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Mario listens to Richard’s 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
When documenting outcome of Richard’s treatment Mario should include the following in his
recording EXCEPT:
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 client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
Mario prepares Richard for postural drainage and percussion. Which of the following is a
special consideration when doing the procedure?
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 client’s 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.
When doing an initial assessment, the best way for you to identify the client’s priority problem
is to:
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
A. Beneficence
B. Fidelity
C. Veracity
D. Nonmaleficence
During which step of the nursing process does the nurse analyze data related to the patient's
health status?
A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation
The basic difference between nursing diagnoses and collaborative problems is that
Situation – Mrs. Seva, 52 years old, asks you about possible problems regarding her
elimination now that she is in the menopausal stage.
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
Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical
changes predispose her to constipation?
A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxative
You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of
the tubing for an adult would be:
Situation– 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.
You are to measure the client’s initial blood pressure reading by doing all of the following
EXCEPT:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
In which type of shock does the patient experiences a mismatch of blood flow to the cells?
A. Distributive
B. Cardiogenic
C. Hypovolemic
D. Septic
The preferred route of administration of medication in the most acute care situations is which
of the following routes?
A. Intravenous
B. Epidural
C. Subcutaneous
D. Intramuscular
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
Through the client’s 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 client’s blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes
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. 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
To ensure client safety before starting blood transfusions the following are needed before the
procedure can be done EXCEPT:
Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:
Which of the following methods is the best method for determining nasogastric tube placement
in the stomach?
A. X-ray
B. Observation of gastric aspirate
C. Testing of pH of gastric aspirate
D. Placement of external end of tube under water
Which of the following is the most important risk factor for development of Chronic
Obstructive Pulmonary Disease?
A. Cigarette smoking
B. Occupational exposure
C. Air pollution
D. Genetic abnormalities
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing
and gently rotating the catheter 360 degrees for which of the following time periods?
A. 10-15 seconds
B. 30-35 seconds
C. 20-25 seconds
D. 0-5 seconds
The nurse auscultates the apex beat at which of the following anatomical locations?
Which of the following terms describes the amount of blood ejected per heartbeat?
A. Stroke volume
B. Cardiac output
C. Ejection fraction
D. Afterload
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
The nurse is correct in performing suctioning when she applies the suction intermittently
during:
Which priority nursing diagnosis is applicable for a patient with indwelling urinary catheter?
An incontinent elderly client frequently wets his bed and eventually develop redness and skin
excoriation at the perianal area. The best nursing goal for this client is to:
As a Nurse Manager, DMLM enjoys her staff of talented and self motivated individuals. She
knew that the leadership style to suit the needs of this kind of people is called:
A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire
A fire has broken in the unit of DMLM R.N. The best leadership style suited in cases of
emergencies like this is:
A. Autocratic
B. Participative
C. Democratic
E. Laissez Faire
Which step of the management process is concerned with Policy making and Stating the goals
and objective of the institution?
A. Planning
B. Organizing
C. Directing
D. Controlling
In the management process, the periodic checking of the results of action to make sure that it
coincides with the goal of the institution is termed as:
A. Planning
B. Evaluating
C. Directing
D. Organizing
The Vision of a certain agency is usually based on their beliefs, Ideals and Values that directs
the organization. It gives the organization a sense of purpose. The belief, Ideals and Values of
this Agency is called:
A. Philosophy
B. Mission
C. Vision
D. Goals and Objectives
Mr. CKK is unconscious and was brought to the E.R. Who among the following can give
consent for CKK’s Operation?
A. Doctor
B. Nurse
C. Next of Kin
D. The Patient
Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is
no longer capable to do so. As a Nurse, You know that this is called:
It is not a legally binding document but nevertheless, Very important in caring for the patients.
In monitoring the patient in PACU, the nurse correctly identify that checking the patient’s vital
signs is done every:
A. 1 hour
B. 5 minutes
C. 15 minutes
D. 30 minutes
diannemayde R.N is conducting a research on her unit about the effects of effective nurse-
patient communication in decreasing anxiety of post operative patients. Which of the following
step in nursing research should she do next?
Before diannemaydee perform the formal research study, what do you call the pre testing,
small scale trial run to determine the effectiveness of data collection and methodological
problem that might be encountered?
A. Sampling
B. Pre testing
C. Pre Study
E. Pilot Study
In the recent technological innovations, which of the following describe researches that are
made to improve and make human life easier?
A. Pure research
B. Basic research
C. Applied research
D. Experimental research
When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
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
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
The law which regulated the practice of nursing profession in the Philippines is:
A. R.A 9173
B. LOI 949
C. Patient’s Bill of Rights
E. Code of Ethics for Nurses
This quality is being demonstrated by a Nurse who raise the side rails of a confuse and
disoriented patient?
A. Autonomy
B. Responsibility
C. Prudence
D. Resourcefulness
Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the
student. The case was frustrated homicide. Nurse Joel and Ana are aware of the different
circumstances of crimes. They are correct in identifying which of the following
Circumstances that will be best applied in this case?
A. Justifying
B. Aggravating
C. Mitigating
D. Exempting
In signing the consent form, the nurse is aware that what is being observed as an ethical
consideration is the patient’s
A. Autonomy
B. Justice
C. Accountability
D. Beneficence
A. Because the law do not clearly state what is right from what is wrong
B. Because morality is subjective and it differs from each individual
C. Because the patient’s right coincide with the nurse’s responsibility
D. Because the nurse lacks ethical knowledge to determine what action is correct and what action
is unethical
Who among the following can work as a practicing nurse in the Philippines without taking the
Licensure examination?
In signing the consent form, the nurse is aware that what is being observed as an ethical
consideration is the patient’s
A. Autonomy
B. Justice
C. Accountability
D. Beneficence
A. Accountable
B. Responsible
C. Critical thinker
D. Assertive
A. Is a form of assigning a nurse to lead a team of registered nurses in care of patient from
admission to discharge
B. A nurse is responsible in doing certain tasks for the patient
C. A registered nurse is responsible for a group of patients from admission to discharge
D. A registered nurse provides care for the patient with the assistant of nursing aides
The best and most effective method in times of staff and financial shortage is:
A. Functional Method
B. Primary Nursing
C. Team Nursing
E. Modular Method
You are doing bed bath to the client when suddenly, The nursing assistant rushed to the
room and tell you that the client from the other room was in Pain. The best intervention in
such case is:
A. Raise the side rails, cover the client and put the call bell within reach and then attend to the
client in pain to give the PRN medication
B. Tell the nursing assistant to give the pain medication to the client complaining of pain
C. Tell the nursing assistant to go the client’s room and tell the client to wait
D. Finish the bed bath quickly then rush to the client in Pain
Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the
following is the best nursing intervention to prevent future falls?
A. 45 °
B. 90 °
C. 180 °
D. Parallel to the skin
The following statements are all true about Z-Track technique except:
Communication is best undertaken if barriers are first removed. Considering this statement,
which of the following is considered as deterrent factor in communication?
Nurse DMLM is correct in identifying the correct sequence of events during abdominal
assessment if she identifies which of the following?
. To prevent injury and strain on the muscles, the nurse should observe proper body
mechanics. Among the following, which is a principle of proper body mechanics?
A. Broaden the space between the feet
B. Push instead of pull
C. Move the object away from the body when lifting
D. Bend at the waist, not on the knees
In taking the client’s blood pressure, the nurse should position the client’s arm:
What principle is used when the client with fever loses heat through giving cooling bed bath to
lower body temperature?
A. Radiation
B. Convection
C. Evaporation
D. Conduction
The most effective way in limiting the number of microorganism in the hospital is:
The immunoglobulin of the mother that crosses the placenta to protect the child is an example
of:
Richard is a subject of a research lead by his doctor. The nurse knows that all of the following
is a correct understanding as his right as a research subject except:
A. I can withdraw with this research even after the research has been started
B. My confidentiality will not be compromised in this research
C. I must choose another doctor if I withdrew from this research
D. I can withdraw with this research before the research has been started
Which of the following is a normal finding during assessment of a Chest tube in a 3 way bottle
system?
A. There is a continuous bubbling in the drainage bottle
B. There is an intermittent bubbling in the suction control bottle
C. The water fluctuates during inhalation of the patient
D. There is 3 cm of water left in the water seal bottle
In obtaining a urine specimen for culture and sensitivity on a catheterized patient, the nurse is
correct if:
A. Clamp the catheter for 30 minutes, Alcoholize the tube above the clamp site, Obtain a sterile
syringe and draw the specimen on the tube above the clamp
B. Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self
sealing port
C. Disconnect the drainage bag, obtain a sterile syringe and draw the specimen from the drainage
bag
D. Disconnect the tube, obtain a sterile syringe and draw the specimen from the tube
A. Teaching the diabetic client on obtaining his blood sugar level using a glucometer
B. Screening patients for hypertension
C. Immunizing infants with BCG
D. Providing PPD on a construction site
An abnormal condition in which a person must sit, stand or use multiple pillows when lying
down is:
A. Orthopnea
B. Dyspnea
C. Eupnea
D. Apnea
As a nurse assigned for care for geriatric patients, you need to frequently assess your
patient using the nursing process. Which of the following needs be considered with the
highest priority?
A. Patients own feeling about his illness
B. Safety of the client especially those elderly clients who frequently falls
C. Nutritional status of the elderly client
D. Physiologic needs that are life threatening
The component that should receive the highest priority before physical examination is the:
Which of the following categories identifies the focus of community/public health nursing
practice?
A. Promoting and maintaining the health of populations and preventing and minimizing the
progress of disease
B. Rehabilitation and restorative services
C. Adaptation of hospital care to the home environment
D. Hospice care delivery
Gina, A client in prolong labor said she cannot go on anymore. The health care team decided
that both the child and the mother cannot anymore endure the process. The baby is premature
and has a little chance of surviving. Caesarian section is not possible because Gina already lost
enough blood during labor and additional losses would tend to be fatal. The husband decided
that Gina should survive and gave his consent to terminate the fetus. The principle that will be
used by the health care team is:
A. Beneficence
B. Non malfeasance
C. Justice
D. Double effect
Situation – There are various developments in health education that the nurse should know
about:
The provision of health information in the rural areas nationwide through television and radio
programs and video conferencing is referred to as:
In teaching the sister of a diabetic client about the proper use of a glucometer in determining
the blood sugar level of the client, The nurse is focusing in which domain of learning
according to bloom?
A. Cognitive
B. Affective
C. Psychomotor
D. Affiliative
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
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:
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 student’s right to:
A. Not be harmed
B. Disclosure
C. Privacy
D. Self-determination
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
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
Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-
care visit typically made?
A. Quasi-Judicial Power
B. Regulatory Power
C. Quasi-Legislative Power
D. Executive/Promulgating Power
Anita is performing BSE and she stands in front of the Mirror. The rationale for standing in
front of the mirror is to check for:
An emerging technique in screening for Breast Cancer in developing countries like the
Philippines is:
After a vaginal examination, the nurse determines that the client’s fetus is in an occiput
posterior position. The nurse would anticipate that the client will have:
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting
The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:
Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.
The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:
A. Measles vaccine
B. DPT
C. Hepa-B vaccine
D. Tetanus toxoids
A. Measles
B. Tetanus toxoids
C. Hepatitis B vaccines
D. DPT
This special form is used when the patient is admitted to the unit. The nurse completes the
information in this record particularly his/her basic personal data, current illness, previous
health history, health history of the family, emotional profile, environmental history as well as
physical assessment together with nursing diagnosis on admission. What do you call this
record?
A. Nursing Kardex
B. Nursing Health History and Assessment Worksheet
C. Medicine and Treatment Record
D. Discharge Summary
These are sheets/forms which provide an efficient and time saving way to record information
that must be obtained repeatedly at regular and/or short intervals of time. This does not replace
the progress notes; instead this record of information on vital signs, intake and output,
treatment, postoperative care, post partum care, and diabetic regimen, etc. This is used
whenever specific measurements or observations are needed to be documented repeatedly.
What is this?
A. Nursing Kardex
B. Graphic Flow Sheets
C. Discharge Summary
D. Medicine and Treatment Record
These records show all medications and treatment provided on a repeated basis. What do you
call this record?
This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the
activity and treatment section and a nursing care plan section. This carries information about
basic demographic data, primary medical diagnosis, current orders of the physician to be
carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and
procedures, safety precautions in patient care and factors related to daily living activities. This
record is used in the charge-of-shift reports or during the bedside rounds or walking rounds.
What record is this?
A. Discharge Summary
B. Medicine and Treatment Record
C. Nursing Health History and Assessment Worksheet
D. Nursing Kardex
Most nurses regard this conventional recording of the date, time, and mode by which the
patient leaves a healthcare unit but this record includes importantly, directs of planning for
discharge that starts soon after the person is admitted to a healthcare institution. It is accepted
that collaboration or multidisciplinary involvement (of all members of the health team) in
discharge results in comprehensive care. What do you call this?
A. Discharge Summary
B. Nursing Kardex
C. Medicine and Treatment Record
D. Nursing Health History and Assessment Worksheet
Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of
nursing responsibility and accountability?
A nurse should be cognizant that professional programs for specialty certification by the Board
of Nursing accredited through the:
Integrated management for childhood illness is the universal protocol of care endorsed by
WHO and is use by different countries of the world including the Philippines. In any case that
the nurse classifies the child and categorized the signs and symptoms in PINK category, You
know that this means:
A. Urgent referral
B. Antibiotic Management
C. Home treatment
D. Out patient treatment facility is needed
You know that fast breathing of a child age 13 months is observed if the RR is more than:
A. 40
B. 50
C. 60
D. 30
Angelo, An 8 month old child is brought to the health care facility with sunken eyes. You pinch
his skin and it goes back very slowly. In what classification of dehydration will you categorize
Angelo?
A. No Dehydration
B. Some Dehydration
C. Severe Dehydration
D. Diarrhea
In responding to the care concerns of children with severe disease, referral to the hospital is of
the essence especially if the child manifests which of the following?
A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken
A child with ear problem should be assessed for the following, EXCEPT:
If the child does not have ear problem, using IMCI, what should you as the nurse do?
All of the following are treatment for a child classified with no dehydration except:
An ear infection that persists but still less than 14 days is classified as:
A. Mastoiditis
B. Chronic Ear Infection
C. Acute Ear Infection
D. Otitis Media
If a child has two or more pink signs, you would classify the child as having:
A. No disease
B. Mild form of disease
C. Urgent Referral
D. Very severe disease
The nurse knows that the most common complication of Measles is:
A client scheduled for hysterosalpingography needs health teaching before the procedure. The
nurse is correct in telling the patient that:
In a population of 9,500. What is your estimate of the population of pregnant woman needing
tetanus toxoid vaccination?
A. 632.5
B. 512.5
C. 450.5
D. 332.5
All of the following are seen in a child with measles. Which one is not?
A. Reddened eyes
B. Coryza
C. Pustule
D. Cough
Mobilizing the people to become aware of their own problem and to do actions to solve it is
called:
A. Community Organizing
B. Family Nursing Care Plan
C. Nursing Intervention
D. Nursing Process
Prevention of work related accidents in factories and industries are responsibilities of which
field of nursing?
In one of your home visit to Mr. JUN, you found out that his son is sick with cholera. There is
a great possibility that other member of the family will also get cholera. This possibility is a/an:
A. Foreseeable crisis
B. Health threat
C. Health deficit
D. Crisis
Aling Maria is nearing menopause. She is habitually taking cola and coffee for the past 20
years. You should tell Aling Maria to avoid taking caffeinated beverages because:
A. It is stimulating
B. It will cause nervousness and insomnia
C. It will contribute to additional bone demineralization
D. It will cause tachycardia and arrhythmias
Theresa, a mother with a 2 year old daughter asks, “at what age can I be able to take the blood
pressure of my daughter as a routine procedure since hypertension is common in the family?”
Your answer to this is:
What is the rationale in the use of bag technique during home visits?
A. It helps render effective nursing care to clients or other members of the family
B. It saves time and effort of the nurse in the performance of nursing procedures
C. It should minimize or prevent the spread of infection from individuals to families
D. It should not overshadow concerns for the patient
In consideration of the steps in applying the bag technique, which side of the paper lining of
the CHN bag is considered clean to make a non-contaminated work area?
A. About 12 words
B. Twenty or more words
C. About 50 words
D. Two, plus “mama” and “papa”
. During operation, The OR suite’s lighting, noise, temperature and other factors that affects the
operation are managed by whom?
A. Nurse Supervisor
B. Surgeon
C. Circulating nurse
D. Scrub nurse
Before and after the operation, the operating suite is managed by the:
A. Surgeon
B. Nurse Supervisor
C. Nurse Manager
D. Chief Nurse
The counting of sponges is done by the Surgeon together with the:
A. Circulating nurse
B. Scrub nurse
C. Assistant surgeon
D. Nurse supervisor
The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?
A. Scrub Nurse
B. Surgeon
C. Anaesthesiologist
D. Circulating Nurse
Surgery schedules are communicated to the OR usually a day prior to the procedure by the
nurse of the floor or ward where the patient is confined. For orthopedic cases, what
department is usually informed to be present in the OR?
A. Rehabilitation department
B. Laboratory department
C. Maintenance department
D. Radiology department
In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is
your nursing priority care in such a case?
The patient’s medical record can work as a double edged sword. When can the medical record
become the doctor’s/nurse’s worst enemy?
