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NLE December 2007 NURSING PRACTICE I SET A _______________________________________________________________________ MULTIPLE CHOICE 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. Ask the client if she is Mrs. Santos B. Ask the client his name C. Ask the room mate if the client is Mrs. Santos D. 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. Use touch when the situation calls for it . B. Touch serves as a connection between the nurse and the patient . C. Use touch with discretion . D. 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. The cane and one foot or both feet are on the floor at all times B. He advances the cane followed by the left leg C. Client keeps the cane on the right side along the weak leg D. 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. Report to the physician the effects of the medication on urination. B. Take the medicine early in the morning C. Take a full glass of water with the medicine D. 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 thatharms 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 theclient 1

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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. Chicken liver, cow liver, eggs B. Lean beef and pork, egg ewhite, fish C. Balut, salted eggs, duck and chicken egg D. 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 ofdyspnea 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. Diabetic client type2 B. Client with chronic obstructive pulmonary disease (COPD) C. Client with second degree burns D. 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 him. Which instruction would you give? A. Apply restraints during night hours only B. Advise hospitalization to prevent future accidents C. Keep a radio or TV for company and to orient the client D. 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 C. vastus lateralis B. ventral forearm 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 C. 30 drops per minute 2

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B. 21 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 C. 60 drops B. 20 drops D. 32 drops 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 C. 10-12 drops B. 17-18 drops D. 15-16 drops 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 C. 2 capsule B. 1 ½ capsule D. 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. 21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should: A. tell the nurse how to give bed baths correctly B. ask another staff nurse to do bed baths instead C. provide a manual to be read on giving bed baths D. bring the staff nurse to a client s room and demonstrate 22. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client. Together, they observe how well the dressings absorb the drainage. In what step of the decision making process are they? A. Testing options C. Defining the problem B. Considering effects on results D. Making final decisions 23. To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act responsibly when at work. Which of the following actions of the nurse demonstrates the attitude of responsibility? A. Thinking of alternative methods of nursing care B. Sharing ideas regarding patient care C. Following standards of practice D. Planning other approaches for patient care 24. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. Roman, a client who is ambulatory and for surgery tomorrow B. A post operative client, Rey, who has a blood pressure of 90/50 mmHg C. Mr. Abad, a client who needs instructions for home medications D. Fred, a client who received pain medications 5 minutes ago 25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a client s problem and its possible cause. The following is an example of a well written nursing diagnosis: A. Acute pain related to altered skin integrity secondary to hysterectomy B. Electrolyte imbalance related to hypocalcemia C. Altered nutrition related to high fat intake secondary to obesity D. Knowledge deficit related to proctosigmoidoscopy Situation 3 You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV. 26. When caring for a dying client, you will perform which of the following activities? A. Encourage the client to reach optimal health B. Assist client perform activities of daily living C. Assist the client towards a peaceful death D. Motivate client to gain independence 27. 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. This client is in the stage of: A. acceptance C. denial B. resolution D. bargaining 3

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28. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a mutidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. You are to give the both medications in one injection. You will: A. withdraw the medication from the vial first then from the ampule B. inject air into the vial, then into the ampule C. inject air into the ampule, aspirate the desired dose, then into the vial D. withdraw medication from the ampule then from the vial 29. 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, what is the total volume that you will inject to the client? A. 2 ml C. 1.5 ml B. 1 ml D. 1.75 ml 30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity? A. Blisters C. Pressure sores B. Reddening of the skin D. Pustules Situation 4 You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility. 31. Ramil s right leg is injured and Nurse Karen has to move him from the bed to w wheel chair. Which of the following is the appropriate nursing action of Nurse Karen? A. Put the client on the edge of the bed and place the wheelchair at her back B. Face the client and place the wheelchair on her left side C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. Put the client on the edge of the bed and place the wheelchair on the client s left side 32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented? A. adduction of the shoulder B. Lateral flexion of the sternocleidomastoid muscle C. Hyperextension of the knees D. Anterior flexion of the lumbar curvature 33. Joseph prefers to be in high fowler s position most of the time. The nurse should prevent which of the following? A. Posterior flexion of the lumbar curvature B. Internal rotation of the shoulder C. External rotation of the hip D. Adduction of the shoulder 34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first? A. Move the patient to the edge of the bed near the nurse B. Adjust the bed to flat position C. Lock the wheels of the bed D. Raise the bed rails opposite the nurse 35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Sandbags C. Pillow B. Firm mattress D. High foot board Situation 5 As you begin to work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them. 36. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote rest and sleep B. Instructing the client about the use of call system C. Raising the side rails D. Placing the bed in high position 37. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? 4

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A. Impaired mobility related to pain secondary to an abdominal incision B. Impaired movements related to pain due to surgery C. Impaired mobility related to surgery D. Severe pain related to surgery 38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. Encourage the client to log roll when turning B. Encourage the client to do self-care C. Instruct the client to do deep breathing exercises D. Ambulate the client in ward premises every twenty minutes 39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozano s hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? A. Involving family members in meeting client s personal needs B. Meeting his needs till he is ready to perform self-care C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care 40. Mr. Ernest Lopez is terminally ill and he chooses to be at home with his family. What nursing action is best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. 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. Tell the client to be with his family Situation 6 Myrna, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 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 needs to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. locating and identifying resources C. clarifying a research topic B. reading and recording notes D. using the library 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. Staff nurses in a selected college of nursing B. Health values C. Health promotion activities D. Relationship between health values and health promotion activities Situation 7 While working in a tertiary hospital, you are assigned to the medical ward. 46. Your client, Mr. Diaz, is concerned that he cannot pay his hospital bills and professional fees. You refer him to a: 5

