives is written in behavioral terms? A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out B. Mang Carlos daughter should learn about DM within the week C. Mang Carlos wife needs to understand the side effects of insulin D. Mang Carlos sister will be able to determine in two days his insulin requirement based on blood glucose levels obtained from glucometer 32. Which of the following is the BEST rationale for written objectives? A. ensure communication among staff members B. facilitate evaluation of the nurse s performance C. ensure learning on the part of the nurse D. document the quality of care 33. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease condition? A. frequent use of technical terms for familiarization B. drawing him into discussion about diabetes C. detailed lengthy explanation about his condition

D. loosely structured teaching session 34. Miss Tingson should encourage exercise in the management of diabetes, because it: A. decrease total triglyceride levels C. lowers blood glucose B. improves insulin utilization D. accomplishes all of the above 35. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is: A. dehydration B. hypertension C. hypoglycemia Situation 8: Caring for the perioperative patient. 36. An appendectomy during a hysterectomy would be classified as: A. Major, emergency, diagnosis C. Minor, elective, ablative B. major, urgent, palliative D. minor, urgent, reconstructive 37. An informed consent is required for: A. closed reduction of a fracture B. insertion of intravenous catheter

D. glucosuria

C. irrigation of the external ear canal D. urethral catheterization

38. The circulating nurse s responsibilities, in contrast to the scrub nurse s responsibilities, include: A. assisting the surgeon C. setting up the sterile tables B. monitoring aseptic practices D. all of the above functions 39. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: A. Laryngospasm C. hypoxemia and hypercapnea B. hyperventilation D. pulmonary edema ad embolism 40. Unless contraindicated, any unconscious patient should be positioned: A. flat on his of her back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications B. in semi-fowlers position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand. c. in fowler s position, which most closely stimulates a sitting position, thus facilitating reparatory as well as gastrointestinal functioning. D. on his or her side without a pillow at the patient s back and his or her chin extended to minimize the danger of aspirations Situation 9: To prevent further injury to patients with problems of immobility / mobility, the nurse should observe certain principles of body mechanics for herself and her patients. 41. Which of the following are appropriate goals for client with positioning and mobility needs? A. developing of contractures C. sensory alterations B. proper body alignment D. decrease in activity tolerance 42. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair? A. bending at the knees C. using body weight to assist with the movement B. standing with feet together D. standing with feet apart 43. Which of the following is the CORRECT guideline when positioning patients? A. put pillows above a joint to immobilize it B. position of the joint should be slightly extended C. joints of patient to be supported with pillow

D. patient s position should be changed at least three or four times a day 44. Which of the following can be used by clients with problem of immobility to enable them raise their body from bed to wheelchair or perform some bed exercises? A. sandbag B. side-rail C. trochanter roll D. trapeze bar 45. The importance of forcing fluids with an immobilized patient is to: A. prevent pneumonia C. prevent skin breakdown B. prevent urinary stasis D. maintain peristalsis 46. Which of the following is the least nursing activity in performing assessment of the patient? A. laboratory test C. Health history B. physical examination D. systemic review 47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of the four assessment techniques did he utilize? 1. auscultation 3. palpation 2. percussion 4. inspection A. 1,2 & 3 B. 3 &4 C. 1 & 2 D. 1,3 & 4 48. Which of the following are the purpose of performing a physical assessment? 1. gather baseline data about the client s health 2. confirm and identify nursing diagnosis 3. evaluate physiological outcome of care 4. make clinical judgment of patients diagnosis A. 1,2 & 4 B. 2, 3 & 4 C. 1, 3 & 4

D. 1,2 & 3

49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient? A. preparation of the equipment C. preparation of the environment B. psychological preparation of the client D. physical preparation of the client 50. During the assessment phase of the nursing process, the nurse is concerned with: A. interpreting data B. designing nursing strategies C. establishing a data base D. comparing client responses with the anticipated outcome Situation 11: The nurse is responsible to accurately records and reports patient s progress. She is able to communicate to the other member of the team by documenting the nursing care plan and the appropriate nursing intervention. 51. A main function of the patient s records is to: A. prepare the nurse for the shift worked B. serve as a record of financial charges C. serve as a vehicle for communication D. ensure that the message is received 52. When the nurse writes in the chart and discovers an error has been made, which is the BEST approach? A. erase the erroneous material B. carefully ink out the erroneous material C. place as asterisk next to the statement, then footnote it