In the hospital, when you need the medical record of a discharged patient for research you will
request permission through:
A. Doctor in charge
B. The hospital director
C. The nursing service
D. Medical records section
You will give health instructions to Carlo, a case of bronchial asthma. The health instruction
will include the following, EXCEPT:
As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
Overdosage of medication or anesthetic can happen even with the aid of technology like infusion
pumps, sphygmomanometer and similar devices/machines. As a staff, how can you improve the
safety of using infusion pumps?
While team effort is needed in the OR for efficient and quality patient care delivery, we should
limit the number of people in the room for infection control. Who comprise this team?
When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:
When administering Tapazole, The nurse should monitor the client for which of the following
adverse effect?
A. Hyperthyroidism
B. Hypothyroidism
C. Drowsiness
D. Seizure
Post bronchoscopy, the nurse priority is to check which of the following before feeding?
A. Gag reflex
B. Wearing off of anesthesia
C. Swallowing reflex
D. Peristalsis
Changes normally occur in the elderly. Among the following, which is a normal change in an
elderly client?
A. Increased weight
B. Irritation of skin around the stoma
C. Liquid stool
D. Establishment of regular bowel movement
The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
A. Increase the irrigating solution flow rate when abdominal cramps is felt
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Position client in semi-Fowler
D. Hang the solution 18 inches above the stoma
What sensation is used as a gauge so that patients with ileostomy can determine how often their
pouch should be drained?
A. Sensation of taste
B. Sensation of pressure
C. Sensation of smell
D. Urge to defecate
In performing a cleansing enema, the nurse performs the procedure by positioning the client in:
Mang Caloy is scheduled to have a hemorrhoidectomy, after the operation, you would expect that
the client’s position post operatively will be:
You would expect that after an abdominal perineal resection, the type of colostomy that will be
use is?
You are an ostomy nurse and you know that colostomy is defined as:
A. It is an incision into the colon to create an artificial opening to the exterior of the abdomen
B. It is end to end anastomosis of the gastric stump to the duodenum
C. It is end to end anastomosis of the gastric stump to the jejunum
D. It is an incision into the ileum to create an artificial opening to the exterior of the abdomen
Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After
taking the history and vital signs the physician does which test as a screening test for colorectal
cancer.
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy
24 Hours after creation of colostomy, Nurse Violy is correct if she identify that the normal
appearance of the stoma is :
In cleaning the stoma, the nurse would use which of the following cleaning mediums?
When observing a return demonstration of a colostomy irrigation, you know that more teaching is
required if pt:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable
What does a sample group represent?
A. Control group
B. Study subjects
C. General population
D. Universe
As a nurse, you can help improve the effectiveness of communication among healthcare givers
by:
A. Hyperglycemia
B. Hypothermia
C. Hyperthermia
D. Hypoglycemia
Mang Edgardo has a chest tube inserted in place after a Lobectomy. The nurse knows that that
Chest tube after this procedure will:
Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions,
EXCEPT:
A. straddling a chair with arms and head resting on the back of the chair
B. lying on the unaffected side with the bed elevated 30-40 degrees
C. lying prone with the head of the bed lowered 15-30 degrees
D. sitting on the edge of the bed with her feet supported and arms and head on a padded overhead
table
Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another
chest x-ray, you will explain:
The RR nurse should monitor for the most common postoperative complication of:
A. hemorrhage
B. endotracheal tube perforation
C. osopharyngeal edema
D. epiglottis
The PACU nurse will maintain postoperative T and A client in what position?
Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy.
You as the RN will make sure that the family knows to:
Situation – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so that an
A-V shunt was surgically created.
Which of the following action would be of highest priority with regards to the external shunt?
A. Avoid taking BP or blood sample from the arm with the shunt
B. Instruct the client not to exercise the arm with the shunt
C. Heparinize the shunt daily
D. Change dressing of the shunt daily
Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium.
The nutrition instructions should include:
A. Recommend protein of high biologic value like eggs, poultry and lean meats
B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
C. Allowing the client cheese, canned foods and other processed food
D. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet
A. E. Coli
B. Klebsiella
C. Pseudomonas
D. Staphylococcus
The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase
the chance of passing the stones, you instructed her to force fluids and do which of the following?
A. Balanced diet
B. Ambulate more
C. Strain all urine
D. Bed rest
Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment
of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper
extremities and right lower extremities. His wife asks what that means? Your most accurate
response would be:
During the first 24 hours after the thermal injury, you should asses Sergio for:
All of the following are instruction for proper foot care to be given to a client with peripheral
vascular disease caused by Diabetes. Which is not?
You are on morning duty in the medical ward. You have 10 patients assigned to you. During your
endorsement rounds, you found out that one of your patients was not in bed. The patient next to
him informed you that he went home without notifying the nurses. Which among the following
will you do first?
You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found
out that what is on record does not tally with the drugs used. Which among the following will you
do first?
A. Write an incident report and refer the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any patient who might have been given narcotics
You are on duty in the medical ward. The mother of your patient who is also a nurse, came
running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
When observing a return demonstration of a colostomy irrigation, you know that more teaching is
required if pt:
E. Lubricates the tip of the catheter prior to inserting into the stoma
F. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
G. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
H. Clamps of the flow of fluid when felling uncomfortable
Which of the four phases of emergency management is defined as “sustained action that reduces
or eliminates long-term risk to people and property from natural hazards and their effects.”?
A. Recovery
B. Mitigation
C. Response
D. Preparedness
Which of the following terms refer to a process by which the individual receives education about
recognition of stress reaction and management strategies for handling stress which may be
instituted after a disaster?
Fires are approached using the mnemonic RACE, in which, R stands for:
A. Run
B. Race
C. Rescue
D. Remove
You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP).
Which intervention should you include in your plan to reduce ICP?
A. desquamation
B. erythema
C. atrophy
D. pigmentation
A guideline that is utilized in determining priorities is to asses the status of the following,
EXCEPT:
A. perfusion C. respiration
B. locomotion D. mentation
Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives
and changes money and then hold the bread without washing her hand. As a nurse, What will you
say to Miss Kate?
A. 18
B. 22
C. 23
D. 24
Before administration of blood and blood products, the nurse should first:
A. Check with another R.N the client’s name, Identification number, ABO and RH type.
B. Explain the procedure to the client
C. Assess baseline vital signs of the client
D. Check for the BT order
A. D5LR
B. D5NSS
C. NSS
D. Plain LR
In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention
should focus on:
A. Slow the infusion, Call the physician and assess the patient
B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the
physician
C. Stop the infusion, Call the physician and assess the client
D. Slow the confusion and keep a patent IV line open for administration of medication
The nurse knows that after receiving the blood from the blood bank, it should be administered
within:
A. 1 hour
B. 2 hours
C. 4 hours
D. 6 hours
During blood administration, the nurse should carefully monitor adverse reaction. To monitor
this, it is essential for the nurse to:
A. Stay with the client for the first 15 minutes of blood administration
B. Stay with the client for the entire period of blood administration
C. Run the infusion at a faster rate during the first 15 minutes
D. Tell the client to notify the staff immediately for any adverse reaction
As Leda’s nurse, you plan to set up an emergency equipment at her beside following
thyroidectomy. You should include:
If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the
following might Leda develop postoperatively?
A. Cardiac arrest C. Respiratory failure
B. Dyspnea D. Tetany
After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm.
What would you anticipate to administer?
NURSES are involved in maintaining a safe and healthy environment. This is part of quality care
management.
A. water C. saline
B. colloidal (oatmeal) D. sodium bicarbonate
Induction of vomiting is indicated for the accidental poisoning patient who has ingested.
Because severe burn can affect the person’s totality it is important that-you apply interventions
focusing on the various dimensions of man. You also have to understand the rationale of the
treatment.
A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin.
The nurse is correct in classifying this burn as:
During the first 24 hours of burn, nursing measures should focus on which of the following?
A. I and O hourly
B. Strict aseptic technique
C. Forced oral fluids
D. Isolate the patient
During the Acute phase of burn, the priority nursing intervention in caring for this client is:
A. Prevention of infection
B. Pain management
C. Prevention of Bleeding
D. Fluid Resuscitation
The nurse knows that the most fatal electrolyte imbalance in burned client during the Emergent
phase of burn is:
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hyponatremia
A. Tall T waves
B. Widening QRS Complex
C. Pathologic Q wave
D. U wave
Pain medications given to the burn clients are best given via what route?
A. IV
B. IM
C. Oral
D. SQ
A. Interventional C. Surgical
B. Mechanical D. Chemical
A. exaggerated contraction
B. random layering of collagen
C. wound ischemia
D. delayed epithelialization
A. case study
B. longitudinal study
C. cross-sectional study
D. evaluative study
The process recording was the principal tool for data collection. Which of the following is NOT a
part of a process recording?
the most significant factor that might affect the nurse’s care for the psychiatric patient is:
In order to establish a therapeutic relationship with the client, the nurse must first have:
A. Self awareness
B. Self understanding
C. Self acceptance
D. Self motivation
Nurse Edna thinks that the patient is somewhat like his father. She then identifies positive feeling
for the patient that affects the objectivity of her nursing care. This emotional reaction is called:
A. Transference
B. Counter Transference
C. Reaction formation
D. Sympathy
A. Mild
B. Moderate
C. Severe
D. Panic
Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is
the child of the covenant that would save this world from the evil forces of Satan. One morning,
while caring for her, she stood in front of you and said “Bow down before me! I am the holy
mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:
Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin
Mary!” is an example of:
A. Delusion of grandeur
B. Visual Hallucination
C. Religious delusion
D. Auditory Hallcucination
The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am
the blessed Virgin Mary!” as important in documenting in which of the following areas of mental
status examination?
A. Thought content
B. Mood
C. Affect
D. Attitude
Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia.
During the morning assessment, Mang David shouted “Did you know that I am the top salesman
in the world? Different companies want me!” As a nurse, you know that this is an example of:
A. Hallucination
B. Delusion
C. Confabulation
D. Flight of Ideas
The recommended treatment modality in clients with obsessive compulsive disorder is:
A. Psychotherapy
B. Behavior therapy
C. Aversion therapy
D. Psychoanalysis
A state of disequilibrium wherein a person cannot readily solve a problem or situation even by
using his usual coping mechanisms is called:
A. Mental illness
B. Mental health
C. Crisis
D. Stress
A. Psychotic disorders
B. Neurotic disorders
C. Major depressive disorder
D. Bipolar disorder
Which nursing diagnosis is a priority for clients with Borderline personality disorder?
An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:
A. Taste the food in front of him and tell him that the food is not poisoned
B. Offer other types of food until the client eats
C. Simply state that the food is not poisoned
D. Offer sealed foods
Toilet training occurs in the anal stage of Freud’s psychosexual task. This is equivalent to
Erikson’s:
During the phallic stage, the child must identify with the parent of:
Ms. ANA had a car accident where he lost her boyfriend. As a result, she became passive and
submissive. The nurse knows that the type of crisis Ms. ANA is experiencing is:
A. Developmental crisis
B. Maturational crisis
C. Situational crisis
D. Social Crisis
Persons experiencing crisis becomes passive and submissive. As a nurse, you know that the best
approach in crisis intervention is to be:
Which physiologic effect should the nurse expect in a client addicted to hallucinogens?
A. Dilated pupils
B. Constricted pupils
C. Bradycardia
D. Bradypnea
Miss CEE is admitted for treatment of major depression. She is withdrawn, disheveled and states
“Nobody wants me” The nurse most likely expects that Miss CEE is to be placed on:
A. Neuroleptics medication
B. Special diet
C. Suicide precaution
D. Anxiolytics medication
In alcoholic patient, the nurse knows that the vitamin deficient to these types of clients that leads
to psychoses is:
A. Thiamine
B. Vitamin C
C. Niacin
D. Vitamin A
Which of the following terms refers to weakness of both legs and the lower part of the trunk?
A. Paraparesis
B. Hemiplegia
C. Quadriparesis
D. Paraplegia
Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and
sleep, and inhibits pain pathways?
A. Serotonin
B. Enkephalin
C. Norepinephrine
D. Acetylcholine
The lobe of the brain that contains the auditory receptive areas is the ____________ lobe.
A. temporal
B. frontal
C. parietal
D. occipital
In preparation for ECT, the nurse knows that it is almost similar to that of:
A. ECG
B. General Anesthesia
C. EEG
D. MRI
The priority nursing diagnosis for a client with major depression is:
A. Altered nutrition
B. Altered thought process
C. Self care deficit
D. Risk for injury
A patient tells the nurse “I am depressed to talk to you, leave me alone” Which of the following
response by the nurse is most therapeutic?
An adolescent client has bloodshot eyes, a voracious appetite and dry mouth. Which drug abuse
would the nurse most likely suspect?
A. Marijuana
B. Amphetamines
C. Barbiturates
D. Anxiolytics
During which phase of therapeutic relationship should the nurse inform the patient for
termination of therapy?
A. Pre orientation
B. Orientation
C. Working
D. Termination
A client says to the nurse “I am worthless person, I should be dead” The nurse best replies:
A. “Don’t say you are worthless, you are not a worthless person”
B. “We are going to help you with your feelings”
C. “What makes you feel you’re worthless?”
D. “What you say is not true”
The nurse’s most unique tool in working with the emotionally ill client is his/her
A. theoretical knowledge
B. personality make up
C. emotional reactions
D. communication skills
The mentally ill person responds positively to the nurse who is warm and caring. This is a
demonstration of the nurse’s role as:
A. counselor
B. mother surrogate
C. therapist
D. socializing agent
The past history of Camila would most probably reveal that her premorbid personality is:
A. schizoid
B. extrovert
C. ambivert
D. cycloid
In an extreme situation and when no other resident or intern is available, should a nurse receive
telephone orders, the order has to be correctly written and signed by the physician within:
A. 24 hours
B. 36 hours
C. 48 hours
D. 12 hours
. If it is established that the child is physically abused by a parent, the most important goal the
nurse could formulate with the family is that:
Cocaine is derived from the leaves of coca plant; the nurse knows that cocaine is classified as:
A. Narcotic
B. Stimulant
C. Barbiturate
D. Hallucinogen
To successfully complete the tasks of older adulthood, an 85 year old who has been a widow for
25 years should be encouraged to:
In a therapeutic relationship, the nurse must understand own values, beliefs, feelings, prejudices
& how these affect others. This is called:
While on Bryant’s traction, which of these observations of Graciela and her traction apparatus
would indicate a decrease in the effectiveness of her traction?
The nurse notes that the fall might also cause a possible head injury. She will be observed for
signs of increased intracranial pressure which include:
A. Venlafaxine (Effexor)
B. Flouxetine (Prozac)
C. Sertraline (Zoloft)
D. Imipramine (Tofranil)
The working phase in a therapy group is usually characterized by which of the following?
A. Caution
B. Cohesiveness
C. Confusion
D. Competition
The mother of a drug dependent would never consider referring her son to a drug rehabilitation
agency because she fears her son might just become worse while relating with other drug users.
The mother’s behavior can be described as:
A. Unhelpful
B. Codependent
C. Caretaking
D. Supportive
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
Lifestyle-related diseases in general share areas common risk factors. These are the following
except:
A. physical activity
B. smoking
C. genetics
D. nutrition
The following mechanisms can be utilized as part of the quality assurance program of your
hospital EXCEPT:
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
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
Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty
Certification Program and Council, which two (2) of the following serves as the strongest for its
enforcement?
(a) Advances made in Science and Technology have provided the climate for specialization in
almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization which
seeks to remove barriers in trade, industry and services imposed by the national laws of countries
all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the
services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International Council of
Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of
deepening and refining nursing practice and enhancing the quality of nursing care.
Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what
should you do?
Which among the following interventions should you consider as the highest priority when caring
for June who has hemiparesis secondary to stroke?
Salome was fitted a hearing aid. She understood the proper use and wear of this device when she
says that the battery should be functional, the device is turned on and adjusted to a:
A. therapeutic level
B. comfortable level
C. prescribed level
D. audible level
A. Insight
B. Productivity
C. Socialization
D. Intimacy
A. conscience
B. ego
C. id
D. super ego
A. Cannabis Sativa
B. Lysergic acid diethylamide
C. Methylenedioxy methamphetamine
D. Methampetamine hydrochloride
Wednesday, November 21, 2007
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 Mario’s nursing
care plan is to loosen and remove excessive secretions in the airway.
Mario listens to Richard’s 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:
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
When documenting outcome of Richard’s treatment Mario should include the following in his
recording EXCEPT:
When assessing Richard for chest percussion or chest vibration and postural drainage, Mario
would focus on the following EXCEPT:
Mario prepares Richard for postural drainage and percussion. Which of the following is a special
consideration when doing the procedure?
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference
between the procedures is:
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently
shakes secretion loose on the exhalation cycle
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.
When doing an initial assessment, the best way for you to identify the client’s priority problem is
to:
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:
C. anger
During which step of the nursing process does the nurse analyze data related to the patient's
health status?
A. Assessment
The basic difference between nursing diagnoses and collaborative problems is that
Situation – Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination
now that she is in the menopausal stage.
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
Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical
changes predispose her to constipation?
You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the
tubing for an adult would be:
C. the distance from the tip of the nose to the tip of the ear lobe
situation– 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.
You are to measure the client’s initial blood pressure reading by doing all of the following
EXCEPT:
C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
A. Distributive
The preferred route of administration of medication in the most acute care situations is which of
the following routes?
