You are on page 1of 8

1. Nurse Suzie is administering 12:00 PM medication in Ward 4.

Two patients have to


receive Lanoxin. What should Nurse Suzie when one of the client 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 roommate if the client is Mrs. Santos
Compare the ID band with the bed tag

Answer: B. Ask the client his name


Rationale: The clients identity should always be further verified by one other method,
such as stating the clients name, or asking the client to state his name
Book source: Foundations of Basic Nursing by Lois White page 341
2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say 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.

Answer: B. Touch serves as a connection between the nurse and the patient.
Rationale: Therapeutic touch allows the nurse to comfort patients on a caring level,
connecting with them on a humanistic level away from the medical proceures and
techniques that are often experienced. In addition, therapeutic touch allows the nurse to
communicate non-verbally a variety of feelings to the patient, including warmth,
reassurance and trust. Therapeutic touch can also be used more formally as a named
technique, such as massage or healing touch, to help the nurse in a variety of physical,
emotional and spiritual aids.
Book source: The Essential Concepts of Nursing: Building Blocks for Practice by John
R. Cutcliffe, Hugh P. McKenna, page 298
3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of
cane. Which observation will indicate that Mr. Lapuz is using the cane properly?
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

Answer:
Rationale:
Book source:
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. Tell me how you feel about the surgery.
Answer: D. This must be very frightening for you. Tell me how you feel about the
surgery.
Rationale: The OR environment can seem cold, stark and frightening to the patient, who
may be feeling isolated and apprehensive. Introducing yourself, addressing the patient by
name frequently, verifying details, providing explanations, and encouraging an answering
questions provided sense of professionalism and friendliness that can help the patient feel
safe and secure. When discussing what the patient can expect surgery, the nurse uses
basic communication skills, such as touch and eye contact, to reduce anxiety. Telling the
patient who else will be present in the OR, how long the procedure is expected to take
and other details helps the patient prepare for the experience and gain sense of control.
Book source: Brunner & Suddarths Textbook of Medical-Surgical Nursing 12th Edition
by Suzanne C. Smeltzer, Brenda G. Bare, et.al Copyright 2010. Page 457
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.

Answer: B. Take the medicine early in the morning.


Rationale: when nursing care involves diuretic therapy, the nurse needs to administer the
medication and monitor the patients response carefully. Administer the diuretic at a time
conducive to patients lifestyle; for example, early in the day to avoid nocturia

Book source: Chart 30-2 Pharmacology: Administering, Monitoring Diuretic Therapy


Brunner & Suddarths Textbook of Medical-Surgical Nursing 12th Edition by Suzanne C.
Smeltzer, Brenda G. Bare, et.al Copyright 2010. Page 832
6. Nurse Glenda gets a call from the neighbour 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 neighbourhood.
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 neighbour to observe the child and give plenty of fluids. If the child does not
improve, bring the child to the hospital.
Answer:
Rationale:
Book source:
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
Answer: C. Liable along with the employer for the use of a defective equipment that
harms the client
Rationale: To establish legal liability for malpractice (professional negligence), the
injured client (plaintiff) must prove the following 4 elements:
a. Duty of care was owed to the injured party.
b. There was breach of that duty
c. The breach of the duty caused the injury (causation).
d. Actual harm or damages were suffered by the plaintiff.
Critical in determining liability for malpractice is the definition of the duty of care owed
by the nursing professional to the client. The standard of care, the minimum requirements
that define an acceptable level of care, is the average degree of skill, care and diligence
exercised by members of the same profession under the same or similar circumstances.
(Aiken 2004, page 39)

Book source: Leadership and Nursing Care Management By Diane Huber page 98
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.
B.
C.
D.

