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


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

adduction of the shoulder Lateral flexion of the sternocleidomastoid muscle Hyperextension of the knees Anterior flexion of the lumbar curvature 33. D. B. C. Face the client and place the wheelchair on her left side C. 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. Demerol is available in a mutidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. Pustules Situation 4 – You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility. C. Motivate client to gain independence 27. 1. 31. then into the vial withdraw medication from the ampule then from the vial 29. The nurse is to administer Demerol 50 mg IM to Mrs. withdraw the medication from the vial first then from the ampule inject air into the vial. Which of the following is the appropriate nursing action of Nurse Karen? A. Anthony asks to be assisted to move up the bed. Mrs. Joseph prefers to be in high fowler’s position most of the time. B.C. 1 ml C. D. then into the ampule inject air into the ampule. The nurse should prevent which of the following? A. Reddening of the skin D. Leyba. B.5 ml D. Ramil’s right leg is injured and Nurse Karen has to move him from the bed to w wheel chair. denial D. Carlo has to be maintained on a dorsal recumbent position. B. Which of the following should be prevented? A. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. D. resolution C. D. C. You are to give the both medications in one injection. You will: A. Put the client on the edge of the bed and place the wheelchair on the client’s left side 32. This client is in the stage of: A. 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 . 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. Pressure sores B. bargaining 28. Put the client on the edge of the bed and place the wheelchair at her back B. acceptance B. Assist the client towards a peaceful death D. aspirate the desired dose. Leyba is emaciated and is at risk for developing which problem in skin integrity? A.75 ml 30. 2 ml B. Blisters C. C. 1. Which of the following should Nurse Diana do first? A. what is the total volume that you will inject to the client? A. Posterior flexion of the lumbar curvature Internal rotation of the shoulder External rotation of the hip Adduction of the shoulder 34.

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

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


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. D. The functions of records include all except: A. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. recording of actions in advance to save time 67. Nursing audit aims to: A. Jose’s chart is the permanent legal recording of all information that relates to his health care management. C. B. the client’s record also shows a document of how much health care agencies will be reimbursed for their services C. Which of the following is the most appropriate action of the nurse supervisor? A. 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. Mr. Jose’s chart contains all information about his health care. Tell the physician that you can not take the order but you will call the nurse supervisor 10 . C. 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 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. 66. Write the order in the client’s chart and have the head nurse co-sign it D. C. 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. D. As such. means of communication that health team members use to communicate their contributions to the client’s health care B. Information in the patient’s chart is inadmissible in court as evidence when: A. What is your most appropriate action? A. D. copy onto the order sheet and indicate that it is a telephone order C. An advantage of automated or computerized client care system is: A. D. B. Repeat the order back to the physician. the entries in the chart must have accurate data. 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. B. C. A telephone order is given for a client in your ward. D.64. C. educational resource for student of nursing and medicine D. B. B.

then withdraw slightly. B. Nurse Roque is giving instructions to Doris. Neutrophils 60% White blood cells (WBC) 9000/mm Erythrocyte sedimentation rate (ESR) is 39 mm/hr Iron 75 mg/100 ml 77. While Doris is doing spone bath. A baby who is wailing after being awakened by the banging door D. the daughter of a comatose patient. 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. What nursing action before cast application is most important for Nurse Roque to do? A. To obtain specimen for sputum culture and sensitivity. Upon waking up. Which of the following client conditions should be Miss Roque’s priority in the pediatric unit? A. B. D. to give a sponge bath. D. applying suction intermittently as catheter is withdrawn C. is asked to take over an absent nurse in another unit. B. Explain procedure to patient. B. D. a newly hired nurse. 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. suction 30 seconds using twirling motion as catheter is withdrawn 73. B. 71. cough deeply and expectorate into container Cough after pursed lip breathing Save sputum for two days in covered container After respiratory treatment. On reviewing the result the nurse notices which of the following as abnormal finding? A. Hyperoxygenate client insert catheter using back and forth motion D. Dina sustained a fracture of the ulna and a cast will be applied. D. When suctioning the endotracheal tube. 76. Surgical sepsis is observed when: A. Dorothy underwent diagnostic test and the result of the blood examination are back. the nurse should: A. 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 . Insert suction catheter four inches into the tube. A baby boy whose circumcision has yellowish exudate 72. which of the following instruction is best? A. C. expectorate into a container Situation 13 – Infections are quite commonly the reasons for a client’s hospitalization. insert catheter gently applying suction. C. Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care. Insert catheter until resistance is met. The baby whose fantanelle is bulging and firm while asleep B. D.Situation 12 – Nurse Roque. C. what action of Doris needs correction? A. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. She will take care of clients with various conditions. Withdrawn using twisting motion B. C. C.

staff nurse 85. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. You join a continuing education program to help you: A. Among the clients you are assigned to take care of. you are a beginning nurse practitioner. advanced beginner 82. 81. C. Clinical nurse specialist B. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. respecting a person’s right to be autonomous demonstrating loyalty to the institution’s rights shared respect. 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 . B. D. 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. D. B. who is the most susceptible to infection? A. client with pulmonary emphysema D. B. client with myocardial infarction Situation 14 – You are a newly hired nurse in a tertiary hospital. C. C. Diabetic client B. 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. Which of the following laboratory test result indicate presence of an infectious process? A. Erythrocyte sedimentation rate (ESR) 12 mm/hr White blood cells (WBC) 18. Client with burns C. trust and collaboration in meeting health needs protecting and supporting another person’s rights 84. B. D. community health nurse D. C. B. D. C. competent nurse B. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. Advocacy is explained by the following EXCEPT: A. proficient nurse D. Using Benner’s stages of nursing expertise. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having: A. You will rank yourself as a/an: A. As you become socialized into the nursing “culture” you become a patient advocate. novice nurse C.000/mm3 Iron 90 g/100ml Neutrophils 67% 80.78. Critical care nurse C. D.

