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NURSING PRACTICE III: CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATION GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions. 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. 5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable by law. Per RA 8981.

INSTRUCTIONS: 1. 2. 3. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. Write the subject title Nursing Practice III on the box provided. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set B.

SITUATION: One learns by doing especially when you practice the best methods. 1. Which action by a new nurse signifies a need for further teaching in infection control? A. The nurse places the side rails the time to an unconscious patient B. The nurse elevates the head of the bed to check the BP. C. The nurse uses her bare hands to change the dressing D. The nurse applies oxygen catheter to the mouth. 2. You are on PM shift and about 5 patients are of discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue? A. Call the attention of the orderly in private B. Ignore the situation because you are busy C. Report this behavior to the nurse in charge D. Monitor the situation and note whether any other items are reported missing. 3. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? A. Try to explore the interaction with the nursing attendant concerned B. Change the attendants assignment C. Initiate a group discussion with all other nursing attendants D. Discuss the matter with the patients family 4. Disposal of Medical Records in the Government hospital needs collaboration with which of the following department except: A. DOH B. MMDA C. DILG D. RMAO

5. You saw one colleague charting medication administration that she has not yet administered. After talking to her, you also report the incident to the charge nurse. The charge nurse should: A. Require the staff to submit an incident report B. Terminate the nurse C. Charge the erring nurse with dishonesty D. Repot to the Board of Nursing

SITUATION: You are assigned at the PACU. 6. Which nursing diagnosis has priority among client in the PACU? A. Acute pain related to discomfort off wound and immobility B. Body image disturbance because of wound dressing and drains. C. Ineffective airway clearance related to general anesthesia. D. Knowledge deficit related to lack of information because patients are all sedated. 7. Which of the following clients at the PACU will demonstrate the effectiveness of nurse teaching? A. The client demonstrated deep breathing, coughing, splintering and leg exercises . B. The client manifests normal temperature C. The client sleeps well D. The client has good balance I and O 8. Which of the following remark indicates that the clients relative understood the discharge instruction for wound care? A. If the wound is painful, I will say it is normal B. It is alright to use adhesive tape over the wound to keep it intact C. It is ok for his pet to remain at his bedside to keep him company D. I will report any redness or swelling of the wound 9. You must transfer out a post-op client to her room. What would your instruction to the family include to prevent accidents? A. Report when the IV infusion is almost finished B. Test the call system if functioning C. Keep the room lights on for 24 hours D. Make sure the side rails are up 10. One of your post-op patients has a temperature of 37.9C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9C. The nursing student asked you to explain the absence of shivering even if the temperature was higher. A. The patient is no longer febrile thus he is no longer chilling B. Shivering normally disappears as temperature becomes higher C. The body has reached its new set point thus the absence of shivering D. The patients is feeling better SITUATION: Patients with chest tubes can be very challenging to new nurses. 11. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. After an hour you noticed that the bubbling stops. Which of the following condition is the possible cause of the malfunctioning sealed drainage? A.A suction being too high B.An air leak C.A tube being too small D.A tension pneumothorax 12. While you were making your endorsement, you found out the chest tube of a client was disconnected. What would be your appropriate action? A.Assist the client back to his bed and place him on the affected side B.Cover the end of the chest tube while sterilize gauze C.Reconnect the tube to the chest tube system D.Put the end of the chest tube into a cup of sterile normal saline 13. Dr. Reyes asked you to assist him with the removal; of Tirsos chest tube. You would instruct the client to: A.Continuously breathe normally during the normal of the chest tube

B.Take a deep breath, exhale, and bear down C.Exhale upon actual removal of the tube D.Hold breath until the chest tube is pulled out 14. You know the chest tubes are usually secured by a: A.Suture B. Tape C. Tie D. Cuff

15. When transporting clients with chest tube, the system should be: A.Disconnected B.Closed C.Placed lower than the patients chest D.Placed between the legs of the client to prevent breakage SITUATION: Caring of clients with various problems is an essential component of nursing care. As a nurse generalist, wide knowledge about different disease condition is essential. 16. Mr. Que, 61 years of age is suffering from rheumatoid arthritis. He asks if there is a cure for RA. The MOST appropriate response is: A. No, most patients with RA also develop osteoarthritis. B. Yes, but the patient must take medication for at least 10 years. C. Yes, new drugs being developed offer a cure. D. No, but new drugs being developed can interfere with the bodys reaction to inflammation and better control the disease process. 17. Rita is assigned to care for group of patients. On review of the patients medical record, she determines that which patient is at risk for fluid volume deficit? A. A client with CHF B. A client receiving frequent wound irrigations C. A client with colostomy D. A client with decreased kidney function 18. In providing general information and assessing the patients level of interest or reaction to surgery, which of the following nursing intervention will receive priority? A. Tell the patient when the surgery is scheduled B. Let the patient know that the family will be kept in formed C. Explain details of perioperative preparation with a tour and viewing of area and equipments D. Offer general information about the surgery 19. In the event of a fire, OR staff are instructed to follow the international RACE. What does R stand for? A. Rest B. Rescue C. Respond D. Run