negotiation C. nutritionist C. decision making D. Mutual respect. 84 years old. Amado. 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. physician 47. the number of times the client calls the nurse D. critical thinking to decide appropriate nursing actions B. the amount of medications administered to the client as ordered C. This is because she has the following competencies: A. creating plans of care for particular clientele B. identifying the correct nursing diagnoses for clients C. lemon glycerine C. the outcome of nursing interventions based on plan of care 54. Social worker C. Complaint of frequent bouts of dizziness 55. the most important tool of the nurse is: A. physician B. schedule the laboratory exams ordered for her B. trust. age 49. While talking with Mrs. Which of the above symptoms would be an objective cue? A. She also had frequent bouts of dizziness. the best description of Nurse Rita s role is: A. shares and implements orders of the health team to ensure quality care C. You are assigned to Mrs. is unconscious. dietitian D. medical pathologist 49. quality nursing care to various clients in any setting. blood pressure of 170/100. Communication. Nurse Rita is successful in collaborating with health team members about the care of Mr. Normal saline solution 6 . 56. To provide safe. it is most important for the nurse to: A. Amado. Conflict management. Linao. The effectiveness of your nursing care plan for your clients is determined by A. hot flashes. Mrs. Mineral oil B. Magno has lung cancer and is going through chemotherapy. observation skills for data collection D. using standards of nursing care as your criteria for evaluation 53. making a thorough assessment of client needs and problems D. provide financial assistance B. A diabetic hypertensive client. tell the client that your shift ends after eight hours D. trust. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. assist with chemotherapy 48. An elderly client. Linao. 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. needs a change in diet to improve her health status. receive emotional support C. Which of the following is BEST to use for oral care? A. Blood pressure measurement of 170/100 B. hydrogen peroxide D. bookkeeping department D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus.:273-2245 A. Assessment of the mouth reveals excessive dryness and presence of sores. Complaint of hot flashes C. Nurse supervisor B. possession of in scientific knowledge about client needs 52. encourages the client s involvement in his care B. and decision making B. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. to be a part of a research study D. Report of pain after ingestion of fatty food D. helps client set goals of care and discharge 50. She should be referred to a: A. have the client sign an informed consent Situation 9 Oral care is an important part of hygienic practices and promoting client comfort. Mr. the number of nursing procedures performed to comfort the client B. she listens to the individual views of the team members D. Negotiation. understanding of various nursing diagnoses C. do an assessment of the client to determine priority needs C. When collaborating with other health team members.

The nurses check client s identification band before giving medications B. improves client s appearance and self-confidence D. 61. Effective management of available resources enables the nurse to provide safe. In the hospital where you work. Note both generic and brand name of the medication in the Medication Administration Method C. swabbing the inside of the cheeks and lips. tongue and gums with dry cotton swabs C. salt solution C. Which of the following indicates implementation of process standards? A. Oral hygiene is recommended for the client and in addition. Your client has difficulty of breathing and is mouth breathing most of the time. This can be avoided by: A. the entries in the chart must have accurate data. During the brainstorming session of the nursing service department. 7 . Keep the client dry by placing towel under the chin C. The advantages of oral care for a client include all of the following. petroleum jelly B. increased incidence of medication error was identified as the number one problem in the unit. Jose s chart is the permanent legal recording of all information that relates to his health care management. Measures waiting time for client s per nurse s call C. Miscommunication of drug orders was identified as a probable cause of medication errors. EXCEPT: A. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. 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 hospital has an ongoing quality assurance program. Encourage clients to ask question about their medications. As such.:273-2245 57. This causes dryness of the mouth with unpleasant odor. Do the procedure with the nurse Situation 11 Mr. Which of the following is process related? A. reduces need to use commercial mouthwash which irritate the buccal mucosa C. The unit has well ventilated medication room 64. lips and ums D. water D. The nurse reports adverse reaction to drugs C. Checks equipment for its calibration schedule D. probable causes were identified. Ask the nurse to find way to learn the procedure C. you will keep the mouth moistened by using: A. suctioning as needed while cleaning the buccal cavity 60. When performing oral care to an unconscious client. Tell the nurse to read the procedure manual D. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. mentholated ointment Situation 10 Errors while providing nursing care to patients must be avoided and minimized at all time. interruptions C. Clean mouth with oral swabs in a careful and an orderly progression 58. Interviews nurses for comments regarding staffing B. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. quality patient care. Average waiting time for medication administration is measured D. tongue. which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. use fingers wrapped with wet cotton washcloth to rub inside the cheeks. Put the client on a sidelying position with head of bed lowered B. decreases bacteria in the mouth and teeth B. Determines whether nurses perform skin assessment every shift 65. failure to identify client 62. Maintain medication in its unit dose package until point of actual administration B. 63. use of unofficial abbreviations D. Only officially approved abbreviations maybe used in prescription orders D. improves appetite and taste of food 59. Which of the following is the most appropriate action of the nurse supervisor? A. Wash hands and observe appropriate infection control D. Which of the following is safe medication practice related to this? A. lack of knowledge B. Assign another nurse to perform the procedure B.

a newly hired nurse. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. Jose s chart contains all information about his health care. The functions of records include all except: A.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. After respiratory treatment. The baby whose fantanelle is bulging and firm while asleep B. expectorate into a container 8 . A baby boy whose circumcision has yellowish exudates 72. Lining the rubber mat with bed sheet as incontinence pad for the patient D. While Doris is doing spone bath. The client objects to its use C. Assess sensation of each arm C. 71. The client s family refuses to have it used B. suction 30 seconds using twirling motion as catheter is withdrawn 73. Upon waking up. the daughter of a comatose patient. The nursing diagnoses for a client s data can be accurately determined B. Check radial pulses bilaterally and compare 75. Hyperoxygenate client insert catheter using back and forth motion D. 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. The number of people to take care of the client will be reduced 68. She will take care of clients with various conditions. the nurse should: A. to give a sponge bath. then withdraw slightly. educational resource for student of nursing and medicine D. what action of Doris needs correction? A. Insert suction catheter four inches into the tube. Mr. Nurse Roque is giving instructions to Doris. provide research data to hospital personnel B. Nursing audit aims to: A. Repeat the order back to the physician. Information concerning the client can b easily updated D. Write the order in the client s chart and have the head nurse co-sign it D. applying suction intermittently as catheter is withdrawn C. Evaluate skin temperature in the area D. The handwriting is not legible D. Cost of confinement will be reduced C. Which of the following client conditions should be Miss Roque s priority in the pediatric unit? A. cough deeply and expectorate into container B. A telephone order is given for a client in your ward. Answering the phone while wearing gloves used for sponge bath B. Explain procedure to patient. Information in the patient s chart is inadmissible in court as evidence when: A. Use baby powder to reduce irritation under the cast B. Tell the physician that you can not take the order but you will call the nurse supervisor Situation 12 Nurse Roque. An advantage of automated or computerized client care system is: A. provide information to health-care providers 70. recording of actions in advance to save time 67. which of the following instruction is best? A. means of communication that health team members use to communicate their contributions to the client s health care B. compare actual nursing done to established standards D. Dina sustained a fracture of the ulna and a cast will be applied. is asked to take over an absent nurse in another unit. Insert catheter until resistance is met.:273-2245 66. study client s illness and treatment regimen closely C. the client s record also shows a document of how much health care agencies will be reimbursed for their services C. Copy the order on to the chart and sign the physician s name as close to his original signature as possible B. What is your most appropriate action? A. Save sputum for two days in covered container D. Rolling the patient like a log to do back rub C. Cough after pursed lip breathing C. It has too many abbreviations that are unofficial 69. copy onto the order sheet and indicate that it is a telephone order C. A baby who is wailing after being awakened by the banging door D. Withdrawn using twisting motion B. When suctioning the endotracheal tube. To obtain specimen for sputum culture and sensitivity. insert catheter gently applying suction.

Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care. shared respect. Benner s Proficient nurse level is different from the other levels in nursing expertise in the context of having: A. Which of the following laboratory test result indicate presence of an infectious process? A. advanced beginner 82. who is the most susceptible to infection? A. washing hands before changing wound dressing D. You join a continuing education program to help you: A. client with myocardial infarction Situation 14 You are a newly hired nurse in a tertiary hospital. the ability to organize and plan activities B. trust and collaboration in meeting health needs D. As you become socialized into the nursing culture you become a patient advocate. Get in touch with colleagues in nursing C. Advocacy is explained by the following EXCEPT: A. proficient nurse B. Client with burns D. Neutrophils 67% 80. competent nurse C. The most important risk factor is: 9 . having attained an advanced level of education C. On reviewing the result the nurse notices which of the following as abnormal finding? A. staff nurse 85. Dorothy underwent diagnostic test and the result of the blood examination are back. Critical care nurse D. Neutrophils 60% B. placing dirty soiled linen in moisture resistant bags 78. protecting and supporting another person s rights 84. 81. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. It is important to include the risk factors of stroke. Clinical nurse specialist C. community health nurse B. Oral temperature shows fever C. 86. You will rank yourself as a/an: A. Update your knowledge and skills related to field of interest Situation 15 When creating your lesson plan for cerebrovascular disease or STROKE. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. White blood cells (WBC) 18. respecting a person s right to be autonomous B.:273-2245 Situation 13 Infections are quite commonly the reasons for a client s hospitalization. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. novice nurse D. Acute symptoms are no longer visible D. Erythrocyte sedimentation rate (ESR) 12 mm/hr B. Client feels sick but can do normal activities 79. intuitive and analytic ability in new situations 83. a holistic understanding and perception of the client D.000/mm3 C. Enhance your basic knowledge D. 76. Iron 90 g/100ml D. Among the clients you are assigned to take care of. Erythrocyte sedimentation rate (ESR) is 39 mm/hr D. Client was exposed to the infection 2 days ago but without any symptoms B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. inserting an intravenous catheter B. you are a beginning nurse practitioner. Using Benner s stages of nursing expertise. disposing of syringes and needles in puncture proof containers C. Surgical sepsis is observed when: A. Iron 75 mg/100 ml 77. White blood cells (WBC) 9000/mm C. client with pulmonary emphysema B. Diabetic client C. demonstrating loyalty to the institution s rights C. Earn credits for license renewal B.

00 cc of Lanoxin today for 1 dose only . 500 mg tid D. Increased RBC count is linked to high cholesterol. Proper positioning of an immobilized unconsciousness client is important for the following reasons EXCEPT: 10 . Cocaine D. with a congenital heart deformity. phlebitis C. Teach the client how the infusion pump operates C. 96. heredity 87. Gomez. Since Potassium Chloride is a high risk drug. Administer Lanoxin intravenously as it is the usual route of administration D. When Nurse Norma was about to administer the medications of client Lennie.500 mg tid B. which of the following should Nurse Paolo prepare for each oral dose? A. Contractures and muscle atrophy D. Discuss the order with the pediatric heart specialist in the unit C. hypostatic pneumonia B.000 mg tid C. Rhona. Put aside the medications she prepared and instead administer the client s medications C. Tell the client that she will inform the physician about this D. has an order from her physician: give 3. damage to blood vessel B. thrombotic stroke 88.5 ml C. Clarify order with the attending physician B. D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Which of the following is the most appropriate action by the nurse? A.5 ml D. The available dose is 125 mg/ml. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. binge drinking D. 2. Santillan a 48 year old woman who is unconscious after a cerebrovascular accident. Hemorrhagic stroke D. Which of the following is the most appropriate action by the nurse? A. All are causes of hemorrhage. shabu B. Hold the nurse administration of the client s medication and refer to the head nurse B. 0. Part of your lesson plan is to talk about etiology or cause of stroke. aneurysm 89. The types of stroke based on cause are the following EXCEPT: A. Your best response is: A. 3 months old.5 ml B. High RBC count increases blood pressure. A participant in the STROKE class asks what is a risk factor of stroke. Bring the medications of the client to the nurse s station and prepare accordingly Situation 17 You are taking care of Mrs. Nurse Robert used an intravenous pump. 10 ml 93. the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. 1. Baby Liza. 1. B. pressure sores 97. Hypertension C. 91. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1. Amphetamines C. Situation 16 Accurate computation prior to drug administration is a basic skill all nurses must have. Impaired mobility C. Demerol 90. Cigarette smoking B. Which drug is closely linked to this? A. 50 mg tid 92. EXCEPT: A. Embolic stroke C.:273-2245 A. Have another nurse check the infusion pump setting D. Which of the following should Nurse Robert do to safely administer this drug? A.5 mg suspension three times a day. trauma D. Hemmorhagic stroke occurs suddenly usually when the person is active.5 gm daily in 3 divided doses for 7 consecutive days. diabetic stroke B. Which of the following is the correct dose of the drug that the client will received per oral administration? A. More red blood cell increases hemoglobin content. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. More red blood cells thicken blood and make clots more possible. a 2 year old female was prescribed to receive 62. Check the pump setting every 2 hours B. 1. Set the alarm of the pump loud enough to be heard 94. C. Refer to the medication administration record for previous administration of Lanoxin 95. You are aware that there are many physical complications due to immobility. You should be alert for the following complications she may experience EXCEPT: A.