damage to blood vessel D. EXCEPT: A. Embolic stroke B.5 ml D. Your best response is: A. B. Discuss the order with the pediatric heart specialist in the unit 13 .5 ml B.” “More red blood cell increases hemoglobin content.” Situation 16 – Accurate computation prior to drug administration is a basic skill all nurses must have. Clarify order with the attending physician B. The most important risk factor is: A.” “High RBC count increases blood pressure. 2. D. Amphetamines B. 500 mg tid C. 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 94.00 cc of Lanoxin today for 1 dose only”. has an order from her physician: “give 3. The types of stroke based on cause are the following EXCEPT: A. B. binge drinking D. It is important to include the risk factors of stroke. 0. Demerol 90. Since Potassium Chloride is a high risk drug. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Hemmorhagic stroke occurs suddenly usually when the person is active.Situation 15 – When creating your lesson plan for cerebrovascular disease or STROKE. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1. 1.5 gm daily in 3 divided doses for 7 consecutive days. Gomez. D. 86. The available dose is 125 mg/ml. Rhona. thrombotic stroke 88.” “Increased RBC count is linked to high cholesterol. Which drug is closely linked to this? A. All are causes of hemorrhage. 3 months old. 10 ml 93. “More red blood cells thicken blood and make clots more possible. 50 mg tid 92. heredity 87.5 mg suspension three times a day. a 2 year old female was prescribed to receive 62. Which of the following is the most appropriate action by the nurse? A. Part of your lesson plan is to talk about etiology or cause of stroke. aneurysm 89.000 mg tid B. trauma C. Cigarette smoking B. with a congenital heart deformity. A participant in the STROKE class asks what is a risk factor of stroke. 1. Baby Liza. Hemorrhagic stroke C. shabu D. C. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. 91. C. diabetic stroke D.500 mg tid D. Hypertension C. which of the following should Nurse Paolo prepare for each oral dose? A. 1. Which of the following should Nurse Robert do to safely administer this drug? A. phlebitis B.5 ml C. Cocaine C. Which of the following is the correct dose of the drug that the client will received per oral administration? A. Nurse Robert used an intravenous pump.

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

transilluminator C. AVOID ERASURES. the outermost covering of the testes? A. 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. the child assumes a caregiver role toward the caregiver 5. 6. a person who has been a good provider quits his or her job D. 10. A strategy for a change that focuses on teaching workers new technology is: 15 . Two or more boxes shaded will invalidate your answer. Organization B. B. a lazy person becomes very productive in the family B. reproduction. Per RA 8981. C. When a nurse breaches the duty of confidentiality. The nurse uses what equipment to check for fluid between the parietal and visceral layers of the tunica vaginalis. Manometer 4. In addition to this discipline. _________________________________________________________________ INSTRUCTIONS: 4. the basis for the decision as to which child gets the organ is given to the child who: A. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. Shade Set Box “A” on your answer sheet if your test booklet is Set A. 30 cc syringe B. he or she can: A. C. the good child takes on a bad child role C. 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. B. Registered nurses can be identified as a: A.NURSING PRACTICE II SET A _________________________________________________________________ NURSING PRACTICE II – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 6. MULTIPLE CHOICE 1. 7. D. Culture C. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . Set Box “B” if your test booklet is Set B. he or she can be disciplined by both the employer and the Board of Nursing. subculture 2. 9. Among children candidates for organ transplant. and/or sale of this test is punishable by law. group D. This is PRC property. Fluid meter D. when all selected children have appropriate tissue matches for the same donated organ. 5. This test booklet contains 100 test questions. 8. Write the subject title “Nursing Practice II” on the box provided. Shade only one (1) box for each question on your answer sheets. Which of the following examples best defines the term role reversal? A. Unauthorized possession.

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

D. and of experience of each practitioner is called: A. skill mix C. when the chest will be greater. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual participation model of care (NMPMC)? A. Which of the following indicates the type(s) of acute renal failure? A. Tertiary care by the home health nurse is directed toward children with: A. D. minor problems D. Two types: acute and subacute 16. “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.” B. short-term needs C. Three types: prerenal. but in some babies this just differs. clinically apparent disease 21. There are numerous definitions of the word “health”. One type: acute C. problems in mobility B. benchmarking D. clinical ladder 17.” 17 . The endometrium thickens during which phase of the menstrual cycle? A. Informal communication takes place when individuals talk and is best described by saying the participants: A. Four types: hemorrhagic with and without clotting. C. C. The BEST response by the nurse is: A. 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. Secretory phase B. abilities. B. C. and mental well-being and not merely the absence of disease or infirmity 19.15. Which definition below is from Florence Nightingale? A. and nonhemorrhagic with and without clottings B. Menstrual phase C. Ischemic phase 22. Proliferative phase D. A means of facilitating professional staff development is by building upon skills. “These circumference normally are the same. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. career enhancement D. situational leadership model C. are involved in a preexisting informal relationship talk with slang words have no particular agenda or protocol are relaxed 20.” C. “This is normal until the age of 1 year. 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. D. “Perhaps your baby was small for gestational age or premature. patient classification 23. the novice to expert model B. social. B. intrarenal and postrenal D. staffing pattern B. B.

” 24. “Let me ask you a few questions. Stay on left side as much as possible when lying down. D. the nurse would teach the caregivers to: A. 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. D. Severe shaking of the hands when trying to hold a glass of water or other object C. D. on most days. Use an adult voice just as you would for anyone. 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.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. and more likely to lead to suicide than major depressive disorder D. C. B. B. A depressed or irritable mood for most of the day. Respond only after the child cries for a while. The nurse notes that the infant is wearing a plastic-coated diaper. Which of the following groups of people in the world disproportionately represents the homeless population? A. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. Communicate through the caregivers. Caucasians 29. B. D. 28. and perhaps we can figure out the cause of this difference. She is stable and has minimal spotting and is being sent home. Asians C. B. The nurse assessing a child or adolescent with a diagnosis of dysrhytmic disorder would find which of the following symptoms? A. D. C. Which of the following approaches would work best when the nurse is communicating with an infant? A. 18 . Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones and associated symptoms B. A depression that is deeper. more acute. Allow the child time to warm up to the nurse. Call if contractions occur. B. C. Hispanics B. Maintain bed rest with bathroom privileges Avoid intercourse for three days. C. African Americans D. C. for 2 or more years and low energy or fatigue. 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. Which of these instructions to the client may indicate a need for further teaching? A. 25. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks.

