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NURSING PRACTICE 1:
Direction: Choose the letter of the BEST answer by shading the corresponding letter of
your choice on the answer sheet provided. STRICTLY NO ERASURE!
Situation 1: Mr. Martin, 71 years old was suddenly rushed to the hospital because of
severe chest pain. On admission, he was diagnosed to have acute myocardial infarction
and was placed in the ICU.
1. While in the ICU, he executes the document that list the medical treatment he
chooses to refuse in case his condition becomes severe to a point that he will
2. After one day, the patient’s condition worsened and feeling hopeless. He requested the
nurse to remove the oxygen. The nurse should:
4. A nurse who supports a patient and family’s need to make decisions that is right for
them is practicing which of the following ethical principles?
Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government
hospital in Valenzuela. On her first day of duty, she tried to remember the elements of
administration she learned from her basic nursing education.
6. One of the first things Ms. Castro did was to engage her until in objective writing,
formulating goals and philosophy of nursing service. Which activities are MOST
appropriately described to which elements of administration?
8. After one month, she and her management committee assess the regulatory measures
taken and correct whatever discrepancies are found. This is part of which element of
administration:
10. In all of the various administrative functions, which of the following management
skill is demanded efficiently and effectively of Ms. Castro?
11. You are to interview her as an initial nursing action so that you can.
A. Document important data in her client records for health team to read.
B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to
develop plan of care
C. provide solutions to her immediate health concern
D. identify the most appropriate nurse diagnosis for her heath problem
12. During the interview, Meldy experiences a sharp abdominal pain on the right side of
her abdomen. She further tells you that an hour ago, she ate fatty food and this had
happened many times before. You will record this as:
A. Client complains of intermittent abdominal pain an hour alter eating fatty foods
B. After eating fatty food the client experienced severe abdominal pain
C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain
medication
D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour
after ingestion of fatty foods.
13. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet
order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In
planning a healthy balanced diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food
groups and take plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular
exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.
14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is
in her pre-menopausal years, the nurse instructs her to decrease consumption of coffee
and cola preparation because:
15. Health education plan for Meldy stresses prevention of NCD or Non-communicable
diseases that are influenced by lifestyle. These include the following EXCEPT:
16. At present, government hospitals are expected to offer comprehensive health services
to include illness prevention and health promotion. In which of the following unit of
services are these services integrated?
17. Which of the following is the MOST recent government initiative to help subsidize
the cost of health services for both the employed and the unemployed?
18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name
a few. Many of these conditions are preventable and have implications are preventable
and have implications in the development of which nursing competencies?
19. The cost of hospitalization is getting more expensive and unaffordable to many of our
people. These facts will MOST LIKELY bring about development in which of the
following?
20. Which of the following latest trend has expanded health services based on prepaid
fees with emphasis on health promotion and illness prevention?
Situation 5: It is Safety Awareness Week in the Community and the nurse checks on the
presence of hazards at home. The nurse plan is to have the residents themselves identify
the physical hazards in their own homes.
21. Which of the following is NOT a physical hazard in the home?
22. Risk factors exist for each of the different developmental levels. From infancy to
preschool age, the most common cause of death is injury rather than disease. To protect
children from harm, that parents should be aware that MOST injuries for this age group
are due to:
23. To promote safety at home, the nurse identifies ways and means of “child proofing”
the house. Which of the following is NOT safe?
24. The nurse knows that a person’s hygienic practices are influenced family customs and
traditions. Which of the following is NOT part of Basic Hygienic Practices?
A. bathing practices, frequency and time, care of eyes, ear and nose
B. oral hygiene practices such as brushing and flossing teeth, gum care
C. care of skin with lesions, cuts with infection
D. hair and skin such as washing hair and face, feet, hand and nail care
25. Falls are the common home accident among elderly and these are due to physical
limitations imposed by aging and some hazards in the home setting. The nurse reduces
the risk of falling through the following EXCEPT:
26. Given the above assessment data, the most immediate goal of the nurse would be
which of the following?
27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post
operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a
foley catheter attached to a urinary drainage system. How will you collect the urine
specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from
the syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from
catheter into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from
the catheter intothe specimen container.
28. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral
irritation?
29. Which of the following menu is appropriate for one with low sodium diet?
30. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed
diabetic patient. She is beginning to write objectives of her teaching plan.
A. Mang Carlos will know about diabetes related to foot care and the techniques and
equipments necessary to carry it out
B. Mang Carlos daughter should learn about DM within the week
C. Mang Carlos wife needs to understand the side effects of insulin
D. Mang Carlos sister will be able to determine in two days his insulin requirement based
on blood glucose levels obtained from glucometer
32. Which of the following is the BEST rationale for written objectives?
33. Which of the following behavior BEST contribute to the learning of Mang Carlos
regarding his disease condition?