Apply restraints D. Facilitates rest and sleep 98. After moving Mrs. Maintain skin integrity B. you should observe good body mechanics for yourself and the client. Uses large muscles only 99. You are going to move Mrs. which action will you avoid? A. Some principls to use when moving the client include the following EXCEPT: A. Promotes optimal lung expansion C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. a 150 lbs unconscious woman. prepare to move client by taking deep breath and tightening abdominal and gluteal muscles B. Santillan. move close to the object to be moved leaning or bending at the waist 100. Assumes correct body alignment and efficient use of muscles to avoid injury C. Place pillows to position client s extremeties C. When positioning your client.:273-2245 A. Uses back muscles B. Santillan to the desired position. push and pull using arms and legs instead of lifting D. Raise bed rails 11 . maintain wide base of support with feet and with knees flexed C. This means that the nurse: A. Avoid friction between bony prominences B. Prevent injuries and deformities of the musculo-skeletal system D. Observes rhythmic movements when moving about D.

A strategy for a change that focuses on teaching workers new technology is: A. the child assumes a caregiver role toward the caregiver 5. he or she can be disciplined by both the employer and the Board of Nursing. Manometer 4. Fluid meter B. is most likely to die without the transplant C. preterm birth B. when all selected children have appropriate tissue matches for the same donated organ. he or she can: A. Which is NOT necessarily correct? A. training D. Join a professional organization C. the good child takes on a bad child role C. macrosomia 8. a person who has been a good provider quits his or her job D. When a nurse breaches the duty of confidentiality. Head lag should not be tested until the child is over 1 year of age. is at the top of the list and has waited the longest time 3. The nurse knows that the occurrence of shoulder dystocia during labor is: A. B.:273-2245 NURSING PRACTICE II SET A MULTIPLE CHOICE 1. The nurse is assessing an 8 month-old infant for head lag. look away to reduce the intensity of the interaction D. Which of the following examples best defines the term role reversal? A. a lazy person becomes very productive in the family B. It does not need to be fitted by the physician.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. power coercive 7. D. drift off to deep sleep to shut out the interaction 9. transilluminator D. Organization C. subculture 2. pulling the infant by the hands from a supine to a sitting position. Culture D. Some strategies to maintain professional health are listed below. normative-reactive C. B. The nurse uses what equipment to check for fluid between the parietal and visceral layers of the tunica vaginalis. Registered nurses can be identified as a: A. The head does not stay in line with the body when being pulled forward. as the infant s head will not stay in line until after 8 months of age. C. 11. It may affect Pap smear results. be fined by the federal government C. the basis for the decision as to which child gets the organ is given to the child who: A. The nurse has not conducted the test correctly and must do it again using proper technique. Which of the following statements best represents the significance of this finding? A. is selected by the lottery system for available organs D. the outermost covering of the testes? A. will receive the most benefit from the new organ B. respond with coordinated. providing information B. The nurse instructs the mother that when overstimulated the infant will: A. D. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations. group B. be held responsible for any damages that result B. synchronous body movement C. maternal age D. C. polyhydramnios C. show increased alertness and eye contact B. immediately lose his or her nursing license 6. It must be removed within 24 hours. This is a normal finding. Among children candidates for organ transplant. It does not require the use of spermicide. Goal setting D. 30 cc syringe C. be sentenced for up to 1 year in jail D. 12 . Read fiction and non-fiction materials 10. In addition to this discipline. Networking with others in the health care field B. Which statement is correct regarding the use of the cervical cap? A.

speaker. Informal communication takes place when individuals talk and is best described by saying the participants: A. Two types: acute and subacute 16. A means of facilitating professional staff development is by building upon skills. career enhancement B. talk with slang words C. patient classification 13 . The school nurse notices a child who is wearing old. being raised by a parent of low intelligence quotient (IQ) B. he talks of playing outside until midnight. Secretory phase C. Proliferative phase B. written and nonverbal B. the novice to expert model C. minor problems B. dirty.:273-2245 12. Which of the following indicates the type(s) of acute renal failure? A. Three types: prerenal. Do you think your child s color is worse ? 18. facial expression. 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. have no particular agenda or protocol D. The major components of the communication process are: A. an orphan C. Being well and using every power the individual possesses to the fullest extent D. When the nurse asks the boy his tiredness. poor-fitting clothes. situational leadership model D. tone of voice and gestures D. One type: acute C. Four types: hemorrhagic with and without clotting. the severity of the burns on a 1 to 5 burn scale. message. a victim of child neglect D. The extent of burns in children are normally assessed and expressed in terms of: A. are relaxed 20. and nonhemorrhagic with and without clottings B. How does your child look to you today? C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. social. verbal. and mental well-being and not merely the absence of disease or infirmity 19. are involved in a preexisting informal relationship B. Which definition below is from Florence Nightingale? A. short-term needs D. has no lunch money. intrarenal and postrenal D. The nurse will suspect that this child is: A. benchmarking B. The state of being free from illness or injury C. sender. percentages of total body surface area (TBSA) C. is always hungry. A state or a process of being and becoming an integrated and whole person B. Where have you been all morning? D. receiver and feedback 13. clinically apparent disease 21. and is always tired. and of experience of each practitioner is called: A. Ischemic phase 22. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual participation model of care (NMPMC)? A. listener and reply C. A state of complete physical. the amount of body surface that is unburned B. staffing pattern C. Have you brushed your child s teeth today? B. skill mix D. 14. abilities. the victim of poverty 15. The endometrium thickens during which phase of the menstrual cycle? A. clinical ladder 17. how deep the deepest burns are D. Menstrual phase D. There are numerous definitions of the word health . channel. problems in mobility C. Tertiary care by the home health nurse is directed toward children with: A.