A. Intravenous
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:
Through the client’s 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 client’s blood pressure for accurate reading?
B. 30 minutes
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:
D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial
artery
To ensure client safety before starting blood transfusions the following are needed before the
procedure can be done EXCEPT:
B. blood should be warmed to room temperature for 30 minutes before blood transfusions is
administered
Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:
D. 1 tsp of salt/day but no patis and toyo
Which of the following methods is the best method for determining nasogastric tube placement in
the stomach?
A. X-ray
Which of the following is the most important risk factor for development of Chronic Obstructive
Pulmonary Disease?
A. Cigarette smoking
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and
gently rotating the catheter 360 degrees for which of the following time periods?
A. 10-15 seconds
The nurse auscultates the apex beat at which of the following anatomical locations?
Which of the following terms describes the amount of blood ejected per heartbeat?
A. Stroke volume
You are to apply a transdermal patch of nitoglycerin to your client. The following are important
guidelines to observe EXCEPT:
The nurse is correct in performing suctioning when she applies the suction intermittently during:
An incontinent elderly client frequently wets his bed and eventually develop redness and skin
excoriation at the perianal area. The best nursing goal for this client is to:
As a Nurse Manager, DMLM enjoys her staff of talented and self motivated individuals. She
knew that the leadership style to suit the needs of this kind of people is called:
D. Laissez Faire
A fire has broken in the unit of DMLM R.N. The best leadership style suited in cases of
emergencies like this is:
A. Autocratic
Which step of the management process is concerned with Policy making and Stating the goals
and objective of the institution?
A. Planning
In the management process, the periodic checking of the results of action to make sure that it
coincides with the goal of the institution is termed as:
B. Evaluating
The Vision of a certain agency is usually based on their beliefs, Ideals and Values that directs the
organization. It gives the organization a sense of purpose. The belief, Ideals and Values of this
Agency is called:
A. Philosophy
Mr. CKK is unconscious and was brought to the E.R. Who among the following can give consent
for CKK’s Operation?
C. Next of Kin
Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is
no longer capable to do so. As a Nurse, You know that this is called:
Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his
bedside. You would:
It is not a legally binding document but nevertheless, Very important in caring for the patients.
In monitoring the patient in PACU, the nurse correctly identify that checking the patient’s vital
signs is done every:
C. 15 minutes
diannemayde R.N is conducting a research on her unit about the effects of effective nurse-patient
communication in decreasing anxiety of post operative patients. Which of the following step in
nursing research should she do next?
Before diannemaydee perform the formal research study, what do you call the pre testing, small
scale trial run to determine the effectiveness of data collection and methodological problem that
might be encountered?
E. Pilot Study
C. Anxiety level
In the recent technological innovations, which of the following describe researches that are made
to improve and make human life easier?
C. Applied research
When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
B. is assigning the responsibility to the aide but not the accountability for those tasks
Process of formal negotiations of working conditions between a group of registered nurses and
employer is
C. collective bargaining
You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by
the hospital employing you. This is
B. inservice education
The law which regulated the practice of nursing profession in the Philippines is:
A. R.A 9173
This quality is being demonstrated by a Nurse who raise the side rails of a confuse and
disoriented patient?
C. Prudence
Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the student.
The case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of
crimes. They are correct in identifying which of the following Circumstances that will be best
applied in this case?
C. Mitigating
In signing the consent form, the nurse is aware that what is being observed as an ethical
consideration is the patient’s
A. Autonomy
Who among the following can work as a practicing nurse in the Philippines without taking the
Licensure examination?
In signing the consent form, the nurse is aware that what is being observed as an ethical
consideration is the patient’s
A. Autonomy
Nurse Buddy gave Inapsine instead of Insulin to a patient in severe hyperglycemia. He reported
the incident as soon as he knew there was an error. A nurse that is always ready to answer for all
his actions and decision is said to be:
A. Accountable
The best and most effective method in times of staff and financial shortage is:
A. Functional Method
You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and
tell you that the client from the other room was in Pain. The best intervention in such case is:
A. Raise the side rails, cover the client and put the call bell within reach and then attend to the
client in pain to give the PRN medication
Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the
following is the best nursing intervention to prevent future falls?
B. 90 °
The following statements are all true about Z-Track technique except:
C. It forces the medication to be contained at the subcutaneous tissues
Communication is best undertaken if barriers are first removed. Considering this statement,
which of the following is considered as deterrent factor in communication?
Nurse DMLM is correct in identifying the correct sequence of events during abdominal
assessment if she identifies which of the following?
To prevent injury and strain on the muscles, the nurse should observe proper body mechanics.
Among the following, which is a principle of proper body mechanics?
In taking the client’s blood pressure, the nurse should position the client’s arm:
What principle is used when the client with fever loses heat through giving cooling bed bath to
lower body temperature?
D. Conduction
The most effective way in limiting the number of microorganism in the hospital is:
D. Handwashing
The immunoglobulin of the mother that crosses the placenta to protect the child is an example of:
Richard is a subject of a research lead by his doctor. The nurse knows that all of the following is a
correct understanding as his right as a research subject except:
Which of the following is a normal finding during assessment of a Chest tube in a 3 way bottle
system?
B. Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self
sealing port
D. Immunization
An abnormal condition in which a person must sit, stand or use multiple pillows when lying down
is:
A. Orthopnea
As a nurse assigned for care for geriatric patients, you need to frequently assess your patient
using the nursing process. Which of the following needs be considered with the highest priority?
The component that should receive the highest priority before physical examination is the:
C. Owned by the hospital and should not be given to anyone who request it other than the doctor
in charge
Which of the following categories identifies the focus of community/public health nursing
practice?
A. Promoting and maintaining the health of populations and preventing and minimizing the
progress of disease
Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that
both the child and the mother cannot anymore endure the process. The baby is premature and has
a little chance of surviving. Caesarian section is not possible because Gina already lost enough
blood during labor and additional losses would tend to be fatal. The husband decided that Gina
should survive and gave his consent to terminate the fetus. The principle that will be used by the
health care team is:
D. Double effect
Situation – There are various developments in health education that the nurse should know about:
The provision of health information in the rural areas nationwide through television and radio
programs and video conferencing is referred to as:
B. Telehealth program
In teaching the sister of a diabetic client about the proper use of a glucometer in determining the
blood sugar level of the client, The nurse is focusing in which domain of learning according to
bloom?
C. Psychomotor
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
D. wellness program
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:
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:
B. Disclosure
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:
B. Feasibility
Data analysis is to be done and the nurse researcher wants to include variability. These include
the following EXCEPT:
D. Mean
Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care
visit typically made?
By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of 1999
entitled: “Adoption of a Nursing Specialty Certification Program and Creation of Nursing
Specialty Certification Council.” This rule-making power is called:
C. Quasi-Legislative Power
Anita is performing BSE and she stands in front of the Mirror. The rationale for standing in front
of the mirror is to check for:
An emerging technique in screening for Breast Cancer in developing countries like the
Philippines is:
After a vaginal examination, the nurse determines that the client’s fetus is in an occiput posterior
position. The nurse would anticipate that the client will have:
B. Intense back pain
The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:
Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to
FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain
to meeting the nursing needs of this particular population group.
Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best
answer?
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:
A. Measles vaccine
C. Hepatitis B vaccines
This special form is used when the patient is admitted to the unit. The nurse completes the
information in this record particularly his/her basic personal data, current illness, previous health
history, health history of the family, emotional profile, environmental history as well as physical
assessment together with nursing diagnosis on admission. What do you call this record?
These are sheets/forms which provide an efficient and time saving way to record information that
must be obtained repeatedly at regular and/or short intervals of time. This does not replace the
progress notes; instead this record of information on vital signs, intake and output, treatment,
postoperative care, post partum care, and diabetic regimen, etc. This is used whenever specific
measurements or observations are needed to be documented repeatedly. What is this?
These records show all medications and treatment provided on a repeated basis. What do you call
this record?
This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the
activity and treatment section and a nursing care plan section. This carries information about
basic demographic data, primary medical diagnosis, current orders of the physician to be carried
out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety
precautions in patient care and factors related to daily living activities. This record is used in the
charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?
D. Nursing Kardex
Most nurses regard this conventional recording of the date, time, and mode by which the patient
leaves a healthcare unit but this record includes importantly, directs of planning for discharge that
starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration
or multidisciplinary involvement (of all members of the health team) in discharge results in
comprehensive care. What do you call this?
A. Discharge Summary
Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing
responsibility and accountability?
A nurse should be cognizant that professional programs for specialty certification by the Board of
Nursing accredited through the:
Integrated management for childhood illness is the universal protocol of care endorsed by WHO
and is use by different countries of the world including the Philippines. In any case that the nurse
classifies the child and categorized the signs and symptoms in PINK category, You know that this
means:
A. Urgent referral
You know that fast breathing of a child age 13 months is observed if the RR is more than:
A. 40
Angelo, An 8 month old child is brought to the health care facility with sunken eyes. You pinch
his skin and it goes back very slowly. In what classification of dehydration will you categorize
Angelo?
C. Severe Dehydration
In responding to the care concerns of children with severe disease, referral to the hospital is of the
essence especially if the child manifests which of the following?
D. Difficulty to awaken
A child with ear problem should be assessed for the following, EXCEPT:
If the child does not have ear problem, using IMCI, what should you as the nurse do?
All of the following are treatment for a child classified with no dehydration except:
An ear infection that persists but still less than 14 days is classified as:
If a child has two or more pink signs, you would classify the child as having:
The nurse knows that the most common complication of Measles is:
A client scheduled for hysterosalpingography needs health teaching before the procedure. The
nurse is correct in telling the patient that:
D. 332.5
All of the following are seen in a child with measles. Which one is not?
C. Pustule
Mobilizing the people to become aware of their own problem and to do actions to solve it is
called:
A. Community Organizing
Prevention of work related accidents in factories and industries are responsibilities of which field
of nursing?
In one of your home visit to Mr. JUN, you found out that his son is sick with cholera. There is a
great possibility that other member of the family will also get cholera. This possibility is a/an:
B. Health threat
D. The pressure of the gravid uterus will exert additional force thus, increasing the blood loss in
the lower extremities
Aling Maria is nearing menopause. She is habitually taking cola and coffee for the past 20 years.
You should tell Aling Maria to avoid taking caffeinated beverages because:
Theresa, a mother with a 2 year old daughter asks, “at what age can I be able to take the blood
pressure of my daughter as a routine procedure since hypertension is common in the family?”
Your answer to this is:
What is the rationale in the use of bag technique during home visits?
B. It saves time and effort of the nurse in the performance of nursing procedures
In consideration of the steps in applying the bag technique, which side of the paper lining of the
CHN bag is considered clean to make a non-contaminated work area?
During operation, The OR suite’s lighting, noise, temperature and other factors that affects the
operation are managed by whom?
C. Circulating nurse
Before and after the operation, the operating suite is managed by the:
C. Nurse Manager
B. Scrub nurse
The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?
C. Anaesthesiologist
Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse
of the floor or ward where the patient is confined. For orthopedic cases, what department is
usually informed to be present in the OR?
D. Radiology department
In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your
nursing priority care in such a case?
The patient’s medical record can work as a double edged sword. When can the medical record
become the doctor’s/nurse’s worst enemy?
In the hospital, when you need the medical record of a discharged patient for research you will
request permission through:
You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will
include the following, EXCEPT:
As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
Overdosage of medication or anesthetic can happen even with the aid of technology like infusion
pumps, sphygmomanometer and similar devices/machines. As a staff, how can you improve the
safety of using infusion pumps?
When surgery is on-going, who coordinates the activities outside, including the family?
B. Nurse Supervisor
D. Communication
To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:
When administering Tapazole, The nurse should monitor the client for which of the following
adverse effect?
B. Hypothyroidism
Post bronchoscopy, the nurse priority is to check which of the following before feeding?
A. Gag reflex
Changes normally occur in the elderly. Among the following, which is a normal change in an
elderly client?
C. Urinary frequency
Skin care around the stoma is critical. Which of the following is not indicated as a skin care
barriers?
A. Increased weight
The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
A. Increase the irrigating solution flow rate when abdominal cramps is felt
What sensation is used as a gauge so that patients with ileostomy can determine how often their
pouch should be drained?
B. Sensation of pressure
In performing a cleansing enema, the nurse performs the procedure by positioning the client in:
Mang Caloy is scheduled to have a hemorrhoidectomy, after the operation, you would expect that
the client’s position post operatively will be:
You would expect that after an abdominal perineal resection, the type of colostomy that will be
use is?
C. Permanent colostomy
You are an ostomy nurse and you know that colostomy is defined as:
A. It is an incision into the colon to create an artificial opening to the exterior of the abdomen
Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After
taking the history and vital signs the physician does which test as a screening test for colorectal
cancer.
D. Proctosigmoidoscopy
24 Hours after creation of colostomy, Nurse Violy is correct if she identify that the normal
appearance of the stoma is :
In cleaning the stoma, the nurse would use which of the following cleaning mediums?
When observing a return demonstration of a colostomy irrigation, you know that more teaching is
required if pt:
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. General population
As a nurse, you can help improve the effectiveness of communication among healthcare givers
by:
B. Hypothermia
Mang Edgardo has a chest tube inserted in place after a Lobectomy. The nurse knows that that
Chest tube after this procedure will:
Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions,
EXCEPT:
C. lying prone with the head of the bed lowered 15-30 degrees
Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another
chest x-ray, you will explain:
The RR nurse should monitor for the most common postoperative complication of:
A. hemorrhage
The PACU nurse will maintain postoperative T and A client in what position?
Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy.
You as the RN will make sure that the family knows to:
Situation – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so that an
A-V shunt was surgically created.
Which of the following action would be of highest priority with regards to the external shunt?
A. Avoid taking BP or blood sample from the arm with the shunt
Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium.
The nutrition instructions should include:
A. Recommend protein of high biologic value like eggs, poultry and lean meats
A. E. Coli
The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase
the chance of passing the stones, you instructed her to force fluids and do which of the following?
B. ambulate more
Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment
of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper
extremities and right lower extremities. His wife asks what that means? Your most accurate
response would be:
During the first 24 hours after the thermal injury, you should asses Sergio for:
All of the following are instruction for proper foot care to be given to a client with peripheral
vascular disease caused by Diabetes. Which is not?
You are on morning duty in the medical ward. You have 10 patients assigned to you. During your
endorsement rounds, you found out that one of your patients was not in bed. The patient next to
him informed you that he went home without notifying the nurses. Which among the following
will you do first?
You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found
out that what is on record does not tally with the drugs used. Which among the following will you
do first?
You are on duty in the medical ward. The mother of your patient who is also a nurse, came
running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
When observing a return demonstration of a colostomy irrigation, you know that more teaching is
required if pt:
F. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
Which of the four phases of emergency management is defined as “sustained action that reduces
or eliminates long-term risk to people and property from natural hazards and their effects.”?
B. Mitigation
Which of the following terms refer to a process by which the individual receives education about
recognition of stress reaction and management strategies for handling stress which may be
instituted after a disaster?
D. Defusion
Fires are approached using the mnemonic RACE, in which, R stands for:
C. Rescue
You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP).
Which intervention should you include in your plan to reduce ICP?
B. erythema
A guideline that is utilized in determining priorities is to asses the status of the following,
EXCEPT:
D. mentation
Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives
and changes money and then hold the bread without washing her hand. As a nurse, What will you
say to Miss Kate?
A. 18
Before administration of blood and blood products, the nurse should first:
A. Check with another R.N the client’s name, Identification number, ABO and RH type.
C. NSS
In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention
should focus on:
B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the
physician
The nurse knows that after receiving the blood from the blood bank, it should be administered
within:
C. 4 hours
During blood administration, the nurse should carefully monitor adverse reaction. To monitor
this, it is essential for the nurse to:
A. Stay with the client for the first 15 minutes of blood administration
As Leda’s nurse, you plan to set up an emergency equipment at her beside following
thyroidectomy. You should include:
D. Support the patient’s head and neck with pillows and sandbags.
If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the
following might Leda develop postoperatively?
D. Tetany
After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm.
What would you anticipate to administer?
B. Calcium gluconate
NURSES are involved in maintaining a safe and healthy environment. This is part of quality care
management.
B. colloidal (oatmeal)
Induction of vomiting is indicated for the accidental poisoning patient who has ingested.
D. aspirin
Because severe burn can affect the person’s totality it is important that-you apply interventions
focusing on the various dimensions of man. You also have to understand the rationale of the
treatment.
A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin.
The nurse is correct in classifying this burn as:
During the first 24 hours of burn, nursing measures should focus on which of the following?
A. I and O hourly
During the Acute phase of burn, the priority nursing intervention in caring for this client is:
D. Fluid Resuscitation
The nurse knows that the most fatal electrolyte imbalance in burned client during the Emergent
phase of burn is:
B. Hyperkalemia
D. U wave
Pain medications given to the burn clients are best given via what route?
A. IV
What type of debridement involves proteolytic enzymes?
D. Chemical
D. Sulfamylon
A. case study
The process recording was the principal tool for data collection. Which of the following is NOT a
part of a process recording?