The financial well-being of the family C. fever and dysphasia. Substantiate Focus. Utilize. Opportunity. You were the nurse assigned to work with a child who has had whole brain radiation. political issue D. Brow position B. Which is NOT a characteristic of emotional intelligence? A. B. A. B. The well-being of the chronically ill B. Understand and Solution Focus. Left Occipito-Posterior Position 38. B. Clarify. which of the following do they also have as their final objective? A. Continuous (process). The well-being of the extended family 19 . Right Occipito-Anterior Position 37. and reduction of fiber 33. desirability and feasibility. Understand. and omission of highly seasoned foods. is a: A. vitamins and minerals Diet as tolerated with lactose hydrolyzed milk instead of milk products. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position? A. people issue B. newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. Opportunity. Clarify. Organize. Self-regulation 34. saying that the child asked to be touched or did not make the abuser to stop D. Solution C. Focus. C. you are to work with the patients in which of the following areas. D. C.31. the child has been blamed by the abuser for his or her sexual behaviors. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea. Self-awareness C. structural issue C. a child blames him or herself for the sexual abuse and begins to withdraw and isolate B. 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.” Which of the following interventions will be most helpful in resolving this nursing problem? A. Organize. While community health nurses focus on the individual or the family. Continuous. technology issue 35. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis of “Nutrition: Less than body requirements. Based on this assessment. FOCUS methodology stands for: 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. C. 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. Some of these are listed below. Empathy D. D. Understand. D. Breech position D. Self-esteem B. Emotional intelligence consists of a number of competencies. malaise. 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. including costs. Substantiate Focus.

Naturalistic B. Preschoolers are able to see things from which of the following perspectives? A. Their peers Their own and their caregivers’ Their own and their mother’s Only their own 44. In conflict management. According to the social-interactional perspective of child abuse and neglect. D. C. 43. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot scalding water B. B. the caregiver. chronic poverty 46. C. D. 42. the win-win approach occurs when: A. genetics C. the child. 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. Nature C. D. the national emphasis on sex D. the presence of a family crisis B. 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. Type of illness of the client Transference and counter transference Effective communication Personality of the participants 41. Which of the following statements best describes the term glove type burn? A. Nurture 20 . The well-being of the community 39. The parents have dipped the child into hot liquid while he or she was asleep C. The burn has the look of a glove immersed in hot scalding water. The nurse likely keeps this list to: A. and A. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. these risk factors are the family members at risk for abuse.D. Which of the following is the best example of the ethical principle of fidelity? A. 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. Doing whatever the client or the client’s physician asks of you. 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. B. These risk factors are the family itself. D. C. this person is most probably coming from which of the following viewpoints or theories? A. C. When a person is discussing the strong influences that childrearing methods have on the development of the child. C. four factors place the family members at risk for abuse. B. Neoclassic D. D. B. The child was wearing a glove when immersed in hot liquid D. B.

By following the prescribed treatment regimen. that is why periods may often be scant or skipped occasionally. responsibility 21 . hypervigilant. 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. A urine dipstick measurement of 2+ proteinuria or more for 3 days. 52. psychomotor skills. Elevated temperature. Her child is now vomiting. and an arching of the back D. Loneliness C. diminished or absent gag reflex. You will tell the mother to: A. Identity 53. burning frequency. and an arching of the back D. Paradoxical irritability.” B. You are the nurse assigned to work with a child with acute glomerulonephritis. 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. and restlessness B. D. The nurse will likely work with this adolescent in which of the following areas? A. A client says she heard from a friend that you stop having periods once you are on the “pill”. Difficulty swallowing. D. 49. Which finding would most lead you to the conclusion that a relapse is happening? A. or the child found to have 3-4+ proteinutria plus edema. she should stop taking the pills and get a pregnancy test as soon as possible. hypervigilant. Paradoxical irritability. and is complaining of abdominal pain.” D.” C. the child experiences a remission. The most appropriate response would be: A. flank pain. Difficulty sleeping. Difficulty swallowing. Difficulty sleeping. The use of interpersonal decision making. “If your friend has missed her period. and cloudy urine. delegation C. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. and vomiting. and respiratory distress C. You are now checking to make sure the child does not have a relapse. A temperature of 37. Teach care daily and let the caregivers do a return demonstration just before discharge B. has bloody diarrhea. B. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. C. cough. increase in urine output. C. diminished or absent gag reflex. Lack of fulfillment D.47. sore throat. Isolation B. Weakness of the leg muscles. the nurse would: A. It sounds like your friend has not been taking the pills properly. “The pill prevents the uterus from making such endometrial lining. and respiratory distress.” 51. loss of sensation in the legs. “The pill should cause a normal menstrual period every month. changing complete blood count (CBC) with diiferential B. urgency on voiding. “Missed period can be very dangerous and may lead to the formation of precancerous cells.8 degrees (100 degrees F). extreme thirst. The urine dipstick showing glucose in the urine for 3 days. In working with the caregivers of a client with an acute or chronic illness. diarrhea. diarrhea. and vomiting 48. 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. C. and a moon face.

B. At 17 weeks’ gestation. 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. B. this is referred to in conflict management as: A. 56. Which of the following statements best describes acquaintance rape? A. The nurse’s best course of action is to: A. supervision D. a type 1 diabetic undergoes an ultrasound examination. B. competence 54. Gestational age D. When two people don’t love each other and engage in sexual activities C. The school nurse is teaching a health education and hygiene course to a group of high school males. A child suffers a head injury in a tumbling accident in gym class. The American Academy of Pediatrics suggests that caregivers do which of the following things in regard to physical activities for preschoolers? A. Estimated fetal weight C. losing B. Which of the following arrangements is generally considered to be best for the parents of hospitalized infant or young child? A. What information about the fetus at this time in pregnancy would be the results of this examination provide? A. the lose-win approach 58. Toddlers require more empathy and more touching and holding 22 . keep assessing. B. 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. D. C. 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. When one person allows the conflict to be resolved at his or her own expense. C. which includes a number of young men who are on competitive sports teams. 59. C. the win-lose approach D. D. C. Rooming-in Separate caregiver sleeping room on the unit Day visits and sleeping at home Staying at a nearby hotel or motel 57. Fetal lung maturity 61. D. winning while losing C. When someone on a date tricks the other person into having sexual intercourse D. Which of the following best describes a difference in communicating with school age children versus toddlers? A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. D. Placental maturity B.B. Sexual intercourse committed with force or the threat of force without a person’s consent. and have someone call the caregivers 55.