A fine rash over the trunk B. avoid the use of clothing on top of the diaper C. integrate individual experience with clinical research D. C. incorporate collaboration within all health care disciplines C. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. This is normal until the age of 1 year. put the diaper on as usual D. A. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis of Nutrition: Less than body requirements. D. but in some babies this just differs. C. Evidence-based care started in medicine as a way to: A. The nurse notes that the infant is wearing a plastic-coated diaper. She is stable and has minimal spotting and is being sent home. Asians D. Which of the following approaches would work best when the nurse is communicating with an infant? A. Allow the child time to warm up to the nurse. African Americans B. Based on this assessment. teach medical students the art and science of medicine 26. promote technological advances in medicine B. You were the nurse assigned to work with a child who has had whole brain radiation. These circumferences normally are the same. The skin turns yellow and then brown over the first 48 hours of life D. Accepting the imminent death of their child 32. D. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. on most days. and perhaps we can figure out the cause of this difference. fever and dysphasia. malaise. B. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea. C. The BEST response by the nurse is: A. avoid covering the area of the topical medication with the diaper B. more acute. Avoid intercourse for three days. Perhaps your baby was small for gestational age or premature. Maintain bed rest with bathroom privileges B.:273-2245 23. The nurse assessing a child or adolescent with a diagnosis of dysrhytmic disorder would find which of the following symptoms? A. Which of the following groups of people in the world disproportionately represents the homeless population? A. Accepting a reoccurrence of the tumor B. when the chest will be greater. Communicate through the caregivers. Which of the following interventions will be most helpful in resolving this nursing problem? A. Caring for the dying child D. 24. High-grade fever 27. A depressed or irritable mood for most of the day. 31. A depression that is deeper. Failure to pass meconium during the first 24 to 48 hours after birth C. for 2 or more years and low energy or fatigue. Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones and associated symptoms B. 28. 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. Respond only after the child cries for a while. B. Stay on left side as much as possible when lying down. Dealing with the side effects of radiation therapy C. Severe shaking of the hands when trying to hold a glass of water or other object C. Let me ask you a few questions. you are to work with the patients in which of the following areas. D. Caucasians 29. Two large meals a day instead of several minimeals and snacks 14 . apply an icepack for 5 minutes to the outside of the diaper 30.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Hispanics C. Use an adult voice just as you would for anyone. Call if contractions occur. Which of these instructions to the client may indicate a need for further teaching? A. 25. and more likely to lead to suicide than major depressive disorder D. the nurse would teach the caregivers to: A.

Being a good friend to the client by sharing secrets D. desirability and feasibility. The well-being of the community 39. vitamins and minerals D. Breech position B. the child has been blamed by the abuser for his or her sexual behaviors. Organize. Self-regulation 34. Understand. Continuous. Substantiate C. Effective communication D. Right Occipito-Anterior Position D. Doing whatever the client or the client s physician asks of you. people issue C. FOCUS methodology stands for: A. Saving the client time and money by not wasting supplies 40. B.:273-2245 B. Opportunity. Focus. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. political issue B. 42. saying that the child asked to be touched or did not make the abuser to stop D. and omission of highly seasoned foods. technology issue 35. The parents have dipped the child into hot liquid while he or she was asleep C. The child was wearing a glove when immersed in hot liquid D. Clarify. 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. Diet as tolerated with lactose hydrolyzed milk instead of milk products. newspapers and the media don t keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. Which of the following is the best example of the ethical principle of fidelity? A. The painful phenomenon known as back labor occurs in a client whose fetus in what position? 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. Empathy B. Which is NOT a characteristic of emotional intelligence? A. Left Occipito-Posterior Position 37. Organize. provide statistics for the Department of Health B. Clarify. Self-awareness D. The well-being of the extended family D. reassure the family that the nurse will respect the family s wishes at all times 15 . Self-esteem C. Personality of the participants 41. structural issue D. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot scalding water B. The well-being of the chronically ill B. Focus. Substantiate D. Emotional intelligence consists of a number of competencies. a child blames him or herself for the sexual abuse and begins to withdraw and isolate B. Understand. and reduction of fiber 33. Salt-free diet high in potassium. Continuous (process). Which of the following statements best describes the term glove type burn? A. Understand and Solution B. which of the following do they also have as their final objective? A. Utilize. Some of these are listed below. While community health nurses focus on the individual or the family. Brow position C. Data collection for driving and restraining forces. The financial well-being of the family C. Special IBD diet (diet that has been proven effective for treating IBD) C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Solution 38. The burn has the look of a glove immersed in hot scalding water. Opportunity. Transference and counter transference C. Focus. Keeping a promise to return to the client s room at a given time C. the child s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge 36. including costs. is a: A. The nurse likely keeps this list to: A. Type of illness of the client B. Focus.