34. Miss Tingson should encourage exercise in the management of diabetes, because it:
35. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is:
39. The primary nursing goal in the immediate postoperative period is maintenance of
pulmonary function and prevention of:
A. flat on his of her back, without elevation of the head, to facilitate frequent turning and
minimize pulmonary complications
B. in semi-fowlers position, to promote respiratory function and reduce the incidence of
orthostatic hypotension when the patient can eventually stand.
C. in fowler’s position, which most closely stimulates a sitting position, thus facilitating
reparatory as well as gastrointestinal functioning.
D. on his or her side without a pillow at the patient’s back and his or her chin extended to
minimize the danger of aspirations
41. Which of the following are appropriate goals for client with positioning and mobility
needs?
42. Which for the following would MOST likely cause injury to the nurse when moving
the patient from bed to the wheelchair?
A. bending at the knees C. using body weight to assist with the movement
B. standing with feet together D. standing with feet apart
43. Which of the following is the CORRECT guideline when positioning patients?
A. put pillows above a joint to immobilize it
B. position of the joint should be slightly extended
C. joints of patient to be supported with pillow
D. patient’s position should be changed at least three or four times a day
44. Which of the following can be used by clients with problem of immobility to enable
them raise their body from bed to wheelchair or perform some bed exercises?
46. Which of the following is the least nursing activity in performing assessment of the
patient?
47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical
head-to-toe assessment of a newly hired factory worker. As part of the assessment, he
took the vital signs. Which of the four assessment techniques did he utilize?
1. auscultation 3. palpation
2. percussion 4. inspection
48. Which of the following are the purpose of performing a physical assessment?
49. Which of the following should be given the HIGHEST PRIORITY before physical
examination is done to a patient?
50. During the assessment phase of the nursing process, the nurse is concerned with:
A. interpreting data
B. designing nursing strategies
C. establishing a data base
D. comparing client responses with the anticipated outcome
Situation 11: The nurse is responsible to accurately records and reports patient’s progress.
She is able to communicate to the other member of the team by documenting the nursing
care plan and the appropriate nursing intervention.
52. When the nurse writes in the chart and discovers an error has been made, which is the
BEST approach?
53. Which of the following persons cannot have the access to the patient record?
54. POMR charting is different from traditional method because of which of the
following practices?
55. Which of the following qualities are relevant in documenting patients care?
Situation 12: The practice of primary nurse in primary nursing is preferred by many
nurses because it supports professional autonomy and accountability of the
Nurses?
A. acts as patient advocate and coordinate the health care team for specific group of
patients
B. act as the charge nurse, organizing staff assignments and help in solving problem in
the unit
C. plans and coordinate the patient care assigned to her from admission to discharge
D. coordinates the care given to a group of patients by support staff
57. Primary nursing is MOST advantageous and satisfying to the patient and nurse
because of which of the following principles?
A. autonomy and authority for planning care are best delegated to a nurse
B. accountability is clearest since our nurse is responsible for the overall plan and
implementation of care
C. the holistic approach provides fro a therapeutic relationship continuity of care and
efficient nursing care
D. continuity of patients care promotes efficient nursing care.
59. In primary nursing, the nurse is responsible for which of the following group of
patient?
60. In primary nursing who among the following is needed to her leadership and quality
control in the ward?
61. Which of the following research activities should you initially do?
A. find out from interview how many patients are willing to participate
B. get the permission from the hospital director
C. review literature on the topic
D. prepare the tool for collecting data
62. Which of the following statements do NOT contribute to the researchabilty of your
proposed problem?
63. A study /research table should NOT contain which of the following ?
64. Which of the following actions will facilitate analysis of research data?
65. The research methodology that is appropriate for the above problem would be:
Situation 14: The nurse meets a new client, Mr. Principe, 50 years old. During the initial
interview, the nurse begins to feel irritated towards the client. Shortly after, he becomes
uncomfortable and politely leaves the room. The nurse realizes the behavior and
mannerism of Mr. Principe reminds him of his strict disciplinarian father who abused him
physically.
