NURSING PRACTICE I SET A ________________________________________________________________________ NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice

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. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . 2. Write the subject title “Nursing Practice I” on the box provided. 3. 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.

1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band? A. B. C. D. Ask the client if she is Mrs. Santos Ask the client his name Ask the room mate if the client is Mrs. Santos Compare the ID band with the bed tag

2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide the staff nurse in the use of touch, which of the following would be BEST response of Lizette? A. B. C. D. “Use touch when the situation calls for it”. “Touch serves as a connection between the nurse and the patient”. “Use touch with discretion”. “Touch is used in physical assessment”.

3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly? A. B. C. D. The cane and one foot or both feet are on the floor at all times He advances the cane followed by the left leg Client keeps the cane on the right side along the weak leg Client leans to the left side which is stronger

4. George, a 43 year old executive is scheduled for cardiac bypass surgery. While being prepared for the surgery, he says to the nurse “I am not going to have the surgery. I may die because of the risk.” Which response by the nurse is most appropriate? A. “Without the surgery you will most likely die sooner.” B. “There are always risks involved with surgery.” C. “There is a client in the other room who had successful surgery and you can talk to him.” D. “This must be very frightening for you. Tel me how you feel about the surgery.”


5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? A. B. C. D. Report to the physician the effects of the medication on urination. Take the medicine early in the morning Take a full glass of water with the medicine Measure frequency of urination in 24 hours

6. Nurse Glenda gets a call from the neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? A. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood. B. Recommend to bring the child immediately to the hospital C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital. D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to the hospital. 7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular accident. While being transported to the X-ray department, he straps accidentally broke and the client fell to the floor hitting to his head. In this situation, the nurse is: A. not responsible because of the doctrine of respondent superior B. free from any negligence that caused harm to the patient C. liable along with the employer for the use of a defective equipment that harms the client D. totally responsible for the negligence 8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna? A. Ignore the incidence B. Report the incidence to the head nurse C. Respect the client’s actions as this provides structure and support to the client D. Call her attention so she can go to sleep 9. A client asks for advice on low cholesterol food. You advise the client to eat the following: A. B. C. D. Chicken liver, cow liver, eggs Lean beef and pork, egg ewhite, fish Balut, salted eggs, duck and chicken egg Pork liempo, cow brain, lungs and kidney

10. The code of ethics for nurses has an interpretative statement that provides: A. continuity of care for the improvement of the client B. guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the profession C. standards of care in carrying out nursing responsibilities D. identical care to all clients in any setting 11. Which of the following situations would possibly cause a nurse to be sued due to negligence? A. Nurse gave a client wrong medication, and an hour later, client complained of dyspnea B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the client’s medicine cup C. As the nurse was about to administer medication, the client questioned why the medication is still given when in fact the physician discontinued it. D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error and complained.


12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital? A. B. C. D. Diabetic client type2 Client with chronic obstructive pulmonary disease (COPD) Client with second degree burns Client with psoriasis

13. Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has observed her to be “too involved” in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse? A. “Don’t worry. I will call the attention of your wife.” B. “Your wife is just trying to help because she is worried about you.” C. “What are your thoughts about your wife’s involvement in your care?” D. “Your wife can assist you well in your care and recovery.” 14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take? A. Approach the two nurses and tell them that their actions are inappropriate especially in a public place B. Wait till the nurses finish the discussion and report the situation to the supervisor C. Say nothing to avoid embarrassing the staff nurses D. Remain quiet and ignore the discussion 15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father has been getting out of bed at night and walks around the house in the early hours of the morning causing him to fall and injure himself. Which instruction would you give? A. B. C. D. Apply restraints during night hours only Advise hospitalization to prevent future accidents Keep a radio or TV for company and to orient the client Have someone check on the client frequently at night

SITUATIONAL Situation 1 – Preparation and administration of medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save patient’s lives. 16. You are to administer an intramuscular injection to Dulce, 1 ½ year old girl. The most appropriate site to administer the drug is: A. dorso gluteal region B. ventral forearm C. vastus lateralis D. gluteal region

17. An infant is ordered to receive 500ml of D5NSS for 24 hours. The intravenous drip is running at 60 drops/minute. How many drops per minute should the flow rate be? A. 60 drops per minute B. 21 drops per minute C. 30 drops per minute D. 15 drops per minute

18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? A. 42 drops B. 20 drops C. 60 drops D. 32 drops


who has a blood pressure of 90/50 mmHg Mr. It defines a client’s problem and its possible cause. a client who received pain medications 5 minutes ago 25. Rey. Together. David observes if the nurses act responsibly when at work. To check if the nurses under her supervision use critical thinking. Lagro is to receive 1 liter of D5LR to run for 12 hours. tell the nurse how to give bed baths correctly ask another staff nurse to do bed baths instead provide a manual to be read on giving bed baths bring the staff nurse to a client’s room and demonstrate 22. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. The bottle contains 100mg/capsule. Which of the following actions of the nurse demonstrates the attitude of responsibility? A. who is terminally ill with ovarian cancer stage IV. A good nursing care plan is dependent on a correctly written nursing diagnosis. C. To improve the care provided to the patients in the unit by Nurse Arthur.19. D. Mrs. 1 ½ capsule D. C. a client who needs instructions for home medications Fred. you will perform which of the following activities? A. In what step of the decision making process are they? A. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client. Testing options B. D. The drop factor of the IV infusion set is 10 drops per minute. B. Encourage the client to reach optimal health B. Thinking of alternative methods of nursing care Sharing ideas regarding patient care Following standards of practice Planning other approaches for patient care 24. 10-12 drops B. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. 21. the nurse supervisor should: A. they observe how well the dressings absorb the drainage. B. Making final decisions 23. C. B. Abad. Mr. 17-18 drops D. 1 capsule C. 66 years old. D. Defining the problem D. The physician ordered Nembutal Na gr XX. 13-14 drops C. C. 2 capsule B. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. B. Leyba. How many capsule will be administered to the client? A. Roman. a client who is ambulatory and for surgery tomorrow A post operative client. When caring for a dying client. 26. D. The following is an example of a well written nursing diagnosis: A. Considering effects on results C. Assist client perform activities of daily living 4 . 15-16 drops 20. Acute pain related to altered skin integrity secondary to hysterectomy Electrolyte imbalance related to hypocalcemia Altered nutrition related to high fat intake secondary to obesity Knowledge deficit related to proctosigmoidoscopy Situation 3– You are taking care of Mrs. Approximately how many drop per minutes should the IV be regulated? A. ½ capsule Situation 2 – The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved.

C. Joseph prefers to be in high fowler’s position most of the time. Face the client and place the wheelchair on her left side C.75 ml 30. Move the patient to the edge of the bed near the nurse Adjust the bed to flat position Lock the wheels of the bed Raise the bed rails opposite the nurse 5 . Put the client on the edge of the bed and place the wheelchair on the client’s left side 32. When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml. Put the client on the edge of the bed and place the wheelchair at her back B. aspirate the desired dose. Leyba is emaciated and is at risk for developing which problem in skin integrity? A. The nurse should prevent which of the following? A. B. 31. 2 ml B. withdraw the medication from the vial first then from the ampule inject air into the vial. C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. B. D. C. B. Which of the following is the appropriate nursing action of Nurse Karen? A. Reddening of the skin D. bargaining 28. Which of the following should be prevented? A. Demerol is available in a mutidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. This client is in the stage of: A. Pustules Situation 4 – You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility. what is the total volume that you will inject to the client? A. B. The nurse is to administer Demerol 50 mg IM to Mrs. D. adduction of the shoulder Lateral flexion of the sternocleidomastoid muscle Hyperextension of the knees Anterior flexion of the lumbar curvature 33. D. 1. Pressure sores B. You will: A. You are to give the both medications in one injection. C. Which of the following should Nurse Diana do first? A. 1 ml C. Mrs. resolution C. Blisters C. The client prepares for her eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. Anthony asks to be assisted to move up the bed. then into the vial withdraw medication from the ampule then from the vial 29. Motivate client to gain independence 27. 1. Leyba. Posterior flexion of the lumbar curvature Internal rotation of the shoulder External rotation of the hip Adduction of the shoulder 34.5 ml D. D. Ramil’s right leg is injured and Nurse Karen has to move him from the bed to w wheel chair. Assist the client towards a peaceful death D. Carlo has to be maintained on a dorsal recumbent position.C. then into the ampule inject air into the ampule. denial D. acceptance B.

the patient complained of pain. Mr. D. An ambulatory client. Mr. For the past 3 days. B. proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. Turning off the lights to promote rest and sleep Instructing the client about the use of call system Raising the side rails Placing the bed in high position 37. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family Situation 6 – Myrna. Ernest Lopez is terminally ill and he choose to be at home with his family. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. a researcher. Which of the following nursing actions promote safety for the client? A. 36. C. C. a 25 year old female client. Ambulate the client in ward premises every twenty minutes 39. Instruct the client to do deep breathing exercises D. Pillow D. is being prepared for bed. High foot board Situation 5 – As you begin to work in the hospital where you are on probation. Zosimo. Twelve hours following surgery. Which of the following is the most appropriate nursing diagnosis? A. Firm mattress C. Mr. 50 year old executive. D. Mikka. The clients have varied needs and you are expected to provide care for them. Encourage the client to do self-care C. Impaired mobility related to pain secondary to an abdominal incision Impaired movements related to pain due to surgery Impaired mobility related to surgery Severe pain related to surgery 38. Lozano? A. Sandbags B. B. Mr. D.35. B. Lozano’s hygiene and grooming needs have been met by the nursing staff. Lozano in his care 40. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Talk with the family members about the advantage of staying in the hospital for proper care B. you are tasked to take care of a few patients. What nursing action are best initiated to prepare the family of Mr. Lopez? A. Encourage the client to log roll when turning B. Which of the following should be included in the nursing care plan? A. C. 6 . Lozano. Which of the following activities should be implemented to achieve the goal of independence for Mr. is admitted with right lower quadrant abdominal pain. Involving family members in meeting client’s personal needs Meeting his needs till he is ready to perform self-care Preparing a day to day activity list to be followed by client Involving Mr. is recovering from severe myocardial infarction. Provide support to the family members by teaching ways to care for their loved one C.

41. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursing’s body of knowledge B. Organizes the development of study and links the findings to nursing’s body of knowledge C. Provides logical structure of the research findings D. Identifies concepts and relationships between concepts 42. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. locating and identifying resources B. reading and recording notes 43. The primary purpose for reviewing literature is to: A. organize materials related to the problem of interest B. generate broad background and understanding of information related to the research problem of interest C. select topics related to the problem of interest D. gather current knowledge of the problem of interest 44. In formulating the research hypotheses, researcher Myrna should state the research question as: A. What is the response of the staff nurses to the health values? B. How is variable “health value” perceived in a population? C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 45. The proposed study shows the relationship between the variables. Which of the following is the independent variable? A. B. C. D. Staff nurses in a selected college of nursing Health values Health promotion activities Relationship between health values and health promotion activities C. clarifying a research topic D. using the library

Situation 7 – While working in a tertiary hospital, you are assigned to the medical ward. 46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a: A. Nurse supervisor B. Social worker C. bookkeeping department D. physician

47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. receive emotional support B. to be a part of a research study C. provide financial assistance D. assist with chemotherapy

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a: A. nutritionist B. dietitian C. physician D. medical pathologist

49. When collaborating with other health team members, the best description of Nurse Rita’s role is: A. encourages the client’s involvement in his care B. shares and implements orders of the health team to ensure quality care


C. she listens to the individual views of the team members D. helps client set goals of care and discharge 50. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies: A. B. C. D. Communication, trust, and decision making Conflict management, trust, negotiation Negotiation, decision making Mutual respect, negotiation and trust

Situation 8 – The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to provide safe nursing to your clients?

51. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is: A. B. C. D. critical thinking to decide appropriate nursing actions understanding of various nursing diagnoses observation skills for data collection possession of in scientific knowledge about client needs

52. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. B. C. D. creating plans of care for particular clientele identifying the correct nursing diagnoses for clients making a thorough assessment of client needs and problems using standards of nursing care as your criteria for evaluation

53. The effectiveness of your nursing care plan for your clients is determined by A. B. C. D. the number of nursing procedures performed to comfort the client the amount of medications administered to the client as ordered the number of times the client calls the nurse the outcome of nursing interventions based on plan of care

54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue? A. B. C. D. Blood pressure measurement of 170/100 Complaint of hot flashes Report of pain after ingestion of fatty food Complaint of frequent bouts of dizziness

55. While talking with Mrs. Amado, it is most important for the nurse to: A. B. C. D. schedule the laboratory exams ordered for her do an assessment of the client to determine priority needs tell the client that your shift ends after eight hours have the client sign an informed consent

Situation 9 – Oral care is an important part of hygienic practices and promoting client comfort. 56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution


57. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. B. C. D. Put the client on a sidelying position with head of bed lowered Keep the client dry by placing towel under the chin Wash hands and observe appropriate infection control Clean mouth with oral swabs in a careful and an orderly progression

58. The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves client’s appearance and self-confidence D. improves appetite and taste of food 59. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums D. suctioning as needed while cleaning the buccal cavity 60. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment

Situation 10 – Errors while providing nursing care to patients must be avoided and minimized at all time. Effective management of available resources enables the nurse to provide safe, quality patient care. 61. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related? A. interruptions B. use of unofficial abbreviations C. lack of knowledge D. failure to identify client

62. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Method C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications. 63. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. B. C. D. The nurses check client’s identification band before giving medications The nurse reports adverse reaction to drugs Average waiting time for medication administration is measured The unit has well ventilated medication room


Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. B. B. D. The functions of records include all except: A. C. Jose’s chart is the permanent legal recording of all information that relates to his health care management. B. C. Nursing audit aims to: A. educational resource for student of nursing and medicine D. B. the entries in the chart must have accurate data. Information in the patient’s chart is inadmissible in court as evidence when: A. D. the client’s record also shows a document of how much health care agencies will be reimbursed for their services C. Repeat the order back to the physician. A telephone order is given for a client in your ward. D. D. D. copy onto the order sheet and indicate that it is a telephone order C. As such. C. recording of actions in advance to save time 67. Mr. What is your most appropriate action? A. means of communication that health team members use to communicate their contributions to the client’s health care B. provide research data to hospital personnel study client’s illness and treatment regimen closely compare actual nursing done to established standards provide information to health-care providers 70.64. Write the order in the client’s chart and have the head nurse co-sign it D. B. Tell the physician that you can not take the order but you will call the nurse supervisor 10 . 66. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. The client’s family refuses to have it used The client objects to its use The handwriting is not legible It has too many abbreviations that are “unofficial” 69. Interviews nurses for comments regarding staffing Measures waiting time for client’s per nurse’s call Checks equipment for its calibration schedule Determines whether nurses perform skin assessment every shift 65. Copy the order on to the chart and sign the physician’s name as close to his original signature as possible B. Assign another nurse to perform the procedure Ask the nurse to find way to learn the procedure Tell the nurse to read the procedure manual Do the procedure with the nurse Situation 11 – Mr. An advantage of automated or computerized client care system is: A. C. The nursing diagnoses for a client’s data can be accurately determined Cost of confinement will be reduced Information concerning the client can b easily updated The number of people to take care of the client will be reduced 68. Jose’s chart contains all information about his health care. Which of the following is the most appropriate action of the nurse supervisor? A. C.