and cloudy urine. and A. In working with the caregivers of a client with an acute or chronic illness. the national emphasis on sex B. or the child found to have 3-4+ proteinutria plus edema. Teach care daily and let the caregivers do a return demonstration just before discharge B. meet national government requirements D. The pill prevents the uterus from making such endometrial lining. A client says she heard from a friend that you stop having periods once you are on the pill . and restlessness B. 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. D. the child experiences a remission. both parties involved are committed to solving the conflict D. The most appropriate response would be: A. B. Only their own 44. C. loss of sensation in the legs.8 degrees (100 degrees F). C. the conflict is settled out of court so the legal system and the parties win 45. 43. Preschoolers are able to see things from which of the following perspectives? A. the win-win approach occurs when: A. there are two conflicts and the parties agree to each one B. and an arching of the back D. diarrhea. 16 . D. In conflict management. 49. diminished or absent gag reflex. increase in urine output. Difficulty swallowing. genetics D. You are now checking to make sure the child does not have a relapse. four factors place the family members at risk for abuse. and respiratory distress C. Difficulty swallowing. and an arching of the back D. relax because these symptoms will pass and the child will be fine C. extreme thirst. Nurture 47. hypervigilant. C. diminished or absent gag reflex. Their own and their caregivers C. administer syrup of ipecac D. By following the prescribed treatment regimen. facilitate exclusion in case of an outbreak of a highly communicable disease in the school. the child. has bloody diarrhea. that is why periods may often be scant or skipped occasionally. Missed period can be very dangerous and may lead to the formation of precancerous cells. and respiratory distress. If your friend has missed her period. call emergency medical services (EMS) and get the child to the emergency room B. and vomiting 48. Elevated temperature. Which finding would most lead you to the conclusion that a relapse is happening? A. Her child is now vomiting. The pill should cause a normal menstrual period every month. Weakness of the leg muscles. These risk factors are the family itself. cough. burning frequency. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. 51. Paradoxical irritability. the presence of a family crisis C. A temperature of 37. these risk factors are the family members at risk for abuse. Neoclassic B. and is complaining of abdominal pain. Difficulty sleeping. she should stop taking the pills and get a pregnancy test as soon as possible. the nurse would: A. and vomiting. and a moon face. urgency on voiding. hypervigilant. A urine dipstick measurement of 2+ proteinuria or more for 3 days.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Nature D. You will tell the mother to: A. Difficulty sleeping. Naturalistic C.:273-2245 C. this person is most probably coming from which of the following viewpoints or theories? A. It sounds like your friend has not been taking the pills properly. sore throat. The urine dipstick showing glucose in the urine for 3 days. When a person is discussing the strong influences that childrearing methods have on the development of the child. the caregiver. flank pain. Paradoxical irritability. According to the social-interactional perspective of child abuse and neglect. each party gives in on 50% of the disagreements making up the conflict C. Their peers B. You are the nurse assigned to work with a child with acute glomerulonephritis. Their own and their mother s D. call the poison control center 50. changing complete blood count (CBC) with diiferential B. chronic poverty 46. diarrhea.

Estimated fetal weight D. Which of the following best describes a difference in communicating with school age children versus toddlers? A. Loneliness D. When someone on a date tricks the other person into having sexual intercourse D. leave the child in the care of an older child and go get help D. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. C. Toddlers require more empathy and more touching and holding B. The nurse s best course of action is to: A. Push the child to practice sports activities while they are more flexible B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Separate caregiver sleeping room on the unit C. Placental maturity C. competence 54.:273-2245 52. supervision D. For toddlers. Avoiding physical contact such as sports hugs or swats 60. the lose-win approach 58. keep assessing. Genetic testing should be performed on a child only if A. delegation C. Identity 53. Making certain towels have been washed in boiling water D. Caregivers need less information when care involves a school aged child D. losing C. When one person allows the conflict to be resolved at his or her own expense. Which of the following arrangements is generally considered to be best for the parents of hospitalized infant or young child? A. stay with the child. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. A child suffers a head injury in a tumbling accident in gym class. which includes a number of young men who are on competitive sports teams. Which of the following statements best describes acquaintance rape? A. winning while losing D. 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. Isolation C. preparation for procedures is just before the procedure and much earlier for school-aged children. At 17 weeks gestation. The use of interpersonal decision making. the parents both want it performed 17 . Encourage a variety of physical activities in a noncompetitive environment C. Day visits and sleeping at home D. The number of words is more when communicating with a toddler than it is with a school aged children 62. The American Academy of Pediatrics suggests that caregivers do which of the following things in regard to physical activities for preschoolers? A. the win-lose approach B. Sexual intercourse committed with force or the threat of force without a person s consent. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. a type 1 diabetic undergoes an ultrasound examination. this is referred to in conflict management as: A. Have the child engage in competitive sports to see where they excel D. No sharing of underarm deodorant or shower soap B. Staying at a nearby hotel or motel 57. Keep physical activities to a minimum until the child is in grade school. get the child up walking and make sure he or she stays awake B. No sharing of razors or toothbrushes C. The school nurse is teaching a health education and hygiene course to a group of high school males. Rooming-in B. 59. When two people don t love each other and engage in sexual activities C. leave the child and go get help C. Lack of fulfillment B. psychomotor skills. The nurse will likely work with this adolescent in which of the following areas? A. What information about the fetus at this time in pregnancy would be the results of this examination provide? A. and have someone call the caregivers 55. Gestational age B. Fetal lung maturity 61. responsibility B. 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. 56.

two concepts 67. three questions B. Eye contact D. Pediatric nurse practitioner 65.:273-2245 B. Ancillary speech D. The plan-do-study-act cycle begins with: A. plastic panties over diapers B. which tells nurses how to make ethical decisions C. The nurse is working with a child who is going to have a bone marrow aspiration. cloth diaper 73. During your shift. 1+ ketones in the urine 68. remind caregivers to do cord care B. is a binding oath. allow visualizations at all times 71. Which of the following roles BEST exemplifies the expanded role of the nurse? A. subcutaneous C. Infant head control is judged by the: A. you noted one of your pregnant clients considered as waiting case manifest morning sickness and which later progressed. Enhancements 66. Which difference does NOT necessarily belong? A. no one objects 63. The level of health of an individual. absorbent disposable diapers C. FHT 155 B. Subject matter B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. group. volume. five agendas D. population. The nurse explains that one of the preventive measures is the use of: A. Conversational style 70. delineates all obligations and responsibilities of the nurse B. rigidity of the neck and head D. The physician orders TAC (tetracaine. Nasal inhalation 69. Personal behavior C. amount of neck wrinkling 64. assists the nurse in formulating a personal belief system D. speed. supports the concept of respect for all persons 18 . family. The nurse is teaching a group of expectant mothers about the prevention of diaper dermatitis. IV using a very slow drip over approximately 4 hours prior to procedure D. Which of the following is the route of administration? A. cultures have different patterns of verbal and nonverbal communication. baby powder or cornstarch D. The tone and pitch of the voice. it is in the best interests of the child C. Which assessment finding may indicate possible developing complication? A. Paraverbal clues C. Maternal pulse 90 C. four stages C. Third element B. presence or absence of head lag C. or community is called: A. keep the diaper from rubbing the cord C. Medication nurse C. The Code of Nurses A. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in such a way as to expose the cord. Circulating nurse in surgery B. grunts and other vocalizations are referred to by which of the following terms? A. adrenaline and cocaine). According to DeRosa and Kochura s (2006) article entitled Implement Culturally Competent Health Care in your workplace. infection. application to the skin. health needs 72. Obstetrical nurse D. it i9s necessary for the child to survive D. The major purpose of exposing the cord is to: A. health assets C. health status D. provide air circulation for the cord D. covered with a dressing prior to the procedure B. ability to hold the head without support B. Trace glucose in the urine D. quality of life B.