For toddlers. B. Eye contact C. keep the diaper from rubbing the cord 23 . FHT 155 D. infection. 1+ ketones in the urine 68. Which of the following roles BEST exemplifies the expanded role of the nurse? A. Caregivers need less information when care involves a school aged child D. The major purpose of exposing the cord is to: A. The number of words is more when communicating with a toddler than it is with a school aged children 62. Circulating nurse in surgery Medication nurse Obstetrical nurse Pediatric nurse practitioner 65. Paraverbal clues B. ability to hold the head without support B. five agendas C. C. D. Which assessment finding may indicate possible developing complication? A. Genetic testing should be performed on a child only if A.B. Trace glucose in the urine C. D. presence or absence of head lag C. The plan-do-study-act cycle begins with: A. three questions D. grunts and other vocalizations are referred to by which of the following terms? A. B. Infant head control is judged by the: A. 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. preparation for procedures is just before the procedure and much earlier for school-aged children. two concepts C. Conversational style 70. Ancillary speech 66. rigidity of the neck and head D. volume. Maternal pulse 90 B. Which difference does NOT necessarily belong? A. speed. Third element D. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in such a way as to expose the cord. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your workplace. C. 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. Enhancements 67. adrenaline and cocaine). amount of neck wrinkling 64. remind caregivers to do cord care B. The physician orders TAC (tetracaine. you noted one of your pregnant clients considered as “waiting case” manifest morning sickness and which later progressed. The tone and pitch of the voice. Subject matter D. C. four stages B. Personal behavior B. C. B.” cultures have different patterns of verbal and nonverbal communication. Which of the following is the route of administration? A. application to the skin. The nurse is working with a child who is going to have a bone marrow aspiration. During your shift. D.

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

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

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

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

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

D. As a surgical nurse. The board of Nursing is vested with power to issue. certificate of Good Moral Character B. B. D. Pain which is resistant to non-pharmacologic for 6 month 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. “I shall expect slight pain and discomfort from the surgical incision”. B. Which of the following clients statement indicates that he understands the nurse’s instruction about postoperative wound pain? A. “I shall call the nurse when my wound itches and smells”. D. Rhizotomy is a condition surgical procedure to manage those that can potentially cause pain.9. RA 7193 stipulates the removal examination of the nurse licensure examination shall be taken: A. certificate of Registration D. C. 16. Nursing assessment and management of pin should address the following beliefs EXCEPT: 29 . C. D. Stand by her side and quietly ask her to describe her feelings. B. C. certificate of Practice C. D. What do you think is an important responsibility related to pain that is subjective in nature? A. B. Let her cry and tell significant other to stand by. suspend or revoke for cause the: A. B. which of the following nursing intervention will allay anxiety and pain among? surgical patients? A. 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. Deep pain with obvious signs of peripheral nerve damage 13. What is the crucial in determining a good candidate for rhizotomy? A. Pain which is resistant to pharmacologic protocol for 12 months C. “I should call my doctor if my wound has no drainage and intact”. Local pain with no radiating pain or signs of nervous compassion D. certificate of Employment 10. C. C.Pain is always associated to surgery 11. 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 . 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. Nurses should be aware that older adults are at risk of underrated pain. “I should not touch my surgical wound” 15. Check her name tag and request anesthesiologist to sedate client 14. Squeeze her hand and assure her that there will b no pain at all because she will be given anesthesia.

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 . more distressing than pain. What should you do? A. Nurses should understand that when a client responds favorably to a placebo. Physical dependence occurs in anyone who takes opioods over a period of time. B. it is known as the ‘placebo effect’. D. What symptom. D. How can you assist such client? A. Placebos do not indicate whether or not a client has: A. B. As an OR nurse. Allergic reactions like pruritis 20. Before you use a disinfected instrument it is essential that you: A. Older patients seldom tend to report pain than the younger ones Pain is a sign of weakness Older patients do not believe in analgesics. Sterilized D. D. Forgetfulness B. Rinse with tap water followed by alcohol Wrap the instrument with sterile water Dry the instrument thoroughly Rinse with sterile water 24. 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.A. should the nurse monitor when giving opioids especially among elderly clients who are in pain? A. Disinfected 22. Constipation C. B. Drowsiness D. D. D. you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. C. You have a critical heat labile instrument to sterilize and are considering touse high level disinfectant. Items that enter sterile tissue or vascular system are categorized as critical items and should be: A.As a perioperative nurse. Clean B. 21. what are your foremost considerations for selecting chemical agents for disinfection? A. Conscience B. Disease D. D. Material compatibility and efficiency Odor and availability Cost and duration of disinfection process Duration of disinfection and efficiency 23. C. they are tolerant Complaining of pain will lead to being labeled a ‘bad’ patient 17. B. C. What do you tell a mother of a ‘dependent’ when asked for advice? A. B. 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. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain. C. C. Real pain C. C. B. Decontaminated C. Drug tolerance 18.

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

Acupuncture uses manipulation of the skeletal muscles to relieve stress and pain D. 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.S. 48. C. knee-chest exercise before menstruation and hot water bag application over lower abdomen during onset C. D. B. D. Situation 9-pain management is not limited to pharmacological means: 41. When the nurse communicates to the attending physician the desire of the patient to be seen by a urologist D. B. He asked you for an eye ointment to relieve the pain and swelling. diet restriction on fatty foods and liberal fluid intake Situation 10 – One learns by doing especially when you practice the best methods. tetracycline ophthalmic ointment B. You noted that the orderly was looking through the items of one of the patients. You are on PM shift and about 5 patients are of discharge. 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. Which action should you pursue? A. 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. 46. 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. Acupuncture uses pressure from the fingers and hands to stimulate body responses 42. B. ice cold drinks 45. Individual patients and society as a whole benefit from nursing participation in decisions made about health care. ice pack over the right eye C. “The doctor is not on duty today” 40. When does a nurse reject the interdependence of providers and patients in achieving access to health care? A. regular bowel movement B. warm shower during onset of menstrual period D. D. C. A nonpharmacological remedy for menstrual pain is: A. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? 32 . When the nurse replies to the client’s relative “You have the best doctor in town” C. You questioned his treatment because: A.39. Menstrual pain and discomfort account for absences in schools and offices. The nurse uses her bare hands to change the dressing The nurse applies oxygen catheter to the mouth. Acupuncture uses needles to stimulate certain points on the body to treat pain B. Your younger brother came home with right black eye. This is exemplified in: A. “Our hospital does not honor visiting doctors” B. You should offer: A. Acupuncture uses variety of herbs and oils from wild plants C. Which action by a new nurse signifies a need for further teaching in infection control? A. hot compress over the right eye D. 47.