66. The recognize that his feeling for the client is known as:
67. Seeing that his negative feelings for Mr. Principe could affect his nursing care, the
nurse applies the concept of therapeutic use of self when:
A. the nurse talks about his personal feelings towards the client
B. the nurse suppresses his feelings and continue to take care of the client
C. the nurse uses his awareness and asks to be reassigned to another client
D. the nurse uses self-awareness to manage his feelings and thoughts towards the client
68. Mr. Principe is terminally ill and his family is coping with his impending death. The
nurse has to deal with his own thoughts and personal feelings about death and grieving in
order to:
A. avoid sharing personal thought about their impending loss and feeling of grief since
this is very subjective
B. get self out of the way while he assists the client and his family express their feelings
of impending loss
C. prevent self from being affected by the family’s grief and remain objective
D. help the family plan for the funeral arrangement and burial services
69. One morning when the nurse enters the client’s room. Mr. Principe asks the nurse to
“leave me alone and stop bothering me and I don’t want your pity”. The following
response by the nurse would be MOST appropriate?
A. “You seem upset this morning” and remains with the client
B. “You are probably upset because you don’t feel well”
C. “Why you are angry with me? What did I do anything to upset you?
D. “I understand and will leave you for a while”
70. The nurse understands that the nurse-client relationship is a therapeutic alliance
when:
Situation 15: Mr. Ong is for admission to the medical unit and you are his nurse.
71. The MOST important initial nursing approach when admitting client is to:
72. When gathering baseline data, the BEST way for you to check if the client has pedal
edema is to:
73. You want to know the sleeping pattern of Mr. Ong You will:
74. Mr. Ong has severe pedal edema. Which accessory device would be appropriate for
his condition?
75. A student nurse is observed putting a standard size cuff on an obese client.
Situation 16: Health is wealth specifically in this time of the century. The nurse is trained
to promote well being of the people.
77. The nurse can be involved with health promotion as a significant person in helping
the family:
78. The nurse should NOT leave medication at the bedside because:
80. When assessing a client’s blood pressure, the nurse finds it necessary to recheck the
reading. How many seconds after deflating the cuff should the nurse wait before
rechecking the pressure?
a. 10 b. 30 c. 45 d. 60
82. The Philippine Nursing Act delineates the scope of nursing. It specifies that
independent practicing nurse is responsible for:
83. Standards of care provide the legal basis for evaluation of nursing practice or
malpractice. Its functions include all EXCEPT:
a. used by nurse experts to define what appropriate nursing practice is in a given situation
b. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably
as any prudent nurse would under similar circumstances
c. used to delineate the scope, function and role of the nurse
d. use to measure or evaluate the conduct of nurse specialists who are certified in their
own specialty fields
a. Autonomy c. Beneficence
b. justice d. nonmalifecence
85. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to
answer for and stand by one’s action refers to:
a. accountability c. advocacy
b. veracity d. responsibility
Situation 18: An understanding of the factors influencing the health care delivery system
will enable nurses to adjust to change, create better ways of providing nursing care and
develop new nursing roles.
86. Wellness clinics and health education activities have been integrated in government
hospitals to render appropriate services. Which of the following purposes LEAST helps
clients in cases of these health promotion activities?
87. With regards to illness prevention activities as part of nursing care, which of the
following will help clients MOST?
88. By experience, which of the following nursing goals are MOST often overlooked by
nurses and other members of the hospital team in the care of their clients in the hospital?
89. Which of the following health care agencies is usually family-centered, relatively
recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory
lifestyle of clients in the terminal phase of illness?
90. Which of the following is NOT a legally binding document but nonetheless very
important in the care of all patients in any setting?
Situation 19: One of the professional competencies that nurse must always demonstrate is
in the area of communication:
91. Which communication technique would be MOST effective in eliciting detailed
information from the client?
92. Which of the following terms refer to the sender’s attitude towards the self, the
message and the listener?
93. In interacting with patients, the nurses should remember that a client’s personal space
is:
A. social C. personal
B. intimate D. professional
95. In demonstrating the method for deep breathing exercises, the nurse places the hands
on the client’s abdomen to explain diaphragmatic movement. This technique involves the
use of which element of communication?
A. appropriateness C. channel
B. feedback D. message
96. Which of the following MOST appropriately describe pain sensation that has periods
of remission and exacerbation?
A. chronic C. acute
B. intractable D. Psychosomatic
97. Roy is constantly asking to be relieved from pain. Since morphine is an addicting
drug, which of the following is BEST for the patient?
A. administer morphine SO4 PRN
B. administer morphine on a routine schedule as ordered
C. give instructions on relaxation technique to reduce frequency of painsensation
D. divert the attention by not limiting visitors
98. To get accurate information about the quality of pain the patient is experiencing,
which of the following statements would be MOST APPROPRIATE?
A. “What cause you the pain?” C. “Have you taken something to relieve the pain?”
B. “ Tell me what your pain feels like” D. “Is it stubbing or radiating pain?”
99. As the nurse assigned to Ray, which of the following can decrease his chest pain?
100. Which of the following is the nurse’s primary goal in caring for clients with chronic
pain?