expectorate into a container Situation 13 – Infections are quite commonly the reasons for a client’s hospitalization. C. Insert catheter until resistance is met. B. Use baby powder to reduce irritation under the cast Assess sensation of each arm Evaluate skin temperature in the area Check radial pulses bilaterally and compare 75. Which of the following client conditions should be Miss Roque’s priority in the pediatric unit? A. C. B. Hyperoxygenate client insert catheter using back and forth motion D. then withdraw slightly. D. On reviewing the result the nurse notices which of the following as abnormal finding? A. C. What nursing action before cast application is most important for Nurse Roque to do? A. to give a sponge bath. While Doris is doing spone bath. Insert suction catheter four inches into the tube. what action of Doris needs correction? A. suction 30 seconds using twirling motion as catheter is withdrawn 73. A baby who is wailing after being awakened by the banging door D. insert catheter gently applying suction. applying suction intermittently as catheter is withdrawn C. D. a newly hired nurse. Answering the phone while wearing gloves used for sponge bath Rolling the patient like a log to do back rub Lining the rubber mat with bed sheet as incontinence pad for the patient Turning the patient on the left side with head slightly elevated 74. C. which of the following instruction is best? A. D. She will take care of clients with various conditions. A baby boy whose circumcision has yellowish exudate 72. 76. Explain procedure to patient. D. Nurse Roque is giving instructions to Doris. Surgical sepsis is observed when: A. B. Withdrawn using twisting motion B. C.Situation 12 – Nurse Roque. cough deeply and expectorate into container Cough after pursed lip breathing Save sputum for two days in covered container After respiratory treatment. The baby whose fantanelle is bulging and firm while asleep B. Dorothy underwent diagnostic test and the result of the blood examination are back. B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. Dina sustained a fracture of the ulna and a cast will be applied. Upon waking up. is asked to take over an absent nurse in another unit. the nurse should: A. B. Neutrophils 60% White blood cells (WBC) 9000/mm Erythrocyte sedimentation rate (ESR) is 39 mm/hr Iron 75 mg/100 ml 77. When suctioning the endotracheal tube. To obtain specimen for sputum culture and sensitivity. D. inserting an intravenous catheter disposing of syringes and needles in puncture proof containers washing hands before changing wound dressing placing dirty soiled linen in moisture resistant bags 11 . Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care. 71. the daughter of a comatose patient.

competent nurse B. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. Among the clients you are assigned to take care of. respecting a person’s right to be autonomous demonstrating loyalty to the institution’s rights shared respect. B. the ability to organize and plan activities having attained an advanced level of education a holistic understanding and perception of the client intuitive and analytic ability in new situations 83. community health nurse D. Client with burns C. You join a continuing education program to help you: A. Which of the following laboratory test result indicate presence of an infectious process? A. staff nurse 85. You will rank yourself as a/an: A. Using Benner’s stages of nursing expertise. B. who is the most susceptible to infection? A. B. B. C.78. novice nurse C. B.000/mm3 Iron 90 g/100ml Neutrophils 67% 80. trust and collaboration in meeting health needs protecting and supporting another person’s rights 84. D. client with pulmonary emphysema D. you are a beginning nurse practitioner. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having: A. D. Clinical nurse specialist B. proficient nurse D. C. Critical care nurse C. Client was exposed to the infection 2 days ago but without any symptoms Oral temperature shows fever Acute symptoms are no longer visible Client “feels sick” but can do normal activities 79. Earn credits for license renewal Get in touch with colleagues in nursing Enhance your basic knowledge Update your knowledge and skills related to field of interest 12 . 81. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. As you become socialized into the nursing “culture” you become a patient advocate. Erythrocyte sedimentation rate (ESR) 12 mm/hr White blood cells (WBC) 18. D. D. client with myocardial infarction Situation 14 – You are a newly hired nurse in a tertiary hospital. Diabetic client B. C. C. Advocacy is explained by the following EXCEPT: A. advanced beginner 82. C. D.

Rhona. 3 months old. aneurysm 89. Demerol 90. a 2 year old female was prescribed to receive 62. shabu D.” “High RBC count increases blood pressure.5 ml C.000 mg tid B. C. Embolic stroke B. diabetic stroke D. The types of stroke based on cause are the following EXCEPT: A. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Clarify order with the attending physician B. thrombotic stroke 88. Discuss the order with the pediatric heart specialist in the unit 13 . 1. Part of your lesson plan is to talk about etiology or cause of stroke. damage to blood vessel D. 86.5 ml B.” Situation 16 – Accurate computation prior to drug administration is a basic skill all nurses must have. 2. 1.5 ml D. has an order from her physician: “give 3. trauma C.” “Increased RBC count is linked to high cholesterol. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1. Nurse Robert used an intravenous pump.5 gm daily in 3 divided doses for 7 consecutive days.Situation 15 – When creating your lesson plan for cerebrovascular disease or STROKE. 10 ml 93. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs.” “More red blood cell increases hemoglobin content. Which of the following should Nurse Robert do to safely administer this drug? A. Your best response is: A. Hemmorhagic stroke occurs suddenly usually when the person is active. D. 500 mg tid C. Hemorrhagic stroke C. D. Check the pump setting every 2 hours Teach the client how the infusion pump operates Have another nurse check the infusion pump setting Set the alarm of the pump loud enough to be heard 94. Which of the following is the correct dose of the drug that the client will received per oral administration? A. Cocaine C. It is important to include the risk factors of stroke. 91. C. 0. Which drug is closely linked to this? A. The available dose is 125 mg/ml. Cigarette smoking B. 50 mg tid 92. B. B. heredity 87. The most important risk factor is: A. Amphetamines B. Since Potassium Chloride is a high risk drug. Gomez. Baby Liza. Which of the following is the most appropriate action by the nurse? A. which of the following should Nurse Paolo prepare for each oral dose? A. phlebitis B. binge drinking D. Hypertension C.500 mg tid D.00 cc of Lanoxin today for 1 dose only”. 1. EXCEPT: A. All are causes of hemorrhage. with a congenital heart deformity.5 mg suspension three times a day. “More red blood cells thicken blood and make clots more possible. A participant in the STROKE class asks what is a risk factor of stroke.

prepare to move client by taking deep breath and tightening abdominal and gluteal muscles B. a 150 lbs unconscious woman. push and pull using arms and legs instead of lifting D. Administer Lanoxin intravenously as it is the usual route of administration D. Which of the following is the most appropriate action by the nurse? A. move close to the object to be moved leaning or bending at the waist 100. B. You should be alert for the following complications she may experience EXCEPT: A. Contractures and muscle atrophy D. After moving Mrs. Hold the nurse administration of the client’s medication and refer to the head nurse B. hypostatic pneumonia B. Proper positioning of an immobilized unconsciousness client is important for the following reasons EXCEPT: A. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. maintain wide base of support with feet and with knees flexed C. Maintain skin integrity Promotes optimal lung expansion Prevent injuries and deformities of the musculo-skeletal system Facilitates rest and sleep 98. Bring the medications of the client to the nurse’s station and prepare accordingly Situation 17 – You are taking care of Mrs. ***END*** 14 . pressure sores 97. C. D. This means that the nurse: A. Uses large muscles only 99. Impaired mobility C. D. 96. Refer to the medication administration record for previous administration of Lanoxin 95. Observes rhythmic movements when moving about D. You are aware that there are many physical complications due to immobility. Avoid friction between bony prominences Place pillows to position client’s extremeties Apply restraints Raise bed rails SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. Uses back muscles B. Assumes correct body alignment and efficient use of muscles to avoid injury C. When positioning your client. Some principls to use when moving the client include the following EXCEPT: A. Tell the client that she will inform the physician about this D. you should observe good body mechanics for yourself and the client. B. Santillan. which action will you avoid? A. Put aside the medications she prepared and instead administer the client’s medications C. C. the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. When Nurse Norma was about to administer the medications of client Lennie. Santillan to the desired position. Santillan a 48 year old woman who is unconscious after a cerebrovascular accident.C. You are going to move Mrs.

C. and/or sale of this test is punishable by law. the outermost covering of the testes? A. the good child takes on a bad child role C. Per RA 8981. group D. This is PRC property. transilluminator C. 5. AVOID ERASURES. 6. 9. Organization B. 7. Culture C. This test booklet contains 100 test questions. When a nurse breaches the duty of confidentiality. In addition to this discipline. Manometer 4. subculture 2. Which of the following examples best defines the term role reversal? A. D.NURSING PRACTICE II SET A _________________________________________________________________ NURSING PRACTICE II – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 6. the child assumes a caregiver role toward the caregiver 5. Shade only one (1) box for each question on your answer sheets. Fluid meter D. a person who has been a good provider quits his or her job D. Unauthorized possession. 8. MULTIPLE CHOICE 1. 10. Two or more boxes shaded will invalidate your answer. _________________________________________________________________ INSTRUCTIONS: 4. Registered nurses can be identified as a: A. B. the basis for the decision as to which child gets the organ is given to the child who: A. C. Among children candidates for organ transplant. B. be held responsible for any damages that result be fined by the federal government be sentenced for up to 1 year in jail immediately lose his or her nursing license 6. reproduction. D. will receive the most benefit from the new organ is most likely to die without the transplant is selected by the lottery system for available organs is at the top of the list and has waited the longest time 3. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. Set Box “B” if your test booklet is Set B. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . he or she can: A. he or she can be disciplined by both the employer and the Board of Nursing. Shade Set Box “A” on your answer sheet if your test booklet is Set A. 30 cc syringe B. A strategy for a change that focuses on teaching workers new technology is: 15 . The nurse uses what equipment to check for fluid between the parietal and visceral layers of the tunica vaginalis. Write the subject title “Nursing Practice II” on the box provided. when all selected children have appropriate tissue matches for the same donated organ. a lazy person becomes very productive in the family B.

C. The nurse will suspect that this child is: A. has no lunch money. D. he talks of playing outside until midnight. poor-fitting clothes. B. B. C. show increased alertness and eye contact respond with coordinated. The major components of the communication process are: A. D. Some strategies to maintain professional health are listed below. The nurse is assessing an 8 month-old infant for head lag. It does not need to be fitted by the physician. maternal age C. tone of voice and gestures message. normative-reactive B. C. It may affect Pap smear results. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations. C.A. B. The school nurse notices a child who is wearing old. C. being raised by a parent of low intelligence quotient (IQ) an orphan a victim of child neglect the victim of poverty 16 . This is a normal finding. as the infant’s head will not stay in line until after 8 months of age. 14. macrosomia 8. The nurse instructs the mother that when overstimulated the infant will: A. Which of the following statements best represents the significance of this finding? A. The nurse knows that the occurrence of shoulder dystocia during labor is: A. 12. channel. polyhydramnios B. D. verbal. Head lag should not be tested until the child is over 1 year of age. The nurse has not conducted the test correctly and must do it again using proper technique. D. B. sender. The head does not stay in line with the body when being pulled forward. receiver and feedback 13. C. pulling the infant by the hands from a supine to a sitting position. written and nonverbal speaker. The extent of burns in children are normally assessed and expressed in terms of: A. D. Which is NOT necessarily correct? A. When the nurse asks the boy his tiredness. and is always tired. dirty. preterm birth D. 11. It must be removed within 24 hours. is always hungry. B. It does not require the use of spermicide. D. B. training C. power coercive 7. synchronous body movement look away to reduce the intensity of the interaction drift off to deep sleep to shut out the interaction 9. C. listener and reply facial expression. the amount of body surface that is unburned percentages of total body surface area (TBSA) how deep the deepest burns are the severity of the burns on a 1 to 5 burn scale. Networking with others in the health care field Join a professional organization Goal setting Read fiction and non-fiction materials 10. D. providing information D. B. Which statement is correct regarding the use of the cervical cap? A.

clinically apparent disease 21. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. D. C.15. Informal communication takes place when individuals talk and is best described by saying the participants: A. “This is normal until the age of 1 year. Four types: hemorrhagic with and without clotting. “Have you brushed your child’s teeth today?” “How does your child look to you today?” “Where have you been all morning?” “Do you think your child’s color is worse”? 18. Which definition below is from Florence Nightingale? A. and nonhemorrhagic with and without clottings B. situational leadership model C. “Perhaps your baby was small for gestational age or premature.” C. The endometrium thickens during which phase of the menstrual cycle? A. B. “These circumference normally are the same. and of experience of each practitioner is called: A. staffing pattern B. B. Ischemic phase 22. Which of the following indicates the type(s) of acute renal failure? A.” 17 . minor problems D. are involved in a preexisting informal relationship talk with slang words have no particular agenda or protocol are relaxed 20. when the chest will be greater. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over a specific period of time is called: A. career enhancement D. but in some babies this just differs. Tertiary care by the home health nurse is directed toward children with: A. A state or a process of being and becoming an integrated and whole person The state of being free from illness or injury Being well and using every power the individual possesses to the fullest extent A state of complete physical. Menstrual phase C. and mental well-being and not merely the absence of disease or infirmity 19. B. social. skill mix C. D. There are numerous definitions of the word “health”. Three types: prerenal. short-term needs C. the novice to expert model B. C.” B. Secretory phase B. clinical ladder 17. abilities. Proliferative phase D. D. A means of facilitating professional staff development is by building upon skills. The BEST response by the nurse is: A. C. intrarenal and postrenal D. benchmarking D. Two types: acute and subacute 16. patient classification 23. problems in mobility B. One type: acute C. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual participation model of care (NMPMC)? A.

D. 18 . 25. Hispanics B. B. B. Which of the following groups of people in the world disproportionately represents the homeless population? A. A depression that is deeper. D. Caucasians 29. Asians C. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Hirschsprung’s disease? A. more acute. B. Respond only after the child cries for a while. and perhaps we can figure out the cause of this difference. Use an adult voice just as you would for anyone. Stay on left side as much as possible when lying down. Severe shaking of the hands when trying to hold a glass of water or other object C. C. Which of these instructions to the client may indicate a need for further teaching? A.” 24. D.D. A fine rash over the trunk Failure to pass meconium during the first 24 to 48 hours after birth The skin turns yellow and then brown over the first 48 hours of life High-grade fever 27. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. Allow the child time to warm up to the nurse. C. Communicate through the caregivers. the nurse would teach the caregivers to: A. She is stable and has minimal spotting and is being sent home. Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones and associated symptoms B. A depressed or irritable mood for most of the day. avoid covering the area of the topical medication with the diaper avoid the use of clothing on top of the diaper put the diaper on as usual apply an icepack for 5 minutes to the outside of the diaper 30. Maintain bed rest with bathroom privileges Avoid intercourse for three days. D. B. African Americans D. Call if contractions occur. Which of the following approaches would work best when the nurse is communicating with an infant? A. “Let me ask you a few questions. The nurse notes that the infant is wearing a plastic-coated diaper. B. on most days. 28. D. The nurse assessing a child or adolescent with a diagnosis of dysrhytmic disorder would find which of the following symptoms? A. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks. C. Evidence-based care started in medicine as a way to: A. promote technological advances in medicine incorporate collaboration within all health care disciplines integrate individual experience with clinical research teach medical students the art and science of medicine 26. C. for 2 or more years and low energy or fatigue. C. and more likely to lead to suicide than major depressive disorder D.