coughing. Which of the following remark indicates that the client’s relative understood the discharge instruction for wound care? A. C. The colleague instructs the clients to perform the valsalva maneuver during the CVP reading D. The charge nurse should: A. The patient is no longer febrile thus he is no longer chilling 33 . You covered him with a blanket and later took his temperature again and it is now 38. “If the wound is painful. you also report the incident to the charge nurse. A. D. The client demonstrated deep breathing. 52. 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. The nurse colleague noted the level at the top of the meniscus C. You must transfer out a post-op client to her room. The nurse colleague charting medication administration that she has not yet given 50. B. B. The client manifests normal temperature C. Which observation from a colleague would indicate a need for further teaching? A. C. D. The nursing student asked you to explain the absence of shivering even if the temperature was higher. 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. C.9°C and was shivering. Acute pain related to discomfort off wound and immobility Body image disturbance because of wound dressing and drains.A. post-op clients started to be ? in from the OR 51. B. B. D. B. D. The client has good balance I and O 53. Knowledge deficit related to lack of information because patients are all sedated. 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. You saw one colleague charting medication administration that she has not yet administered. What would your instruction to the family include to prevent accidents? A. You have been in the surgical ward for almost a year and have cared for a number of patients with CVP. The colleague turns the stop-cock to the off position from the IV fluid to the patient B. C. 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.9°C. After talking to her. Which nursing diagnosis has priority among client in the PACU? A. At 9:30 AM. Which of the following clients at the PACU will demonstrate the effectiveness of ? teaching? A. The client sleeps well D. Ineffective airway clearance related to general anesthesia. One of your post-op patients has a temperature of 37. B. splintering and leg exercises. D.

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

D. streptomycin was given by IV not IM. Gluteal area Deltoid area Anterior area Abdominal area 69. It is necessary for a diabetic client to exercise regularly. It will make you fit and energized Situation 15. 57. You should emphasize that the space between sites should be: A. It lowers glucose. C.0 units to 2. decrease total triglyceride levels D. D. Communicate with the ward nurse to verify if insulin was incorporated or not C. Deliver a continuous basal rate of insulin at 5. C. 35 . Communicate with the client to verify if insulin was incorporated D. Progress notes Incident report Nurse’s not Patient’s chart 72. EXCEPT: A. who is diabetic is for debridement if incision wound. improves insulin utilization. What should the circulating nurse do? A. The documentation of all nursing activities performed is legally and professionally vital. The current insulin pumps available in the market have the following capability. B. D. she found out that there is no insulin incorporated as ordered. It is critical also that a diabetic client should be educated in the possible sites if regular insulin injection. Deliver a pre-meal bolus dose of insulin before each meal. B.0 units per hour 67. If there is any deviation from normal practice or procedure e. It burns excess glucose B.g. 66. It improves insulin utilization and lowers blood glucose C. Rosie.5 cm 4 cm 68. Situation 14 – Technology and patient’s education has dramatically improved the management of the diabetic client. Double check the doctor’s order and call the attending MD B. When the circulating nurse checked the present IV fluid. D. Client with proliferative retinopathy Unstable diabetes Hypoglycemia without warning Abdominal renal glucose threshold 70. this should documented in the: A. B.65. C. The fastest absorption rate happens at the tissue areas of: A. Discharge plan of diabetic clients include injection-site-rotation. Prevent unexpected saving in blood glucose measurements. Detect signs and symptoms of hypoglycaemia and hypercalcemia. B. What is the effect of regular exercise to a diabetic client? A. 6 cm 5 cm 2. Self-monitoring of blood glucose (SMBG) is recommended for patient’s use. You will recommend this technology in the following diabetic patients. B. 71. C. EXCEPT: A. Incorporate insulin as ordered.RN’s should always be conscious that the contents in charting are admissible in court as evidence. D. C.

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

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

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

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

Write the subject title “Nursing Practice IV” on the box provided. D. D. 19. Notify anesthesiologist B. she will not be given her favorite dessert. You over0hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say. You are the nurse in an Adult Care Unit. Assault C. 20. which of the following sources should you take into consideration when making effective assignments for the next shift? A. that if she refuses to take her medications. Malpractice 102. 17. You report your co-staff’s behavior as: A.***END*** NURSING PRACTICE IV SET A ________________________________________________________________________ NURSING PRACTICE IV – Foundation of PROFESSIONAL Nursing Practice GENERAL INSTRUCTIONS: 16. As a head nurse of the unit. Reduce IV rate 103. Negligence D. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs. 18. As the triage nurse. AVOID ERASURES. seniority preferences recent performance evaluation personality traits client classification data 104. MULTIPLE CHOICE 101. B. Unauthorized possession. Set Box “B” if your test booklet is Set B. C. Which of the following will you do FIRST? A. 12. Battery B. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set . Increase O2 flow rate C. C. He has an IV of Dextrose 5% Lactated Ringers Solution. ________________________________________________________________________ INSTRUCTIONS: 10. Per RA 8981. This is PRC property. you would assign the HIGHEST priority to the client with the: A. reproduction. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. Place on Fowler’s position D. 11. This test booklet contains 100 test questions. Jake is in the Post Anesthesia Care Unit follwing a colorectal resection. B. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. moist respiration and tachypnea. Shade Set Box “A” on your answer sheet if your test booklet is Set A. and/or sale of this test is punishable by law. 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 .