C. Audio-visual recording
the most significant factor that might affect the nurse’s care for the psychiatric patient is:
In order to establish a therapeutic relationship with the client, the nurse must first have:
A. Self awareness
Nurse Edna thinks that the patient is somewhat like his father. She then identifies positive feeling
for the patient that affects the objectivity of her nursing care. This emotional reaction is called:
B. Counter Transference
C. Listening
B. Moderate
Obsessive compulsive disorder is characterized by:
Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is
the child of the covenant that would save this world from the evil forces of Satan. One morning,
while caring for her, she stood in front of you and said “Bow down before me! I am the holy
mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:
Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin
Mary!” is an example of:
C. Religious delusion
The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am
the blessed Virgin Mary!” as important in documenting in which of the following areas of mental
status examination?
A. Thought content
Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia.
During the morning assessment, Mang David shouted “Did you know that I am the top salesman
in the world? Different companies want me!” As a nurse, you know that this is an example of:
B. Delusion
The recommended treatment modality in clients with obsessive compulsive disorder is:
A. Psychotherapy
A state of disequilibrium wherein a person cannot readily solve a problem or situation even by
using his usual coping mechanisms is called:
C. Crisis
B. Neurotic disorders
Which nursing diagnosis is a priority for clients with Borderline personality disorder?
An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:
A paranoid client refuses to eat telling you that you poisoned his food. The best intervention to
this client is:
Toilet training occurs in the anal stage of Freud’s psychosexual task. This is equivalent to
Erikson’s:
During the phallic stage, the child must identify with the parent of:
Ms. ANA had a car accident where he lost her boyfriend. As a result, she became passive and
submissive. The nurse knows that the type of crisis Ms. ANA is experiencing is:
C. Situational crisis
Persons experiencing crisis becomes passive and submissive. As a nurse, you know that the best
approach in crisis intervention is to be:
Which physiologic effect should the nurse expect in a client addicted to hallucinogens?
A. Dilated pupils
cardia
D. Bradypnea
Miss CEE is admitted for treatment of major depression. She is withdrawn, disheveled and states
“Nobody wants me” The nurse most likely expects that Miss CEE is to be placed on:
C. Suicide precaution
In alcoholic patient, the nurse knows that the vitamin deficient to these types of clients that leads
to psychoses is:
A. Thiamine
Which of the following terms refers to weakness of both legs and the lower part of the trunk?
A. Paraparesis
Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and
sleep, and inhibits pain pathways?
A. Serotonin
The lobe of the brain that contains the auditory receptive areas is the ____________ lobe.
A. temporal
In preparation for ECT, the nurse knows that it is almost similar to that of:
B. General Anesthesia
The priority nursing diagnosis for a client with major depression is:
One of the following statements is true with regards to the care of clients with depression:
An adolescent client has bloodshot eyes, a voracious appetite and dry mouth. Which drug abuse
would the nurse most likely suspect?
A. Marijuana
During which phase of therapeutic relationship should the nurse inform the patient for
termination of therapy?
B. Orientation
A client says to the nurse “I am worthless person, I should be dead” The nurse best replies:
The nurse’s most unique tool in working with the emotionally ill client is his/her
D. communication skills
The mentally ill person responds positively to the nurse who is warm and caring. This is a
demonstration of the nurse’s role as:
B. mother surrogate
The past history of Camila would most probably reveal that her premorbid personality is:
A. schizoid
In an extreme situation and when no other resident or intern is available, should a nurse receive
telephone orders, the order has to be correctly written and signed by the physician within:
A. 24 hours
If it is established that the child is physically abused by a parent, the most important goal the
nurse could formulate with the family is that:
A. Narcotic
To successfully complete the tasks of older adulthood, an 85 year old who has been a widow for
25 years should be encouraged to:
In a therapeutic relationship, the nurse must understand own values, beliefs, feelings, prejudices
& how these affect others. This is called:
D. Self awareness
While on Bryant’s traction, which of these observations of Graciela and her traction apparatus
would indicate a decrease in the effectiveness of her traction?
The nurse notes that the fall might also cause a possible head injury. She will be observed for
signs of increased intracranial pressure which include:
B. Vomiting
D. Imipramine (Tofranil)
The working phase in a therapy group is usually characterized by which of the following?
B. Cohesiveness
B. Codependent
You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes.
Which of the following is true?
B. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM)
diabetes which is genetic in etiology
Lifestyle-related diseases in general share areas common risk factors. These are the following
except:
C. genetics
The following mechanisms can be utilized as part of the quality assurance program of your
hospital EXCEPT:
The use of the Standards of Nursing Practice is important in the hospital. Which of the following
statements best describes what it is?
D. The Standards of Care includes the various steps of the nursing process and the standards of
professional performance
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?
B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign
his order within 24 hours
Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty
Certification Program and Council, which two (2) of the following serves as the strongest for its
enforcement?
(a) Advances made in Science and Technology have provided the climate for specialization in
almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization which
seeks to remove barriers in trade, industry and services imposed by the national laws of countries
all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the
services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International Council of
Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of
deepening and refining nursing practice and enhancing the quality of nursing care.
Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what
should you do?
Which among the following interventions should you consider as the highest priority when caring
for June who has hemiparesis secondary to stroke?
Salome was fitted a hearing aid. She understood the proper use and wear of this device when she
says that the battery should be functional, the device is turned on and adjusted to a:
D. audible level
A. Insight
B. ego
D. Methampetamine hydrochloride
* all that has been discussed and stressed by sir Jungco, ung PA-lmr
lec nya, no need to sweat it out reading Venzon
* my 300 items reviewer, lalo na ung side lectures and notes q
during our rationalization
* the MS reviewer posted here, don't you ever skip reading the
rationales! lalo na if you don't have the CDs
* the fatima exclusive material and the last ten tips for last june
posted at http://pinoybsn.blogspot.com/
* all medication administration procedure na naka-table sa
Fundamentals of Nursing by Kozier
* Appendix C of the PHN book
* Sir V's OR nursing and "special lec"
* all that i stressed and wrote in bold letters during our
rationalization
* love ma'am Mallari promise!
* all notes na makukuha nyo during the final coaching! don't be
absent, wag nyo q gayahin pls lang!
* percussion and vibration Kozier
* Udan MS all practice test and end of the chapter questions
* Makasaysayang RESEARCH METHODOLOGY MANUAL of olfu
* Pilliteri pages 570-590
* mga appendix at glossary of Venzon PA
* new immunization table
* page 215-216 Venzon Management 3rd ed
* Ung likod ng Souvenir chuva namin
* Tables of child development sa pilliteri, tonsillectomy and
contraindications to immunization, ung 2 pages na fine print
* Operating Room technique Instructional Manual 1st ed pages 41-55
* My JCAHO, pain and nle CBQs handout
Thursday, October 18, 2007
guys these are almost the same as what was in the june board and same concepts as the june 06
and dec 06.....
1.
According to Maslow, which of the following categories of needs represents the most basic?
Physiologic needs
Physiologic needs must be met before an individual is able to move toward psychological health
and well-being.
Self-actualization
Self-actualization is the highest level of need
Belongingness
Belongingness and affection needs are not essential to physiologic survival.
2.
Which of the following statements reflects the World Health Organization’s definition of health?
A state of complete physical, mental, and social well-being and not merely the absence of disease
and infirmity.
Such a definition, however, does not allow for any variations in the degrees of wellness or illness.
A fluid, ever-changing balance reflected through physical, mental, and social behavior.
The WHO definition does not allow for any variations in the degrees of wellness and illness.
3.
Which of the following statements defines culture?
The learned patterns of behavior, beliefs, and values that can be attributed to a particular group of
people.
Included among characteristics that distinguish cultural groups are manner of dress, values,
artifacts, and health beliefs and practices.
4.
The reason that case management has gained such prominence in health care can be traced to
5.
A preferred provider organization is described as a
6.
Which of the following categories identifies the focus of community/public health nursing
practice?
Promoting and maintaining the health of populations and preventing and minimizing the progress
of disease
Although nursing interventions used by public health nurses might involve individuals, families,
or small groups, the central focus remains promoting health and preventing disease in the entire
community.
7.
A major goal for home care nurses is
8.
In the United States, nurses performing invasive procedures need to be up-to-date with their
immunizations, particularly
hepatitis B.
Hepatitis B is transmitted through contact with infected blood or plasma.
hepatitis E.
Hepatitis E is found mainly in underdeveloped countries with substandard sanitation and water
quality.
hepatitis A.
hepatitis A is transmitted through the oral route from the feces and saliva of an infected person.
hepatitis C.
At present, immunization against hepatitis C is not available.
9.
At what time during a patient’s hospital stay does discharge planning begin?
Admission
To prepare for early discharge and the possible need for follow-up in the home, discharge
planning begins with the patient’s admission.
10.
The leading health problems of elementary school children include
cancer.
The leading health problems of elementary school children are injuries, infections, malnutrition,
dental disease, and cancer.
homicide.
Homicide is a leading health problem for high school children.
11.
Which skill needed by the nurse to think critically involves identification of patient problems
indicated by data?
Analysis
Analysis is used to identify patient problems indicated by data.
Interpretation
Interpretation is used to determine the significance of data that is gathered.
Inferencing
Inferences are used by the nurse to draw conclusions.
Explanation
Explanation is the justification of actions or interventions used to address patient problems and to
help a patient move toward desired outcomes.
12.
The ethics theory that focuses on ends or consequences of actions is the
utilitarian theory.
Utilitarian theory is based on the concept of the greatest good for the greatest number.
formalist theory.
Formalist theory argues that moral standards exist independently of the ends or consequences.
deontological theory.
Deontological theory argues that moral standards exist independently of the ends or
consequences.
adaptation theory.
Adaptation theory is not an ethics theory.
13.
Which of the following ethical principles refers to the duty to do good?
Beneficence
Beneficence is the duty to do good and the active promotion of benevolent acts.
Fidelity
Fidelity refers to the duty to be faithful to one's commitments.
Veracity
Veracity is the obligation to tell the truth.
Nonmaleficence
Nonmaleficence is the duty not to inflict, as well as to prevent and remove, harm; it is more
binding than beneficence.
14.
During which step of the nursing process does the nurse analyze data related to the patient's
health status?
Assessment
Analysis of data is included as part of the assessment.
Implementation
Implementation is the actualization of the plan of care through nursing interventions.
Diagnosis
Diagnosis is the identification of patient problems.
Evaluation
Evaluation is the determination of the patient's responses to the nursing interventions and the
extent to which the outcomes have been achieved.
15.
The basic difference between nursing diagnoses and collaborative problems is that
nursing diagnoses incorporate physiologic complications that nurses monitor to detect change in
status.
Nursing diagnoses refer to actual or potential health problems that can be managed by
independent nursing interventions.
16.
Health education of the patient by the nurse
17.
Nonadherence to therapeutic regimens is a significant problem for which of the following age
groups?
Teenagers
Problems of teenagers, generally, are time limited and specific, and require promoting adherence
to treatment to return to health.
Children
In general, the compliance of children depends on the compliance of their parents.
Middle-aged adults
Middle-aged adults, in general, have fewer health problems, thus promoting adherence.
18.
Experiential readiness to learn refers to the patient's
emotional status.
Emotional readiness refers to the patient's acceptance of an existing illness or the threat of an
illness and its influence on the ability to learn.
19.
Asking the patient questions to determine if the person understands the health teaching provided
would be included during which step of the nursing process?
Evaluation
Evaluation includes observing the person, asking questions, and comparing the patient's
behavioral responses with the expected outcomes.
Assessment
Assessment includes determining the patient's readiness regarding learning.
Implementation
Implementation is the step during which the teaching plan is put into action.
20.
Which of the following items is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the person's needs?
Physical examination
The physical examination is helpful but often only validates the information obtained from the
history.
Biographical data
Biographical information puts the health history in context but does not focus the diagnosis.
21.
Of the following areas for assessing the patient profile, which should be addressed after the
others?
Body image
The patient is often less anxious when the interview progresses from information that is less
personal to information that is more personal.
Education
Educational level is relatively impersonal and readily revealed by the patient.
Occupation
Occupation is relatively impersonal and readily revealed by the patient.
Environment
Housing, religion, and language are relatively impersonal and readily revealed by the patient.
22.
Which of the following methods of physical examination refers to the translation of physical
force into sound?
Percussion
Percussion translates the application of physical force into sound.
Palpation
Palpation refers to examination by non-forceful touching.
Auscultation
Auscultation refers to the skill of listening to sounds produced within the body created by
movement of air or fluid.
Manipulation
Manipulation refers to the use of the hands to determine motion of a body part.
23.
In which range of body mass index (BMI) are patients considered to have increased risk for
problems associated with poor nutritional status?
Below 24
Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are
associated with individuals who have low BMI.
25-29
Those who have a BMI of 25 to 29 are considered overweight.
30 to 39
Those who have BMI of 30-39 are considered obese.
Over 40
Those who have BMI over 40 are considered extremely obese.
24.
To calculate the ideal body weight for a woman, the nurse allows
25.
A steady state within the body is termed
homeostasis.
When a change occurs that causes a body function to deviate from its stable range, processes are
initiated to restore and maintain the steady state or homeostasis.
constancy.
Constancy refers to the balanced internal state of the human body maintained by physiologic and
biochemical processes.
adaptation.
Adaptation refers to a constant, ongoing process that requires change in structure, function, or
behavior so that the person is better suited to the environment.
stress.
Stress refers to a state produced by a change in the environment that is perceived as challenging,
threatening, or damaging to the person's dynamic balance or equilibrium.
26.
Which of the following terms, according to Lazarus, refers to the process through which an event
is evaluated with respect to what is at stake and what might and can be done?
Cognitive appraisal
The outcome of cognitive appraisal is identification of the situation as either stressful or non-
stressful.
Coping
Coping consists of both cognitive and behavioral efforts made to manage the specific external or
internal demand that taxes a person's resources.
Hardiness
Hardiness is a personality characteristic that is composed of control, commitment, and challenge.
Adaptation
Lazarus believed adaptation was affected by emotion that subsumed stress and coping.
27.
An increase in the number of new cells in an organ or tissue that is reversible when the stimulus
for production of new cells is removed is termed
hyperplasia.
Hyperplasia occurs as cells multiply and are subjected to increased stimulation resulting in tissue
mass enlargement.
hypertrophy.
Hypertrophy is an increase in size and bulk of tissue that does not result from an increased
number of cells.
atrophy.
Atrophy refers to reduction in size of a structure after having come to full maturity.
neoplasia.
With neoplasia, the increase in the number of new cells in an organ or tissue continues after the
stimulus is removed.
28.
Which of the following types of cells have a latent ability to regenerate?
Stable
Stable cells have a latent ability to regenerate if they are damaged or destroyed and are found in
the kidney, liver, and pancreas, among other body organs.
Labile
Labile cells multiply constantly to replace cells worn out by normal physiologic processes.
Permanent
Permanent cells include neurons --- the nerve cell bodies, not their axons. Destruction of a neuron
causes permanent loss, but axons may regenerate.
Epithelial
Epithelial cells are a type of labile cell that multiply constantly to replace cells worn out by
normal physiologic processes.
29.
The relaxation techniques of progressive muscle relaxation, relaxation with guided imagery, and
the Benson Relaxation Response share which of the following elements?
Nutritional foundation
Relaxation techniques do not encompass specific nutritional guidelines.
Analgesic preparation
Relaxation techniques are used to reduce one's response to stress and do not require analgesia
prior to practicing the techniques.
Physician's order
A physician's order is not required to assist an individual to learn techniques to reduce one's
response to stress.
30.
Which of the following terms has been defined by the American Psychiatric Association as a
group of behavioral or psychological symptoms or a pattern that manifests itself in significant
distress, impaired functioning, or accentuated risk of enduring severe suffering or possible death?
Mental disorder
The definition was adopted by the American Psychiatric Association in 1994.
Emotional disorder
There is no universally accepted definition of what constitutes an emotional disorder.
Anxiety
Anxiety is defined as fear of the unknown.
Schizophrenia
Schizophrenia is a specific disorder characterized by psychosis.
31.
Establishing financial security has been identified as a developmental task of which of the
following groups?
Middle adult
The middle adult's tasks also include launching children, and refocusing on one's marital
relationship.
Older adult
The older adult's tasks include adapting to retirement and declining physical stamina.
Young adult
The young adult's tasks include establishing a lifestyle and independence.
Teenager
The teenager's primary developmental tasks include developing an identity and intimacy.
32.
When up to a 6-month period elapses between the experience of trauma and the onset of
symptoms of posttraumatic stress disorder (PTSD), the episode is termed
delayed.
In the case of delayed PTSD, there may be up to a 6-month period of time that elapses between
the trauma and the manifestation of symptoms.
acute.
Acute PTSD is defined as the experience of symptoms for less than a 3-month period.
chronic.
Chronic PTSD is defined as the experience of symptoms lasting longer than 3 months.
primary.
The concept of primary disease is not used in relation to PTSD.
33.
Which of the following statements accurately describes a risk factor for depression?
Male gender
A risk factor for depression is female gender.
34.
Of the following stages of grieving as described by Kubler-Ross, which is the initial?
Denial
The stages include: denial, anger, bargaining, depression, and acceptance.
Anger
Anger is the second stage of the process.
Bargaining
Bargaining is the third stage of the process.
Depression
Depression is the fourth stage of the process.
35.
Which of the following terms refers to Leininger's description of the learned and transmitted
knowledge about values, beliefs, rules of behavior, and lifestyle practices that guide a designated
group in their thinking and actions in patterned ways?