20. In preparing the patient for endoscopic examinations of the upper GI tract, the patients pharynx is anesthetized with Xylocaine spray. Nursing interventions for post-endoscopic examination include: A. Keeping patient NPO until gag reflex returns B. Prohibiting smoking before the test C. Withholding anticholinergic medications D. Allowing fluids up to 4 hours before examination 21. Modern medicine has divided the human body into different systems/organs or the so called specialty medicine practice. Collaboration of the specialists will in effect treat the client as: A. Multiple specialty B. Multi-organ C. One whole human being D. Compartmentalized body

22. Discharge teaching for the client with hypoparathyroidism should include which of the following instructions: A. Use OTC vitamin D preparation B. Avoid strenuous exercises C. Supplement calcium intake D. Avoid diuretics to minimize calcium loss

23. An important nursing intervention goal to establish for Mang Carlos who has iron-deficiency anemia is: A. Alternate periods of rest and activity to balance oxygen supply and demand B. Increase fluids to stimulate erythropoises C. Decrease fluids to prevent sickling of RBCs D. Use birth control to avoid pregnancy 24. KN is monitoring the status of a postoperative patient. He would become MOST concerned with which of the following signs which could indicate an evolving complication? A. A negative Homans sign B. BP of 110/170 mmHg and a pulse of 80 beats per minute C. Increasing restlessness D. Hypoactive bowel sounds in all four quadrants 25. The Patients Bill of rights helps practitioners provide more effective patient care. Which of the following should NOT be included in the list? A. Be informed of administrative and policies and practices B. Considerate and respectful ca re C. Confidentiality of communications and records D. Relevant current and understandable information concerning diagnosis, treatment diagnosis, specific procedures treatment and risks involved. 26. Urinary tract infection is the most common site of nosocomial infection particularly with urinary catheterization. It can be reduced significantly by through: A. Intermittent drainage B. Open system drainage 27. The professional license of an RN is: A. Transferable B. Lifetime C. Can be revoked for reasons stipulated in RA 9173 D. Personal 28. In medical and nursing practice, code means a call for: A. DNR state B. Call to order 29. Who revokes the nursing license? A. PRC B. BON C. PNA D. MMDA C. Clinical case D. Cardiopulmonary resuscitation C. Hanging system drainage D. Closed system drainage

30. The OR team collaborates from the first to the last surgical procedure. Who monitors the activities of each OR suite? A. Scrub nurse B. Anesthesiologist C. Circulating nurse D. Surgeon

31. Organ donation to save life was initially with the first transplant done by:

A. Dr. Christian Barnard of the Union of South Africa B. Dr. Christian of the U.S.A. C. Dr. Christian Barnard of Soviet Union D. Dr. Christian Barnard of U.K. 32. Ms. C.O., age 45, is being evaluated to rule out pulmonary tuberculosis. Which finding is MOST closely associated with TB? A. Green-colored sputum B. Night sweats C. Leg cramps D. Skin discoloration

33. Following a renal angiography, the patient assessment priority is the: A. Respiratory effort B. Blood pressure C. Urinary output D. Puncture site

34. In patients with acute pancreatitis, the administration of the analgesic morphine may cause: A. Addiction B. Urinary retention C. Paralytic ileus D. Spasms of the sphincter of Oddi

35. Who is responsible in daily monitoring the standards of safe, nursing practice in the operating suite? A. Surgeon B. Perioperative nurse C. OR nurse supervisor D. Chief nurse

SITUATION: Consider the following components of research: I. Recent research on this problem shows that woman post mastectomy develops chronic low self esteem problems that eventually lead to depression, According to. (AJN, 2008: J Tobias, Suzares et al.) The more positive the body Image of woman who has experienced a mastectomy, the higher is their self-esteem level. Is there a correlation between body Image and self esteem levels of women who have experienced mastectomy? Anxiety is termed as the fear of the unknown Anxiety will be measured by using the levels of anxiety description and will be categorized as either MILD, MODERATE or SEVERE Post mastectomy woman ages 30 to 50. 10 Post mastectomy woman ages 30 to 50 namely: Magda, Maria, Henerosa, Jade, Alena, Katrina, Magda, Violeta, Dana and Devita. Aling Alena The relationship between Body Image and Self Esteem levels of woman post-mastectomy Maslow noted two versions of esteem needs, a lower one and a higher one. The lower one is the need for the respect of others, the need for status, fame, glory, recognition, attention, reputation, appreciation, dignity, even dominance. The higher form involves the need for selfrespect, including such feelings as confidence, competence, achievement, mastery, independence, and freedom.