Knowledge and skills C. Which laboratory result should you expect to find? A. C. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. C. C. While Jayvee. B. B. Hold the IV bottle Check the IV stand Place the IV stand on the foot part of the stretcher Restrain Jayvee 110. The nurse was proven guilty of negligence. B. While Mrs. 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. If you will evaluate her nutritional status. D. He sustained a laceration on his forehead. Paras is receiving total parenteral nutrition (TPN).105. C. D. At 10am. a burn patient is being transferred from the burn unit to the operating room. Communication skills B. C. It was started at 8am. D. B. As his nurse. volunteer nurse. D. B. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. D. 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. Which of the following did the nurse fail to do? A. which of the following will you do FIRST? A. D. assess Olga and check level of fluid left in the bottle 41 . Vision and passion D. Interpersonal abilities 112. her relative informed you that the bottle is empty. refer to nurse manager B. Which of the following will you do first? A. B. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs? A. C. When a nurse volunteers to work in a hospital setting and she commits a mistake. Mrs. administer Compazine before meals enrich diet with red meats serve hot soup and food increase the amount of spice in the diet 111. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength? A. Assess bone pain Administer prescribed analgesic Teach pain relief strategies Support position with pillow 107. laboratory work up adequate hydration weight gain diminish episode of nausea and vomiting 109. Daniel with multiple myeloma complains of deep bone pain. Increased platelet count Altered blood urea nitrogen (BUN) and creatinine levels Electrolyte imbalance Elevated erythrocyte sedimentation rate (ESR) 108. who is legally responsible? A. which of the following indicators will tell you that TPN was effective? A.

C. Juana. B. C. Which of the following patients is most at risk for metabolic alkalosis? A. 20 years old approaches you and tells you “I am worried about the mass on my neck”. discontinue IV and assess Olga D. bleach 115. 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. Alcohol B. you should: A. Inferential statistics 114. Which of the following measurement of data was used in this study? A. Although the client exhibits no adverse reactions to the larger dose. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution 117. What should be included in the plan of care to minimize skin damage from the radiation therapy? A. ammonia D. Nino is being treated with radiation therapy. Rachel a 55 year old who has just experienced a stroke C. Acetone C.C. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: A. Measures of central tendency C. complete an incident report call the hospital attorney inform the client’s family do nothing because the client’s condition is stable 119. You are assigned to the following patients. you accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. B. Measures of variability B. Standardized care plans are used on all of the nurse’s clients. B. 30 year old post surgical patient who has continuous nasogastric suction B. D. Frequency distribution D. C. Client’s care is planned based on the nurse’s clinical expertise and latest research findings B. replace IV fluid with prescribed follow-up 113. What should you do as a nurse? A. a client with hepatitis B dislodges her IV line and bleeds on the surface of the over-the-bed table. Grace. During a meal. C. 70 year old with altered level of consciousness who is unable to access water freely D. D. Helen. You are the nurse manager of the Medical Unit. A research study found out that 60% of patients complains were due to delayed responses of nurses in the emergency department. As a nurse. D. Studies have shown that the highest incidence of Hodgkin’s disease is common among young adults. 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. Standards of care are developed by the hospital nursing service and should be followed 42 . 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.

B. D. D. 126. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium? A. . Pathologic Q wave Situation 2 – To be able to help our clients with their psychological concerns. Which of the following procedures may be done through the said system? A. ST segment C. ST segment D. ST segment suppression B. QRS complex D. End depolarization B. a QRS complex represents: A. You are expected to recognize electrocardiographic readings on the cardiac monitor. 121.D. greater than . From an ECG reading. T wave B. QRS interval C. 120.20 sec C. Ventricular repolarization D. which of the following would be most important to ask? A. Client’s needs are assessed and individualized care plan are developed for each client.20 sec 125.20 sec B. The most appropriate nursing intervention to facilitate client’s acceptance of a change in body image would be to: A. P wave B. a tertiary hospital utilized a computerized medication order system. When assessing patient’s body image. . we have to explore how they view themselves and their body image. 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. It is important that the nurse measures intervals of QRS complex. C. establish a therapeutic relationship 43 . Venticular depolarization C. . PR interval 122. Because of increase incidents of medication error due to wrong transcription of physician medication orders by the nurse. Atrial depolarization Which of the following represents ventricular repolarization? A. Cruz. 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. Short T wave C. 124. 65 years old. Prolonged PR interval D. 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. B.10 sec D. which of the following typically appears as the first sign of tissue death? A. PR interval of ventricular 123.12 sec to . Later in the acute phase of Myocardial Infarction. encourage dependence B. C.

B.her stamp collection with the nurse Showing no interest in the dressing change 129. 130. easy fatigability. 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. 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. Albert is admitted with a radiation induced thrombocytopenia. Feeling of the dressing over the incisional site Stating he/she is too tired to have visitors Discussing his. that a sudden change in body image would occur from: A. gastrointestinal. ecchymosis. With emphasis on multidisciplinary management you have important responsibilities as nurse. D. Which of the following nursing interventions would be most helpful for Albert? A. C. 131. C. As a nurse you should observe the following symptoms: A. D. B. Albert is A. D. cerebral. C. cardiovascular. establish a social relationship 128. peripheral. B. C. blurred vision severe sore throat. D.C. B. C. C. pallor headache. considered radioactive for 24 hrs given a complete bath placed on isolation for 6 hours free from radiation 133. 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. dizziness. Albert is receiving external radiation therapy and he complains of fatigue and malaise. B. D. joke with the client D. C. D. Knowledge deficit regarding thrombocytopenia precautions Activity intolerance Impaired tissue integrity Ineffective tissue perfusion. 134. It is important for you to remember. What intervention should you include in your care plan? 44 . bacteremia. Immediately following the radiation teletherapy. D. B. B. epistaxis weakness. renal 135. hepatomegaly What nursing diagnosis should be of highest priority? A. petechiae. Which of the following responses would indicate that the client is beginning to accept change in his/her body image? A.

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

decreased bladder capacity C. D. During the immediate postoperative period. 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. have increased hepatic. Peter underwent pneumonectomy. diuretic use D. B. breathing. Administration of analgesic to the older persons requires careful patient assessment because older people: A. C. C. B. On which of the following positions should you place Peter who just underwent pneumonectomy? A. C. 148. B. increased glomerular filtration B. B. 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. Less than 25 ml drainage in the drainage bottle 143. Following lobectomy. C. D. The most dependable cause of infection in the older person is A. airway. D. D. circulation disability (neurologic). D. breathing airway. airway. Are expected to experience chronic pain Experienced reduce sensory perception Have increased sensory perception Have a decreased pain threshold 147. 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. circulation. breathing disability (neurologic) airways. Pain in the older persons require careful assessment because they: A. breathing 46 . C. B. D. you can best help Horace to reduce pain during deep breathing and coughing exercises by: A. change in mental status fever decreased breath sounds with crackles pain 150. 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. B. Your priorities when caring for the older person who sustained traumatic injuries include: A. C.D. dilated urethra 149. C. deep tracheal suction should be done with extreme caution because: A. 146. D. B.