Empathy D. Focus. D. Continuous (process).31. C. is a: A. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization that occurs when: A. including costs. saying that the child asked to be touched or did not make the abuser to stop D. people issue B. you are to work with the patients in which of the following areas. malaise. Solution C. While community health nurses focus on the individual or the family. Two large meals a day instead of several minimeals and snacks Special IBD diet (diet that has been proven effective for treating IBD) Salt-free diet high in potassium. Clarify. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis of “Nutrition: Less than body requirements. D. newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. Substantiate Focus. technology issue 35. Self-esteem B. which of the following do they also have as their final objective? A. Self-awareness C. B. The well-being of the extended family 19 . Utilize. Understand and Solution Focus. desirability and feasibility. Opportunity. Breech position D. Right Occipito-Anterior Position 37. Emotional intelligence consists of a number of competencies. fever and dysphasia. Substantiate Focus. Understand. Understand. Clarify. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position? A. Opportunity. Organize. You were the nurse assigned to work with a child who has had whole brain radiation. Some of these are listed below. and reduction of fiber 33. Left Occipito-Posterior Position 38. D. Based on this assessment.” Which of the following interventions will be most helpful in resolving this nursing problem? A. structural issue C. C. political issue D. The financial well-being of the family C. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea. Data collection for driving and restraining forces. the child’s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge 36. A. Which is NOT a characteristic of emotional intelligence? A. The well-being of the chronically ill B. B. vitamins and minerals Diet as tolerated with lactose hydrolyzed milk instead of milk products. a child blames him or herself for the sexual abuse and begins to withdraw and isolate B. Brow position B. C. Continuous. and omission of highly seasoned foods. Self-regulation 34. the child has been blamed by the abuser for his or her sexual behaviors. Organize. B. FOCUS methodology stands for: A. Accepting a reoccurrence of the tumor Dealing with the side effects of radiation therapy Caring for the dying child Accepting the imminent death of their child 32.

the win-win approach occurs when: A. The child was wearing a glove when immersed in hot liquid D. there are two conflicts and the parties agree to each one each party gives in on 50% of the disagreements making up the conflict both parties involved are committed to solving the conflict the conflict is settled out of court so the legal system and the parties win 45. B. C. the national emphasis on sex D. B. the presence of a family crisis B. Preschoolers are able to see things from which of the following perspectives? A. The burn has the look of a glove immersed in hot scalding water. D. In conflict management. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot scalding water B. B. Their peers Their own and their caregivers’ Their own and their mother’s Only their own 44. Neoclassic D. 42. Nature C. genetics C. Nurture 20 . B. D. When a person is discussing the strong influences that childrearing methods have on the development of the child. D. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. C. Type of illness of the client Transference and counter transference Effective communication Personality of the participants 41. These risk factors are the family itself. The parents have dipped the child into hot liquid while he or she was asleep C. 43. C. D. this person is most probably coming from which of the following viewpoints or theories? A. Keeping a promise to return to the client’s room at a given time Being a good friend to the client by sharing secrets Saving the client time and money by not wasting supplies 40. the caregiver. these risk factors are the family members at risk for abuse. B. Naturalistic B. four factors place the family members at risk for abuse. Which of the following statements best describes the term glove type burn? A.D. Doing whatever the client or the client’s physician asks of you. According to the social-interactional perspective of child abuse and neglect. C. The school nurse keeps a list of enrolled students who have medical or religious objections to immunizations and those who are likely to have decreased immunity. the child. The well-being of the community 39. Which of the following is the best example of the ethical principle of fidelity? A. C. The nurse likely keeps this list to: A. D. provide statistics for the Department of Health reassure the family that the nurse will respect the family’s wishes at all times meet national government requirements facilitate exclusion in case of an outbreak of a highly communicable disease in the school. and A. chronic poverty 46.

Difficulty swallowing. Isolation B. C. Difficulty sleeping. and respiratory distress. “The pill should cause a normal menstrual period every month. You are now checking to make sure the child does not have a relapse. D. sore throat.” C. Her child is now vomiting. A urine dipstick measurement of 2+ proteinuria or more for 3 days. diminished or absent gag reflex. The nurse will likely work with this adolescent in which of the following areas? A. delegation C.47. The urine dipstick showing glucose in the urine for 3 days. increase in urine output. and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of: A. Identity 53. flank pain. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. that is why periods may often be scant or skipped occasionally. and an arching of the back D. D. Which finding would most lead you to the conclusion that a relapse is happening? A. “The pill prevents the uterus from making such endometrial lining. she should stop taking the pills and get a pregnancy test as soon as possible. cough. the child experiences a remission. psychomotor skills. 49.8 degrees (100 degrees F). has bloody diarrhea. changing complete blood count (CBC) with diiferential B. C. It sounds like your friend has not been taking the pills properly. Lack of fulfillment D. Loneliness C. Paradoxical irritability. and vomiting 48. B. Elevated temperature. A temperature of 37. Weakness of the leg muscles.” D. You will tell the mother to: A. call emergency medical services (EMS) and get the child to the emergency room relax because these symptoms will pass and the child will be fine administer syrup of ipecac call the poison control center 50. burning frequency. The use of interpersonal decision making. Teach care daily and let the caregivers do a return demonstration just before discharge B. loss of sensation in the legs. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. 52. responsibility 21 .” 51. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. and a moon face. the nurse would: A. In working with the caregivers of a client with an acute or chronic illness. You are the nurse assigned to work with a child with acute glomerulonephritis. extreme thirst. urgency on voiding. or the child found to have 3-4+ proteinutria plus edema. and cloudy urine. A client says she heard from a friend that you stop having periods once you are on the “pill”. and restlessness B. diminished or absent gag reflex. “Missed period can be very dangerous and may lead to the formation of precancerous cells. and vomiting. By following the prescribed treatment regimen. hypervigilant. Difficulty swallowing. and respiratory distress C. diarrhea. and is complaining of abdominal pain.” B. C. The most appropriate response would be: A. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. “If your friend has missed her period. hypervigilant. diarrhea. Paradoxical irritability. Difficulty sleeping. and an arching of the back D.

Gestational age D. the win-lose approach D. this is referred to in conflict management as: A. D. winning while losing C. What information about the fetus at this time in pregnancy would be the results of this examination provide? A. which includes a number of young men who are on competitive sports teams. get the child up walking and make sure he or she stays awake leave the child and go get help leave the child in the care of an older child and go get help stay with the child. No sharing of underarm deodorant or shower soap No sharing of razors or toothbrushes Making certain towels have been washed in boiling water Avoiding physical contact such as sports hugs or swats 60. Which of the following health practices would the nurse most stress in preventing the transmission of human immunodeficiency virus (HIV) virus in case any team member has HIV or acquired immunodeficiency syndrome (AIDS)? A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. and have someone call the caregivers 55. the lose-win approach 58. keep assessing. C. C. a type 1 diabetic undergoes an ultrasound examination. D. B. The nurse’s best course of action is to: A. Toddlers require more empathy and more touching and holding 22 . Push the child to practice sports activities while they are more flexible Encourage a variety of physical activities in a noncompetitive environment Have the child engage in competitive sports to see where they excel Keep physical activities to a minimum until the child is in grade school.B. A child suffers a head injury in a tumbling accident in gym class. The school nurse is teaching a health education and hygiene course to a group of high school males. When someone on a date tricks the other person into having sexual intercourse D. At 17 weeks’ gestation. Which of the following best describes a difference in communicating with school age children versus toddlers? A. When one person allows the conflict to be resolved at his or her own expense. competence 54. C. C. B. Estimated fetal weight C. Sexual intercourse committed with force or the threat of force without a person’s consent. supervision D. The American Academy of Pediatrics suggests that caregivers do which of the following things in regard to physical activities for preschoolers? A. 56. B. When two people don’t love each other and engage in sexual activities C. 59. Which of the following statements best describes acquaintance rape? A. Which of the following arrangements is generally considered to be best for the parents of hospitalized infant or young child? A. Fetal lung maturity 61. D. D. losing B. Placental maturity B. Rooming-in Separate caregiver sleeping room on the unit Day visits and sleeping at home Staying at a nearby hotel or motel 57. B.

Enhancements 67. grunts and other vocalizations are referred to by which of the following terms? A. The tone and pitch of the voice. four stages B. Which of the following roles BEST exemplifies the expanded role of the nurse? A. application to the skin. Maternal pulse 90 B. Genetic testing should be performed on a child only if A. Paraverbal clues B. The nurse is working with a child who is going to have a bone marrow aspiration. Conversational style 70. the parents both want it performed it is in the best interests of the child it i9s necessary for the child to survive no one objects 63.” cultures have different patterns of verbal and nonverbal communication. two concepts C. B. D. Circulating nurse in surgery Medication nurse Obstetrical nurse Pediatric nurse practitioner 65. speed. The number of words is more when communicating with a toddler than it is with a school aged children 62. C. amount of neck wrinkling 64. ability to hold the head without support B. During your shift. you noted one of your pregnant clients considered as “waiting case” manifest morning sickness and which later progressed. keep the diaper from rubbing the cord 23 . Eye contact C. Infant head control is judged by the: A. C. B. D. FHT 155 D. rigidity of the neck and head D. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your workplace. 1+ ketones in the urine 68. Subject matter D. Which assessment finding may indicate possible developing complication? A. Ancillary speech 66. remind caregivers to do cord care B. The major purpose of exposing the cord is to: A. Caregivers need less information when care involves a school aged child D. infection. B. three questions D. Which difference does NOT necessarily belong? A. volume. Which of the following is the route of administration? A. The physician orders TAC (tetracaine.B. presence or absence of head lag C. C. Trace glucose in the urine C. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in such a way as to expose the cord. Personal behavior B. D. preparation for procedures is just before the procedure and much earlier for school-aged children. For toddlers. adrenaline and cocaine). Third element D. five agendas C. The plan-do-study-act cycle begins with: A. C. covered with a dressing prior to the procedure subcutaneous IV using a very slow drip over approximately 4 hours prior to procedure Nasal inhalation 69.

B. What would Nurse Lisa hope to find? A. the baby is an embryo After the 20th week of pregnancy. health needs 72. The following conditions pertain to the GROWING FETUS. baby powder or cornstarch 73. Has MArichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy. Place one hand on the abdomen above the symphysis pubis. Assignment C. group. or community is called: A. responsibility D. B. Marichu is worried that her baby will be born with a congenital heart disease. The nurse is teaching a group of expectant mothers about the prevention of diaper dermatitis. C. Her baby will be a fetus as soon as the placenta forms From the time of implantation until 5 to 8 weeks. Which action should the nurse take to decrease the risk of uterine inversion during uterine massage? A. plastic panties over diapers D. 24 . Position the client in a slight Trendelenburg position. What assessment of a fetus at birth is important to help detect congenital heart defect? A. The obligation to correctly perform one’s assigned duties is: A. family. D. the baby is called a zygote This term is used during the time before fertilization 77. C. Determining that the color of the umbilical cord if not green. which tells nurses how to make ethical decisions assists the nurse in formulating a personal belief system supports the concept of respect for all persons C. Has Marichu been overly anxious about something. Ask the client to ambulate to the bathroom to empty her bladder. Massage only when cramping begins. 78. Assessing whether the umbilical cord has two arteries and one vein. B. accountability 75. allow visualizations at all times 71. population.C. quality of life D. B. What would be your best explanation? A. The nurse explains that one of the preventive measures is the use of: A. cloth diaper 74. SITUATIONAL Situation 1 – Nurse Lisa manages her own Reproductive and Children’s Nursing Clinic in Sorsogon and necessarily she attends to health conditions of mothers children. C. delineates all obligations and responsibilities of the nurse is a binding oath. Measuring the length of the cord to be certain that it is longer than 3 feet. Delegation B. The level of health of an individual. health assets B. B. Assessing whether the Wharton’s jelly of the cord has a pH higher than 7. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo. C. the nurse notes the fundus to be slightly boggy. provide air circulation for the cord D. Nurse Lisa would gather more information about Marichu’s worry about what may threaten the health of her baby. absorbent disposable diapers B. D. and 76. During a routine postpartum assessment following a normal vaginal delivery. D. D. Additionally. The Code of Nurses A. health status C.2.

Marichu is scheduled to have an ultrasound examination. C. breastfeeding the newborn early ambulation administration of anticoagulant postpartum immobilization and elevation of the lower extremities 25 . Incomplete abortion C. C. Which term best describes the client’s condition? A.g. B. D. D.C. In a big government hospital. You can have medicine for pain for any contractions caused by the test. Situation 2 – Health instructions are essentially given to pregnant mothers. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy? A. taking drugs. Threatened abortion 83. Inevitable abortion D. Presence of dark color in the neck Increased vaginal discharge Swelling of the face Breast tenderness 82. On physical examination. Drink at least 3 glasses of fluid before the procedure. drinking. 81. C. B. Has MArichu engaged in any detrimental activities during the fetal development stage e. Grand multiparity D. 35 year old postpartum client is at risk of thrombophlebitis. 79. C. What complication of this condition is of most concern to Nurse Pura? A. B. a bad fall. C. A woman who is 9 weeks pregnant comes to the Health Center with moderate bright red vaginal bleeding. which is why only a small amount is removed. Void immediately before the procedure to reduce your bladder size. D. The intravenous fluid infused to dilate your uterus does not hurt the fetus. smoking. Void immediately before the procedure to reduce your bladder size. Hacienda Gracia. D. Mrs. The intravenous fluid infused to dilate your uterus does not hurt the fetus. What instruction would you give her before this procedure? A. Nurse Pura is taking care of a woman with a diagnosis of abruption placenta. the physician finds the client’s cervix 2 cm dilated. Premature rupture of membrane 85. Epidural anesthesia C. D. or attempts to terminate pregnancy. B. Missed abortion B. No more amniotic fluid forms afterward. What instruction would you give her before her examination? A. 80. B. D. Which of the following findings on a newly delivered woman’s chart would indicate she is at risk for developing postpartum hemorrhage? A. Post-term delivery B. Which of the following nursing interventions decreases her chance of developing postpartum thrombophlebitis? A. Has MArichu engaged in sexual activity during the fetal development state of her child. Marichu is scheduled to have an amniocentesis to test for fetal maturity. Urinary tract infection Pulmonary embolism Hypocalcemia Disseminated intravascular coagulation 84. The X-ray used to reveal your fetus’ position has no long term effects.

Those under early treatment B. families. nursing protocol C. Marked anorexia. Conduct community assemblies. C. This is nursing parlance is nothing less than the: A. nursing process Situation 4 – Dengue hemmorhagic fever is a common health concern in Philippine society. providing warmth through light weight covers 26 . Referral to cancer specialist those clients with symptoms of cancer. 88. The following conditions apply. Who among the following are recipients of the secondary level of care for cancer cases? A. conducting strong health education drives/campaign directed towards proper garbage disposal C. In Community Health Nursing. Those scheduled for surgery 90. C. C. Those scheduled for surgery D. D. In the prevention and control of cancer. explaining to the individuals. Those under post case treatment C. the best tool any nurse should be wel be prepared to apply is a scientific approach. An important role of the community health nurse in the prevention and control of Dengue Hfever includes: A. The following is NOT an indicator for hospitalization of H-fever suspects? A. B. Which among the following is the primary focus of prevention of cancer? A. The community health nurses’ primary concern in the immediate control of hemorrhage among patients with dengue is: A. Who among the following are recipients of the tertiary level of care for cancer cases? A. B. Those under early case detection B.Situation 3 – With the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. B. nursing research D. Elimination of conditions causing cancer Diagnosis and treatment Treatment at early stage Early detection 87. both 91. despite the availability and use of many equipment and devices to facilitate the job of the community health nurse. It does not only pose a threat to health but more so to the lives of young and old. which of the following activities is the most important function of the community health nurse? A. This approach ensures quality of care even at the community setting. Those under supportive care C. abdominal pain and vomiting Increasing hematocrit count Fever for more than 2 days Persistent headache 93. Community health nurses should be alert in observing a Dengue suspect. and well as rich and marginalized sectors of the society. D. Teach woman about proper/correct nutrition. D. practicing residual spraying with insecticides 92. control and treatment modalities. 86. nursing diagnosis B. advising low fiber and non-fat diet B. Use the nine warning signs of cancer as parameters in our process of detection. advising the elimination of vectors by keeping water containers covered B. groups and community the nature of the disease and its causation D. Those under early detection D. Those undergoing treatment 89.