Culture
Leininger was the founder of the specialty called transcultural nursing and advocated culturally
competent nursing care.
Minority
Minority refers to a group of people whose physical or cultural characteristics differ from the
majority of people in a society.
Race
Race refers to a group of people distinguished by genetically transmitted characteristics.
Subculture
Subculture refers to a group that functions within a culture.
36.
The inability of a person to recognize his or her own values, beliefs, and practices and those of
others because of strong ethnocentric tendencies is termed
cultural blindness.
Cultural blindness results in bias and stereotyping.
acculturation.
Acculturation is the process by which members of a culture adapt or learn how to take on the
behaviors of another group.
cultural imposition.
Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of
behavior on a person from a different culture.
cultural taboo.
Cultural taboos are those activities governed by rules of behavior that are avoided, forbidden, or
prohibited by a particular cultural group.
37.
Which of the following groups of individuals may stare at the floor during conversations as a sign
of respect?
Native Americans
Some Native Americans stare at the floor during conversations, conveying respect and indicating
that the listener is paying close attention to the speaker.
Indo-Chinese
The Indo-Chinese may consider direct eye contact impolite or aggressive.
Arabs
Arabs may consider direct eye contact impolite or aggressive.
Asians
Asians may consider direct eye contact impolite or aggressive.
38.
For which of the following religious groups is all meat prohibited?
Hinduism
Hinduism prohibits consumption of all meats and animal shortening.
Seventh-Day Adventism
Seventh-Day Adventism prohibits consumption of pork.
Judaism
Judaism prohibits consumption of pork.
Islam
Islam prohibits the consumption of pork and animal shortening.
39.
The paradigm that explains the cause of illness as an imbalance in the forces of nature is the
holistic perspective.
The naturalist or holistic perspective believes that health exists when all aspects of a persona are
in perfect balance or harmony.
magico-religious view.
The magico-religious view holds that illness is caused by forces of evil.
biomedical view.
The biomedical view holds life events as cause and effect and incorporates the bacterial or viral
explanation of communicable disease.
scientific view.
The scientific view holds life events as cause and effect and incorporates the bacterial or viral
explanation of communicable disease.
40.
The aim of genomic medicine is
reproduction
The focus of genomic medicine is broader than the reproduction of cells.
cure of disease
The focus of genomic medicine is broader than the cure of disease.
cloning
Genomic medicine is gene-based health care.
41.
Nondisjunction of a chromosome results in which of the following diagnoses?
Down Syndrome
When a pair of chromosomes fails to separate completely and creates a sperm or oocyte that
contains two copies of a particular chromosome (nondisjunction) Down syndrome results from
three number 21 chromosomes.
Huntingon Disease
Huntington disease is one example of a germ-line mutation.
Marphan Syndrome
Marphan Syndrome is a genetic condition that may occur in a single family member as a result of
spontaneous mutation.
42.
Which type of Mendelian inherited condition results in both genders being affected equally in a
vertical pattern?
X-linked inheritance
X-linked conditions may be inherited in families in recessive or dominant patterns. In both, the
gene mutation is located on the X-chromosome. All males inherit an X chromosome from their
mother with no counterpart; hence, all males express the gene mutation.
43.
A specific BRCA1 cancer-predisposing gene mutation seems to occur more frequently among
women of which descent?
Ashkanazi Jewish
Expression of the BRCA1 gene is an example of inheritance in the development of breast cancer.
Mediterranean
Glucose-6-phosphate dehydrogenase deficiency (G6PD) is a common enzyme abnormality that
affects millions of people throughout the world, especially those of Mediterranean, South East
Asian, African, Middle Eastern, and Near Eastern origin.
African American
Sickle cell anemia is associated with the African-American population.
44.
Which of the following statements describes accurate information related to chronic illness?
Most people with chronic conditions do not consider themselves sick or ill.
Although some people take on a sick role identity, most people with chronic conditions do not
consider themselves sick or ill and try to live as normal a life as is possible.
45.
In which phase of the trajectory model of chronic illness are the symptoms under control and
managed?
Stable
The stable phase indicates that the symptoms and disability are under control or managed.
Acute
The acute phase is characterized by sudden onset of severe or unrelieved symptoms or
complications that may necessitate hospitalization for their management.
Comeback
The comeback phase is the period in the trajectory marked by recovery after an acute period.
Downward
The downward phase occurs when symptoms worsen or the disability progresses despite attempts
to control the course through proper management.
46.
Which phase of the trajectory model of chronic illness is characterized by reactivation of the
illness?
Unstable
The unstable phase is characterized by development of complications or reactivation of the
illness.
Stable
The stable phase indicates that the symptoms and disability are under control or managed.
Acute
The acute phase is characterized by sudden onset of severe or unrelieved symptoms or
complications that may necessitate hospitalization for their management.
Comeback
The comeback phase is the period in the trajectory marked by recovery after an acute period.
47.
Which phase of the trajectory model of chronic illness is characterized by the gradual or rapid
decline in the trajectory despite efforts to halt the disorder?
Dying
The dying phase is characterized by stoppage of life-maintaining functions.
Unstable
The unstable phase is characterized by development of complications or reactivation of the
illness.
Acute
The acute phase is characterized by sudden onset of severe or unrelieved symptoms or
complications that may necessitate hospitalization for their management.
Downward
The downward phase occurs when symptoms worsen or the disability progresses despite attempts
to control the course through proper management.
48.
In order to help prevent the development of an external rotation deformity of the hip in a patient
who must remain in bed for any period of time, the most appropriate nursing action would be to
use
a trochanter roll extending from the crest of the ilium to the midthigh.
A trochanter roll, properly placed, provides resistance to the external rotation of the hip.
a hip-abductor pillow.
A hip-abductor pillow is used for the patient after total hip replacement surgery.
a footboard.
A footboard will not prevent the hips from rotating externally.
49.
To prevent footdrop, the patient is positioned in:
A sitting position with legs hanging off the side of the bed
In order to prevent footdrop, the feet must be supported.
A side-lying position
Side-lying positions do not provide support to prevent footdrop.
50.
Through which of the following activities does the patient learn to consciously contract excretory
sphincters and control voiding cues?
Biofeedback
Cognitively intact patients who have stress or urge incontinence may gain bladder control through
biofeedback.
Kegel exercises
Kegel exercises are pelvic floor exercises that strengthen the pubococcygeus muscle.
Habit training
Habit training is used to try to keep the patient dry by strictly adhering to a toileting schedule and
may be successful with stress, urge, or functional incontinence.
Bladder training
Habit training is a type of bladder training.
51.
During which stage of pressure ulcer development does the ulcer extend into the subcutaneous
tissue?
Stage III
Clinically, a deep crater with or without undermining of adjacent tissues is noted.
Stage IV
A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly
the bone.
Stage II
A stage II ulcer exhibits a break in the skin through the epidermis or dermis.
Stage I
A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion,
and the patient complains of discomfort.
52.
During which stage of pressure ulcer development does the ulcer extend into the underlying
structures, including the muscle and possibly the bone?
Stage IV
A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly
the bone.
Stage III
A stage III ulcer extends into the subcutaneous tissue.
Stage II
A stage II ulcer exhibits a break in the skin through the epidermis or dermis.
Stage I
A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion,
and the patient complains of discomfort.
53.
Which type of incontinence is associated with weakened perineal muscles that permit leakage of
urine when intra-abdominal pressure is increased?
Stress incontinence
Stress incontinence may occur with coughing or sneezing.
Urge incontinence
Urge incontinence is involuntary elimination of urine associated with a strong perceived need to
void.
Functional incontinence
Functional incontinence refers to incontinence in patients with intact urinary physiology who
experience mobility impairment, environmental barriers, or cognitive problems.
54.
Ageism refers to
loss of memory.
Age-related loss of memory occurs more with short-term and recent memory.
55.
When assessing the older adult, the nurse anticipates increase in which of the follow components
of respiratory status?
Vital capacity
The nurse anticipates decreased vital capacity.
Cough efficiency
The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.
56.
According to the classification of hypertension diagnosed in the older adult, hypertension that can
be attributed to an underlying cause is termed
secondary.
Secondary hypertension may be caused by a tumor of the adrenal gland (e.g.,
pheochromacytoma).
primary.
Primary hypertension has no known underlying cause.
essential.
Essential hypertension has no known underlying cause.
isolated systolic.
Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds
140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).
57.
Which of the following terms refers to the decrease in lens flexibility that occurs with age,
resulting in the near point of focus getting farther away?
Presbyopia
Presbyopia usually begins in the fifth decade of life, when reading glasses are required to
magnify objects.
Presbycusis
Presbycusis refers to age-related hearing loss.
Cataract
Cataract is the development of opacity of the lens of the eye.
Glaucoma
Glaucoma is a disease characterized by increased intraocular pressure.
58.
Which of the following states is characterized by a decline in intellectual functioning?
Dementia
Dementia is an acquired syndrome in which progressive deterioration in global intellectual
abilities is of such severity that it interferes with the person's customary occupational and social
performance.
Depression
Depression is a mood disorder that disrupts quality of life.
Delirium
Delirium is often called acute confusional state.
Delusion
Delusion is a symptom of psychoses.
59.
When a person who has been taking opioids becomes less sensitive to their analgesic properties,
that person is said to have developed a (an)
tolerance.
Tolerance is characterized by the need for increasing dose requirements to maintain the same
level of pain relief.
addiction.
Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take
the drug primarily to experience its psychic effects.
dependence.
Dependence occurs when a patient who has been taking opioids experiences a withdrawal
syndrome when the opioids are discontinued.
balanced analgesia.
Balanced analgesia occurs when the patient is using more than one form of analgesia
concurrently to obtain more pain relief with fewer side effects.
60.
Prostaglandins are chemical substances thought to
61.
Which of the following principles or guidelines accurately informs the nurse regarding placebos?
Placebos should never be used to test the person's truthfulness about pain.
Perception of pain is highly individualized.
A placebo effect is an indication that the person does not have pain.
A placebo effect is a true physiologic response.
A placebo should be used as the first line of treatment for the patient.
A placebo should never be used as a first line of treatment.
A positive response to a placebo indicates that the person's pain is not real.
Reduction in pain as a response to placebo should never be interpreted as an indication that the
person's pain is not real.
62.
Regarding tolerance and addiction, the nurse understands that
although patients may need increasing levels of opioids, they are not addicted.
Physical tolerance usually occurs in the absence of addiction.
the nurse must be primarily concerned about development of addiction by the patient in pain.
Addiction is rare and should never be the primary concern for a patient in pain.
63.
The preferred route of administration of medication in the most acute care situations is which of
the following routes?
Intravenous
The IV route is the preferred parenteral route in most acute care situations because it is much
more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and
reliably.
Epidural
Epidural administration is used to control postoperative and chronic pain.
Subcutaneous
Subcutaneous administration results in slow absorption of medication.
Intramuscular
Intramuscular administration of medication is absorbed more slowly than intravenously
administered medication.
64.
Mu opioids have which of the following effects on respiratory rate:
No change
Kappa opioids result in no change in respiratory rate.
Stimulation, only
Delta opioids result in stimulation of respiratory rate.
Depression, only
Neither mu, nor kappa, nor delta opoids depress respiratory rate as its only effect upon respiratory
rate.
65.
Which of the following electrolytes is a major cation in body fluid?
Potassium
Potassium is a major cation that affects cardiac muscle functioning.
Chloride
Chloride is an anion.
Bicarbonate
Bicarbonate is an anion.
Phosphate
Phosphate is an anion.
66.
Which of the following electrolytes is a major anion in body fluid?
Chloride
Chloride is a major anion found in extracellular fluid.
Potassium
Potassium is a cation.
Sodium
Sodium is a cation.
Calcium
Calcium is a cation.
67.
Oncotic pressure refers to
68.
Which of the following solutions is hypotonic?
0.45% NaCl.
Half-strength saline is hypotonic
0.9% NaCl.
Normal saline (0.9% NaCl) is isotonic.
5% NaCl.
A solution that is 5% NaCl is hypertonic.
69.
The normal serum value for potassium is
3.5-5.5 mEq/L.
Serum potassium must be within normal limits to prevent cardiac dysrhythmias.
135-145 mEq/L.
Normal serum sodium is 135-145 mEq/L.
96-106 mEq/L.
Normal serum chloride is 96-106 mEq/L.
8.5-10.5 mg/dL.
Normal total serum calcium is 8.5-10.5mg/dL.
70.
In which type of shock does the patient experiences a mismatch of blood flow to the cells?
Distributive
Distributive or vasogenic shock results from displacement of blood volume, creating a relative
hypovolemia.
Cardiogenic
Cardiogenic shock results from the failure of a heart as a pump.
Hypovolemic
In hypovolemic shock, there is a decrease in the intravascular volume.
Septic
In septic shock, overwhelming infection results in a relative hypovolemia.
71.
Which stage of shock is best described as that stage when the mechanisms that regulate blood
pressure fail to sustain a systolic pressure above 90 mm Hg?
Progressive
In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer
compensate, and the mean arterial pressure falls below normal limits.
Refractory
The refractory or irreversible stage of shock represents the point at which organ damage is so
severe that the patient does not respond to treatment and cannot survive.
Compensatory
In the compensatory state, the patient's blood pressure remains within normal limits due to
vasoconstriction, increased heart rate, and increased contractility of the heart.
Irreversible
The refractory or irreversible stage of shock represents the point at which organ damage is so
severe that the patient does not respond to treatment and cannot survive.
72.
When the nurse observes that the patient's systolic blood pressure is less than 80--90 mm Hg,
respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less
than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock?
Compensatory
In compensatory shock, the patient's blood pressure is normal, respirations are above 20, and
heart rate is above 100 but below 150.
Progressive
In progressive shock, the patient's skin appears mottled and mentation demonstrates lethargy.
Refractory
In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic
support.
Irreversible
In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic
support.
73.
Which of the following vasoactive drugs used in treating shock results in reduced preload and
afterload, reducing oxygen demand of the heart?
Nitroprusside (Nipride)
A disadvantage of nitroprusside is that it causes hypotension.
Dopamine (Intropin)
Dopamine improves contractility, increases stroke volume, and increases cardiac output.
Epinephrine (adrenaline)
Epinephrine improves contractility, increases stroke volume, and increases cardiac output.
Methoxamine (Vasoxyl)
Methoxamine increases blood pressure by vasoconstriction.
74.
The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of
shock?
Septic
Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic
illness, and invasive procedures.
Neurogenic
Neurogenic shock is associated with spinal cord injury and anesthesia.
Cardiogenic
Cardiogenic shock is associated with disease of the heart.
Anaphylactic
Anaphylactic shock is associated with hypersensitivity reactions.
75.
Which of the following colloids is expensive but rapidly expands plasma volume?
Albumin
Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive
heart failure.
Dextran
Dextran is a colloid, synthetic plasma expander that interferes with platelet aggregation and is not
recommended for hemorrhagic shock.
Lactated Ringers
Lactated ringers is a crystalloid, not a colloid.
Hypertonic Saline
Hypertonic saline is a crystalloid, not a colloid.
76.
Which of the following terms refers to cells that lack normal cellular characteristics and differ in
shape and organization with respect to their cells of origin?
Anaplasia
Usually, anaplastic cells are malignant.
Neoplasia
Neoplasia refers to uncontrolled cell growth that follows no physiologic demand.
Dysplasia
Dysplasia refers to bizarre cell growth resulting in cells that differ in size, shape, or arrangement
from other cells of the same type of tissue.
Hyperplasia
Hyperplasia refers to an increase in the number of cells of a tissue, most often associated with a
period of rapid body growth.
77.
Palliation refers to
hair loss.
Alopecia is the term that refers to hair loss.
the spread of cancer cells from the primary tumor to distant sites.
Metastasis is the term that refers to the spread of cancer cells from the primary tumor to distant
sites.
the lowest point of white blood cell depression after therapy that has toxic effects on the bone
marrow.
Nadir is the term that refers to the lowest point of white blood cell depression after therapy that
has toxic effects on the bone marrow.
78.
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant
behavior?
Progression
During this third step, cells show a propensity to invade adjacent tissues and metastasize.
Promotion
During promotion, repeated exposure to promoting agents causes the expression of abnormal
genetic information even after long latency periods.
Initiation
During this first step, initiators such as chemicals, physical factors, and biologic agents escape
normal enzymatic mechanisms and alter the genetic structure of cellular DNA.
Prolongation
No stage of cellular carcinogenesis is termed prolongation.
79.
The drug, Interleukin-2, is an example of which type of biologic response modifier?
Cytokine
Other cytokines include interferon alfa and filgrastim.
Monoclonal antibodies
Monoclonal antibodies include rituximab, trastuzumab, and gemtuzumab.
Retinoids
Retinoic acid is an example of a retinoid.
Antimetabolites
Antimetabolites are cell cycle-specific antineoplastic agents.
80.
Of the following terms, which is used to refer to the period of time during which mourning a loss
takes place?
Bereavement
Bereavement is the period of time during which mourning a loss takes place.
Grief
Grief is the personal feelings that accompany an anticipated or actual loss
Mourning
Mourning is the individual, family, group and cultural expressions of grief and associated
behaviors
Hospice
Hospice is a coordinated program of interdisciplinary care and services provided primarily in the
home to terminally ill patients and their families.
81.