IV. V.




A miniature, trial version of the study was conducted before the actual research. This is to prevent any future disaster that might results from incorrect data analysis, data collection procedures and research design.

36. Which statement delivers the title of the research? A. II B. VI C. IX D. IV

37. Paragraph number X is your: A. Conceptual framework B. Theoretical framework 38. Paragraph number IV is your: A. Theoretical definition B. Conceptual definition 39. Paragraph number V is your: A. Theoretical definition B. Conceptual definition C. Operational Definition D. Description C. Operational Definition D. Description C. Review of related literature D. Introduction

40. Which paragraph defines your target population or the group of interest? A. VI B. VII C. VIII D. IX

41. Which paragraph defines your subgroup chosen to represent your target population? A. VI B. VII C. VIII D. IX

42. Paragraph number VIII is your: A. Sample B. Subject 43. Paragraph number XI is your: A. Design B. Population 44. Which paragraph shows your problem statement? A. I B. II C. Introduction D. Pilot Study C. Population D. Element



45. An appropriate title for this study is best shown by which paragraph? A. I B. II C. III D. IX

46. Which is your Independent variable? A. Positive body image B. Post mastectomy woman 47. Which is your Dependent variable? A. Positive body image B. Post mastectomy woman 48. What is the universe? A. Positive body image C. Higher self esteem C. Higher self esteem D. Mastectomy C. Higher self esteem D. Mastectomy

B. Post mastectomy woman

D. Mastectomy

49. What is the best research design that you can use in this study? A. Descriptive B. Experimental 50. Which paragraph Reviews the related literature? A. I B. X C. XI D. IX C. Comparative D. Case study

SITUATION: Records and Records management is one of the core of professional nursing practice. 51. The National Archives of the Phils. (NAP) is mandated by R.A. 9470 of 2007 to plan, formulate and implement records management and archival administration program for the efficient action, utilization, maintenance, retention, preservation, conservation and disposal of public records including the adoption of security measures and vital records protection program for the government and give technical assistance to all branches of government. Hospitals should safe keep their record and coordinate with which of the following agency for its disposal? A. National Archives of the Philippines B. Metropolitan Manila Development Authority C. Record Management and Archive Office D. Department Of Health

52. If the research team finished the research about Anas case and they are done disseminating data and after the report has been completed and written, Pre-processed data about Ana should be: A. Preserved B. Destroyed by Burning or Shredding C. Stored for future use D. Keep in a private file nobody can


53. All of the following are purposes of the chart EXCEPT: A. To document the quality of care B. A vehicle for communication 54. What is an example of a subjective data? A. Color of wound drainage B. Odor of breath C. Respiration of 14 breaths/minute D. The patients statement of I feel sick to my stomach 55. Charting should be legible and include only standard abbreviations. Which of the following is NOT a standard abbreviation? A. PRN B. OD C. NNO D. NPO C. For the prerecording of nursing actions D. For research and education

SITUATION: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting. 56. Which of the following statements best describes acquaintance rape? A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. When two people dont love each other and engage in sexual activities C. When someone on a date tricks the other person into having sexual intercourse D. Sexual intercourse committed with force or the threat of force without a persons consent 57. Male to male rape is also another problem that a nurse can encounter. The nurse knows that in male to male rape, The perpetrator is usually: A. An effeminate male homosexual B. A young, newcomer heterosexual male C. A heterosexual who believes that he is superior D. A passive homosexual male