D. Nina’s treatment should include the following EXCEPT: A. Which of the following is the most important treatment of patients with Dengue H-Fever? A. Bronchopneumonia SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. Pneumonia D. The following questions apply: 96. D. reassess the child and classify him for dehydration B. 40 breaths per minute or more 50 breaths per minute 30 breaths per minute or more 60 breaths per minute 98. no chest in-drawing. give 100-200 ml clean water as well during this period C. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue H-fever? A. C. Nina 18 months old weighed 18 kgs. She is irritable. Bronchopneumonia B. and her temperature registered at 37 degrees C. Using Integrated Management and Childhood Illness (IMCI) approach. The 1st child who is 13 months has fast breathing using IMCI parameters he has: A. Some dehydration B. ***END*** 27 . D. A. Severe pneumonia C. Severe pneumonia D. observing closely the patient for vital signs leading to shock D. No pneumonia : cough or cold C. There is no blood in the stool. Her mother says she developed cough 3 days ago. C. the 2nd child has diarrhea for 5 days. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. Give in the health center the recommended amount of ORS for 4 hours. Do not give any other foods to the child for home treatment 100. D. While on treatment. Nina has no general danger signs. Give aspirin for fever Replacement of body fluids Avoid unnecessary movement of patient Ice cap over the abdomen in case of melena Situation 5 – Two children were brought to you. C. How would you classify Nina’s illness? A. no stridor. How would you classify Nina’s manifestation. keeping the patient at rest 94. One with chest indrawing and the other had diarrhea. Severe dehydration D. Pneumonia 97. B. Dysentery C. Prolonged bleeding time Appearance of at least 5 petechiae Steadily increasing hematocrit count Fall in the platelet count 95. Nina.C. B. No pneumonia B. B. for infants under 6 months old who are not breastfed. The nurse offered fluids and and the child drinks eagerly. how would you classify the 1st child? A. She has 45 breaths/minute. and her eyes are sunken. No dehydration 99.

all registered professionals B. 10 credit units required 28 . As a nurse that this is a measure of observing signs of: A. 8. 13. Two or more boxes shaded will invalidate your answer. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.NURSING PRACTICE III SET A ________________________________________________________________________ NURSING PRACTICE III – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 11. Pulmonary edema is a potential danger that we nurses should monitor in post pneumonectomy. rapid infusion of IV fluids D. An NCLEX and CGFNS passer 7. What is the basic requirement of the state for a nurse to practice her profession? A. all registered nurses 8. A BSN degree C. This is usually due to: A. Shade only one (1) box for each question on your answer sheets. 30 credit units for 3 years C. This test booklet contains 100 test questions. The code of Good Governance for the professions in the Philippines shall be adapted by: A. 9. Unauthorized possession. This is PRC property. hypoxia B. Write the subject title “Nursing Practice III” on the box provided. 6. The standardized guidelines and procedures for the implementation of Continuing Professional Education (CPE) for all professional. Willingness to practice the profession B. There is an order of Central Venus pressure (CVP) reading. AVOID ERASURES. ________________________________________________________________________ INSTRUCTIONS: 7. 20 credit units per year B. fluid retention due to prolonged bed rest Situation 2-The PRC regulates the practice of 42 professions in the Philippines. liberal fluid intake C. 60 credit units for 3 years D. and/or sale of this test is punishable by law. 15. all Filipino professionals C. Resolution Number 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be: A. 14. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. Shade Set Box “A” on your answer sheet if your test booklet is Set A. MULTIPLE CHOICE 5. hypovolemia C. extreme temperature B. hypothermia D. A nursing license D. 12. Per RA 8981. Set Box “B” if your test booklet is Set B. hypoxemia 6. all professionals D. reproduction.

As a surgical nurse. B. D. Let her cry and tell significant other to stand by. C. 16. What is the crucial in determining a good candidate for rhizotomy? A.Pain is always associated to surgery 11. C. suspend or revoke for cause the: A. B. B. Divert attention of client in pain Leave the patient alone while in pain Believe what the patient says about the pain Assume responsibility to eliminate pain as described by the client Situation 4-Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain. which of the following nursing intervention will allay anxiety and pain among? surgical patients? A. C. certificate of Registration D. What do you think is an important responsibility related to pain that is subjective in nature? A. Check her name tag and request anesthesiologist to sedate client 14. “I shall call the nurse when my wound itches and smells”. “I should not touch my surgical wound” 15. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and management of pin should address the following beliefs EXCEPT: 29 . Within 3 years after the last failed examination Anytime the examinee wants to take the examination Within 2 years after the last failed examination Within the same year after the filed examination Situation 3 . B. B. “I shall expect slight pain and discomfort from the surgical incision”. “I should call my doctor if my wound has no drainage and intact”. RA 7193 stipulates the removal examination of the nurse licensure examination shall be taken: A. certificate of Practice C. Which of the following clients statement indicates that he understands the nurse’s instruction about postoperative wound pain? A. D. Local pain with no radiating pain or signs of nervous compassion D. The board of Nursing is vested with power to issue. C. certificate of Employment 10.9. certificate of Good Moral Character B. Stand by her side and quietly ask her to describe her feelings. D. D. Squeeze her hand and assure her that there will b no pain at all because she will be given anesthesia. Pain which is resistant to non-pharmacologic for 6 month B. C. D. Rhizotomy is a condition surgical procedure to manage those that can potentially cause pain. Pain which is resistant to pharmacologic protocol for 12 months C. Deep pain with obvious signs of peripheral nerve damage 13. Which of the following would be the nurse’s appropriate response to a crying female client scheduled for emergency surgery who is verbalizing fear of pain but afraid to go to sleep? A. Asses the client for concerns especially those that can potentially cause pain Verify that the operated permit is signed Discourage the client from discussing the details of the surgical procedure Ensure safety of client while in surgery 12.

D. You have a critical heat labile instrument to sterilize and are considering touse high level disinfectant. Cover the soaking vessel to contain the vapor Double the amount of high level disinfectant Test the potency of the high level disinfectant Prolong the exposure time according to manufacturer’s direction 30 . What do you tell a mother of a ‘dependent’ when asked for advice? A. B. Clean B. Physical dependence occurs in anyone who takes opioods over a period of time. C. Real pain C. Placebos do not indicate whether or not a client has: A. B. D. Disease D. Material compatibility and efficiency Odor and availability Cost and duration of disinfection process Duration of disinfection and efficiency 23. B. What should you do? A. Items that enter sterile tissue or vascular system are categorized as critical items and should be: A. Decontaminated C. Rinse with tap water followed by alcohol Wrap the instrument with sterile water Dry the instrument thoroughly Rinse with sterile water 24. Constipation C. C. 21. D. The pain is vague By charting-it hurts all over Identify the absence and presence of pain As the client to point to the painful are by just one finger 19.A. D. D. B. they are tolerant Complaining of pain will lead to being labeled a ‘bad’ patient 17. C. Drowsiness D. it is known as the ‘placebo effect’. Conscience B. C. Disinfected 22. should the nurse monitor when giving opioids especially among elderly clients who are in pain? A. B. more distressing than pain. As an OR nurse. Older patients seldom tend to report pain than the younger ones Pain is a sign of weakness Older patients do not believe in analgesics. Drug tolerance 18. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain. C. Allergic reactions like pruritis 20. What symptom. Nurses should understand that when a client responds favorably to a placebo. what are your foremost considerations for selecting chemical agents for disinfection? A. C. you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection.As a perioperative nurse. How can you assist such client? A. Sterilized D. Start another drug and slowly lessen the opioid dosage Indulge in recreational outdoor activities Isolate opioid dependent to a restful resort Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms Situation 5. Before you use a disinfected instrument it is essential that you: A. D. Forgetfulness B. B.

D. Collaboration with other OR personnel regarding the practices of surgeons collecting exorbitant professional fees D. Affiliating with The Healthcare Alliance 38. Therefore. Alcoholized Situation 6-The OR is divided into three zones to control traffic flow and contamination 26. 2 ml 35. Operation Linis C. Sterile C. What OR attires are worn in the restricted area? A. 0. D. scrub suit Cap. C. OR shoes. Scrub suit. you know that intact skin acts as an effective barrier to most microorganisms.25. Perioperative examples of collaboration are the following EXCEPT: A. mask. C. Disinfected B. items that come in contact with the intact skin should be: A. An example of collaborating effort on public service particularly during summer is: A. shoes 33. OR shoes Mask. Clean and Green D. The doctor ordered to incorporate 1000”u” insulin to the remaining on going IV. Boto mo. gloves. kept in narcotic cabinet D. How much should you incorporate into the IV solution? A. 10 ml B. Joining the Mayo Uno Labor Union C. 5 ml Situation 8-Collaborative planning is essential if nursing and health care are to be made available to all people. The nurses collaborate with other members of the health profession to improve the integrity of the hospital working environment the following ways EXCEPT A. Joining barangay health club projects B. B. OR shoes. kept in the refrigerator C. Communicate with other members of the health profession to improve the integrity B. mask. Nursing intervention for a patient on low dose IV insulin therapy includes the following. Operation Tuli 31 . The strength is 500 /ml. Joining labor day rally to increase wages of healthcare workers and improve dilapidated health centers D. store in the freezer C. Ipatrol mo B.5 ml D. scrub suit. Clean D. EXCEPT: A. As a nurse. B. Elevation of serum ketones to monitor ketosis Vital signs including BP Estimate serum potassium Elevation of blood glucose levels 34. Communicate with health officials the incidence of Hepatitis B among OR personnel C. head cap Head cap. 36. kept at room temperature B. Collaborate with DOH regarding disposal or specimens 37. Multiple vial-dose-insulin when in use should be A.

This is exemplified in: A. You should offer: A. Acupuncture uses manipulation of the skeletal muscles to relieve stress and pain D.39. When the nurse replies to the client’s relative “You have the best doctor in town” C. “The doctor is not on duty today” 40. 47. C. Menstrual pain and discomfort account for absences in schools and offices. C. The nurse places the side rails the time to an unconscious patient The nurse elevates the head of the bed to check the BP. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? 32 . diet restriction on fatty foods and liberal fluid intake Situation 10 – One learns by doing especially when you practice the best methods. Call the attention of the orderly in private Ignore the situation because you are busy Report this behavior to the nurse in charge Monitor the situation and note whether any other items are reported missing. You questioned his treatment because: A. Individual patients and society as a whole benefit from nursing participation in decisions made about health care. 46. C. You are on PM shift and about 5 patients are of discharge.S. tetracycline ophthalmic ointment B. Acupuncture uses variety of herbs and oils from wild plants C. ice cold drinks 45. A nonpharmacological remedy for menstrual pain is: A. 48. Situation 9-pain management is not limited to pharmacological means: 41. B. D. hot compress over the right eye D. “Our hospital does not honor visiting doctors” B. You noted that the orderly was looking through the items of one of the patients. Which action by a new nurse signifies a need for further teaching in infection control? A. ice pack over the right eye C. When does a nurse reject the interdependence of providers and patients in achieving access to health care? A. Ronald one of your clients who is being worked out for AIDS tells you that he has been using acupuncture to help with his pain. D. knee-chest exercise before menstruation and hot water bag application over lower abdomen during onset C. Which action should you pursue? A. Acupuncture uses needles to stimulate certain points on the body to treat pain B. D. B. Supporting political candidates that advance nursing care issues Bringing the NCLEX in Philippines Supporting the proliferation of colleges of nursing in the country Following the decision of CGFNS to retake Test III and IV to validate the visa screen for the U. When the nurse communicates to the attending physician the desire of the patient to be seen by a urologist D. Your younger brother came home with right black eye. The nurse uses her bare hands to change the dressing The nurse applies oxygen catheter to the mouth. He asked you for an eye ointment to relieve the pain and swelling. Acupuncture uses pressure from the fingers and hands to stimulate body responses 42. regular bowel movement B. B. warm shower during onset of menstrual period D.

Require the staff to submit an incident report Terminate the nurse Charge the erring nurse with dishonesty Repot to the Board of Nursing Situation 11 – You are assigned at the PACU. Knowledge deficit related to lack of information because patients are all sedated. splintering and leg exercises. Acute pain related to discomfort off wound and immobility Body image disturbance because of wound dressing and drains. One of your post-op patients has a temperature of 37. B. “If the wound is painful. you also report the incident to the charge nurse. After talking to her. B. The nurse colleague charting medication administration that she has not yet given 50. The nursing student asked you to explain the absence of shivering even if the temperature was higher. The client manifests normal temperature C. D. Which of the following remark indicates that the client’s relative understood the discharge instruction for wound care? A. Try to explore the interaction with the nursing attendant concerned Change the attendant’s assignment Initiate a group discussion with all other nursing attendants Discuss the matter with the patient’s family 49. coughing. Report when the IV infusion is almost finished Test the call system if functioning Keep the room lights on for 24 hours Make sure the side rails are up 55. C. C.9°C. At 9:30 AM. C. post-op clients started to be ? in from the OR 51. I will say it is normal” “It is alright to use adhesive tape over the wound to keep it intact” “It is ok for his pet to remain at his bedside to keep him company” “I will report any redness or swelling of the wound” 54. D. Which observation from a colleague would indicate a need for further teaching? A. The nurse colleague noted the level at the top of the meniscus C. B. The colleague instructs the clients to perform the valsalva maneuver during the CVP reading D. D. The charge nurse should: A. You must transfer out a post-op client to her room. What would your instruction to the family include to prevent accidents? A. A. B. The client demonstrated deep breathing. You covered him with a blanket and later took his temperature again and it is now 38.9°C and was shivering. You have been in the surgical ward for almost a year and have cared for a number of patients with CVP. D. B. C.A. Ineffective airway clearance related to general anesthesia. The client sleeps well D. The client has good balance I and O 53. The patient is no longer febrile thus he is no longer chilling 33 . Which of the following clients at the PACU will demonstrate the effectiveness of ? teaching? A. D. Which nursing diagnosis has priority among client in the PACU? A. 52. You saw one colleague charting medication administration that she has not yet administered. C. B. The colleague turns the stop-cock to the off position from the IV fluid to the patient B.

D. DOH C. D.M. B. of Tirso’s chest tube. Continuously breathe normally during the normal of the chest tube Take a deep breath. biomedical division B. Upon checking the chart.e. you found out the chest tube of a client was disconnected. The patients is feeling better Situation 12 – Patients with chest tubes can be very challenging to new nurses. A tube being too small D. C. pathology department 63. D. Dr. C. disconnected closed placed lower than the patient’s chest placed between the legs of the client to prevent breakage Situation 13 – The preoperative nurse collaborates with the client significant others. prn for pain. Malou found out that she has an order of Demerol 100 mg I. Crematorium B. A tension pneumothorax 57. To control environmental hazards in the OR. exhale. Reyes asked you to assist him with the removal. infection control committee D. DILG 64. When transporting clients with chest tube. amputated limbs) disposal should be coordinated with following agencies EXCEPT: A. B. Chest tube diameter is measured or expressed in: A. gauge C. the system should be: A. Assist the client back to his bed and place him on the affected side Cover the end of the chest tube while sterilize gauze Reconnect the tube to the chest tube system Put the end of the chest tube into a cup of sterile normal saline 58.B. Shivering normally disappears as temperature becomes higher C. milliliters D. who weights 110 lbs prior to surgery. french B. Biological wastes (i. discovered that Malou. You would instruct the client to: A. Waste disposal poses a big problem for the hospital. is in severe pain 3 hrs after cholecystectomy. Intern on duty 34 . The body has reached its new set point thus the absence of shivering D. 61. What would be your appropriate action? A. and healthcare providers. Anesthesiologist C. C. Nurse supervisor B. 56. Surgeon D. the PACU nurse. Tess. While you were making your endorsement. inches 60. A suction being too high B. Which of the following condition is the possible cause of the malfunctioning sealed drainage? A. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. An air leak C. B. Tess should verify the order with: A. chaplaincy services C. MMDA D. the nurse collaborates with the following departments EXCEPT: A. and bear down Exhale upon actual removal of the tube Hold breath until the chest tube is pulled out 59. After an hour you noticed that the bubbling stops.