Ignore the incidence


Report the incidence to the head nurse
Respect the clients action as this provides structure and support to the client
Call her attention so she can go to sleep

Answer:
Rationale:
Book source:
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 white, fish
Balut, salted eggs, duck and chicken egg
Pork liempo, cow brain, lungs and kidney

Answer:
Rationale:
Book source:
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
Answer: B. guide for carrying out nursing responsibilities that provide quality care and
for the ethical obligation of the profession
Rationale: Code of ethics is a formal statement of a groups ideals and values. It is a set
of ethical principles that (a) is shared by members of the group, (b) reflects their moral
judgments over time, and (c) serves as a standard for their professional action.
Book source: Kozier and Erbs Fundamentals in Nursing, 8th Edition page 85
11. Which of the following situation 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 in the clients medication 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.
Answer:
Rationale:
Book source:
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 type 2


Client with chronic obstructive pulmonary disease (COPD)
Client with second degree burn
Client with psoriasis

Answer: C. Client with 2nd degree burn


Rationale: The immunologic responses of the body are greatly altered by a burn injury.
Patients with burn injury are at high risk for infection and sepsis. The skin is the largest
barrier to infection, and when it is compromised, the patient is continually exposed to the
environment. The loss of skin integrity is compounded by the release of abnormal
inflammatory factors, altered levels of immunoglobulins, and serum complement,
impaired neutrophil function, and a reduction in lymphocytes (lymphocytopenia). These
alterations result in immunosupression and increase the risk for sepsis. As a result, the
major cause of death in burn who survives after 24 hours is multiple organ dysfunction
syndrome (MODS) (Greenhalgh, 2007)
Book source: Brunner & Suddarths Textbook of Medical-Surgical Nursing 12th Edition
by Suzanne C. Smeltzer, Brenda G. Bare, et.al Copyright 2010. Page 1724
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.
B.
C.
D.

Dont worry. I will call the attention of your wife.


Your wife is just trying to help because she is worried about you.
What are your thoughts about your wifes involvement in your care?
Your wife can assist you well in your care and recovery.

Answer:

Rationale:
Book source:
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
Answer:
Rationale:
Book source:
15. The son of Mr. Rosario, a 76 years 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

Answer: D. Have someone check on the client frequently at night


Rationale: A safe home and hospital environment allows the patient to move about as
freely as possible and relieves the family of constant worry about safety. To prevent falls
and other injuries, all obvious hazards are removed in the home. A hazard-free
environment allows the patient maximum independence and a sense of autonomy. The
patient may have a short attention span and be forgetful. Wandering behaviour can often
be reduced by gentle persuasion or distraction. Restraints should be avoided because they
increase agitation. All activities must be supervised to protect the patient.
Book source: Brunner & Suddarths Textbook of Medical-Surgical Nursing 12th Edition
by Suzanne C. Smeltzer, Brenda G. Bare, et.al Copyright 2010. Page 219
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 patients lives.

16. You are to administer an intramuscular injection to Dulce, 1 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

Answer: C. vastus lateralis


Rationale: The vastus lateralis site is recommended as the site of choice for toddler an
children. There are no major blood vessels or nerves in this area, and it is the infant and
toddlers largest mass. It is situated on the anterior lateral aspect of the thigh.
Book source: Kozier and Erbs Fundamentals in Nursing, 8th Edition page 877
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

Answer: B. 21 drops per minute


Rationale: (500mL/hr)(60drops per minute)
(60 minutes)(24 hours)
Book source: Focus on Nursing Pharmacology by Amy M. Karch 5th Edition page 58
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 millilitre. 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

Answer: A. 42 drops
Rationale: (1000mL/hr)(20drops per minute)
(60 minutes)(8 hours)
Book source: Focus on Nursing Pharmacology by Amy M. Karch 5th Edition page 58
19. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV
infusion set is 10 drops per minute. Approximately how many drop per minutes should
the IV be regulated?
A. 13-14 drops
B. 17-18 drops

C. 10-12 drops
D. 15-16 drops

Answer: A. 13-14 drops


Rationale: (1000mL/hr)(10drops per minute)
(60 minutes)(12 hours)
Book source: Focus on Nursing Pharmacology by Amy M. Karch 5th Edition page 58
20. The physician ordered Nembutal Na gr XX. The bottle contains 100mg/capsule. How
many capsule will be administered to the client?
A. 1 capsule
B. 1 capsule
Answer:
Rationale:
Book source:

C.
D.

2 capsule
capsule