D. draw a straight line through the error and initial it. 53. Which of the following persons cannot have the access to the patient record? A. physical therapist C. the patient B. lawyer of the family D. speech therapist 54. POMR charting is different from traditional method because of which of the following practices? 1. SOAP charting 3. narrative charting 2. use of flow sheet 4 . use of checklist A. 3 & 4 B. 1 & 2 C. 1 & 3 D. 2 & 3 55. Which of the following qualities are relevant in documenting patients care? Accuracy and consciousness thoroughness and currentness systematic and orderly legibly, properly dated and signed use of locally accepted abbreviation A. 1,3,4 & 5 B. 2,3,4 & 5 C. 1,2,3 & 5 D. 1,2,3 & 4 Situation 12: The practice of primary nurse in primary nursing is preferred by many nurses because it supports professional autonomy and accountability of the nurses> 56. What is the function of the primary nurse in primary nursing? A. acts as patient advocate and coordinate the health care team for specific group of patients B. act as the charge nurse, organizing staff assignments and help in solving problem in the unit C. plans and coordinate the patient care assigned to her from admission to discharge D. coordinates the care given to a group of patients by support staff 57. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the following principles? A. autonomy and authority for planning care are best delegated to a nurse B. accountability is clearest since our nurse is responsible for the overall plan and implementation of care C. the holistic approach provides fro a therapeutic relationship continuity of care and efficient nursing care D. continuity of patients care promotes efficient nursing care. 58. Which is the role of the associate nurse in primary nursing? A. over-all manager of the unit B. responsible for the over-all care of the patient during off days of primary nurse C. patient advocate in the health care team D. coordinator of comprehensive, holistic patient care 59. In primary nursing, the nurse is responsible for which of the following group of patient? A. the whole ward B. small group of patient like 3-5 patients C. big group of patients like 10-15 patients D. the whole unit 60. In primary nursing who among the following is needed to her leadership and quality control in the ward? A. the chief nurse C. the nurse supervisor B. the head nurse D. the service director

1. 2. 3. 4. 5.

Situation 13: Your nursing unit plans to conduct a study on the use of structured preoperative preparation in lessening the demand for post-operative pain medications. 61. Which of the following research activities should you initially do? A. find out from interview how many patients are willing to participate B. get the permission from the hospital director C. review literature on the topic D. prepare the tool for collecting data 62. Which of the following statements do NOT contribute to the researchabilty of your proposed problem? A. potential use of findings C. well-defined problem statement B. readability of findings D. measurability of variables 63. A study /research table should NOT contain which of the following ? A. categories of data collected C. specific title of table B. relevant rows and columns D. names and sample of the selected 64. Which of the following actions will facilitate analysis of research data? A. consult a physician C. consult a complete expert B. consult an adviser D. categorize data collected 65. The research methodology that is appropriate for the above problem would be: A. descriptive B. normative C. experimental experimental

D. quasi

Situation 14: The nurse meets a new client, Mr. Principe, 50 years old. During the initial interview, the nurse begins to feel irritated towards the client. Shortly after, he becomes uncomfortable and politely leaves the room. The nurse realizes the behavior and mannerism of Mr. Principe reminds him of his strict disciplinarian father who abused him physically. 66. The recognize that his feeling for the client is known as: A. denial B. counter transference transference

C. revenge

D.

67. Seeing that his negative feelings for Mr. Principe could affect his nursing care, the nurse applies the concept of therapeutic use of self when: A. the nurse talks about his personal feelings towards the client B. the nurse suppresses his feelings and continue to take care of the client C. the nurse uses his awareness and asks to be reassigned to another client D. the nurse uses self-awareness to manage his feelings and thoughts towards the client 68. Mr. Principe is terminally ill and his family is coping with his impending death. The nurse has to deal with his own thoughts and personal feelings about death and grieving in order to: A. avoid sharing personal thought about their impending loss and feeling of grief since this is very subjective B. get self out of the way while he assists the client and his family express their feelings of impending loss C. prevent self from being affected by the family s grief and remain objective D. help the family plan for the funeral arrangement and burial services

69. One morning when the nurse enters the client s room. Mr. Principe asks the nurse to leave me alone and stop bothering me and I don t want your pity . The following response by the nurse would be MOST appropriate? A. You seem upset this morning and remains with the client B. You are probably upset because you don t feel well C. Why you are angry with me? What did I do anything to upset you? D. I understand and will leave you for a while 70. The nurse understands that the nurse-client relationship is a therapeutic alliance when: A. the nurse is a role model for a client B. this is an essential part of the nursing process C. the nurse has to be therapeutic at all times D. how the nurse thinks and feels affects her actions and behavior towards her client and her work Situation 15: Mr. Ong is for admission to the medical unit and you are his nurse. 71. The MOST important initial nursing approach when admitting client is to: A. introduce the client to the ward staff B. orient the client to the physical set up of the unit C. identify the most immediate needs of the client and implement the necessary intervention D. take V/S fro baseline assessment 72. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to: A. talk to the relatives C. do auscultation B. interview the client D. do a physical assessment 73. You want to know the sleeping pattern of Mr. Ong You will: A. interview the clients and relatives B. take his BP before sleeping and upon waking up C. observe his sleeping pattern over a period of time D. perform physical assessment 74. Mr. Ong has severe pedal edema. Which accessory device would be appropriate for his condition? A. footboard B. cradle C. bed board D. rolled pillows 75. A student nurse is observed putting a standard size cuff on an obese client. The action would probably result in BP reading that is: A. false high B. false low C. normal D. undetectable Situation 16: Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people. 76. How does a nurse promote one s well being? A. periodic travels for rest and recreation B. faithful and observance of healthy simple lifestyle C. run away from polluted, stressful areas D. avoid sleepless, over fatigue nights 77. The nurse can be involved with health promotion as a significant person in helping the family:

A. become a better family

B. prevent disease C. control their symptoms D. modify health promotive behaviors

78. The nurse should NOT leave medication at the bedside because: a. the bedside table is not sterile b. it is convenient for the nurse c. the nurse will not be able to accurately document that the patient actually took the medication d. the patient may forget to take it. 79. Non-pharmacologic pain management includes all the following EXCEPT: a. relaxation techniques c. use of herbal medicines b. massage d. body movement 80. When assessing a client s blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. 10 b. 30 c. 45 d. 60 Situation 17: Safe nursing practice involves an understanding of the law. 81. In the Philippines, this law is : a. The Philippine Nursing Act of 2002 or R.A. 9173 b. the Philippine Nursing Act of 1991 or R.A. 7164 c. IRR or Resolution 425 of 2003 d. Republic Act No. 8981 82. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for: a. health promotion and prevention of illness b. administration of written prescription for treatment and therapies c. rehabilitative aspect of care d. Collaborating with other healthcare providers for health restoration and alleviation of suffering 83. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions include all EXCEPT: a. used by nurse experts to define what appropriate nursing practice is in a given situation b. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances c. used to delineate the scope, function and role of the nurse d. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields 84. As a standard in ethics, this represents an understanding and agreement to respect another person s right to decide a course his or her own destiny: a. Autonomy c. Beneficence b. justice d. nonmalifecence 85. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and stand by one s action refers to: a. accountability c. advocacy b. veracity d. responsibility Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change, create better ways of providing nursing care and develop new nursing roles.

86. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. maintain maximum functions C. promote health habits B. reduce the costs of health care D. identify disease symptoms 87. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST? A. maintain maximum function C. promote habits related to health care B. reduce risk factor D. manage stress 88. By experience, which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital? A. illness prevention C. diagnosis and treatment B. health promotion D. rehabilitation of patients 89. Which of the following health care agencies is usually family-centered, relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness? A. non-government organization C. community health center B. hospice D. support group 90. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting? A. Bill of rights as provided in the Philippine Constitution B. Scope of nursing practice as defined in R.A. 9173 C. Patient s Bill of Rights ( as adopted by American Nurses Association ) D. Board of Nursing resolution adopting the Code of Ethics Situation 19: One of the professional competencies that nurse must always demonstrate is in the area of communication: 91. Which communication technique would be MOST effective in eliciting detailed information from the client? A. open-ended questioning C. active listening B. verbalizing observations D. summarizing clients views 92. Which of the following terms refer to the sender s attitude towards the self, the message and the listener? A. verbal communication C. non-verbal communication B. double-bind communication D. meta communication 93. In interacting with patients, the nurses should remember that a client s personal space is: A. that which revolves around the client B. highly mobile depending upon certain situation C. clearly visible to others D. the same as that of the nurse 94. In interpersonal communication is LEAST threatening during what type of relationship? A. social C. personal B. intimate D. professional

95. In demonstrating the method for deep breathing exercises, the nurse places the hands on the client s abdomen to explain diaphragmatic movement. This technique involves the use of which element of communication? A. appropriateness C. channel B. feedback D. message Situation 20: Roy, an adolescent, was diagnosed to have pneumonia. He constantly complains of chest pain and has a standing order of Morphine SO4. 96. Which of the following MOST appropriately describe pain sensation that has periods of remission and exacerbation? A. chronic C. acute B. intractable D. Psychosomatic 97. Roy is constantly asking to be relieved from pain. Since morphine is an addicting drug, which of the following is BEST for the patient? A. administer morphine SO4 PRN B. administer morphine on a routine schedule as ordered C. give instructions on relaxation technique to reduce frequency of pain sensation D. divert the attention by not limiting visitors 98. To get accurate information about the quality of pain the patient is experiencing, which of the following statements would be MOST APPROPRIATE? A. What cause you the pain? C. Have you taken something to relieve the pain? B. Tell me what your pain feels like D. Is it stubbing or radiating pain? 99. As the nurse assigned to Ray, which of the following can decrease his chest pain? A. supporting his rib cage when he coughs C. teaching him B. advising him D. encouraging him to breathe deeply 100. Which of the following is the nurse s primary goal in caring for clients with chronic pain? A. change the clients perception of pain B. reduce the clients perception of pain C. change the clients reaction to pain D. enumerate the source of pain