The documentation of all nursing activities performed is legally and professionally vital. The current insulin pumps available in the market have the following capability. It is critical also that a diabetic client should be educated in the possible sites if regular insulin injection. It improves insulin utilization and lowers blood glucose C. What is the effect of regular exercise to a diabetic client? A. Incorporate insulin as ordered. C.5 cm 4 cm 68. B. D. who is diabetic is for debridement if incision wound. C. Communicate with the client to verify if insulin was incorporated D. Situation 14 – Technology and patient’s education has dramatically improved the management of the diabetic client.g. she found out that there is no insulin incorporated as ordered. EXCEPT: A. this should documented in the: A. Client with proliferative retinopathy Unstable diabetes Hypoglycemia without warning Abdominal renal glucose threshold 70. B. 6 cm 5 cm 2. C. D. It burns excess glucose B. Communicate with the ward nurse to verify if insulin was incorporated or not C. Deliver a pre-meal bolus dose of insulin before each meal. EXCEPT: A.0 units per hour 67. You will recommend this technology in the following diabetic patients. 57. If there is any deviation from normal practice or procedure e. improves insulin utilization. It will make you fit and energized Situation 15. streptomycin was given by IV not IM. C. Self-monitoring of blood glucose (SMBG) is recommended for patient’s use. It lowers glucose. D. 35 . B. Double check the doctor’s order and call the attending MD B. The fastest absorption rate happens at the tissue areas of: A. It is necessary for a diabetic client to exercise regularly. D. What should the circulating nurse do? A. Discharge plan of diabetic clients include injection-site-rotation. B.0 units to 2. Deliver a continuous basal rate of insulin at 5. Rosie. Prevent unexpected saving in blood glucose measurements. 66.65. C. You should emphasize that the space between sites should be: A. Gluteal area Deltoid area Anterior area Abdominal area 69. decrease total triglyceride levels D. When the circulating nurse checked the present IV fluid. Progress notes Incident report Nurse’s not Patient’s chart 72. B.RN’s should always be conscious that the contents in charting are admissible in court as evidence. 71. Detect signs and symptoms of hypoglycaemia and hypercalcemia. D.

Your appropriate action would be: A. Your nursing management includes the following EXCEPT: A. and additions in medical records and the nurse’s notes can be avoided. C. Insert additions or corrections D. Tipol. 60 year old widower tried to sit up an instead of holding to the side rail held the IV stand causing the IV bottle to fall and break. alterations. State the reason for any deviation from normal procedure/practice 75. you should palpate the following: A. Cross out blank spaces B. Document the incident Be a part of the patient’s chart Present confidential report Evidence of the quality of care 74. Instruct Kathy’s uncle to present a written authorization signed by the patient B. Refer to the attending physician Situation 16. Cross out wrong word or phrase with one or two lines making the crossed out word discernible C. C. The ears. B.During your morning rounds. Mr. Among the patients with upper airway infection. For nurse to asses an upper respiratory tract infection. D. emotional. Baseline physical. C. D. etc. Erasures. D. Presence of prosthetoid devices such as dentutes. B. nose. 76. who is a doctor. and psychosocial data Arguments between nurses and residents regarding treatments Observed untoward signs and symptoms and interventions including contaminant intervening factors 73. Instruct Kathy’s uncle to present a written request to the Medical Records Section of the hospital D. B. C. Suggest a soft or liquid diet during acute stage Encourage liberal amount of cold fruit juices Encourage bed rest during stage Apply ice collar for sympathetic relief of severe sore throat 77. you noticed that there is an incidence of upper respiratory Disorders. B. and throat Adenoids tonsils and nose Nose and throat only The tracheal and nasal mucosa including the frontal sinuses 78. Regularly administering prescribed vasoconstrictive medication Decreasing systematic hydration Positional drainage Humidifying inspired room air 79.During the month of July. Kathy is one of your patient’s. One of your cases is with acute pharyngitis. wants to read her chart. eyes. You wrote an incident report to show: A. airway clearance can be facilitated by the following EXCEPT: A. C. A friend asked you some nursing measures of uncomplicated common colds. Refer to the hospital director C. D. Her uncle. D. You will include the following measures EXCEPT: 36 . The following are some tips on how to do corrections EXCEPT: A. B. artificial limbs hearing aid.Which of the following should NOT be included in the patient’s chart? A.

C. Send specimens to laboratory right away after the operation with the proper labels B. A post dilation and curettage (D and C) client is for discharge. B. urethra 37 . B. seeds or bullets are also considered as a specimen. Consult an ENT surgeon C. hospital number Name of the client. B. She is scheduled in your room on 5 for frozen section. D. Santos. needles.Mr. sex. type of specimen. When asked what are the organs to be examined during cystoscopy. age. hospital number. Prepare 4 specimen vials first thing in the morning Situation 18. C. How will you label this specimen? What information was essential in the label? A. 50. Instruct client about symptoms of secondary infections Administer prescribed antibiotics Teach that the causative virus is contagious even before symptoms appear Suggest adequate of fluids and rest 80. Name of the client. Label specimen at once D. How do you prevent switching of specimens? A. The department of pathology The national bureau of investigation The OR head nurse Client’s family 84. During the surgery the specimen to: A.A. doctor. Send to pathology immediately without soaking solution C. D. 81. Follow-up of lab result should be part of the discharge plan. Soak it in formalin 82. D. site. Santos. D. How will you prepare the specimen for laboratory? A. Refrigerate and send it along with the day’s specimens B. type of specimen.A specimen is a piece of tissue or body fluid taken from the disease body organ or tissue to aid the health care team in diagnosis and effective treatment. bladder. Medical record Laboratory Doctor’s clinic Nurse’s station 85. is to undergo cystoscopy due to multiple problems like scantly urination. Carmen is suspected to have a left CA. you will enumerate as follows: A. doctor Name. You assisted in the multiple gun-shot wound exploration. hospital number 83. Advice adequate fluid intake Situation 17. C. Foreign body the extracted from the body like pins. Soak it in NSS D. hematuria and dysuria. You are the circulating nurse in OR 2. You will instruct the client to follow up result at the: A. Local heat application to promote drainage B. age. Urethra. Increase humidity D. You are the nurse in charge in Mr. The following are your nursing suggestions for a patient with acute or chronic sinusitis EXCEPT: A. B. C. You have 4 thyroidectomy cases for the day. sex Name. Collect all specimens and send to laboratory at the end of the day C. 86. kidney. age.

B. “Cystoscopy is done by x-ray visualization of the urinary tract”. After cystoscopy. C. EXCEPT: A.B. Urethra. B. During the surgery. Pink-tinged urine Distended bladder Signs of infection Prolonged hematuria 90. movement of personnel including the circulating nurse is: A. it is normal to observe one the following: A. The following techniques illustrates the concept “confine and contain” EXCEPT: A. Nursing intervention includes: A. Within 24-48 hours post cystoscopy. “Cystoscopy is done by using lasers on the urinary tract”. uterine wall. Amount of handling C. Bladder wall. Mr. Contaminated items like sponges are handled using loves B. Santos who is cystoscopy in: A. B. contamination should be confined and contained within the immediate vicinity of the surgical field to prevent the spread of pathogenic microorganisms. “Cystoscopy is direct visualization and examination by urologist”. In the OR. Supine Lithotomy Semi-fowler Trendelenburg 88. D. Which is NOT considered a piece of PPE? A. and body fluid specimens should be placed in leak-proof containers C. D. What do you tell him? A. Santos asked you to explain why there is no incision of any kind. C. Surgeons conduct their patient’s rounds in scrub suit D. C. Temperature and humidity are set for patient and personnel safety and reduce bacterial contamination. Prompt cleanup of accidental spills of contaminated debris e. D. 89. ureteral opening C. C. and urethral opening D. All blood tissue. Type of sterilizer used to sterilize items B. Urethral opening. Precaution recommends that the use of standard personal protective equipment (PPE) to prevent cross contamination. The OR is a restricted area where OR attire is worn. Leg cramps are NOT uncommon post cystoscopy. trigone. blood. Sterile is the condition of almost all items. B. devices or supplies used in the OR for any surgical procedure. B. bladder wall. “Cystoscopy is an endoscopic procedure of the urinary tract”. D. you will position Mr. C. D. Storage conditions 94. ureteral opening bladder 87.g. Kept to minimum Eliminated when possible Restricted Monitored 93. body fluids 92. 91. Shelf-life of a packaged sterile item is event related and depends on the following.During the surgical procedure. Bed rest Warm moist soak Early ambulation Hot sitz bath Situation 19. Cover gown 38 . The quality of packaging material used D.

. What is the identifying color of the tank which contains ‘laughing gas’? A. In health care when lad apron is required in any procedure like orthosurgery. Gloves D. An instrument tray with black striped autoclave/steam chemical indicator tape communicates that the instrument tray. In the field of healthcare. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. Traffic patterns in the OR suite should. C. B. C. D. B. B. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb.. D. 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as stand by. Yellow bin Orange bin Green bin Black bin 99. there is danger of exposure to: A. B. where do you discard your used tissue papers? A. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. D. Water and blood splashes Pseudomonas Radiation Bone fragments SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. B. C. C. Other ways of communicating to relay information or instructions exist even in the healthcare setting. On the traffic light. Prevent unauthorized personnel from entering the OR Prevent transmission of pathogenic microorganisms Assure that the personnel walk in the same direction Allows personnel to move freely between restricted and unrestricted areas Situation 20. A. C. Eyewear C. Is clean Is ready for use in surgery Is sterile Has undergone the sterilization process 100. yellow means “proceed with caution”. D. Medical gases are used a lo9t in the OR. C. D. A. all through communication via the cellphone. B. Face shields 95.Nokia is so powerful to “connect people” from the continent to continent. D. Yellow Green Black Blue 98. 96.B. 39 . What gauge spinal sets will make available in the OR suite? A. Gauge 16 and 22 Gauge 18 and 16 Gauge 16 and 20 Gauge 5 and 22 97.

Write the subject title “Nursing Practice IV” on the box provided. This is PRC property. Reduce IV rate 103. C.***END*** NURSING PRACTICE IV SET A ________________________________________________________________________ NURSING PRACTICE IV – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 16. that if she refuses to take her medications. she will not be given her favorite dessert. 11. D. D. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . MULTIPLE CHOICE 101. You are the nurse in an Adult Care Unit. 17. Notify anesthesiologist B. moist respiration and tachypnea. You over0hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say. Assault C. Shade only one (1) box for each question on your answer sheets. B. Two or more boxes shaded will invalidate your answer. and/or sale of this test is punishable by law. C. Malpractice 102. Jake is in the Post Anesthesia Care Unit follwing a colorectal resection. Increase O2 flow rate C. You report your co-staff’s behavior as: A. you would assign the HIGHEST priority to the client with the: A. As the triage nurse. 12. B. Unauthorized possession. 18. Negligence D. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. seniority preferences recent performance evaluation personality traits client classification data 104. 19. Set Box “B” if your test booklet is Set B. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. ________________________________________________________________________ INSTRUCTIONS: 10. AVOID ERASURES. severe head injury and no blood pressure maxillofacial injury and gurling respirations second trimester pregnancy with premature labor lumbar spinal cord injury and lower extremity paralysis 40 . Battery B. 20. reproduction. As a head nurse of the unit. Shade Set Box “A” on your answer sheet if your test booklet is Set A. He has an IV of Dextrose 5% Lactated Ringers Solution. This test booklet contains 100 test questions. Which of the following will you do FIRST? A. Place on Fowler’s position D. Per RA 8981. which of the following sources should you take into consideration when making effective assignments for the next shift? A.

who is legally responsible? A. When a nurse volunteers to work in a hospital setting and she commits a mistake. B. B. C. He sustained a laceration on his forehead. Interpersonal abilities 112. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. D. Which laboratory result should you expect to find? A. Hold the IV bottle Check the IV stand Place the IV stand on the foot part of the stretcher Restrain Jayvee 110. which of the following will you do FIRST? A. D. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs? A. a burn patient is being transferred from the burn unit to the operating room. B. The nurse was proven guilty of negligence. Which of the following will you do first? A. hospital and the nurse in charge the professional organization which the volunteer nurse represents hospital volunteer nurse because there is no employer employee relationship 106. the IV bottle fell on Jayvee’s head. refer to nurse manager B. It was started at 8am. Paras is receiving total parenteral nutrition (TPN). Increased platelet count Altered blood urea nitrogen (BUN) and creatinine levels Electrolyte imbalance Elevated erythrocyte sedimentation rate (ESR) 108. administer Compazine before meals enrich diet with red meats serve hot soup and food increase the amount of spice in the diet 111. C. If you will evaluate her nutritional status. Knowledge and skills C. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. Nurses working in the 35 bed Female Medical Unit were noted to implement new and innovative client care activities long before other units in the hospital. Which of the following did the nurse fail to do? A. which of the following indicators will tell you that TPN was effective? A. While Mrs. Assess bone pain Administer prescribed analgesic Teach pain relief strategies Support position with pillow 107. B. Communication skills B. B. C. C. D. D. At 10am. Mrs. her relative informed you that the bottle is empty. While Jayvee. volunteer nurse.105. Daniel with multiple myeloma complains of deep bone pain. As his nurse. B. C. D. assess Olga and check level of fluid left in the bottle 41 . Vision and passion D. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength? A. D. laboratory work up adequate hydration weight gain diminish episode of nausea and vomiting 109. C.

Measures of central tendency C. Which of the following measurement of data was used in this study? A. You are the nurse manager of the Medical Unit. ammonia D. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: A. B. Studies have shown that the highest incidence of Hodgkin’s disease is common among young adults. Alcohol B. Standards of care are developed by the hospital nursing service and should be followed 42 . D. C. B. C. complete an incident report call the hospital attorney inform the client’s family do nothing because the client’s condition is stable 119. 70 year old with altered level of consciousness who is unable to access water freely D. replace IV fluid with prescribed follow-up 113. Grace. you should: A. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution 117. What should you do as a nurse? A. You are assigned to the following patients. D. bleach 115. What should be included in the plan of care to minimize skin damage from the radiation therapy? A. B. Standardized care plans are used on all of the nurse’s clients.C. During a meal. Helen. Tell her there is nothing to worry if it does not bother her Palpate Juana’s neck and explain the possible cause Tell her Hodgkin’s disease is common among young adults like her Tell her to see a doctor 118. Acetone C. a client with hepatitis B dislodges her IV line and bleeds on the surface of the over-the-bed table. 20 years old approaches you and tells you “I am worried about the mass on my neck”. Frequency distribution D. Which of the following patients is most at risk for metabolic alkalosis? A. A research study found out that 60% of patients complains were due to delayed responses of nurses in the emergency department. discontinue IV and assess Olga D. Nino is being treated with radiation therapy. Measures of variability B. Inferential statistics 114. C. Juana. Although the client exhibits no adverse reactions to the larger dose. you accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. As a nurse. Rachel a 55 year old who has just experienced a stroke C. C. 30 year old post surgical patient who has continuous nasogastric suction B. Client’s care is planned based on the nurse’s clinical expertise and latest research findings B. Which of the following is a priority for you to consider when planning for the care of a group of clients utilizing evidence-based practice? A. Cover the areas with thick clothing materials Apply a heating pad to the site Wash skin with water after the therapy Avoid applying creams and powders to the area 116. D.