C. Amber 152.” In considering your response to Daria. You noted a change in flow rate. C.Situation 7 – Mang Felix. C. you must depend on the ethical principle of: A. if there is a change refer to urologist for possible irrigation.000/æL develops epistaxis and melena. color. D. B. You are invited by the nursing service department to participate in their bioethical review committee. D. C. Daria states “I don’t need surgery. This will go away on its own. Bright red D. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post operative day. C. D. You are assigned to receive him. What is your assessment finding? A. C. Remove his catheter then allow him to void on his own Irrigate his catheter tell him to “Go ahead and void. B. 154. Treatment with corticosteroids and immunoglobulin has not been successful. 156. Mang Felix informs you that he feels som discomfort on the hypogastric area and he has to void. Beneficence C. You have an indwelling catheter. B. Her physician recommended splenectomy. You decided to check on Mang Felix’s IV fluid infusion. pallor and coldness around the insertion site. 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. B. 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. 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. Phlebitis Infiltration to subcutaneous tissue Pyrogenic reaction Air embolism 155. D. Immediately after surgery.” assess color and rate of outflow. Autonomy 47 . Pinkish to red The purpose of the continuous bladder irrigation is to: A. B. Light yellow B. what would you expect his urine to be? A. What will be your most appropriate action? A. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20. Chest pain and vital signs Intravenous infusion rate Amount. 151. 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. Which of the following is the purpose of the ethical review committee? A. You are expected to know the purpose and apply bioethical principles. which of the following is the LEAST relevant to document in the case of Mang Felix? A. a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection.

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

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

Heart failure C. C. facilitate Frank’s verbal communication maintain sterility of the ventilation system assess his response to the equipment prepare him for emergency surgery Dyspnea. B. after reporting this to the physician. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. D. cardiogenic shock B. Shortly after this increase. D. you should first: A. right-sided heart failure C. D. Frank’s respiratory status necessitates endotracheal intubation and positive pressure ventilation. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. C. D. the physician gave a diagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain. 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 . intracardiac epinephrine insertion of a pacemaker bolus of Lidocaine manual cardiopulmonary resuscitation 174. you anticipate that the physician will order. Based on the ECG obtained on admission at the ER and clinical findings. A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI. E. facilitate Frank’s verbal communication maintain sterility of the ventilation system assess his response to the equipment prepare him for emergency surgery 178. When suctioning the endotracheal tube. When assessing Frank you would expect to find: A. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. Flaring of the Nares 177. Your most immediate nursing intervention for Frank at this time would be to: A. acute pulmonary edema D. 176. To immediate promote oxygenation and relief of dyspnea. 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. You are caring for Lulu has acute pulmonary edema. you notice Cedric is in ventricular tachycardia. The cardiac monitor indicates that Cedric’s heart rate has increased to 150 beats per minute. pneumonia 175. you should: A. B. C. Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. Your presence and critical decision making as a nurse are important. You should recognize this as signs and symptoms of: A. Take note that the major cause of death after an MI is: A. C. D. B. B. A. Cardiac arrhythmias B. C. Pulmonary embolism 173. B. you have to anticipate occurrence of complications.172. As Aimee’s nurse. Cardiogenic shock D.

C. fever 185. Verify client identity and blood product blood product. cross matching results. From the time you obtain it from the blood bank how long should you infuse it? A. You are preparing a unit of whole blood for transfusion. what will be your priority intervention? A. 181. expiration date 183. D. As Diego’s nurse what will you do after the transfusion has been started? A. C. 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. for early indications of respiratory acidosis. infuse dextrose 5% in water and call the physician B. B. which include: A. Immediately stop the blood transfusion. Slow the blood transfusion and monitor the patient closely C. The physician orders low concentration oxygen to be given continuously for Kenneth who has a chronic obstructive pulmonary disease to prevent: A. Verify physician’s order C. blood type. Verify client identity and blood product. 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. 4 hours B. chills. D. cross matching results. notify the blood bank 51 . 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. restlessness 180. Immediately stop the blood transfusion. B. infuse normal saline solution. In case Diego will experience an acute hemolytic reaction. serial number. Check IV site and use appropriate BT set and needle B. As a nurse. oliguria and jaundice urticaria and wheezing hypertension and flushing headache. light-headedness B. serial number. Immediately stop the blood transfusion. D. who has a restrictive airway disease. C. notify the blood bank and administer antihistamines D. blood type. 2 hours D. bradypnea C. Diego is undergoing blood transfusion of the first unit. C. B.179. call the physician. 6 hours What should you do FIRST before you administer blood transfusion? A. bradycardia D. you should observe Bernard. The earliest signs of transfusion reactions are: A. 1 hour 182. expiration date with another nurse D.

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

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

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

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. “I get that. Reaction formation 55 . Suspicious affect C.” The nurse diverts the attention to talk about non-threatening topics. Reyes would necessitate referral to a doctor? A. and Mrs. The paranoid client utilizes which of the following defense mechanisms? A. C. Reyes are about conflicting ways of bringing up their children. call a priest counsel the client refer the client to the psychiatrist refer the matter to the police 5. “Would you rather wish that I don’t come and visit you may regard me as a stranger?” B.with all the media news about child kidnapping and robberies. B. Mr. C.A. “It must be distressing to think and feel the way you do. Projection C. Reyes remarked “I am wary about people visiting. aged 7 and 4 years. “The nurse’s BEST response would be: A. 6.” D. Reyes is lax and tolerant while Mr. Reyes expressed that her socializing with neighbors is limited because her husband thinks she is getting overly friendly with a guy next door. Rationalization D. C. Hypervigilance B. An appropriate topic would be: A. D. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents. When the nurse identifies a client who has attempt to commit suicide the nurse should: A. “I acknowledge what you are saying.e. Upon her visit she observed that common areas of arguments between Mr. D. D. She is applying the principle of: A. community and neighbors that cannot be trusted. My concern is the health care of your family and information are strictly confidential. 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. D. B. Reyes often insists strict ways to a point of protectiveness from what he perceives as unsafe i. loss of reality contact 10. Mrs. C. C. Which of these symptoms if demonstrated by Mr. hypersensitive D. Mrs. responsibility and accountability consistency and predictability honesty and integrity empathy and compassion 9. D. 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. 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. B. Sublimation B. B. Which of the following would the nurse emphasize as basic? A. B.” 7.