Which of the following "awareness contexts" is characterized by the patient, the family, and the
health care professionals being aware that the patient is dying but all pretend otherwise?
Closed awareness
In closed awareness, the patient is unaware of his terminality in a context where others are aware.
Suspected awareness
In suspected awareness, the patient suspects what others know and attempts to find it out.
Open awareness
In open awareness, all are aware that the patient is dying and are able to openly acknowledge that
reality.
82.
For individuals known to be dying by virtue of age and/or diagnoses, which of the following
signs indicate approaching death:
Increased restlessness
As the oxygen supply to the brain decreases, the patient may become restless.
Increased wakefulness
As the body weakens, the patient will sleep more and begin to detach from the environment.
Increased eating
For many patients, refusal of food is an indication that they are ready to die.
83.
Which of the following terms best describes a living will?
Medical directive
The living will is a type of advance medical directive in which the individual of sound mind
documents treatment preferences.
Proxy directive
A proxy directive is the appointment and authorization of another individual to make medical
decisions on behalf of the person who created an advance directive when he/she is no loner able
to speak for him/herself.
84.
A malignant tumor
grows by expansion.
A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy
surrounding tissues.
85.
Which of the following classes of antineoplastic agents is cell--cycle-specific?
Antimetabolites (5-FU)
Antimetabolites are cell--cycle-specific (S phase).
Nitrosureas (carmustine)
Nitrosureas are cell-cycle nonspecific.
86.
Regarding the surgical patient, which of the following terms refers to the period of time that
constitutes the surgical experience?
Perioperative phase
Perioperative period includes the preoperative, intraoperative, and postoperative phases.
Preoperative phase
Preoperative phase is the period of time from when the decision for surgical intervention is made
to when the patient is transferred to the operating room table.
Intraoperative phase
Intraoperataive phase is the period of time from when the patient is transferred to the operating
room table to when he or she is admitted to the postanesthesia care unit.
Postoperative phase
Postoperative phase is the period of time that begins with the admission of the patient to the
postanesthesia care unit and ends after a follow-up evaluation in the clinical setting or home.
87.
When the indication for surgery is without delay, the nurse recognizes that the surgery will be
classified as
emergency.
Emergency surgery means that the patient requires immediate attention and the disorder may be
life-threatening.
urgent.
Urgent surgery means that the patient requires prompt attention within 24-30 hours.
required.
Required surgery means that the patient needs to have surgery, and it should be planned within a
few weeks or months.
elective.
Elective surgery means that there is an indication for surgery, but failure to have surgery will not
be catastrophic.
88.
When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the
nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which
time period?
89.
Which of the following categories of medications may result in seizure activity if withdrawn
suddenly?
Tranquilizers
Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn
suddenly.
Adrenal corticosteroids
Abrupt withdrawal of steroids may precipitate cardiovascular collapse.
Antidepressants
Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics.
Diuretics
Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an
associated electrolyte imbalance.
90.
When the patient is encouraged to concentrate on a pleasant experience or restful scene, the
cognitive coping strategy being employed by the nurse is
imagery.
Imagery has proven effective for oncology patients.
optimistic self-recitation.
Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts
such as “I know all will go well.”
distraction.
Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a
favorite poem.
P3
Classification P3 patients are those who have compensated heart failure, cirrhosis, or poorly
controlled diabetes, for example.
P4
Classification P4 patients have an incapacitating systemic disease that is a constant threat to life.
P1
Classification P1 refers to a normal healthy patient
P2
Classification P2 reflects a patient with mild systemic disease
92.
Which stage of anesthesia is termed surgical anesthesia?
III
With proper administration of the anesthetic, this stage may be maintained for hours.
I
Stage I is beginning anesthesia, as the patient breathes in the anesthetic mixture and experiences
warmth, dizziness, and a feeling of detachment.
II
Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or
crying.
IV
Stage IV is a stage of medullary depression and is reached when too much anesthesia has been
administered.
93.
Fentanyl (Sublimaze) is categorized as which type of intravenous anesthetic agent?
Neuroleptanalgesic
Fentanyl is 75-100 times more potent than morphine and has about 25% of the duration of
morphine (IV).
Tranquilizer
Examples of tranquilizers include midazolam (Versed) and diazepam (Valium).
Opioid
Opioids include morphine and meperidine hydrochloride (Demerol).
Dissociative agent
Ketamine is a dissociative agent.
94
Which of the following manifestations is often the earliest sign of malignant hyperthermia?
Hypotension
Hypotension is a later sign of malignant hyperthermia.
Elevated temperature
The rise in temperature is actually a late sign that develops rapidly.
Oliguria
Scant urinary output is a later sign of malignant hyperthermia.
95.
Which of the following terms is used to refer to protrusion of abdominal organs through the
surgical incision?
Evisceration
Evisceration is a surgical emergency.
Hernia
A hernia is a weakness in the abdominal wall.
Dehiscence
Dehiscence refers to partial or complete separation of wound edges.
Erythema
Erythema refers to redness of tissue.
96.
When the method of wound healing is one in which wound edges are not surgically approximated
and integumentary continuity is restored by granulations, the wound healing is termed
second intention healing.
When wounds dehisce, they will be allowed to heal by secondary intention.
97.
The nurse recognizes which of the following signs as typical of the patient in shock?
Flushed face
Pallor is an indicator of shock.
98.
When the nurse observes that the postoperative patient demonstrates a constant low level of
oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the
patient may be suffering which type of hypoxemia?
Subacute
Supplemental oxygen may be indicated.
Hypoxic
Hypoxic hypoxemia results from inadequate breathing.
Episodic
Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia,
cerebral dysfunction, and cardiac arrest.
Anemic
Anemic hypoxemia results from blood loss during surgery.
99.
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will
be identified as
clean contaminated.
Clean-contaminated cases are those with a potential, limited source for infection, the exposure to
which, to a large extent, can be controlled.
clean.
Clean cases are those with no apparent source of potential infection.
contaminated.
Contaminated cases are those that contain an open and obvious source of potential infection.
dirty.
A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be
considered a dirty case.
100.
Which of the following terms is used to describe inability to breathe easily except in an upright
position?
Orthopnea
Patients with orthopnea are placed in a high Fowler's position to facilitate breathing.
Dyspnea
Dyspnea refers to labored breathing or shortness of breath.
Hemoptysis
Hemoptysis refers to expectoration of blood from the respiratory tract.
Hypoxemia
Hypoxemia refers to low oxygen levels in the blood.
101.
In relation to the structure of the larynx, the cricoid cartilage is
the valve flap of cartilage that covers the opening to the larynx during swallowing.
The epiglottis is the valve flap of cartilage that covers the opening to the larynx during
swallowing.
102.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal
expiration?
Tidal volume
Tidal volume is the volume of air inhaled and exhaled with each breath.
Residual volume
Residual volume is the volume of air remaining in the lungs after a maximum exhalation.
103.
The individual who demonstrates displacement of the sternum is described as having a
pigeon chest.
Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis.
barrel chest.
A barrel chest is seen in patients with emphysema as a result of over-inflation of the lungs.
funnel chest.
A funnel chest occurs when there is a depression in the lower portion of the sternum.
kyphoscoliosis.
Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine.
104.
When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of
leather being rubbed together, she records her finding as
crackles.
Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration.
sonorous wheezes.
Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration.
sibilant wheezes.
Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during
inspiration and expiration.
105.
Which of the following terms is used to describe hemorrhage from the nose?
Epistaxis
Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the
nose.
Xerostomia
Xerostomia refers to dryness of the mouth.
Rhinorrhea
Rhinorrhea refers to drainage of a large amount of fluid from the nose.
Dysphagia
Dysphagia refers to difficulties in swallowing.
106.
The herpes simplex virus (HSV-1), which produces a cold sore (fever blister), has an incubation
period of
2-12 days.
HSV-1 is transmitted primarily by direct contact with infected secretions.
0-3 months.
The time period 0-3 months exceeds the incubation period.
20-30 days.
The time period 20-30 days exceeds the incubation period.
3-6 months.
The time period 3-6 months exceeds the incubation period.
107.
Another term for clergyman's sore throat is
aphonia.
Aphonia refers to the inability to use one's voice.
atrophic pharyngitis.
Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times
wrinkled.
hypertrophic pharyngitis.
Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal
mucous membrane.
108.
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?
Obstructive
Obstructive sleep apnea occurs usually in men, especially those who are older and overweight.
Simple
Types of sleep apnea do not include a simple characterization.
Mixed
Mixed sleep apnea is a combination of central and obstructive apnea with one apneic episode.
Central
In central sleep apnea, the patient demonstrates simultaneous cessation of both airflow and
respiratory movements.
109.
When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors
him very carefully because he is identified as being at high risk for
carotid artery hemorrhage.
The carotid artery lies close to the stoma and may rupture from erosion if the wound does not
heal properly.
pulmonary embolism.
Pulmonary embolism is associated with immobility.
dehydration.
Dehydration may lead to poor wound healing and breakdown.
pneumonia.
Pneumonia is a risk for any postoperative patient.
110.
Which of the following terms refers to lung tissue that has become more solid in nature due to a
collapse of alveoli or infectious process?
Consolidation
Consolidation occurs during an infectious process such as pneumonia.
Atelectasis
Atelectasis refers to collapse or airless condition of the alveoli caused by hypoventilation,
obstruction to the airways, or compression.
Bronchiectasis
Bronchiectasis refers to chronic dilation of a bronchi or bronchi in which the dilated airway
becomes saccular and a medium for chronic infection.
Empyema
Empyema refers to accumulation of purulent material in the pleural space.
111.
Which of the following community-acquired pneumonias demonstrates the highest occurrence
during summer and fall?
Legionnaires' disease
Legionnaires' disease accounts for 15% of community-acquired pneumon
Posted by StuffedNurse (co-author) at 8:32 PM
Wednesday, January 23, 2008
SITUATIONAL
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.
A. Reduce anaphylaxis
B. Relieve hypersensitivity to allergen
C. Relieve respiratory distress due to bronchial spasm
D. Restore client’s 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:
5. The rationale for giving medications through the subcutaneous route is:
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
10. Client’s 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 Mario’s nursing
care plan is to loosen and remove excessive secretions in the airway.
11. Mario listens to Richard’s 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 Richard’s treatment Mario should include the following in his
recording EXCEPT:
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 client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s 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?
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 client’s 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 client’s priority
problem is to:
17. Upon establishing Mr. Regalado’s 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:
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:
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:
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 “what’s the use? My time
is running out.” The nurse’s 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 children’s 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 Nancy’s illness and tells her head nurse during the end of shift
endorsement that “it’s 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 Nancy’s condition, the nurse learns that being self-aware
is a conscious process that she should do in any situation like this because:
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?
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:
Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse’s 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:
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:
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
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
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:
44. The nurse applies dressing on the bleeding site. This intervention is done to:
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:
Situation 10 – While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctor’s appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and
make an assessment.
A. Record pertinent information in the client’s 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 a few weeks now. You
will record this as follows:
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
note: guys pacensya na dont have time yet to post the rationales, super haba most of them, maybe
later this month or maybe i'll post ung mga sources na lang na books so you can read them on
your own.(^^,)
-diannemaydee
SITUATIONAL
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.
2. When preparing the epinephrine injection from an ampule, the nurse initially:
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:
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:
Qualitative research
7. The type of research design that does not manipulate independent variable is:
Non-experimental design
8. This research topic has the potential to contribute to nursing because it seeks to
A. athering data about what is already known or unknown about the problem
10. Client’s rights should be protected when doing research using human subjects. Martha
identifies these rights as follows EXCEPT:
right to compensation
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 Mario’s nursing
care plan is to loosen and remove excessive secretions in the airway.
11. Mario listens to Richard’s 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:
Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his
back and on his abdomen
12. When documenting outcome of Richard’s treatment Mario should include the following in his
recording EXCEPT:
14. Mario prepares Richard for postural drainage and percussion. Which of the following is a
special consideration when doing the procedure?
15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The
difference between the procedures is:
Percussion delivers cushioned blows to the chest with cupped palms while vibration gently
shakes secretion loose on the exhalation cycle
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 client’s priority
problem is to:
17. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:
18. Mr. Regalado says he has “trouble going to sleep”. In order to plan your nursing intervention
you will:
19. Mr. Regalado’s 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?
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:
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:
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:
anger
23. The nurse visits Nancy and prods her to eat her food. Nancy replies “what’s the use? My time
is running out.” The nurse’s best response would be:
24. The nurse feels sad about Nancy’s illness and tells her head nurse during the end of shift
endorsement that “it’s 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:
Advise the nurse to “be strong and learn to control her feelings”
25. Realizing that she feels angry about Nancy’s condition, the nurse learns that being self-aware
is a conscious process that she should do in any situation like this because:
How the nurse thinks and feels affect her actions towards her client and her work
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?
27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what
physical changes predispose her to constipation?
28. The nurse understands that one of these factors contributes to constipation:
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:
Thorough washing, rising and drying of skin area that get wet with urine
Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse’s 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:
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:
Hypoxemia
33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of
the tubing for an adult would be:
the distance from the tip of the nose to the tip of the ear lobe
34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area
by:
Applying no suction while inserting the catheter
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:
Orthopnea
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:
deflated fully then immediately start second reading for same client
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
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
prevention nutrition
39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes.
Which of the following is true?
Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes
which is genetic in etiology
40. Lifestyle-related diseases in general share areas common risk factors. These are the following
except:
genetics
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
Ryan who has chest injury, is pale and with difficulty breathing
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:
44. The nurse applies dressing on the bleeding site. This intervention is done to:
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:
Instructing the client to see you after discharge for further assistance
Situation 10 – While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctor’s appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and
make an assessment.
Understand her lifestyle, health needs and possible problems to develop a plan of care
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 a few weeks now. You
will record this as follows:
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:
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?
Malnutrition and its possible effects on growth and development problems in the unborn fetus
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:
Cancer
Wednesday, January 23, 2008
SITUATIONAL
A. Eat more frequent small meals instead of three large one daily
B. Walk for at least half an hour daily to stimulate peristalsis
C. Drink more milk, increased calcium intake prevents constipation
D. Drink eight full glasses of fluid such as water daily
3. If you were Minette, which of the following actions would alert you
that a new mother is entering a postpartal taking-hold phase?
A. She urges the baby to stay awake so that she can breast-feed him
or her
B. She tells you she was in a lot of pain all during labor
C. She says that she has not selected a name for the baby as yet
D. She sleeps as if exhausted from the effort of labor
A. 350 kcal/day
B. 500 kcal/day
C. 200 kcal/day
D. 1000 kcal/day
A. Quasi-Judicial Power
B. Regulatory Power
C. Quasi-Legislative Power
D. Executive/Promulgating Power
10. The NSCC was created for the purpose of implementing the
Nursing Specialty policy under the direct supervision and
stewardship of the Board of Nursing. Who shall comprise the NSCC?
Situation 3 –Nurse Anna is a new BSN graduate and has just passed
her Licensure Examination for Nurses in the Philippines. She has
likewise been hired as a new Community Health Nurse in one of the
Rural Health Units in their City, which of the following conditions
may be acceptable TRUTHS applied to Community Health Nursing
Practice.
A. Cure of illnesses
B. Prevention of illnesses
C. Rehabilitation back to health
D. Promotion of health
A. The community
B. The extended members of every family
C. The individual members of the Barangay
D. The Family
A. evaluation
B. assessment
C. implementation
D. planning
A. goal-setting
B. monitoring
C. evaluation of data
D. provision of data
A. Contracted pelvis
B. Maternal disproportion
C. Cervical insufficiency
D. Fetopelvic disproportion
18. The nurse would anticipate a cesarean birth for a client who has
which infection present at the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting
20. The rationales for using a prostaglandin gel for a client prior to
the induction of labor is to:
21. Dina, 17 years old, asks you how a tubal ligation prevents
pregnancy. Which would be the best answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is
blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes
are blocked
D. The ovary no longer releases ova as there is no where for them to
go.
A. She will not be able to conceive for 3 months after the procedure
B. The sonogram of the uterus will reveal any tumors present
C. Many women experience mild bleeding as an after effect
D. She may feel some cramping when the dye is inserted
A. Measles vaccine
B. DPT
C. Hepa-B vaccine
D. Tetanus toxoids
A. Measles
B. Tetanus toxoids
C. Hepatitis B vaccines
D. DPT
29. This is the vaccine needed before a child reaches one (1) year in
order for him/her to qualify as a :fully immunized child”.
A. DPT
B. Measles
C. Hepatitis B
D. BCG
30. Which of the following dose of tetanus toxoid is given to the
mother to protect her infant from neonatal tetanus and likewise
provide 10 years protection for the mother?
A. Tetanus toxoid 3
B. Tetanus toxoid 2
C. Tetanus toxoid 1
D. Tetanus toxoid 4
31. This special form is used when the patient is admitted to the unit.
The nurse completes the information in this record particularly
his/her basic personal data, current illness, previous health history,
health history of the family, emotional profile, environmental history
as well as physical assessment together with nursing diagnosis on
admission. What do you call this record?