Measuring the length of the cord to be certain that it is longer than 3 feet. the baby is called a zygote D. Situation 2 Health instructions are essentially given to pregnant mothers. Marichu is scheduled to have an ultrasound examination. smoking. D. Delegation C. Swelling of the face D. Assessing whether the Wharton s jelly of the cord has a pH higher than 7. Presence of dark color in the neck B. B. What assessment of a fetus at birth is important to help detect congenital heart defect? A. During a routine postpartum assessment following a normal vaginal delivery. Marichu is worried that her baby will be born with a congenital heart disease. drinking. B. 81. Assessing whether the umbilical cord has two arteries and one vein. D. B. the nurse notes the fundus to be slightly boggy. Inevitable abortion 19 . Position the client in a slight Trendelenburg position. Which action should the nurse take to decrease the risk of uterine inversion during uterine massage? A. D. No more amniotic fluid forms afterward. Void immediately before the procedure to reduce your bladder size. accountability 75. C. You can have medicine for pain for any contractions caused by the test. C. Increased vaginal discharge C. the X-ray used to reveal your fetus position has no long term effects. Has MArichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy. On physical examination. What instruction would you give her before her examination? A. The following conditions pertain to the GROWING FETUS. C. or attempts to terminate pregnancy. Ask the client to ambulate to the bathroom to empty her bladder. Massage only when cramping begins.2. responsibility B. Drink at least 3 glasses of fluid before the procedure. Place one hand on the abdomen above the symphysis pubis. Has MArichu engaged in sexual activity during the fetal development state of her child. Void immediately before the procedure to reduce your bladder size. D. From the time of implantation until 5 to 8 weeks. 80. Which term best describes the client s condition? A. D. the baby is an embryo C. A woman who is 9 weeks pregnant comes to the Health Center with moderate bright red vaginal bleeding. Additionally. B. Has Marichu been overly anxious about something. The obligation to correctly perform one s assigned duties is: A. C. The intravenous fluid infused to dilate your uterus does not hurt the fetus. The intravenous fluid infused to dilate your uterus does not hurt the fetus. What would Nurse Lisa hope to find? A. the physician finds the client s cervix 2 cm dilated. Has MArichu engaged in any detrimental activities during the fetal development stage e. 76. B. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo. taking drugs.:273-2245 74. Assignment D. a bad fall. C. 79. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy? A. This term is used during the time before fertilization 77. 78. Nurse Lisa would gather more information about Marichu s worry about what may threaten the health of her baby. Marichu is scheduled to have an amniocentesis to test for fetal maturity. 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 and children. Breast tenderness 82. which is why only a small amount is removed. Her baby will be a fetus as soon as the placenta forms B. What would be your best explanation? A.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Missed abortion C. After the 20th week of pregnancy. What instruction would you give her before this procedure? A.g. Determining that the color of the umbilical cord if not green.

Urinary tract infection B. Premature rupture of membrane 85. Incomplete abortion D. abdominal pain and vomiting 20 . Those under early detection B. Who among the following are recipients of the secondary level of care for cancer cases? A. In Community Health Nursing. nursing research B. 35 year old postpartum client is at risk of thrombophlebitis. Hypocalcemia D. The following is NOT an indicator for hospitalization of H-fever suspects? A. Those scheduled for surgery 90. Early detection 87. Which among the following is the primary focus of prevention of cancer? A. Threatened abortion 83. early ambulation C. Those under early treatment C. What complication of this condition is of most concern to Nurse Pura? A. Mrs. Conduct community assemblies. Treatment at early stage D. groups and community the nature of the disease and its causation D. Grand multiparity B. Use the nine warning signs of cancer as parameters in our process of detection. 86. Epidural anesthesia ` D. D. Marked anorexia. The following conditions apply. In the prevention and control of cancer. This is nursing parlance is nothing less than the: A. Those under post case treatment C.:273-2245 B. Those undergoing treatment 89.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. administration of anticoagulant postpartum D. nursing diagnosis C. An important role of the community health nurse in the prevention and control of Dengue Hfever includes: A. which of the following activities is the most important function of the community health nurse? A. Who among the following are recipients of the tertiary level of care for cancer cases? A. nursing protocol D. 88. Elimination of conditions causing cancer B. the best tool any nurse should be well be prepared to apply is a scientific approach. It does not only pose a threat to health but more so to the lives of both young and old. Nurse Pura is taking care of a woman with a diagnosis of abruption placenta. Community health nurses should be alert in observing a Dengue suspect. Those under early case detection B. This approach ensures quality of care even at the community setting. immobilization and elevation of the lower extremities Situation 3 With the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. Diagnosis and treatment C. Hacienda Gracia. C. In a big government hospital. families. Disseminated intravascular coagulation 84. Those under supportive care D. breastfeeding the newborn B. nursing process Situation 4 Dengue hemmorhagic fever is a common health concern in Philippine society. Teach woman about proper/correct nutrition. Pulmonary embolism C. B. explaining to the individuals. Which of the following nursing interventions decreases her chance of developing postpartum? thrombophlebitis? A. conducting strong health education drives/campaign directed towards proper garbage disposal C. control and treatment modalities. practicing residual spraying with insecticides 92. 91. despite the availability and use of many equipment and devices to facilitate the job of the community health nurse. advising the elimination of vectors by keeping water containers covered B. Referral to cancer specialist those clients with symptoms of cancer. Those scheduled for surgery D. Which of the following findings on a newly delivered woman s chart would indicate she is at risk for developing postpartum hemorrhage? A. and well as rich and marginalized sectors of the society. Post-term delivery C.