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

” 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. showered for an hour and still did not feel clean. nausea. This is a process wherein the client’s chart is reviewed to compare criteria for quality care with actual practice: A. 26. denial D. B. B. D.” I would be best of help if you stop crying. Which of these communicate unconditional acceptance of Anita and hr situation? A. 21. D. She had been invited to a fraternity party.” Why did you date a guy you hardly knew?” Tell me when you are ready and I’ll come back to you. D. C. When the nurse approached Anita. The following situations and behaviors are means to achieve this goal. Anita expressed to the nurse that she douched. D. anger C. vomiting. felt she was in a nightmare and she was at a loss. Psychiatric Audit Nursing Care Process Interaction Process Analysis Algorithms 57 . C. frustration 23. helplessness. Situational low self-esteem Sexual violence Ineffective coping Sexual dysfunction 22. intimacy Situation 5 – Anita is experiencing rape-trauma syndrome in an acute phase. developmental crisis C. B. The pedophile’s choice of a sex object is primarily based on: A. She had too much drink and she has feelings of anger. Trust D. D. maturational crisis B. initially she was just crying. Anita is experiencing: A.19. Anita is experiencing: A. B. humiliation. C. “You are here and I am ready to listen. industry B. 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. difficulty relating with adults feelings of tenderness toward children fears of incestuous impulses preferred for a passive sexual role 20. C. frustration 25. Autonomy C. guilt B. B. Which of these behaviors of Anita signal her readiness to proceed to the working phase of the nurse-patient relationship? A. C. The appropriate nursing diagnosis is A. Social crisis D. nightmare and muscle tension.

C. B. C. B. Is the nursing data base complete? D. How long did it take to complete the nursing data base? C. 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 . Such studies have the advantages EXCEPT: A. D. 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. The type of study conducted is: A. B. All of these are the advantages of peer review EXCEPT: A. efficiency D. A semi-structured interview was conducted. C. 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. C. institutionalized people?” 31. D. the nurse would ask herself which of the following questions regarding her recording: A. D. Descriptive B. experimental D. In order to assess “Reliability” as a behavioral characteristic. D. reliability C. Follow the problem solving approach Do not pass judgment on the ideas presented Ideas must be feasible Suggestions must be cost effective 30. case study 34. Investigation of cognitively impaired individual presented some ethical dilemmas. 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. elderly.27. One of the most important ground rules is: A. “Did the nurse perform in the best possible manner without waste?” aims to describe the nurse’s: A. thoroughness B. C. Did the history of the present problem correlate with the review of growth and development? B. Quasi-experimental C. The nursing team leader wants to involve all the nurses in participating in their own personal and professional growth through a brainstorming session. B. Are the nursing history and psychosocial assessment accurate? 28. B. D. Which of the following protocol would be considered unethical? A. This means that: A. The review of literature included reference to retrospective studies. 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.

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

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

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

Refer her for activity therapy 59. 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. it is best to: A. C. Which of these nursing approaches is MOST appropriate for the nurse to begin with? A. C. the nurse can be said to be suffering from: A. Make self available while maintaining distance until patient shows readiness to interact D. Engage Marina for at least one hour in a one-to-one interaction daily B. The supervising nurse intervenes therapeutically by taking the role of: A. B. C. When she resists to take her medication. B. psychotic anxiety staff burnout personality maladjustment neurotic depression 64. The nurse’s action is: A. A priority in the nurse’s personal development would be to: A. The most relevant professional program for her would be: A. D. address her physical well-being boost her self-confidence provide social support help her find value and meaning in her work 65. B. anger. D. D. 61. D. administer the drug request the doctor to give her medication 60. who she interacts with regularly. C. 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. Invite her to socialize with other patients C. 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. 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. The nurse expressed increasing feelings of dissatisfaction. and even indifference toward clients and co-workers. B. D. mental and physical fatigue and actual withdrawal from client contact and nursing duties. C.58. The initial action of the supervisor would be to: A. Coupled with poor work performance. B. B. D. Another reason why she refuses to take Thorazine is because she complains of robot like movement and slurred speech. B. assertiveness training stress management group dynamics and team building behavior modification 62 . D. C. C.

Situation 14 – The purpose of the nursing care plan is to identify the care for an individual patient based on his problems. D. B. B. The nurse writes a nursing care plan for a patient based on nursing care standards. The initial step in identifying problems is: A. C. 66. B. When planning for nursing care for Mr. The “due to” or the reason for the problem should be included if it is known. to start rehabilitation as much as possible C. to improve muscle tone B. D. Given this example of an expected outcome: “Openly verbalize anxiety about job interview. A? A. D. C. Which of these practices on evaluation support nursing care? Review of care plan is: A. 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. D. to treat the disease 63 . C. 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. 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. “Anxiety due to a job interview”.” Which of these is not a criterion of expected outcomes? A. 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. C. 71. The following are reasons for setting deadlines within which to achieve outcomes of care EXCEPT: A. Ma. What communication strategies should the nurse avoid when interacting with Mr. B. B. Identify how he can prepare for the job interview. Given this example of a problem. gather data about the patient determine if the problems are usual or unusual analyze the data analyze the problems as concisely as possible 67. C. B who has Parkinson’s disease. which of the following goals would be MOST appropriate? A. 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. C. D. Which of these is not a relevant nursing order? A.

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

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

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

He would count pencils in a mug over and over with the thought that stopping could result in something bad happening. D. assign task that can be done repetitively D. excited D. neurosis D. psychosis C. C. self-determination 99. personality disorder B. He is demonstrating: A. self-mastery B. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. habitual disorder SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. This is a pattern of: A. 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. suspicious C. C. ideas of reference denial and projection obsession and compulsion rationalization and over reaction 98.Jim. chew each bite he east 24 times and go up and down the stairs four to five times before it feels right. self-actualization D. 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 . B. B. Which of the following must be considered while planning activities for the depressed patient? A. 96. impose limits every time the behavior becomes repetitive B.95. self worth C. All of these are therapeutic interventions EXCEPT: A. The objective of nursing care for Jim is to develop or increase feelings of: A. D. ***END*** 67 . facilitate self-expression 100. confused B. age 25. recalled that his problem began around age 15-16. anxious 97. Jim is aware of his behavior yet realizes that it is very disturbing to him.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.