A. Nursing Kardex
B. Nursing Health History and Assessment Worksheet
C. Medicine and Treatment Record
D. Discharge Summary
A. Nursing Kardex
B. Graphic Flow Sheets
C. Discharge Summary
D. Medicine and Treatment Record
34. This flip-over card is usually kept in a portable file at the Nurse’s
Station. It has 2-parts: the activity and treatment section and a
nursing care plan section. This carries information about basic
demographic data, primary medical diagnosis, current orders of the
physician to be carried out by the nurse, written nursing care plan,
nursing orders, scheduled tests and procedures, safety precautions
in patient care and factors related to daily living activities. This
record is used in the charge-of-shift reports or during the bedside
rounds or walking rounds. What record is this?
A. Discharge Summary
B. Medicine and Treatment Record
C. Nursing Health History and Assessment Worksheet
D. Nursing Kardex
35. Most nurses regard this conventional recording of the date, time,
and mode by which the patient leaves a healthcare unit but this
record includes importantly, directs of planning for discharge that
starts soon after the person is admitted to a healthcare institution. It
is accepted that collaboration or multidisciplinary involvement (of all
members of the health team) in discharge results in comprehensive
care. What do you call this?
A. Discharge Summary
B. Nursing Kardex
C. Medicine and Treatment Record
D. Nursing Health History and Assessment Worksheet
37. Based on the Code of Ethics for Filipino Nurses, what is regarded
as the hallmark of nursing responsibility and accountability?
40. Mr. Santos, R.N. works in a nursing home, and he knows that one
of his duties is to be an advocate for his patients. Mr. Santos knows a
primary duty of an advocate is to;
46. Josie brought her 3 months old child to your clinic because of
cough and colds. Which of the following is your primary action?
A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken
A. Giving antibiotics
B. Taking of the temperature of the sick child
C. Provision of Careful Assessment
D. Weighing of the sick child
50. Which of the following is the principal focus of the CARI program
of the Department of Health?
answer key np
note: guys, i'll post the rationales later this month na lang ha, super
hectic lang talaga my sched (^^,)
SITUATIONAL
3. If you were Minette, which of the following actions would alert you
that a new mother is entering a postpartal taking-hold phase?
She urges the baby to stay awake so that she can breast-feed him or
her
500 kcal/day
R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing released
Resolution No. 14 Series of 1999 entitled: “Adoption of a Nursing
Specialty Certification Program and Creation of Nursing Specialty
Certification Council.” This rule-making power is called:
Quasi-Legislative Power
10. The NSCC was created for the purpose of implementing the
Nursing Specialty policy under the direct supervision and
stewardship of the Board of Nursing. Who shall comprise the NSCC?
Situation 3 –Nurse Anna is a new BSN graduate and has just passed
her Licensure Examination for Nurses in the Philippines. She has
likewise been hired as a new Community Health Nurse in one of the
Rural Health Units in their City, which of the following conditions
may be acceptable TRUTHS applied to Community Health Nursing
Practice.
The Family
assessment
goal-setting
18. The nurse would anticipate a cesarean birth for a client who has
which infection present at the onset of labor?
Herpes-simplex virus
20. The rationales for using a prostaglandin gel for a client prior to
the induction of labor is to:
21. Dina, 17 years old, asks you how a tubal ligation prevents
pregnancy. Which would be the best answer?
Sperm can no longer reach the ova, because the fallopian tubes are
blocked
Measles vaccine
Hepatitis B vaccines
29. This is the vaccine needed before a child reaches one (1) year in
order for him/her to qualify as a :fully immunized child”.
Measles
30. Which of the following dose of tetanus toxoid is given to the
mother to protect her infant from neonatal tetanus and likewise
provide 10 years protection for the mother?
Tetanus toxoid 4
31. This special form is used when the patient is admitted to the unit.
The nurse completes the information in this record particularly
his/her basic personal data, current illness, previous health history,
health history of the family, emotional profile, environmental history
as well as physical assessment together with nursing diagnosis on
admission. What do you call this record?
34. This flip-over card is usually kept in a portable file at the Nurse’s
Station. It has 2-parts: the activity and treatment section and a
nursing care plan section. This carries information about basic
demographic data, primary medical diagnosis, current orders of the
physician to be carried out by the nurse, written nursing care plan,
nursing orders, scheduled tests and procedures, safety precautions
in patient care and factors related to daily living activities. This
record is used in the charge-of-shift reports or during the bedside
rounds or walking rounds. What record is this?
Nursing Kardex
35. Most nurses regard this conventional recording of the date, time,
and mode by which the patient leaves a healthcare unit but this
record includes importantly, directs of planning for discharge that
starts soon after the person is admitted to a healthcare institution. It
is accepted that collaboration or multidisciplinary involvement (of all
members of the health team) in discharge results in comprehensive
care. What do you call this?
Discharge Summary
The present code utilized the Code of Good Governance for the
Professions in the Philippines
37. Based on the Code of Ethics for Filipino Nurses, what is regarded
as the hallmark of nursing responsibility and accountability?
40. Mr. Santos, R.N. works in a nursing home, and he knows that one
of his duties is to be an advocate for his patients. Mr. Santos knows a
primary duty of an advocate is to;
Heparin does not cross placenta and so does not affect a fetus
I take an iron pill every day to help grow new red blood cells
46. Josie brought her 3 months old child to your clinic because of
cough and colds. Which of the following is your primary action?
Difficulty to awaken
50. Which of the following is the principal focus of the CARI program
of the Department of Health?
NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part
A)
SITUATIONAL
Situation 1 – Concerted work efforts among members of the surgical team is essential to the
success of the surgical procedure.
1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is
a need for sterile supply which is not in the sterile field, who hands out these items by opening its
outer cover?
A. Circulating Nurse
B. Anaesthesiologist
C. Surgeon
D. Nursing Aide
2. The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?
A. Scrub Nurse
B. Surgeon
C. Anaesthesiologist
D. Circulating Nurse
3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the
nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is
usually informed to be present in the OR?
A. Rehabilitation department
B. Laboratory department
C. Maintenance department
D. Radiology department
4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team,
who else has to be present when a client undergoes laparoscopic surgery?
A. Information technician
B. Biomedical technician
C. Electrician
D. Laboratory technician
5. In massive blood loss, prompt replacement of compatible blood is crucial. What department
needs to be alerted to coordinate closely with the patient’s family for immediate blood component
therapy?
A. Security Division
B. Chaiplaincy
C. Social Service Section
D. Pathology department
Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in
varying degrees upon movement of body parts.
6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain.
Which of the following observation would prompt you to call the doctor?
7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at
5 pm. The next dose of Demerol 50 mg I.M. is given:
8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors
indicate appropriate adaptation?
9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as
cultural or psychological that influence pain. How can you alter these factors as the nurse?
A. Explain all the possible interventions that may cause the client to worry
B. Establish trusting relationship by giving his medication on time
C. Stay with the client during pain episodes
D. Promote client’s sense of control and participation in control by listening to his concerns
10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is
your nursing priority care in such a case?
11. The patient’s medical record can work as a double edged sword. When can the medical record
become the doctor’s/nurse’s worst enemy?
13. In the hospital, when you need the medical record of a discharged patient for research you
will request permission through:
A. Doctor in charge
B. The hospital director
C. The nursing service
D. Medical records section
14. You readmitted a client who was in another department a month ago. Since you will need the
previous chart, from whom do you request the old chart?
15. Records Management and Archives Office of the DOH is responsible for implementing its
policies on record disposal. You know that your institution is covered by this policy if:
Situation 4 – In the OR, there are safety protocols that should be followed. The OR nurse should
be well versed with all these to safeguard the safety and quality of patient delivery outcome.
16. Which of the following should be given highest priority when receiving patient in the OR?
17. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures
but considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. According to the surgeon’s preference
18. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing
care during the intraoperative phase. As the circulating nurse, you make certain that throughout
the procedure…
19. Another nursing check that should not be missed before the induction of general anesthesia is:
20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for:
Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient.
21. Which of the following role would be the responsibility of the scrub nurse?
22. As a perioperative nurse, how can you best meet the safety need of the client after
administering preoperative narcotic?
A. Put side rails up and ask the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form
23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If
hair at the operative site is not shaved, what should be done to make suturing easy and lessen
chance of incision infection?
A. Draped
B. Pulled
C. Clipped
D. Shampooed
24. It is also the nurse’s function to determine when infection is developing in the surgical
incision. The perioperative nurse should observe for what signs of impending infection?
25. Which of the following nursing interventions is done when examining the incision wound and
changing the dressing?
Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and
he appears to be in acute respiratory distress.
28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction
will include the following, EXCEPT:
29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic
attack starts. What will be the best position?
30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially
manifest symptoms of:
A. metabolic alkalosis
B. respiratory acidosis
C. respiratory alkalosis
D. metabolic acidosis
31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm
systems?
32. Overdosage of medication or anesthetic can happen even with the aid of technology like
infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong
person, and wrong procedure/surgery includes the following, EXCEPT:
34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient
harm resulting from fall, you can implement the following, EXCEPT:
A. Assess potential risk of fall associated with the patient’s medication regimen
B. Take action to address any identified risks through Incident Report (IR)
C. Allow client to walk with relative to the OR
D. Assess and periodically reassess individual client’s risk for falling
35. As a nurse, you know you can improve on accuracy of patient’s identification by 2 patient
identifiers, EXCEPT:
A. identify the client by his/her wrist tag and verify with family members
B. identify client by his/her wrist tag and call his/her by name
C. call the client by his/her case and bed number
D. call the patient by his/her name and bed number
36. If you are the nurse in charge for scheduling surgical cases, what important information do
you need to ask the surgeon?
37. In the OR, the nursing tandem for every surgery is:
38. While team effort is needed in the OR for efficient and quality patient care delivery, we
should limit the number of people in the room for infection control. Who comprise this team?
39. When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care
barriers?
42. What health instruction will enhance regulation of a colostomy (defecation) of clients?
A. Increased weight
B. Irritation of skin around the stoma
C. Liquid stool
D. Establishment of regular bowel movement
44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
A. Increase the irrigating solution flow rate when abdominal cramps is felt
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Position client in semi-Fowler
D. Hang the solution 18 inches above the stoma
45. What sensation is used as a gauge so that patients with ileostomy can determine how often
their pouch should be drained?
A. Sensation of taste
B. Sensation of pressure
C. Sensation of smell
D. Urge to defecate
Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of
the research process.
A. Control group
B. Study subjects
C. General population
D. Universe
A. Randomization
B. Appropriate location
C. Appropriate number
D. Representativeness
49. Which of the following methods allows the use of any group of research subject?
A. Purposive
B. Convenience
C. Snow-ball
D. Quota
50. You decided to include 5 barangays in your municipality and chose a sampling method that
would get representative samples from each barangay. What should be the appropriate method
ofor you to use in this care?
A. Cluster sampling
B. Random sampling
C. Startified ampling
D. Systematic sampling
NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part
A)
SITUATIONAL
Situation 1 – Concerted work efforts among members of the surgical team is essential to the
success of the surgical procedure.
1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is
a need for sterile supply which is not in the sterile field, who hands out these items by opening its
outer cover?
Circulating Nurse
2. The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?
Anaesthesiologist
3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the
nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is
usually informed to be present in the OR?
Radiology department
4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team,
who else has to be present when a client undergoes laparoscopic surgery?
Biomedical technician
5. In massive blood loss, prompt replacement of compatible blood is crucial. What department
needs to be alerted to coordinate closely with the patient’s family for immediate blood component
therapy?
Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in
varying degrees upon movement of body parts.
6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain.
Which of the following observation would prompt you to call the doctor?
7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at
5 pm. The next dose of Demerol 50 mg I.M. is given:
At 11 pm
8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors
indicate appropriate adaptation?
9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as
cultural or psychological that influence pain. How can you alter these factors as the nurse?
Promote client’s sense of control and participation in control by listening to his concerns
10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is
your nursing priority care in such a case?
Situation 3 – Records are vital tools in any institution and should be properly maintained for
specific use and time.
11. The patient’s medical record can work as a double edged sword. When can the medical record
become the doctor’s/nurse’s worst enemy?
13. In the hospital, when you need the medical record of a discharged patient for research you
will request permission through:
14. You readmitted a client who was in another department a month ago. Since you will need the
previous chart, from whom do you request the old chart?
15. Records Management and Archives Office of the DOH is responsible for implementing its
policies on record disposal. You know that your institution is covered by this policy if:
Situation 4 – In the OR, there are safety protocols that should be followed. The OR nurse should
be well versed with all these to safeguard the safety and quality of patient delivery outcome.
16. Which of the following should be given highest priority when receiving patient in the OR?
17. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures
but considered ‘dirty cases’. When are these procedures best scheduled?
Last case
18. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing
care during the intraoperative phase. As the circulating nurse, you make certain that throughout
the procedure…
strap made of strong non-abrasive materials are fastened securely around the joints of the knees
and ankles and around the 2 hands around an arm board.
19. Another nursing check that should not be missed before the induction of general anesthesia is:
20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for:
delayed wound healing
Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient.
21. Which of the following role would be the responsibility of the scrub nurse?
Account for the number of sponges, needles, supplies, used during the surgical procedure.
22. As a perioperative nurse, how can you best meet the safety need of the client after
administering preoperative narcotic?
Put side rails up and ask the client not to get out of bed
23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If
hair at the operative site is not shaved, what should be done to make suturing easy and lessen
chance of incision infection?
Clipped
24. It is also the nurse’s function to determine when infection is developing in the surgical
incision. The perioperative nurse should observe for what signs of impending infection?
25. Which of the following nursing interventions is done when examining the incision wound and
changing the dressing?
Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and
he appears to be in acute respiratory distress.
27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its
indication, the nurse will say:
28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction
will include the following, EXCEPT:
30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially
manifest symptoms of:
respiratory acidosis
31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm
systems?
32. Overdosage of medication or anesthetic can happen even with the aid of technology like
infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong
person, and wrong procedure/surgery includes the following, EXCEPT:
34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient
harm resulting from fall, you can implement the following, EXCEPT:
35. As a nurse, you know you can improve on accuracy of patient’s identification by 2 patient
identifiers, EXCEPT:
36. If you are the nurse in charge for scheduling surgical cases, what important information do
you need to ask the surgeon?
Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery?
37. In the OR, the nursing tandem for every surgery is:
38. While team effort is needed in the OR for efficient and quality patient care delivery, we
should limit the number of people in the room for infection control. Who comprise this team?
39. When surgery is on-going, who coordinates the activities outside, including the family?
Circulating Nurse
Communication
41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care
barriers?
42. What health instruction will enhance regulation of a colostomy (defecation) of clients?
Increased weight
44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
Increase the irrigating solution flow rate when abdominal cramps is felt
45. What sensation is used as a gauge so that patients with ileostomy can determine how often
their pouch should be drained?
Sensation of pressure
Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of
the research process.
General population
Representativeness
49. Which of the following methods allows the use of any group of research subject?
Convenience
50. You decided to include 5 barangays in your municipality and chose a sampling method that
would get representative samples from each barangay. What should be the appropriate method
ofor you to use in this care?
Cluster sampling
Wednesday, January 23, 2008
MULTIPLE CHOICE
Situation 1 – Because of the serious consequences of severe burns, management requires a
multidisciplinary approach. You have important responsibilities as a nurse.
1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns into flames. The
most effective way to extinguish the flames with as little further damage as possible is to:
3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the
assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk,
right upper extremities and right lower extremities. His wife asks what that means? Your most
accurate response would be:
4. During the first 24 hours after the thermal injury, you should asses Sergio for:
5. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior
chest and both upper extremities two days ago begins to exhibit extreme restlessness. You
recognize that this most likely indicates that Teddy is developing:
6. You are in night duty in surgical ward. One of your patients Martin is a prisoner who sustained
an abdominal gunshot wound. He is being guarded by policeman from the local police unit.
During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You
asked why he was trying to hit Martin. He denied the matter. Which among the following
activities will you do first?
7. You are on morning duty in the medical ward. You have 10 patients assigned to you. During
your endorsement rounds, you found out that one of your patients was not in bed. The patient
next to him informed you that he went home without notifying the nurses. Which among the
following will you do first?
8. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found
out that what is on record does not tally with the drugs used. Which among the following will you
do first?
A. Write an incident report and refer the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any patient who might have been given narcotics
9. You are on duty in the medical ward. The mother of your patient who is also a nurse, came
running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other
modes of treatment are done to ensure quality of life. You are assigned in the cancer institute to
care of patients with this type of cancer.
11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After
taking the history and vital signs the physician does which test as a screening test for colorectal
cancer.
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy
12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
A. Carcinoembryonic antigen
B. Proctosigmoidoscopy
C. Stool hematologic test
D. Abdominal computed tomography (CT) test
13. The following are risk factors for colorectal cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
C. Smoking
D. Genetic factors-familial adenomatous polyposis
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin
primarily to:
A. promote rest of the bowel by minimizing peristalsis
B. reduce the bacterial content of the colon
C. empty the bowel of solid waste
D. soften the stool by retaining water in the colon
16. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7th postoperative day
17. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the
procedure:
18. When observing a return demonstration of a colostomy irrigation, you know that more
teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable
19. You are aware that teaching about colostomy care is understood when Fermin states, “I will
contact my physician and report:
A. If I have any difficulty inserting the irrigating tub into the stoma.”
B. If I noticed a loss of sensation to touch in the stoma tissue.”
C. The expulsion of flatus while the irrigating fluid is running out.”
D. When mucus is passed from the stoma between the irrigations.”
20. You would know after teaching Fermin that dietary instruction for him is effective when he
states, “It is important that I eat:
A. Soft food that are easily digested and absorbed by my large intestines.”
B. Bland food so that my intestines do not become irritated.”
C. Food low in fiber so that there is less stool.”
D. Everything that I ate before the operation, while avoiding foods that cause gas.”
Situation 5 – Ensuring safety is one of your most important responsibilities. You will need to
provide instructions and information to your clients to prevent complications.
