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 0.3mg
subcutaneously

a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respirator distress due to bronchial
spasm
d. Restore client\u2019s cardiac rhythm

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:

or 27
c. Syringe 2ml and needle gauge 22
d. Syringe 1-3ml and needle gauge 25 to 27

a. There are many alternative sites for
subcutaneous injection
b. Absorption time of the medicine is slower
c. There are less pain receptors in this area
d. The medication can be injected while the
client is in any position

Situation 2 - The use of massage and meditation
to help decrease stress and pain have been
strongly recommended based on documented
testimonials.

6. Martha wants to do a study on, this topic.
"Effects of massage and meditation on
stress and pain." The type of research that
best suits this topic is:

a. applied research
b. qualitative research
c. basic research
d. quantitative research

a. experimental design
b. quasi-experimental design
c. non-experimental design
d. quantitative design

a. include new modalities of care
b. resolve a clinical problem
c. clarify an ambiguous modality of care
d. enhance client care

a. determine statistical treatment of data
research
b. gathering data about what is already known or
unknown
c. to identify if problem can be replicated
d. answering the research question

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:

a. Color, amount and consistent of sputum
b. Character of breath sounds and
respirator/rate before and after procedure
c. Amount of fluid intake of client before and
after the procedure
d. Significant changes in vital signs

13. When assessing Richard for chest
percussion or chest vibration and postural
drainage Mario would focus on the following
EXCEPT:

a. Amount of food and fluid taken during the last
meal before treatment
b. Respiratory rate, breath sounds and location
of congestion
c. Teaching the client's relatives to perform 'the
procedure
d. Doctor's order regarding position restriction

14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration when doing the procedure?

a. Respiratory rate of 16 to 20 per minute
b. Client can tolerate sitting and lying position
c. Client has no signs of infection
d. Time of fast food and fluid intake of the client

15. The purpose of chest percussion and
vibration is to loosen secretions in the lungs.
The difference between the procedure is;

a. Percussion uses only one hand white
vibration uses both hands
b. Percussion delivers cushioned blows to the
chest with cupped palms while 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\u2019s
priority problem is to:

a. Interview the client for chief complaints and
other symptoms
b. Talk to the relatives to gather data about
history of illness
c. Do auscultation to check for chest congestion
d. Do a physical examination white asking the
client relevant questions

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.

a. Observe his sleeping patterns in the next few
days
b. Ask him what he means by this statement
c. Check his physical environment to decrease
noise level
d. Take his blood pressure before sleeping and
upon waking up

19. Mr. Regalado's lower extremities are
swollen and shiny. He has pitting pedal
edema. When taking care of Mr. Regalado,
which of the following intervention would be
the most appropriate immediate nursing
approach.

a. Moisturize lower extremities to prevent skin
irritation
b. Measure fluid intake and output to decrease
edema
c. Elevate lower extremities for postural
drainage
d. Provide the client a list of food low in sodium

20. Mr. Regalado will be discharged from
your unit within the hour. Nursing actions
when preparing a client for discharge include
all EXCEPT:

a. Making a final physical assessment before
client leaves the hospital
b. Giving instructions about his medication
regimen
c. Walking the client to the hospital exit to
ensure his safety
d. Proper recording of pertinent data

Situation 5 - Nancy, mother of 2 young kids. 36
years old, had a mammogram and was told that
she has breast cysts and that she may need
surgery. This causes her anxiety as shown by
increase in her pulse and respiratory rate,
sweating and feelings of tension.

a. Giving her activities to divert her attention
b. Giving detailed explanations about the
treatments she will undergo
c. Preparing her and her family in case surgery
is not successful

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 fee! but you have 1o
try for your children's sake."
c. "Have you told your, doctor how you feel? Are
you changing your mind) about 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 kinds. 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 statements prescribed for
her
c. 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 Seams that
being self-aware is a conscious process that
she should do in any situation like this
because:

a. This is a necessary part of the nurse -client
relationship process
b. The nurse is a role model for the client and