1.You are the nurse in an Adult Care Unit. You over-hear one of your co-staff nurse assigned to Aling Josie who is78 years old say, that if she refuses to take her medications she will not be given her favorite dessert. You reportyour co-staff’s behavior as:A.BatteryB.AssaultC.NegligenceD.MalpracticeCORRECT ANS: BRATIONALE: Involves any action that causes a person to fear being touched in a way that is offensive, insulting,or physically injurious without consent or authority. Examples include making threats to retsrain the client to givehim or her an injection for failure to cooperate.(Source: Psychiatric Nursing 3
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edition; Shiela Videbeck; pp. 173)OTHER OPTIONS:Battery – involves harmful or unwarranted contact with a client; actual harm or injury may or may not haveoccurred. Examples include touching a client without consent or unnecessarily restraining the client.Negligence – an unintentional tort that involves causing harm by failing to do what a reasonable andprudent person would do in similar circumstance.Malpractice – is a type of negligence that refers specifically to professionals such as nurses & physicians.2.Jake is in the Post Anesthesia Care Unit following a colorectal resection. He has an IV of Dextrose 5% LactatedRingers Solution Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs, moistrespiration and tachypnea. Which of the following will you do FIRST?A.Notify anaesthesiologistB.Increase 02 flow rareC.Place on Fowler's positionD.Reduce IV rate CORRECT ANS: CRATIONALE: Fowlers positions improve breathing by decreasing pressure on the diaphragm as gravity pullsabdominal contents downward. These positions also facilitate visiting and divisional activities. In this positionclients tend to slide toward the foot of the bed.(Source: Mosby’s Nursing interventions and clinical skills 3
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edition; Elkin, Perry, Potter; pp. 116)OTHER OPTIONS:Notify Anaesthesiologist, Increase 02 Flow Rate, & Reduce IV rate – Premature intervention and Needs order from Attending Physician ( Dependent Nursing Interventions)3.As a head nurse of the unit, which of the following sources should you take into consideration when makingeffective assignments for the next shift?A.Seniority preferencesB.Recent performance evaluationC.Personality traitsD.Client classification dataCORRECT ANS: DRATIONALE: Staffing levels should reflect individual and aggregate patient needs. Functions to support qualitypatient care should be used when determining staffing levelsOPTIONS A,B and C are incorrect4.Four clients injured in an automobile accident enter the emergency department (ED) at the same time and areimmediately seen by a triage nurse. As the triage nurse you would assign, the HIGHEST priority to the client withthe:A.severe head injury and no blood pressureB.maxillofacial injury and gurgling respirationsC.second trimester pregnancy with premature labor D.lumbar spinal cord injury and lower extremity paralysisCORRECT ANSWER: BRATIONALE: Problems in airway is always the highest priority.5.When a nurse volunteers to work in a hospital setting and she commits a mistake, who is legally responsible?A.Volunteer nurse, hospital and the nurse in chargeB.The professional organization which the volunteer nurse representsC.HospitalD.Volunteer nurse because there is no employer employee relationship
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CORRECT ANSWER: ARATIONALE: The nurse volunteer nurse is liable including the head nurse and the hospital based on the principleof respondeat superior.6.Daniel with multiple myeloma complains of deep bone pain. As his nurse, which of the following will you doFIRST?A.Assess bone painB.Administer prescribed analgesicC.Teach pain relief strategiesD.Support position with pillowCORRECT ANS: DRATIONALE: Independent intervention, promotes relaxation thus reducing pain and painful stimuli.OTHER OPTIONS:A - Late intervention. Remember the patient is in pain. Assessment is of No value.B – May follow after if the pain still exists.C – Patient in pain may not able to learn the pain relief strategies. Should be done when pain is not present.7.You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should youexpect to find?A.Increased platelet countB.Altered blood urea nitrogen (BUN) and creatinine levelsC.Electrolyte imbalanceD.Elevated erythrocyte sedimentation rate (ESR)CORRECT ANS: DRATIONALE:
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Increased rate seen in inflammation and necrotic processes. An increase is often seen in anyinflammatory connective tissue disease, often indicating increased inflammation and resulting inclustering of RBCs, which makes them heavier than normal. The higher the sedimaentation rate, thegreater the inflammatory activity.