D. a tertiary hospital utilized a computerized medication order system. What are your hobbies? What kind of work did you do prior to this illness? Are your living accommodation all on one level? What kind of food do you like? 127.D. greater than . Short T wave C. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium? A. Client’s needs are assessed and individualized care plan are developed for each client. PR interval of ventricular 123. QRS interval C. which of the following typically appears as the first sign of tissue death? A.12 sec to . You are expected to recognize electrocardiographic readings on the cardiac monitor.20 sec 125. 124. D. 65 years old. Prolonged PR interval D.20 sec B. From an ECG reading. . Which of the following procedures may be done through the said system? A. which of the following would be most important to ask? A. Atrial depolarization Which of the following represents ventricular repolarization? A. Cruz. ST segment D. Venticular depolarization C. 126. ST segment suppression B. 120. . encourage dependence B. P wave B. Because of increase incidents of medication error due to wrong transcription of physician medication orders by the nurse. B. ST segment C.10 sec D. It is important that the nurse measures intervals of QRS complex. Pathologic Q wave Situation 2 – To be able to help our clients with their psychological concerns. 121. C. PR interval 122. Ventricular repolarization D. we have to explore how they view themselves and their body image. B.20 sec C. establish a therapeutic relationship 43 . The most appropriate nursing intervention to facilitate client’s acceptance of a change in body image would be to: A. When assessing patient’s body image. QRS complex D. a QRS complex represents: A. T wave B. End depolarization B. C. was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. Which of the following represent the normal interval of QRS complex? A. Later in the acute phase of Myocardial Infarction. Correct errors in the physician medication order Eliminate drug interaction Provide a list of drugs with their generic name Document drug administration SITUATIONAL Situation 1 – P. .

easy fatigability. It is important for you to remember. D. B. Weight gain Side effects of medication on skin Radiation treatment of the breast Surgical removal of an eyeball Before you can help Lorna accept a change in body image you must FIRST: A. D. B. D. considered radioactive for 24 hrs given a complete bath placed on isolation for 6 hours free from radiation 133. D. Knowledge deficit regarding thrombocytopenia precautions Activity intolerance Impaired tissue integrity Ineffective tissue perfusion. peripheral. D. C. cardiovascular. blurred vision severe sore throat. pallor headache.her stamp collection with the nurse Showing no interest in the dressing change 129. Albert is A. C. Immediately following the radiation teletherapy. Tell him that sometimes these feelings can be psychogenic Refer him to the physician Reassure him that these feelings are normal Help him plan his activities 132. Which of the following responses would indicate that the client is beginning to accept change in his/her body image? A. ecchymosis. B. that a sudden change in body image would occur from: A. What intervention should you include in your care plan? 44 .C. dizziness. 134. Which of the following nursing interventions would be most helpful for Albert? A. petechiae. epistaxis weakness. B. C. joke with the client D. renal 135. B. C. With emphasis on multidisciplinary management you have important responsibilities as nurse. C. B. D. B. Albert is receiving external radiation therapy and he complains of fatigue and malaise. bacteremia. 130. Feeling of the dressing over the incisional site Stating he/she is too tired to have visitors Discussing his. D. C. hepatomegaly What nursing diagnosis should be of highest priority? A. 131. As a nurse you should observe the following symptoms: A. cerebral. Albert is admitted with a radiation induced thrombocytopenia. gastrointestinal. establish a social relationship 128. C. be in agreement with the philosophy of therapy for the client become aware of her own attitude toward mutilation and disfigurement be aware of the attitudes and feelings of the client and her family accept the fact that a person can live with a body part missing Situation 3 – Radiation therapy is another modality of cancer management.

B. B. D. The fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration C. Inspect his skin for petechiae. Placement of a nasogastric tube Placement of a second IV line Endotracheal intubation or surgical airway placement CT scan of the head 139. C. GI bleeding regularly Place Albert on strict isolation precaution Provide rest in between activities Administer antipyretics if his temperature exceeds 38C Situation 4 – Andrea is admitted to the ER following an assault where she was hit in the face and head. 137. D. D. promote cerebral-tissue fluid movement promote renal perfusion correct acid-base imbalances enhance renal excretion of drugs 140. Partially obstructed airway Ineffective breathing pattern Head injury Pain 138. As Andrea’s nurse your goal is to prevent increased intracranial pressure (ICP). B. Andrea’s physician gives an order of Mannitol 0. Emergency measures were started. Which of the following independent nursing interventions nursing interventions is NOT suited for her? A. Keep head of bed 30-45 degrees elevated C. C. You should prepare for which of the following FIRST? A. Which of the following observations indicates that the closed chest drainage system is functioning properly? A. Insert an intravenous catheter Insert an oral or nasopharyngeal airway Obtain arterial blood gases Give 100% oxygen by mask Andrea’s arterial blood gases reflect respiratory acidosis. B. Prevent constipation and increases in intra-abdominal pressure Situation 5 – Specific surgical interventions may be done when lung cancer is detected early. Maintain Andrea’s head in straight alignment and prevent hip flexion D. C. D. C. Horace underwent lobectomy. Andrea loses consciousness. B. B.A.25 g/kg IV bolus for increased ICP. C. You have “important peri-operative” responsibilities in caring for patients with lung cancer. D. bruising. 136. She was brought to the ER by a police woman. what will be your priority interventions A. This is given to: A. Absence of bubbling in the suction-control bottle B. 141. Intermittent bubbling through the long tube of the suction control bottle 45 . Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration B. C. As Andrea’s nurse. Facilitation of coughing Promotion of wound healing Expansion of the remaining lung Prevention of mediastinal shift the purpose of Horace’s 142. D. Which of the following is closed chest drainage post lobectomy? A. This is most likely related to: A.

C. diuretic use D. Peter underwent pneumonectomy. 146. Pain in the older persons require careful assessment because they: A. On which of the following positions should you place Peter who just underwent pneumonectomy? A. dilated urethra 149. C. placing him on his operative side during exercises splinting his chest with both hands during the exercises administering the prescribed analgesic immediately prior to exercises providing rest for six hours before exercises 144. breathing. airway. B. breathing disability (neurologic) airways. B. Less than 25 ml drainage in the drainage bottle 143. D. D. B. C. 148. During the immediate postoperative period. B. B.D. D. have increased hepatic. B. C. C. increased glomerular filtration B. Prone position On his abdomen or on the side opposite the surgery On his back or on the side of surgery Any position is acceptable Situation 6 – As a nurse you should be able to address problems and discomforts experienced by the acutely ill older persons. circulation disability (neurologic). C. breathing 46 . D. Administration of analgesic to the older persons requires careful patient assessment because older people: A. change in mental status fever decreased breath sounds with crackles pain 150. you can best help Horace to reduce pain during deep breathing and coughing exercises by: A. D. The most dependable cause of infection in the older person is A. D. airway. Your priorities when caring for the older person who sustained traumatic injuries include: A. Peter will not be able to tolerate coughing The tracheobrachial trees are dry The remaining normal lung needs minimal stimulation The bronchial suture line may be traumatized 145. breathing airway. deep tracheal suction should be done with extreme caution because: A. renal and gastrointestinal functions mobilize drug more rapidly have increased sensory perception are more sensitive to drugs The older person is at higher risk for incontinence because of: A. C. B. Following lobectomy. Are expected to experience chronic pain Experienced reduce sensory perception Have increased sensory perception Have a decreased pain threshold 147. D. circulation. decreased bladder capacity C.

C. Promote implementation of general standards Enhance health care provider’s liability Increase individuals responsibility for decision making Decrease public scrutiny of health care provider’s action 157. Which of the following is the purpose of the ethical review committee? A. You decided to check on Mang Felix’s IV fluid infusion. Mang Felix informs you that he feels som discomfort on the hypogastric area and he has to void. What will be your most appropriate action? A. Treatment with corticosteroids and immunoglobulin has not been successful. D. You are assigned to receive him. Remove his catheter then allow him to void on his own Irrigate his catheter tell him to “Go ahead and void. You are invited by the nursing service department to participate in their bioethical review committee. which of the following is the LEAST relevant to document in the case of Mang Felix? A. allow continuous monitoring of the fluid output status provide continuous flushing of clots and debris from the bladder allow for proper exchange of electrolytes and fluid ensure accurate monitoring of intake and output 153. Bright red D. Amber 152. a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20. 151. B. 154. Light yellow B. B. 156. You noted a change in flow rate. D. You are expected to know the purpose and apply bioethical principles. This will go away on its own. C. D. You noted that he has a 3-way indwelling urinary catheter for continuous fast drip bladder irrigation which is connected to a straight drainage. Immediately after surgery. B. D.Situation 7 – Mang Felix. if there is a change refer to urologist for possible irrigation. pallor and coldness around the insertion site.000/æL develops epistaxis and melena. B. C. what would you expect his urine to be? A. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post operative day. You have an indwelling catheter. Chest pain and vital signs Intravenous infusion rate Amount. color. Her physician recommended splenectomy. Pinkish to red The purpose of the continuous bladder irrigation is to: A. Daria states “I don’t need surgery.” In considering your response to Daria. Phlebitis Infiltration to subcutaneous tissue Pyrogenic reaction Air embolism 155. B. What is your assessment finding? A. C. C. Beneficence C. and consistency of bladder irrigation drainage Activities of daily living started Situation 8 – Many hospitals form bioethical review committees to ensure better quality of life of patients. C. D. you must depend on the ethical principle of: A. Autonomy 47 .” assess color and rate of outflow.

Right after thoracentesis. you brought the patient to the nearest hospital. What ethical principles is she practicing? A. Justice B. She goes out of her way to help other. Autonomy Situation 9 – Ensuring safety before. Justice D. Justice D. Advocacy 158. Tricia. With help. you should instruct him to practice which of the following prior to the procedure? A. Following a bronchoscopy. 161. B.B. Justice 160. a staff nurse working in a cancer unit. You felt good. which of the following is most appropriate intervention? 48 . Autonomy C. Zorayda is aware that they are having financial problems. 163. An older person collapsed and nobody seem to notice her. is considered a role model not only by her colleagues but also by her patients. Advocacy 159. Advocacy D. B. D. clenching his fist every 2 minutes breathing in and out through the nose with his mouth open tensing the shoulder muscles while lying on his back holding his breath periodically for 30 seconds 162. D. Autonomy C. What principle was applied? A. B. B. you instructed Fernan to: A. A. D. Zorayda is terminally ill and is experiencing severe pain. Advocacy B. Beneficence D. The security guard tried to make her sit down but she remained unconscious. Beneficence B. which of the following complains to Fernan should be noted as a possible complication: A. She developed hypoglycemia. To help Fernan better tolerate the bronchoscopy. She as bone and liver metastasis. Thoracentesis may be performed for cytologic study of pleural fluid. keep the sterile equipment from contamination assist the physician open and close the three-way stopcock observe the patient’s vital signs 165. during and after a diagnostic procedure is an important responsibility of the nurse. You were able to save a life. Beneficence C. You saw what happened and you decided to help. You are commuting to work riding the LRT. As a nurse your most important function during the procedure is to: A. C. C. She decides to sign a DNR form. What ethical principle did Zorayda and her family utilize as basis for their decision to sign a DNR. C. She is very active in their professional organization and she practices what she teaches. D. You learned later that woman was diabetic. nausea and vomiting shortness of breath and laryngeal stridor blood tinged sputum and coughing sore throat and hoarseness Immediately after bronchoscopy. C. She was on her way to the diabetes clinic to have her fasting blood sugar tested. exercise the neck muscles breathe deeply retrain from coughing and talking clear his throat 164. She has been on morphine for several months now.

D. Activity intolerance Impaired oral mucous membrane Impaired tissue perfusion. severe pain 169. A. C. 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease: A. Dry and intact wound dressing C. C. Domingo. D. D. weight 168. Which among the following will you do FIRST? A.A. cerebral. Which outcome criterion would be most appropriate for a client with a nursing diagnosis of ineffective airway clearance? A. You review Getty’s laboratory report and note that he has anemia. B. C. You came in and saw Domingo slumped on the floor moaning. He climbed over the side rail but his foot got caught in the beddings. At 2:00 AM. Oral temperature of 38. cardiovascular. 171. Side rails were placed to ensure that he will not fall from bed. Getty is receiving chemotherapy for cancer. Heart rate of 88 beats/min B. D. breathing. C. Wound healing by first intention Situation 11 – Nurses have important responsibilities when caring for hospitalized acutely ill patients. Transfer him to bed Apply restraints Ensure airway. He has an open wound on his forehead. His physician was considering dementia. 166. impaired skin integrity related to purulent wound drainage. Continued use of oxygen when necessary Breath sounds clear on auscultation Respiratory rate of 24/min Presence of congestion 170. gastrointestinal Impaired tissue integrity 167. His daughter told you that he got out of bed to go to the toilet. B. alteration in body image B. frequent dressing change D. the call light at his room was on. Pain C. maintenance of sterility C. B.8 deg C D. B. instruct the patient not to cough or deep breathe for two hours observe for symptoms of tightness of chest for bleeding place an ice pack to the puncture site remove the dressing to check for bleeding Situation 10 – As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients. Which assessment would be most supportive of the nursing diagnosis. A difficult problem to deal with when caring for a patient with a partial-thickness burns sustained 3 days ago is: A. circulation Call his physician 49 . Hypertension B. hematuria D. To which nursing diagnosis should you give the highest priority? A.

right-sided heart failure C. D. C. You are caring for Lulu has acute pulmonary edema. you anticipate that the physician will order. apply suction while inserting the catheter use short and jabbing movements of the catheter to loosen secretions hyperoxygenate with 100% oxygen before and after suctioning suction two to three timed in quick succession to remove all secretions 50 . Your most immediate nursing intervention for Frank at this time would be to: A. Cardiac arrhythmias B. you should first: A. facilitate Frank’s verbal communication maintain sterility of the ventilation system assess his response to the equipment prepare him for emergency surgery Dyspnea. Heart failure C. Cardiogenic shock D. Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. C. As Aimee’s nurse. B. D. When suctioning the endotracheal tube. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. B. C. A. Based on the ECG obtained on admission at the ER and clinical findings. D. B. Shortly after this increase. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. Your presence and critical decision making as a nurse are important. E. Flaring of the Nares 177. D. B. facilitate Frank’s verbal communication maintain sterility of the ventilation system assess his response to the equipment prepare him for emergency surgery 178. the physician gave a diagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain. C. The cardiac monitor indicates that Cedric’s heart rate has increased to 150 beats per minute. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. you should: A. after reporting this to the physician. perform chest physiotherapy have her take deep breaths and cough place Lulu on high fowler’s position administer oxygen Situation 12 – Acute respiratory distress is life threatening. acute pulmonary edema D. D. To immediate promote oxygenation and relief of dyspnea. intracardiac epinephrine insertion of a pacemaker bolus of Lidocaine manual cardiopulmonary resuscitation 174.172. C. A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI. Take note that the major cause of death after an MI is: A. you notice Cedric is in ventricular tachycardia. Pulmonary embolism 173. 176. Frank’s respiratory status necessitates endotracheal intubation and positive pressure ventilation. When assessing Frank you would expect to find: A. cardiogenic shock B. pneumonia 175. You should recognize this as signs and symptoms of: A. B. you have to anticipate occurrence of complications.

181. who has a restrictive airway disease. As a nurse. C. Immediately stop the blood transfusion. restlessness 180. 1 hour 182. oliguria and jaundice urticaria and wheezing hypertension and flushing headache. serial number. From the time you obtain it from the blood bank how long should you infuse it? A. C. serial number. B. an excessive drying of the respiratory mucosa depression of the respiratory center rupture of emphysematous bullae a decrease in red blood cell formation Situation 13 – As a nurse you have to be prepared to care for patients receiving blood transfusion. Check IV site and use appropriate BT set and needle B. D. You are preparing a unit of whole blood for transfusion. Discontinue the primary IV of Dextrose 5% water Stay with Diego for 15 minutes to note for any possible BT reaction Check his vital signs every 15 minutes Add the total amount of the blood to be transfused to the intake and output 184. Slow the blood transfusion and monitor the patient closely C. Verify client identity and blood product. B. light-headedness B. infuse normal saline solution. expiration date 183. fever 185. The physician has ordered 3 units of whole blood to be transfused to Diego following following a repair of a dissecting aneurysm of the aorta. you should observe Bernard. bradypnea C. D. 6 hours What should you do FIRST before you administer blood transfusion? A. Immediately stop the blood transfusion. C. Verify client identity and blood product blood product. which include: A. cross matching results.179. bradycardia D. 2 hours D. what will be your priority intervention? A. chills. The physician orders low concentration oxygen to be given continuously for Kenneth who has a chronic obstructive pulmonary disease to prevent: A. C. As Diego’s nurse what will you do after the transfusion has been started? A. infuse dextrose 5% in water and call the physician B. Immediately stop the blood transfusion. D. Verify physician’s order C. The earliest signs of transfusion reactions are: A. notify the blood bank and administer antihistamines D. for early indications of respiratory acidosis. call the physician. 4 hours B. blood type. expiration date with another nurse D. Diego is undergoing blood transfusion of the first unit. notify the blood bank 51 . B. blood type. cross matching results. In case Diego will experience an acute hemolytic reaction.