21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
22. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that
would be indicative of a developing thrombophlebitis would be:
23. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct
her to:
24. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding
his laryngectomy tube being dislodged. What should you teach him first?
25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority
would be to maintain:
A. supplementary oxygen
B. ventilation exchange
C. chest tube drainage
D. blood replacement
Situation 6 – Infection can cause debilitating consequences when host resistance is compromised
and virulence of microorganisms and environmental factors are favorable. Infection control is one
important responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a
workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for
herself and her household help. Your most appropriate response would be:
27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your
best response would be:
A. “You acquired the infection after you have been admitted to the hospital.”
B. “This is a highly contagious infection requiring complete isolation.”
C. “The infection you had prior to hospitalization flared up.”
D. “As a result of medical treatment, you have acquired a secondary infection.’
28. As a nurse you know that one of the complications that you have to watch out for when caring
for Omar who is receiving total parenteral nutrition is:
A. stomatitis
B. hepatitis
C. dysrhythmia
D. infection
A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine
30. Which of the following is the most reliable in diagnosing a wound infection?
31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma
Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a
nurse assigned to Wendy what will be your priority goal?
32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what
should you do?
33. Which among the following interventions should you consider as the highest priority when
caring for June who has hemiparesis secondary to stroke?
34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia.
She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While
waiting for surgery, you can provide a therapeutic environment by doing which of the following?
35. When performing a neurologic assessment on Walter, you find that his pupils are fixed and
dilated. This indicated that he:
Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it
is important to provide quality care to our older patients. There are frequently encountered
situations and issues relevant to the older patients.
36. Hypoxia may occur in the older patients because of which of the following physiologic
changes associated with aging.
37. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity
40. The most dependable sign of infection in the older patient is:
41. Which of the four phases of emergency management is defined as “sustained action that
reduces or eliminates long-term risk to people and property from natural hazards and their
effects.”?
A. Recovery
B. Mitigation
C. Response
D. Preparedness
42. You are a community health nurse collaborating with the Red Cross and working with disaster
relief following a typhoon which flooded and devastated the whole province. Finding safe
housing for survivors, organizing support for the family, organizing counseling debriefing
sessions and securing physical care are the services you are involved with. To which type of
prevention are these activities included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention
43. During the disaster you see a victim with a green tag, you know that the person:
A. has injuries that are significant and require medical care but can wait hours with threat to life
or limb
B. has injuries that are life threatening but survival is good with minimal intervention
C. indicates injuries that are extensive and chances of survival are unlikely even with definitive
care
D. has injuries that are minor and treatment can be delayed from hours to days
44. The term given to a category of triage that refers to life threatening or potentially life
threatening injury or illness requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent
45. Which of the following terms refer to a process by which the individual receives education
about recognition of stress reaction and management strategies for handling stress which may be
instituted after a disaster?
Situation 10 – As a member of the health and nursing team you have a crucial role to play in
ensuring that all the members participate actively is the various tasks agreed upon.
46. While eating his meal, Matthew accidentally dislodges his IV lines and bleeds. Blood oozes
on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to
clean the table with:
A. Acetone
B. Alcohol
C. Ammonia
D. Bleach
47. You are a member of the infection control team of the hospital. Based on a feedback during
the meeting of the committee there is an increased incidence of pseudomonas infection in the
Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority
activity?
48. Part of your responsibility as a member of the diabetes core group is to get referrals from the
various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4
patients are referred to you. How would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start your session taking into consideration their distance
from your office
B. Contact the nurse in-charge and find out from her the reason for the referral
C. Determine their learning needs then prioritize
D. Involve the whole family in the teaching class
49. You have been designated as a member of the task force to plan activities for the Cancer
Consciousness Week. Your committee has 4 months to plan and implement the plan. You are
assigned to contact the various cancer support groups in your hospital. What will be your priority
activity?
50. You are invited to participate in the medical mission activity of your alumni association. In
the planning stage everybody is expected to identify what they can do during the medical mission
and what resources are needed. You thought it is also your chance to share what you can do for
others. What will be your most important role where you can demonstrate the impact of nursing
in health?
note: i may not be able to post the rationales, its start of the review season and i am super busy,
plus there are people na nangpipirate ng materials...so so so bad
MULTIPLE CHOICE
1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns into flames. The
most effective way to extinguish the flames with as little further damage as possible is to:
3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the
assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk,
right upper extremities and right lower extremities. His wife asks what that means? Your most
accurate response would be:
4. During the first 24 hours after the thermal injury, you should asses Sergio for:
5. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior
chest and both upper extremities two days ago begins to exhibit extreme restlessness. You
recognize that this most likely indicates that Teddy is developing:
metabolic acidosis
Situation 2 – You are now working as a staff nurse in a general hospital. You have to be prepared
to handle situations with ethico-legal and moral implifications.
6. You are in night duty in surgical ward. One of your patients Martin is a prisoner who sustained
an abdominal gunshot wound. He is being guarded by policeman from the local police unit.
During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You
asked why he was trying to hit Martin. He denied the matter. Which among the following
activities will you do first?
7. You are on morning duty in the medical ward. You have 10 patients assigned to you. During
your endorsement rounds, you found out that one of your patients was not in bed. The patient
next to him informed you that he went home without notifying the nurses. Which among the
following will you do first?
8. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found
out that what is on record does not tally with the drugs used. Which among the following will you
do first?
9. You are on duty in the medical ward. The mother of your patient who is also a nurse, came
running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
Bring the crash cart to the room
10. You are admitting Jorge to the ward and you found out that he is positive for HIV. Which
among the following will you do first?
Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other
modes of treatment are done to ensure quality of life. You are assigned in the cancer institute to
care of patients with this type of cancer.
11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After
taking the history and vital signs the physician does which test as a screening test for colorectal
cancer.
12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
Proctosigmoidoscopy
13. The following are risk factors for colorectal cancer, EXCEPT:
Smoking
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin
primarily to:
16. You plan to teach Fermin how to irrigate the colostomy when:
The stools starts to become formed, around the 7th postoperative day
17. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the
procedure:
18. When observing a return demonstration of a colostomy irrigation, you know that more
teaching is required if Fermin:
Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
19. You are aware that teaching about colostomy care is understood when Fermin states, “I will
contact my physician and report:
If I have any difficulty inserting the irrigating tub into the stoma.”
20. You would know after teaching Fermin that dietary instruction for him is effective when he
states, “It is important that I eat:
A. Everything that I ate before the operation, while avoiding foods that cause gas.”
Situation 5 – Ensuring safety is one of your most important responsibilities. You will need to
provide instructions and information to your clients to prevent complications.
21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
22. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that
would be indicative of a developing thrombophlebitis would be:
23. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct
her to:
24. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding
his laryngectomy tube being dislodged. What should you teach him first?
25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority
would be to maintain:
ventilation exchange
Situation 6 – Infection can cause debilitating consequences when host resistance is compromised
and virulence of microorganisms and environmental factors are favorable. Infection control is one
important responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a
workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for
herself and her household help. Your most appropriate response would be:
27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your
best response would be:
“You acquired the infection after you have been admitted to the hospital.”
28. As a nurse you know that one of the complications that you have to watch out for when caring
for Omar who is receiving total parenteral nutrition is:
infection
Dakin’s solution
30. Which of the following is the most reliable in diagnosing a wound infection?
Situation 7 – As a nurse you need to anticipate the occurrence of complications of stroke so that
life threatening situations can be prevented.
31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma
Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a
nurse assigned to Wendy what will be your priority goal?
32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what
should you do?
34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia.
She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While
waiting for surgery, you can provide a therapeutic environment by doing which of the following?
35. When performing a neurologic assessment on Walter, you find that his pupils are fixed and
dilated. This indicated that he:
Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it
is important to provide quality care to our older patients. There are frequently encountered
situations and issues relevant to the older patients.
36. Hypoxia may occur in the older patients because of which of the following physiologic
changes associated with aging.
37. The older patient is at higher risk for incontinence because of:
38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:
functional decline
Acute confusion
40. The most dependable sign of infection in the older patient is:
41. Which of the four phases of emergency management is defined as “sustained action that
reduces or eliminates long-term risk to people and property from natural hazards and their
effects.”?
Mitigation
42. You are a community health nurse collaborating with the Red Cross and working with disaster
relief following a typhoon which flooded and devastated the whole province. Finding safe
housing for survivors, organizing support for the family, organizing counseling debriefing
sessions and securing physical care are the services you are involved with. To which type of
prevention are these activities included:
Tertiary prevention
43. During the disaster you see a victim with a green tag, you know that the person:
has injuries that are minor and treatment can be delayed from hours to days
44. The term given to a category of triage that refers to life threatening or potentially life
threatening injury or illness requiring immediate treatment:
Emergent
45. Which of the following terms refer to a process by which the individual receives education
about recognition of stress reaction and management strategies for handling stress which may be
instituted after a disaster?
Defusion
Situation 10 – As a member of the health and nursing team you have a crucial role to play in
ensuring that all the members participate actively is the various tasks agreed upon.
46. While eating his meal, Matthew accidentally dislodges his IV lines and bleeds. Blood oozes
on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to
clean the table with:
Bleach
47. You are a member of the infection control team of the hospital. Based on a feedback during
the meeting of the committee there is an increased incidence of pseudomonas infection in the
Burn Unit (3 out of 10 patients had positive blood and wound culture). What is your priority
activity?
Do data gathering about the possible sources of infection (observation, chart review, interview).
48. Part of your responsibility as a member of the diabetes core group is to get referrals from the
various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4
patients are referred to you. How would you start prioritizing your activities?
49. You have been designated as a member of the task force to plan activities for the Cancer
Consciousness Week. Your committee has 4 months to plan and implement the plan. You are
assigned to contact the various cancer support groups in your hospital. What will be your priority
activity?
Clarify objectives of the activity with the task force before contacting the support groups
50. You are invited to participate in the medical mission activity of your alumni association. In
the planning stage everybody is expected to identify what they can do during the medical mission
and what resources are needed. You thought it is also your chance to share what you can do for
others. What will be your most important role where you can demonstrate the impact of nursing
in health?
SITUATIONAL
A. case study
B. longitudinal study
C. cross-sectional study
D. evaluative study
7. The process recording was the principal tool for data collection.
Which of the following is NOT a part of a process recording?
A. Non verbal narrative account
B. Analysis and interpretation
C. Audio-visual recording
D. Verbal narrative account
9. The investigator also provided the nursing care of the subject. The
investigator is referred to as a/an:
A. Participant-observer
B. Observer researcher
C. Caregiver
D. Advocate
11. Which of the following approaches of the nurse validates the data
gathered?
A. “I learned that you were up till ten last night, tell me what
happened
before you were finally able to sleep and how was your sleep?”
B. “Hmm.. You look like you had a very sound sleep. That pill you
were
given last night is effective isn’t it?”
C. “Regina, did you sleep well?”
D. “Regina, how are you?”
15. Regina commits to herself that she understood and will observe
all the medicine precautions by:
A. affixing her signature to the teaching plan that she has understood
the nurse
B. committing what she learned to her memory
C. verbally agreeing with the nurse
D. relying on her husband to remember the precautions
16. The nurse’s most unique tool in working with the emotionally ill
client is his/her
A. theoretical knowledge
B. personality make up
C. emotional reactions
D. communication skills
17. The psychiatric nurse who is alert to both the physical and
emotional needs of clients is working from the philosophical
framework that states:
A. observation
B. intervention
C. validation
D. collaboration
19. All of the following responses are non therapeutic. Which is the
MOST direct violation of the concept, congruence of behavior?
20. The mentally ill person responds positively to the nurse who is
warm and caring. This is a demonstration of the nurse’s role as:
A. counselor
B. mother surrogate
C. therapist
D. socializing agent
21. The best time to inform the client about terminating the nurse-
patient relationship is:
22. The client says, “I want to tell you something but can you
promise that you will keep this a secret?” A therapeutic response of
the nurse is:
A. trustworthiness
B. loyalty
C. integrity
D. professionalism
25. The client has not been visited by relatives for months. He gives a
telephone number and requests the nurse to call. An appropriate
action of the nurse would be:
26. The past history of Camila would most probably reveal that her
premorbid personality is:
A. schizoid
B. extrovert
C. ambivert
D. cycloid
A. is irritable
B. feels superior of others
C. anticipates rejection
D. is depressed
A. anxiety disorder
B. neurosis
C. psychosis
D. personality disorder
A. sensory deprivation
B. social isolation
C. cognitive impairment
D. ego despair
33. The nurse will assist Salome and her daughter to plan a goal
which is for Salome to:
A. adjust to the loss of sensory and perceptual function
B. participate in conversation and other social situations
C. accept the steady loss of hearing that occurs with aging
D. increase her self-esteem to maintain her authoritative role
35. Salome was fitted a hearing aid. She understood the proper use
and wear of this device when she says that the battery should be
functional, the device is turned on and adjusted to a:
A. therapeutic level
B. comfortable level
C. prescribed level
D. audible level
A. acrophobia
B. claustrophobia
C. agoraphobia
D. xenophobia
37. Cecilia’s problem is that she always sees and thinks negative
things hence she is always fearful. Phobia is a symptom described as:
A. organic
B. psychosomatic
C. psychotic
D. neurotic
A. communication
B. cognition
C. observation
D. perception
39. Cognitive therapy is indicated for Cecilia when she is already able
to handle anxiety reactions. Which of the following should the nurse
implement?
A. Informed consent
B. Confidentiality
C. Least restrictive environment
D. Civil liberty
42. The nurse must see to it that the written consent of mentally ill
patients must be taken from:
A. Doctor
B. Social worker
C. Parents or legal guardian
D. Law enforcement authorities
A. 24 hours
B. 36 hours
C. 48 hours
D. 12 hours
45. Nursing care plans provide very meaningful data for the patient
profile and initial plan because the focus is on the:
48. To help Marie who bed wets at night practice acceptable and
appropriate behavior, it is important for the parents to be consistent
with the following approaches EXCEPT:
A. “You are supposed to get up and go in the toilet when you feel you
have to go and did not. The next time you bed wet, I’ll tell your
friends and hang your sheets out the window for them to see.”
B. “You are supposed to get up and go in the toilet when you feel you
have to go and did not. I expect you to from now on without fail.”
C. “If you bed wet, you will change your bed linen and wash the
sheets.”
D. “If you don’t make an effort to control your bedwetting, I’d be
upset and disappointed.”
A. Give a star each time she wakes up dry and every set of five stars,
give a prize.
B. Tokens make her materialistic at an early age. Give praise and
hugs occasionally.
C. What does your child want that you can give every time he/she
wakes up dry in the morning?
D. Promise him/her a long awaited vacation after school is over.
SITUATIONAL
progress notes
case study
7. The process recording was the principal tool for data collection.
Which of the following is NOT a part of a process recording?
Audio-visual recording
Manipulation of variable
9. The investigator also provided the nursing care of the subject. The
investigator is referred to as a/an:
Observer researcher
11. Which of the following approaches of the nurse validates the data
gathered?
“I learned that you were up till ten last night, tell me what happened
before you were finally able to sleep and how was your sleep?”
15. Regina commits to herself that she understood and will observe
all the medicine precautions by:
communication skills
17. The psychiatric nurse who is alert to both the physical and
emotional needs of clients is working from the philosophical
framework that states:
18. One way to increase objectivity in dealing with one’s fears and
anxieties is through the process of:
validation
19. All of the following responses are non therapeutic. Which is the
MOST direct violation of the concept, congruence of behavior?
20. The mentally ill person responds positively to the nurse who is
warm and caring. This is a demonstration of the nurse’s role as:
mother surrogate
21. The best time to inform the client about terminating the nurse-
patient relationship is:
trustworthiness
25. The client has not been visited by relatives for months. He gives a
telephone number and requests the nurse to call. An appropriate
action of the nurse would be:
26. The past history of Camila would most probably reveal that her
premorbid personality is:
schizoid
anticipates rejection
Insecurity feelings
psychosis
social isolation
33. The nurse will assist Salome and her daughter to plan a goal
which is for Salome to:
35. Salome was fitted a hearing aid. She understood the proper use
and wear of this device when she says that the battery should be
functional, the device is turned on and adjusted to a:
prescribed level
agoraphobia
37. Cecilia’s problem is that she always sees and thinks negative
things hence she is always fearful. Phobia is a symptom described as:
neurotic
cognition
39. Cognitive therapy is indicated for Cecilia when she is already able
to handle anxiety reactions. Which of the following should the nurse
implement?
Confidentiality
42. The nurse must see to it that the written consent of mentally ill
patients must be taken from:
24 hours
45. Nursing care plans provide very meaningful data for the patient
profile and initial plan because the focus is on the:
48. To help Marie who bed wets at night practice acceptable and
appropriate behavior, it is important for the parents to be consistent
with the following approaches EXCEPT:
“If you don’t make an effort to control your bedwetting, I’d be upset
and disappointed.”
What does your child want that you can give every time he/she
wakes up dry in the morning?