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ESR is particularly useful as a guide to the management of the client with RA.(Source: Medical Surgical Nursing 7
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edition; Black & Hawks)OTHER OPTIONS:A.Increased Platelet Count – may indicate hemorrhage, infectious disorders, malignancies, IDA, recent surgery,recent pregnancy, recent splenoctomy, inflammatory disorders, fractures, cryoglobulinemia, asplenia,asphyxiation, rheumatoid arthritis, heart disease, cirrhosis, chronic pancreatitis, TB, recovery from bonemarrow depression, multiple myeloma, primary thrombocytosis, myelofibrosis with myeloid metaplasia,polycythemia vera, or chronic myelogenous leukemia.B.BUN – Measures renal function and hydration. CREATININE – this blood test helps in the diagnosis of muscular diseases or trauma as well as MI.C.Electrolyte Imbalance – Usually for Fluid and Electrolyte disorders.8.Mrs. Paras is receiving total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of thefollowing indicators will tell you that TPN was effective?A.Laboratory work upB.Adequate hydrationC.Weight gainD.Diminish episode of nausea and vomitingCORRECT ANS: ARATIONALE: Laboratory work up is done to assess levels of serum albumin, total protein, transferring,prealbumin, trigycerides, glucose, and urine nitrogen balance. It is also done in the assessment phase prior toadministration of TPN to provide baseline measures of nutritional status and blood glucose levels.(Source: Mosby’s Nursing interventions and clinical skills 3
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edition; Elkin, Perry, Potter; pp. 904-905)OTHER OPTIONS:B, C, D – inadequate indicators in measuring the effectivity of TPN.9.While Jayvee, a burn patient is being transferred from the burn unit to the operating room, the IV bottle fell onJayvee's head. He sustained a laceration on his forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do?A.Hold the IV bottleB.Check the IV standC.Place the IV stand on the foot part of the stretcher D.Restrain JayveeCORRECT ANS: B
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RATIONALE: Negligence – the commission of an act that a prudent person would not have done or the omissionof the duty that a prudent person would have fulfilled, resulting in injury or harm to another person. (Source:Mosby’s pocket Dictionary 4
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edition; pp. 844). Appropriate and proper check up of the IV stand prior totransferring the patient would guarantee security of the IV bottle.OTHER OPTIONS:A – Always support or hold the client rather than the equipment. (Source: Fundamentals of Nursing 7
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edition, Kozier et al; pp.1091)C – Doesn’t guarantee the security of the bottle during transfer.D – Improper. Need doctor’s order and patient’s and or folks approval.10.While Mrs. Enriquez is receiving chemotherapy which of the following will you include in the plan of care toaddress her nutritional needs?A.Administer Compazine before mealsB.Enrich diet with red meatC.Serve hot soup and foodD.Increase the amount of spice in the dietCORRECT ANS: BRATIONALE: This is a whole-foods diet high in protein. It is designed to support the body and minimize sideeffects while enhancing the ability of the chemotherapeutic agents to kill the cancer.A – Compazine (Prochlorperazine). This drug is indicated for control of severe Nausea and Vomiting as well as for the teatment of schizophreniaC & D – may irritate the GIT linings thus increasing the risk of infection.11.Nurses working in the 35 bed female Medical Unit were noted to implement new and innovative client careactivities long before other units in the hospital. Which of the following leadership characteristics exhibited by thenurse manager best describes this strength?A.Communication skillsB.Vision and passionC.Knowledge and skillsD.Interpersonal abilitiesCORRECT ANS: BRATIONALE: Nurse leaders have vision. They share a dream and direction that other people want to share andfollow. The leadership vision goes beyond your written organizational mission statement and your visionstatement. The vision of leadership permeates the workplace and is manifested in the actions, beliefs, values andgoals of your organization’s leaders.Leadership is passion. Without passion, a person will have very littleinfluence as a leader. Passion provides an individual with the light of leadership and creates an undeniable driveto make a difference.12.Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. It was started at 8 am. At 10 amher relative informed you that the bottle is empty. Which of the following will you do first?A.Refer to nurse manager B.Assess Olga and check level of fluid left in the bottleC.Discontinue IV and assess OlgaD.Replace the IV fluid with prescribed follow-upCORRECT ANS: BRATIONALE: Assessment process begins at the moment the nurse sees the client and continues with eachencounter. It is important to have as much awareness as possible of the client’s health history. Preparation of environment, equipment and client facilitates smooth assessment. Assessment provides baseline data for nursesworking on clients.(Source: Mosby’s Nursing Interventions and Clinical Skills 3
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Edition; Elkin, Perry, Potter;pp.298)Assessment is the first step in the nursing process. It involves getting the facts. Collect, organize, validate andrecording the clients data. Before Referring to nurse manager and Replacing prescribed IV fluid, assessmentshould be done first. ( Kosier, B., Fundamentals of Nursing Concept, Process and Practice)OTHER OPTIONS:A – Assigned nurse did nothing. Referrals should be made after an independent interventions and or when the intervention didn’t work out.C – Requires Physician’s Order.D – No assessment done.13.A research study found out that 60% of patients complaints were due to delayed responses of nurses in theemergency department. Which of the following measurement of data was used in this study?A.Measures of variabilityB.Measures of central tendencyC.Frequency distributionD.Inferential statisticsCORRECT ANS: A
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