Majority need extensive rehabilitation All have been hospitalized previously Are physically unstable Most have chronic illness 190. Hospital food B. opioids are drug of choice for severe pain 52 . anticonvulsants. Provision of comfortable space Emotional support Updated information on client’s status Spiritual counseling Situation 15 – Pain is the most common reasons why people consult their physicians. D. Families of critically ill patients desire which of the following needs to be met first by the nurse? A. C. Inadequate nursing staff Who of the following is at greatest risk of developing sensory problem? A. adjuvant medication such as steroids. pruritus 193. physical dependence B. Lack of blankets 187. The WHO Analgesic ladder provides the health professional with: A. C. As a nurse caring for patients in pain. Respiratory depression D. Adoloscent C. gender medication educational level previous knowledge of illness 189. B. 186. Which of the following statements does not apply to critically ill patients? A. D. you should evaluate for opioid side effects which include the following EXCEPT: A. C. This strategy is used to give emphasis on how pain should be managed. non-steroidal antiinflammatory drugs enhance pain perception C. it is important for nurses to gather as much information to be able to address their needs for nursing care. C. You have collaboration as well as independent nursing interventions for pain.Situation 14 – Based on studies of nurses working in special units like the intensive care unit and coronary care unit. Lack of privacy D. B. Critically ill patients frequently complain about which of the following when hospitalized? A. Unresponsive patient 188. B. C. D. Female patient B. Transplant patient D. 191. It is now regarded as the 5th vital sign. B. constipation Which of the following statements about cancer pain is NOT TRUE: A. C. pharmacologic and nonpharmacologic pain management choices general pain management choices based on level of pain nonpharmacologic interventions based on level of pain specific pain management choices based on severity of pain 192. D. Which of the following factors may inhibit learning in critically ill patients? A. undertreatment of pain is often due to a clinician’s failure to evaluate the severity of the client’s problem B.

Remove all clothing containing the chemical 198. You are assigned in the Burn Unit and you are going to evaluate the status of Raymond who sustained a burn injury 12 hours ago and has a urinary output of 200 ml since the injury. Assess for associated injuries D. pain problem identification B. Which of the following will you do FIRST? A. Continue to eat high caloric high food for the next month Wear a pressure garment daily for one year Avoid sunlight for the next three months Avoid facial makeup for at least a year 200. Which of the following should you include in your discharge teaching? A. Dino sustained circumferential thermal burns of the left upper extremity and chest. C. Wash the chemical off with cool water C. effectiveness for patient Situation 16 – The nurse’s accurate assessment is very crucial in preventing complication during the severe post burn period. pain associated with cancer and the terminal phase of the disease occurs in majority of patients 194. 196. Which of the following would you consider as the priority intervention in the emergency management of Mark? A. skill of health professional D. you gathered the following: Hemoglobin 13. Increase the rate of the IV fluid Administer the prescribed Furosemide (Lasix) Check catheter for kinks Increase the oral intake to 30/hr 199. Elevate the injured extremity to increase blood flow to the heart Remove the dead tissues which impede circulation Try to take the pulse in the uninjured extremity Notify the physician immediately as this requires emergency intervention 197. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively.D. Which of the following will you do FIRST? A. B. inquiries about skin care after discharge.5 g/100 ml. serum Na 130 mEq/L. type of opioid being used C. The guidelines for choosing appropriate nonpharmacologic interventions for pain include all of the following EXCEPT: A. All the laboratory tests are within normal rage C. D. Mark accidentally spilled the whole can of corrosive chemicals all over his body. Kathy. You are caring for Lenard who sustained severe burn injury and he is in the emergent phase of burn injury. Assuming that nothing has changed in his condition. D. While unloading containers with chemicals from a truck. who has partial-thickness burns on the face. C. C. They are slightly abnormal but will normalize once IV fluids have been started 53 . B. B. D. becoming psychologically dependent needing to have morphine discontinued developing tolerance to morphine exaggerating his level of pain 195. D. Maintain a patent airway B. Jack has been on morphine on a regular basis for several weeks. you would suspect that Jack is: A. How will you explain the laboratory results? A. These are due to hemodilution from rapid IV fluid replacement B. B. You noted that pulse could not be appreciated in his injured extremity. As his nurse. C. Hematocrit 50%.

Select the best answer. ________________________________________________________________________ INSTRUCTIONS: 13. 24. Set Box “B” if your test booklet is Set B. 15. The most important role of the nurse as a member of the team is to: A. C. Per RA 8981. 23. This is PRC property. Million therapy B.D. and/or sale of this test is punishable by law. Write the subject title “Nursing Practice V” on the box provided. SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. Behavioral therapy D. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. AVOID ERASURES. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . A biological/medical approach to patient care utilizes which of the following? A. Unauthorized possession. Somatic therapy C. carry out medical orders meet the needs for the physical well being of patients coordinate the psychological care and management of clients keep a 24 hour watch for the patients 2. 22. Which of these nursing actions belong to the secondary level of preventive intervention? 54 . B. D. 25. MULTIPLE CHOICE SITUATIONAL Situation 1 – The following questions refer to nurse’s efforts to do collaboration and teamwork. ***END*** NURSING PRACTICE V SET A ________________________________________________________________________ NURSING PRACTICE V – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 21. Shade only one (1) box for each question on your answer sheets. 14. 1. Psychotherapy 3. Shade Set Box “A” on your answer sheet if your test booklet is Set A. This test booklet contains 100 test questions. reproduction. These are due to a loss of serum and interstitial fluid through the burn wound. Two or more boxes shaded will invalidate your answer. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.

e.” The nurse diverts the attention to talk about non-threatening topics. B. “I get that. C. loss of reality contact 10. Reyes is lax and tolerant while Mr.A. D. Rationalization D. responsibility and accountability consistency and predictability honesty and integrity empathy and compassion 9. Mr. B. B. and Mrs. C. D. An appropriate topic would be: A. Reyes expressed that her socializing with neighbors is limited because her husband thinks she is getting overly friendly with a guy next door. Reyes would necessitate referral to a doctor? A. “Would you rather wish that I don’t come and visit you may regard me as a stranger?” B. Which of these symptoms if demonstrated by Mr. Keeping trust in the relationship Avoid relating with neighbors to minimize conflict Be assertive to express to express her individuality Ignore the husband and just be supportive 8. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents. B. D. Suspicious affect C. community and neighbors that cannot be trusted. C. Sublimation B. Upon her visit she observed that common areas of arguments between Mr. C. hypersensitive D. My concern is the health care of your family and information are strictly confidential. She is applying the principle of: A. Mrs. D. Reaction formation 55 . call a priest counsel the client refer the client to the psychiatrist refer the matter to the police 5. aged 7 and 4 years. C. When the nurse identifies a client who has attempt to commit suicide the nurse should: A. Which of the following would the nurse emphasize as basic? A. “I acknowledge what you are saying. “The nurse’s BEST response would be: A. Projection C. D. 6. Hypervigilance B. “It must be distressing to think and feel the way you do.with all the media news about child kidnapping and robberies. Mrs.” 7. For the nurse to be effective in developing rapport with the family it is essential that she keeps her appointment on time and stick to a care plan. The paranoid client utilizes which of the following defense mechanisms? A. C. Providing mental health consultation to health care providers Providing emergency psychiatric services Being politically active in relation to mental health issues Providing mental health education to members of the community 4. Reyes are about conflicting ways of bringing up their children.” D. Reyes remarked “I am wary about people visiting. Reyes often insists strict ways to a point of protectiveness from what he perceives as unsafe i. B. the legal aspects of drug abuse disciplining children at home and school marital crises the problems of out of school youth Situation 2 – The nurse visited the Reyes family to check on their two growing children.

C. Aggressiveness D. D. Sison has been diagnosed as having early chronic glaucoma. D. An oral-dependent personality is characterized by which of the following? A. C. C. hence the need for annual eye examinations: A. aggressiveness D. pessimistic and moody anxious. The nurse identified a nursing problem of disturbed sensory perception: visual impairment characterized by: A. sudden loss of eyesight loss of night vision loss of peripheral vision loss of central vision 12. with the head held back and with the eye looking: A. suspiciousness 17. B. Constricts the pupil Acts as osmotic diuretic Reduces the production of aqueous humor Facilitates outflow of aqueous humor 14. The nurse can respond MOST therapeutically by doing which of the following? A. downward Situation 4 – SEXUAL DISORDER 16. B. Telling him she is married and too old for him Introducing him to female clients his own age Encouraging him to watch TV in his room Ignoring his flirtatious and provocative behaviors C. D. it is important for the nurse to know that glaucoma is usually caused by: A. insecure and conforming dependent. He has been admitted to the hospital for treatment. B. unpredictable. Suspiciousness 56 . Public health nurses should identify which of these patients as a risk group for development of glaucoma. A hospitalized male adolescent flirts with and is sexually provocative toward a female nurse. The premorbid personality of a person with a non-psychotic maladaptive response to anxiety may most accurately be described as: A. 11. Upward B. impulsive and aggressive rigid. D.Situation 3 – Mr. D. B. Which of these is the effect of this drug? A. Hopelessness C. Patient with Parkinson’s disease Cancer patients Diabetic and hypertensive patients Patient with COPD 15. Helplessness B. C. Diamox is a drug used in the treatment of glaucoma. opacity in the lens gradual diminution of the retina damage to the proteins in the lens increase production of aqueous fluid 13. B. D. C. In order to understand the rationale for drug therapy. insensitive and self-absorbed 18. The appropriate method of instilling eye drops is: Instilling into an opened eye. B. C.

showered for an hour and still did not feel clean. A young adult male unable to stay put in one job and has no commitment in his relationship is having difficulty achieving a sense of: A. humiliation. C. This is a process wherein the client’s chart is reviewed to compare criteria for quality care with actual practice: A. nightmare and muscle tension. Psychiatric Audit Nursing Care Process Interaction Process Analysis Algorithms 57 .” 24. She states she trusted the nurse She wants to talk to a lawyer She inquires about personal information about the nurse She wants to be told what her rights are Situation 6 – The psychiatric mental health nurse adheres to standards that ensure quality improvement. “You are here and I am ready to listen.19. denial D. maturational crisis B. The appropriate nursing diagnosis is A. initially she was just crying. D. D. B. Which of these behaviors of Anita signal her readiness to proceed to the working phase of the nurse-patient relationship? A.” I would be best of help if you stop crying. D. D. Situational low self-esteem Sexual violence Ineffective coping Sexual dysfunction 22. Anita is experiencing: A. C. industry B. intimacy Situation 5 – Anita is experiencing rape-trauma syndrome in an acute phase. Trust D. helplessness. When the nurse approached Anita.” Why did you date a guy you hardly knew?” Tell me when you are ready and I’ll come back to you. Autonomy C. 21. Anita expressed to the nurse that she douched. The pedophile’s choice of a sex object is primarily based on: A. difficulty relating with adults feelings of tenderness toward children fears of incestuous impulses preferred for a passive sexual role 20. Which of these communicate unconditional acceptance of Anita and hr situation? A. Anita is experiencing: A. anger C. developmental crisis C. B. 26. frustration 23. frustration 25. guilt B. nausea. felt she was in a nightmare and she was at a loss. B. C. B. B. Social crisis D. D. C. vomiting. The following situations and behaviors are means to achieve this goal. She had too much drink and she has feelings of anger. C. She had been invited to a fraternity party.

B. Did the history of the present problem correlate with the review of growth and development? B. D. D. C. Such studies have the advantages EXCEPT: A. analytic sense Situation 7 – A nurse was interested to study the research question: “What are the differences and similarities between aggressive and non-aggressive cognitively impaired. reliability C. elderly. B. Data are inexpensive to obtain Possibility of memory bias and distortion of fact There is much material available It is easy to get data 58 . Are the nursing history and psychosocial assessment accurate? 28. Quasi-experimental C. In order to assess “Reliability” as a behavioral characteristic. C. institutionalized people?” 31. D. Recording interaction with the elderly with their permission Verbal permission from the subject is unnecessary Data coded and recorded solely by the investigation A written consent from the institution and a significant other 32. How long did it take to complete the nursing data base? C. the nurse would ask herself which of the following questions regarding her recording: A. B. “Did the nurse perform in the best possible manner without waste?” aims to describe the nurse’s: A. One of the most important ground rules is: A. D. All of these are the advantages of peer review EXCEPT: A. Follow the problem solving approach Do not pass judgment on the ideas presented Ideas must be feasible Suggestions must be cost effective 30. The review of literature included reference to retrospective studies. Investigation of cognitively impaired individual presented some ethical dilemmas. case study 34. B. C. The type of study conducted is: A. B. Demands accountability for nursing actions Has the possibility of enhancing intra professional respect It requires the development of standards for quality care Provide an evaluation of the nurse’s abilities 29. experimental D. thoroughness B. The nursing team leader wants to involve all the nurses in participating in their own personal and professional growth through a brainstorming session. Interview is conducted precisely in the same manner Interviewer is not held to any specific question Subject is allowed to express without any suggestion from interviewer Interviewer is free to probe beyond a number of specific major questions 33. D. C. C. Is the nursing data base complete? D. A semi-structured interview was conducted.27. Descriptive B. efficiency D. This means that: A. Which of the following protocol would be considered unethical? A.

“Baka ini-istorbo ka na naman ng mga boses. Bed rest with bed elevated at 45 degrees 37. D. Soledad is terminally ill of cancer. D. controls muscle spasm D. David is brought to the hospital due to pain radiating to the hip and leg. Place the client in most comfortable position C. Which position is recommended when the brace is applied? A. Standing position C. B. The average age of the respondents was 86. 41.“ 59 . Controls nausea B. the sum ages divided by total number of participants the youngest participant is 86 years old the oldest participant is 86 years old most of the number participant is 86 years old Situation 8 – Mr.” „Sinabi mo sana sa nars nabigyan ka ng sedative mo. Andito po ako at puwede tayong mag-usap. H is scheduled for myelogram.“ Relax lang! Huwag ka masyadong mag-iisip ng mga problema mo. B. 36. the nurse intervenes utilizing effective communication techniques. controls edema 39. C. B. Assess for movement and sensation of the lower extremity B. David has to wear back brace. The following are varied situations in a psychiatry ward. lying on his side in bed D. Get another nurse for help Maneuver the client to a sitting position Get back to his bed and place in side lying position Assist the client to form a wide base of support and lean against the nurse 40. David is to ambulate for the first time following surgery. Logroll the client with the help of another nurse Inform the client that he should be in supine position Assess the sensory loss in his legs Instruct the patient to move from side to side 38. Sitting position B. What nursing action should be BEST when the client begins to faint? A.“ “Maari mo bang sabihin sa akin and mga naiisip at nararamdaman mo?“ 42. Hindi ako nakatulog kagabi. Looking sad. Controls pain C. Mr. D. she expresses. “Masama and pakiramdam ko. D. “Mukhang napakabigat ang dinaramdam ninyo. “Wala na yata akong pagasang mabuhay pa. Trimethobenzamine Hydrochloride (Tigan) was administered postoperatively. C. the nurse must include which of th following nursing action in his care? A. The patient verbalizes. Lying supine with heels flexed D. C. Mr.35. After the procedure. B. supine position in bed Situation 9 – Through the nurse-patient relationship. Mr.” A response which fosters hope is: A. He is diagnosed with a herniated lumbar disk. David is scheduled for lumbar laminectomy. C. The action of this drug is effective when it: A. Post operatively the nurse should: A. this represents: A.“A therapeutic response of the nurse would be: A.