58. An 18 year old male client was rushed to the hospital due to burns, bruises and cuts on the face and body. The teenager confessed that he was raped by 4 of his classmates, all of which are also male. Male to male rape also occurs and the nurse must know that: A. If there is an erection, the male victim also consents to the rape itself. B. That all male to male rape cases occurs at home, which is statutory most of the time. C. That male rape victims are usually homosexuals. Which are very much deserving to be raped. D. Most victims of male to male rapes never dare to report the incident. 59. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when: A. A child blames him or herself for the sexual abuse and begins to withdraw and Isolate B. Newspapers and the media dont keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop D. The childs agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge 60. Which of the following is an example of hostile environment in terms of sexual harassment? A. The boss assures you of a big promotion if you go out on a couple of dates with him B. Your supervisor makes masturbatory gestures every time you walk pass him C. The personnel manager hints that the job will be yours if you cooperate sexually with him D. Your boss suggests that your raise is dependent upon having sex with him SITUATION: You are a nurse working in the medical ward. 61. Mr. E.O. age 52 had a laryngectomy due to cancer of the larynx. Discharge instructions are given to Mr.F.O. and his family. Which response by written communication from Mr. F.O. or verbal response from the family will be a signal to the nurse that the instructions need to be reclarified? A. It is acceptable to take over-the-counter medications now that condition is stable B. The suctioning at home must be a clean procedure, not sterile . C. Report swelling, pain or excessive drainage D. Cleans skin around stoma BID, use hydrogen peroxide and rinse with water, pat dry. 62. Dr. Tuazon scheduled Mrs. Poe for a right breast mass incision with frozen section and possible mastectomy on Monday, first case. As the nurse in-charge for scheduling you will collaborate with the following departments EXCEPT: A. Pathology C. Anesthesia B. Dietary

D. Surgery

63. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. In the process the fetus died. The doctrine that justifies the death of the fetus is: A. Justice B. Anatomy C. Exception to the role D. Double effect

64. A nurse is waiting for a report to be sent by fax. The machine activates but instead of the report, the nurse received a sexually oriented photograph. The MOST appropriate nursing action is to: A. Call the nursing supervisor and report the incident B. Cut the photograph and throws it away. C. Call the police D. Call the unit who sent it and ask for the name of person who sent the photograph

65. Ms. F.X... has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays would be acceptable for her? A. Liver, fried potatoes and avocado B. Whole milk, rice and pastry C. Ham, mashed potatoes, cream peas D. Skim milk, lean fish, tapioca pudding

66. Maria is administering a cleansing enema to a patient with fecal impaction. Before administering the enema, she should place the patient in which of the following positions? A. On the right side of the body with the head of the bed elevated 45 degrees B. Left Sims position C. On the left side of the body with the head of the bed elevated 45 degree D. Right Sims position 67. The functionality and integrity of instruments and medical devices used in surgical procedure, is the responsibility of the: A. surgeon B. bio-med technician D. scrub nurse C. OR nurse

68. Maria will be preparing a patient for thoracentesis. She should assist the patient to which of the following positions for the procedure? A. Prone with the head turned to the side and supported by a pillow B. Lying in bed on the affected side with the head of the bed elevated 45 degrees C. Sims position with the head of the bed flat D. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees 69. When a patient comes to the clinic for an eye examination, the ophthalmologists administers phenylephrine 2.5% drops to: A. Dilate retinal blood vessels B. Anesthetize the cornea C. Dilate the pupil D. Removed any obstruction on the cornea 70. Which of the following statements by Ms. S.O. a chemotherapy patient with a low WBC count, a low platelet count and a hemoglobin measurement of 5.6 g would indicate the need for further teaching? A. My lips are dry an d cracking. I need some lubricant B. My husband and I have been using vaginal lubrication before my intercourse C. I check my mouth and teeth after each meal D. Ive been very constipated and need an enema SITUATION: You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are their common concerns. You should be able to address their concerns in a holistic manner. 71. The WHO analgesic ladder provides the health professional with: A. Specific pain management choices based on severity of pain B. General pain management choices based on level of pain C. Pharmacologic and nonpharmacologic pain management choices D. Nonpharmacologic interventions based on level of pain 72. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT: A. Pruritus B. Respiratory depression C. Constipation D. Physical dependence

73. Which of the following statements about cancer pain is NOT true? A. Opioids are drugs of choice for severe pain B. Pain associated with cancer and the terminal phase of the disease occurs in majority of patients C. Under treatment of pain is often due to a clinicians failure or inability to evaluate or appreciate the severity of the clients problem D. Adjuvant medications such as steroids, anti convulsants, nonsteroidal Antiinflammatory drugs enhance pain perception 74. TR has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that TR is: A. Becoming psychologically dependent B. Needing to have the morphine discontinued C. Developing tolerance to the morphine D. Exaggerating his level of pain

75. The guidelines for choosing appropriate nonpharmacologic intervention for pain includes all of the following EXPECT: A. Effectiveness for patient B. Pain problem identification C. Skill of the clinician health professional D. Type of opioid being used