After three days of antidepressant medication. NIcanor was readmitted with an entirely different behavior. “Nalulungkot ba ang pakiramdam mo?” “Hayaan mo sila. however. The psychodymanics of depression is: A. D.” D. C. wala kanga lam! Marunong pa ako sa iyo e. reaction formation B. put him in his right senses . He says. C. Prevent him from becoming more furious by giving an extra PRN dose of sedative. Which of these drugs is likely to indicated to Nicanor? A. D. “Nicanor. Dapat sumunod ka sa akin.” B. B. Lahat naman po tayo ay doon ang patutunguhan. “Pinag-uusapan nila ako.B. “Gagaling din po kayo. sympathizing with the miserable feelings of Nicanor engaging Nicanor in productive activity engaging NIcanor in introspective thinking suppressing her own feelings toward NIcanor 50. “Nagagalit ka sa nurse at nawawala ka ng control sa sarili mo. B. B.“ A therapeutic response is: A. Serenace (Haloperidol) Valium (Diazepam) Tofranil (Imipramine HCl) Trilaton (Pherpenazine) 49. nurse. Nicanor becomes verbally assaultive to the nurse. Ayaw nila ako. pare-pareho lang kayo ng mga ibang pasyente dito. Nicanor was provoked. C.” “Sino ang ‘nila’ na tinutukoy mo?” “Huwag mong isipin yan. compensation 47. became furious and started shouting “Walang hiya kayo! Ako ang bida dito!” The nurse’s action is: A.” C. galit ka sa nurse pero hindi tama na naninigaw ka. “Huwag po ninyong isipin ang sakit ninyo. “Oo nga.” D. C. Camilia verbalizes. Immediately restrain him and put him on isolation to protect other patients. Acknowledging his behavior and respond.” 45. Nicanor still manifests depression. The defense mechanism utilized by manic patients to cover up depression is: A. Respond with. C. displacement D. Ano ba ang ipinagmamalaki mo!” The nurse responds therapeutically by: A. Therapeutic use of self is essential in relating with psychiatric patients. Ang mahalaga ay ang palagay mo sa sarili mo. B. “Lakasan ang loob ninyo. D. admonishing him with. denial 48. B. “Ikaw. respond with. Hindi tama yan.” 44. D. D.” C. Huwag po kayong mag-aalala. Acknowledging his behavior. Ignoring the behavior of the patient Situation 10 – Nicanor was discharged form the hospital and recovered from a manic episode of Bipolar Disorder. This is BEST demonstrated in: A. “Ako ang nurse dito. lax super-ego weak super-ego internalized hostility feelings narcissistic personality C. Bale wala yon. 46.” 43. Take him away form the group until he manages to have control of himself. The nurse evaluates this as: 60 . Andito naman ako para makausap ninyo. During socialization. he was very depressed.

unusual because action of antidepressant drug is immediate expected because it takes about two weeks for the medication to be effective unexpected because it takes within one week for the medication to be effective ineffective because perhaps the drug’s dose is inadequate Situation 11 . Generativity C. Breathing treatments are to be given to Purita. D. Seclusion 55. The nurse would encourage family conference for: A. Purita talks about her joy in having responsible and accomplished children and recalls challenging career as a lawyer. B. She claims that the medications being given her are meant to poison her. Purita has six children who are already adults. the eldest child’s opinion to be given priority majority of the children to decide allowing the medical staff to decide in their behalf consensus building 53. She is demonstrating a sense of: A. In anticipation that Purita might refuse. impulses. involuntarily refuses to acknowledge reality D. B. Intimacy B.A. Marina is suspicious because of her inability to develop a sense of: A. Which of these etical principles can guide the nurse in her action? A. Trust D. B. Beneficence B. unconsciously refuses to accept a feeling. thought or impulse and attributes it to someone else B. is aloof in relating with other patients and members of the staff. Right to refuse treatment Right to privacy Right to informed consent Right of habeas consent 54. Fidelity C. The nurse explains that Purita is rational in her thinking and which of these client’s right must be regarded? A. This means that she: A. Which of these would be the nurse’s priority following the treatment principle of least restrictive alternative? A. C. D. one of the children requests that he be the one to sign the consent in behalf of their mother. Marina utilizes projection by being suspicious. justifies behavior. generativity D.Ninety year old Purita is confined at the medical unit for respiratory ailment for which a breathing apparatus is prescribed for her to use while she sleeps. attitudes and feelings with excuses C. They differ in their opinion whether or not to allow their mother to decide for herself. C. Physical restraint D. autonomy Situation 12 – Marina. ego integrity B. C. She is also suspicious about the food being served for her. Basically. 51. Use of on site guard/watcher C. Dinio. Autonomy D. Nonmaleficence 52. D. industry C. Intiative 57. involuntarily excludes wishes. One of one staffing B. She refuses to wear it continuously though she fully understands the medical indication for it. 56. memories and feelings from awareness 61 . 26 years old.

Make self available while maintaining distance until patient shows readiness to interact D. administrator by relieving her of responsibilities therapist by delving into the nurse’s internal conflicts counselor by actively listening educator by reorienting her of her role as a nurse 63. anger. decrease the dosage of thorazine explain the extrapyramidal side effects and administer Benadryl avoid giving foods that are rich in tyramine withhold medication until referral is made to the doctor Situation 13 – The supervising nurse received report that a staff nurse is displaying frequent irritation. C. Invite her to socialize with other patients C. who she interacts with regularly. D. B. address her physical well-being boost her self-confidence provide social support help her find value and meaning in her work 65. C. psychotic anxiety staff burnout personality maladjustment neurotic depression 64. Coupled with poor work performance. Another reason why she refuses to take Thorazine is because she complains of robot like movement and slurred speech. D. C. The nurse expressed increasing feelings of dissatisfaction. D. C.58. D. The initial action of the supervisor would be to: A. 61. Refer her for activity therapy 59. D. assertiveness training stress management group dynamics and team building behavior modification 62 . When she resists to take her medication. B. B. The most relevant professional program for her would be: A. C. administer the drug request the doctor to give her medication 60. Engage Marina for at least one hour in a one-to-one interaction daily B. The nurse’s action is: A. B. and even indifference toward clients and co-workers. C. The supervising nurse intervenes therapeutically by taking the role of: A. post guidelines on proper decorum of nurses in the bulletin board write a memo of warning to the nurse request anecdotal report form nurse’s co-workers call the nurse for a one on one conference 62. C. B. the nurse can be said to be suffering from: A. let her read the drug literature to convince her that it is therapeutic force her to take the drug to maintain therapeutic effectiveness of the drug have the same nurse. A priority in the nurse’s personal development would be to: A. D. D. B. Which of these nursing approaches is MOST appropriate for the nurse to begin with? A. it is best to: A. mental and physical fatigue and actual withdrawal from client contact and nursing duties. B.

C. B. “Anxiety due to a job interview”. Ask the patient any untoward side effects of medications he is taking Have patient role play interview situation Discuss with a patient with specific means he might prepare for the job interview Ask the patient what he is feeling about the job interview 70. A with myasthenia gravis is having difficulty speaking. B. Identify how he can prepare for the job interview. D. C. 71. to treat the disease 63 . D. An expected outcome is stated in terms of what the patient will do An expected outcome is stated in terms of what the nurse will do Every outcome must be measurable Every outcome answers the question “How will you know when the problem is resolved?” 68. Indicate specific times to review progress or lack of progress Does not allow plans to be changed Allow plans the need to be changed Set the time by which the expected outcome should be reached 69. B. gather data about the patient determine if the problems are usual or unusual analyze the data analyze the problems as concisely as possible 67. The “due to” or the reason for the problem should be included if it is known. When planning for nursing care for Mr. C. D. which of the following goals would be MOST appropriate? A. Which of these practices on evaluation support nursing care? Review of care plan is: A. Given this example of a problem. C. The nurse writes a nursing care plan for a patient based on nursing care standards. C. B who has Parkinson’s disease. D. D. C. 66. B. A? A. to improve muscle tone B.” Which of these is not a criterion of expected outcomes? A. The initial step in identifying problems is: A. Which of these is not a relevant nursing order? A. to start rehabilitation as much as possible C.Situation 14 – The purpose of the nursing care plan is to identify the care for an individual patient based on his problems. D. Repeating what the client says for better understanding Using paper and pencil in communicating with the client Encouraging the client to speak slowly Encouraging the client to speak quickly 72. Given this example of an expected outcome: “Openly verbalize anxiety about job interview. The following are reasons for setting deadlines within which to achieve outcomes of care EXCEPT: A. B. What communication strategies should the nurse avoid when interacting with Mr. Ma. a nursing team responsibility the sole responsibility of the primary nurse the responsibility of peers the sole responsibility of the supervisor Situation 15 – A nurse assigned in the neurologic unit is taking care of clients with varying degrees of degenerative disorders. B.

Santos? A. moderate anxiety 79. B.” C. D. Physical signs of anxiety become more pronounced. B.D. Let us walk and find a quiet place where we can talk. C. “You need not worry. D. Alma. panic C. strengthen muscle coordination establish routine develop perseverance and motivation establish good health habits 74. Parkinsonian like syndrome 64 . “He will soon recover in his condition. Focus becomes limited and client experiences tunnel vision. C.” Which of the following responses of the nurse is MOST appropriate? A. has had multiple sclerosis.” B. “I could not understand my husband anymore. Santos was unable to stand and is having difficulty swallowing and talking. Mr. To help clients in a group therapy setting to take on specific roles and reenact in front of an audience. He has changed drastically. She asks the nurse what desensitization therapy is: 76. To prevent bladder distention To prevent decubitus ulcer To prevent contracture To prevent aspiration pneumonia 75. D. The wife of a seventy two (72) year old male with a diagnosis of Alzheimer’s disease begins to cry and tells the nurse. On his second day of hospitalization. cognitive capacity diminishes. C. The accurate information of the nurse of the goal of desensitization is: A. To help clients cope with their problems by learning behaviors that are more functional and be better equipped to face reality and make decisions. 42 years old. C. As part of the rehabilitation planned for Alma. Clients with multiple sclerosis experience many different symptoms. For the past 10 years. B. In this level of anxiety. the nurse suggested therapy and hobbies to help her: A. “The physician and the staff will make sure that your husband will be comfortable and safe here. Antianxiety medications should be used with extreme caution be cause long term use can lead to: A. To provide corrective emotional experiences through a one-to-one intensive relationship. “This has been a difficult time for you.” D. Which of the following is the priority of the nurse in assisting Mr. to maintain optimal body function 73. B.” Situation 16 – Annie has a morbid fear of heights. A. we are doing the best we could. to help the clients relax and progressively work up a list of anxiety provoking situations through imagery. situations in which interpersonal conflict is involved. D. severe anxiety B. It is essential in desensitization for the patient to: A. have rapport with the therapist use deep breathing or another relaxation technique assess one’s self for the need of an anxiolytic drug work through unresolved unconscious conflicts 78. 77. mild anxiety D.

I hope to have more seminars of its kind.e. role play 84. the nurse teaches the procedure to the client.B. “Self-enhancement through Assertiveness”. Some of the victims suffered injuries in the different part of their bodies. One of the victims. C. The program inspired me a lot. 65 . A priority objective of the program is: A. group discussion and report return demonstration attendance individual interviews 85. D. survey 82. D. To reduce anxiety. C. “I will write a plan for personal development program. Leave the cast uncovered to promote drying. which of the following topics should NOT be included in the teaching plan? A. Hepatic failure D. Risk of addiction 80. brainstorming session 83. The victims were brought to the nearby hospital. Josephine was confirmed to have a fractured left arm. observation D. Hypertensive crisis C. 86. Josephine appears to be anxious. B. Which of these feedback from individual participants indicate maximum gain from the staff development program? A. An appropriate assessment tool to maximize gathering of needs of nurses is through: A. The most effective way to practice assertiveness skills is through: A. develop the art of public speaking project a positive image of the nursing profession develop art and skills of therapeutic use of self earn continuing education units C. written evaluation form B. 81. interview of nurses B. A stockinet will be placed over the left arm to be placed in cast. D. The least satisfactory method to evaluate the effectiveness of the program is through: A. Trim and reshape finish cast with knife or cutter. C.” “I feel very good. B. B. encourage participation in recreation or sports activities reassure client’s safety while touching client speak in a calm soothing voice remain with the client while fear level is high Situation 17 – For personal and professional development. C. B. C. the nursing staff decided to hold a staff development program.” Situation 18 – A vehicle hit some pedestrians while waiting for a bus ride. While waiting for the plaster cast to be applied. Handle hardening cast with palm of hands D. The nursing management of anxiety related with post traumatic stress disorder includes all of the following EXCEPT: A. Bear weight on the plaster cast for one hour. B. to approach my clinical supervisor regularly to discuss nursing care of our clients. process recording C.” “I have a “Do it Now” project for myself i. descriptive report D.” “I learned a lot. D.

Provide a punching bag as an alternative to express upset emotions 66 . insist to stop obscene language by verbal reprimand C. rubber shoes 94. Suspend the trapeze within easy reach of the client D. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward? A. B. the MOST effective way to deal with Carlo’s behavior is initially to: A. D. 90. bottle of coke D. allows reduction of the fracture site for bone healing. that weights hang free and knots in the rope are tied securely C. a sixty year old woman sustained hip fracture. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. Secures the fracture site to prevent damage to the muscle tissues D. wants and desire Anger is incompatible with love Aggression can be expressed in a constructive as well as a destructive manner. Support the affected extremity while the weights are removed. if the client is agitated. Dizon was visiting her son at the Psychiatry Ward. In assessing the neurovascular status of the client. C. One of the victims. set limits on the behavior by verbal command administer PRN tranquilizer remove the chairs from the room restrain the patient and place him in the “Isolation Room” 93. discuss the feelings especially anger B.87. box of cake C. reduces muscle spasms and helps to immobilize the fracture B. D. He is not allowed move from side to side. string rosary bracelet B. 92. Prior to surgery. Pain on the left arm Swelling of the fingers Skin abrasions on the edges of the plaster cast Nail bed capillary refill time of 10 seconds 88. Which of the following nursing interventions is useful in maintaining effective traction? A. B. Cast was applied on Josephine’s left arm. B. Check the apparatus. B. Secures the fracture site for rigid immobilization 89. C. To prevent complications when a child is in Buck’s traction. Hostility is destructive Frustration develops in response to unmet needs. B. All of the following concepts are true EXCEPT: A. C. Which of the following items will the nurse not allow to be brought inside the ward? A. give client support and positive feedback for controlling use of obscene language D. D. D. the nurse should” A. Mrs. C. Phillip was placed in skeletal leg traction with an overbed frame. The rationale of traction is primarily based on the understanding that Buck’s extension traction: A. clean the extremity and keep the skin dry assess any skin and circulatory disturbances clean the pin sites as necessary provide high fiber small meals 91. Assist the client by holding the trapeze and raising the hips off the bed. C. which of the following assessment findings should be reported to the physician? A. a Buck’s extension traction is to be applied.

He is demonstrating: A. C. He has change clothes 20 times before work. establish a routine for him C. There are many things Jim seems he has to do to keep himself from feeling: A. All of these are therapeutic interventions EXCEPT: A. age 25. personality disorder B. facilitate self-expression 100. self-determination 99. recalled that his problem began around age 15-16. ***END*** 67 . D. neurosis D. self worth C. B. confused B. psychosis C. The objective of nursing care for Jim is to develop or increase feelings of: A. Jim is aware of his behavior yet realizes that it is very disturbing to him. C. impose limits every time the behavior becomes repetitive B.Jim. self-mastery B. suspicious C. Which of the following must be considered while planning activities for the depressed patient? A. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. He would count pencils in a mug over and over with the thought that stopping could result in something bad happening. chew each bite he east 24 times and go up and down the stairs four to five times before it feels right. 96. assign task that can be done repetitively D. habitual disorder SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. activities which require exertion of energy challenging activities to get him out of his depression variety of structured activities variety of unstructured activities Situation 20 . ideas of reference denial and projection obsession and compulsion rationalization and over reaction 98. D. anxious 97.95. This is a pattern of: A. excited D. B. self-actualization D.

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