SITUATION: Problems with immobility are very common in post operative patients. Recognizing the complications, the impact and ways to prevent them are necessary aspect of nursing care. 76. What is inertia? A. The ability of an object to stay in motion while in motion and stay at rest while at rest. B. The force that resist movements. C. A fixed point where a lever moves. D. Efficient and coordinated use of the body to accomplish movements. 77. Which of the following is used to raise the body of a client from the bed either to change the linen or perform a range of motion exercises? A. IV Pole B. Sandbag C. Trochanter Roll D. Trapeze bar

78. In moving a client from a lying position, which of the following will most likely cause an injury to the nurse? A. bending at the knees B. using body weight to assist with the movement C. standing with feet together D. standing with feet apart 79. Which of the following equipments is used in order to prevent the external rotation of the leg? A. Sandbag B. Side-rail C. Cradle Bed D. Pillows

80. If a client has a pedal edema, you would expect that which of the following equipment is appropriate for his condition? A. Footboard B. Cradle Bed C. Rolled Pillows D. Bed board

81. It means decreasing the degree from the fulcrum: A. Extension B. Rotation C. Circumduction D. Flexion


82. It means increasing the degree from the fulcrum: A. Extension B. Rotation C. Circumduction D. Flexion

83. Which of the following is a GOOD sign that a nurse is aware of the principle of body mechanics? A. Pillows under the knees or at the back are recommended for support B. Joints should be hyperextended C. Pillows above the joint is used to immobilize it D. The position of the client should be changed 3 to 4 times a day 84. In a client with mobility problems, which of the following is a good nursing goal? A. developing of contractures B. proper body alignment 85. In an immobilized client, forcing fluid is necessary to: A. prevent pneumonia B. prevent urinary stasis C. prevent skin breakdown D. maintain peristalsis C. sensory alterations D. decrease in activity tolerance

SITUATION: Some equipments and materials in our hospital are color coded, this is to increase the safety and proficiency of rendering patients care. 86. In case a fire has broke out in the ward, the nurse knows that the typical color of a fire extinguisher is: A. Red B. Green C. Blue D. White

87. If a nurse has been ordered to prepare a spinal set gauge 16, the nurse knew that the color for that spinal set is coded at: A. Red B. Pink C. Yellow D. Blue 88. If the anaesthesiologist asked for a 22 gauge spinal set, the nurse knew that the color of the set that she will obtain is: A. Red B. Pink C. Yellow D. Blue

89. For pediatric patients, the spinal set is coded with color: A. Red B. Pink C. Yellow or Orange D. Blue

90. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb, 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as stand by. What gauge spinal sets will make available in the OR suite? A.Gauge 16 and 22 B.Gauge 18 and 16 D. Gauge 5 and 22 C. Gauge 16 and 20

91. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains laughing gases? A. Yellow B. Green C. Black D. Blue

92. On the traffic light, yellow means proceed with caution. In the field of healthcare, where do you discard your used tissue papers? A. Yellow bin B. Orange bin C. Green bin D. Black bin

93. Biodegradable materials like foods and foodstuff, soap, papers and special biodegradable food packaging are all disposed in what bin? A. Yellow bin B. Orange bin C. Green bin D. Black bin


94. Radioactive waste, such as feces and urine from a person undergoing brachytherapy as well as radioactive strontium rods are all disposed in what bin? A. Yellow bin with radioactive waste signage B. Orange bin without radioactive waste signage C. Yellow bin without radioactive waste signage D. They are incinerated immediately 95. Oxygen tanks are also color coded to prevent errors of administering compressed air instead of oxygen. In the operating room as well as in any health care settings, the typical color of these oxygen tanks are: A. Red 96. While Air is colored: A. Red B. Yellow C. Blue D. Green B. Black C. Blue D. Green

97. An instrument tray with black striped autoclave/steam chemical indicator tape communicates that the instrument tray... A.Is clean B. Is ready for use in surgery C. Is sterile D. Has undergone the sterilization process 98. In health care when lead apron is required in any procedure like orthosurgery, there is danger of exposure to: A. Water and blood splashes B. Pseudomonas 99. Used syringes are always disposed in the: A. Punctured proof container B. Yellow bin C. Radiation D. Bone fragments C. Green bin D. Black bin

100. Nitrazine papers are used to check if the membrane of the amniotic fluid has already been ruptured. If the amniotic sac was ruptured, it will give a blue color. It means that the PH is alkaline just like the litmus paper. However, unlike the litmus paper, the original color of a nitrazine paper is: A. Yellow B. Green C. Blue D. Red

Study. Study in earnest. If you are to be salt and light, you need knowledge. Or do you imagine that an idle and lazy life will entitle you to receive infused knowledge?