No dehydration 99. Avoid unnecessary movement of patient D. for infants under 6 months old who are not breastfed. Using Integrated Management and Childhood Illness (IMCI) approach. Give aspirin for fever B. 30 breaths per minute or more D.:273-2245 B. Severe dehydration B. the 2nd child has diarrhea for 5 days. reassess the child and classify him for dehydration B. D. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue H-fever? A. Steadily increasing hematocrit count D. and her temperature registered at 37 degrees C. keeping the patient at rest 94. Pneumonia 97. 60 breaths per minute 98. Bronchopneumonia C. Nina 18 months old weighed 18 kgs. 50 breaths per minute C. Nina s treatment should include the following EXCEPT: A. Dysentery D. Fall in the platelet count 95. Prolonged bleeding time B. how would you classify the 1st child? A. 40 breaths per minute or more B. advising low fiber and non-fat diet B. Replacement of body fluids C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. The community health nurses primary concern in the immediate control of hemorrhage among patients with dengue is: A. The 1st child who is 13 months has fast breathing using IMCI parameters he has: A. Ice cap over the abdomen in case of melena Situation 5 Two children were brought to you. No pneumonia: cough or cold D. observing closely the patient for vital signs leading to shock D. Give in the health center the recommended amount of ORS for 4 hours. While on treatment. no chest indrawing. Some dehydration C. give 100-200 ml clean water as well during this period C. Increasing hematocrit count C. How would you classify Nina s manifestation? A. Persistent headache 93. Do not give any other foods to the child for home treatment 100. Severe pneumonia D. Severe pneumonia B. The nurse offered fluids and and the child drinks eagerly. She is irritable. No pneumonia C. How would you classify Nina s illness? A. Bronchopneumonia 21 . and her eyes are sunken. Nina has no general danger signs. There is no blood in the stool. Her mother says she developed cough 3 days ago. Which of the following is the most important treatment of patients with Dengue H-Fever? A. One with chest indrawing and the other had diarrhea. providing warmth through light weight covers C. no strider. She has 45 breaths/minute. Pneumonia B. Fever for more than 2 days D. Appearance of at least 5 petechiae C. The following questions apply: 96. Nina.

hypovolemia D. I shall call the nurse when my wound itches and smells . certificate of Employment 10. 22 . Local pain with no radiating pain or signs of nervous compassion D.:273-2245 NURSING PRACTICE III SET A ________________________________________________________________________ MULTIPLE CHOICE 5. As a surgical nurse. Let her cry and tell significant other to stand by. which of the following nursing intervention will allay anxiety and pain among? surgical patients? A. liberal fluid intake C. The board of Nursing is vested with power to issue. hypoxemia 6. What is the basic requirement of the state for a nurse to practice her profession? 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. There is an order of Central Venus pressure (CVP) reading. What is the crucial in determining a good candidate for rhizotomy? A. Anytime the examinee wants to take the examination C. certificate of Good Moral Character C. 30 credit units for 3 years D. 6. Pulmonary edema is a potential danger that we nurses should monitor in post pneumonectomy. The code of Good Governance for the professions in the Philippines shall be adapted by: A. fluid retention due to prolonged bed rest Situation 2-The PRC regulates the practice of 42 professions in the Philippines. certificate of Practice D. 10 credit units required 9. This is usually due to: A. certificate of Registration B. extreme temperature B. rapid infusion of IV fluids D. C. Check her name tag and request anesthesiologist to sedate client 14. Stand by her side and quietly ask her to describe her feelings. An NCLEX and CGFNS passer 7. 20 credit units per year C. Verify that the operated permit is signed C. hypothermia B. Within the same year after the filed examination Situation 3 . all Filipino professionals D. A nursing license D. all professionals B. Discourage the client from discussing the details of the surgical procedure D. RA 7193 stipulates the removal examination of the nurse licensure examination shall be taken: A.Pain is always associated to surgery 11. A BSN degree C. 60 credit units for 3 years B. The standardized guidelines and procedures for the implementation of Continuing Professional Education (CPE) for all professional. Within 2 years after the last failed examination D. Pain which is resistant to pharmacologic protocol for 12 months C. all registered professionals C. Willingness to practice the profession B. all registered nurses 8. Deep pain with obvious signs of peripheral nerve damage 13. suspend or revoke for cause the: A. D. Which of the following clients statement indicates that he understands the nurse s instruction about postoperative wound pain? A. Squeeze her hand and assure her that there will b no pain at all because she will be given anesthesia. Ensure safety of client while in surgery 12.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Asses the client for concerns especially those that can potentially cause pain B. Pain which is resistant to non-pharmacologic for 6 month B. Rhizotomy is a condition surgical procedure to manage those that can potentially cause pain. hypoxia C. Within 3 years after the last failed examination B. As a nurse that this is a measure of observing signs of: A. Resolution Number 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be: A. B.

Older patients do not believe in analgesics. Placebos do not indicate whether or not a client has: A. Nurses should be aware that older adults are at risk of underrated pain. Wrap the instrument with sterile water C. Material compatibility and efficiency B. Disinfected 22. Cover the soaking vessel to contain the vapor B. Double the amount of high level disinfectant 23 . Divert attention of client in pain B. Drowsiness B. Believe what the patient says about the pain D. Older patients seldom tend to report pain than the younger ones B. Start another drug and slowly lessen the opioid dosage B. Dry the instrument thoroughly D. they are tolerant D. 16. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain. Before you use a disinfected instrument it is essential that you: A. Physical dependence occurs in anyone who takes opioods over a period of time. Rinse with sterile water 24. Complaining of pain will lead to being labeled a bad patient 17. Disease B. What symptom. What should you do? A.As a preoperative nurse. Rinse with tap water followed by alcohol B. C. Forgetfulness C. Identify the absence and presence of pain D. As an OR nurse. 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. 21. Odor and availability C. Constipation D.:273-2245 B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. D. Isolate opioid dependent to a restful resort D. I shall expect slight pain and discomfort from the surgical incision . Indulge in recreational outdoor activities C. Decontaminated D. Clean C. you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. more distressing than pain. The pain is vague B. Nurses should understand that when a client responds favorably to a placebo. Pain is a sign of weakness C. What do you think is an important responsibility related to pain that is subjective in nature? A. I should call my doctor if my wound has no drainage and intact . Cost and duration of disinfection process D. Allergic reactions like pruritis 20. what are your foremost considerations for selecting chemical agents for disinfection? A. What do you tell a mother of a dependent when asked for advice? A. Leave the patient alone while in pain C. As the client to point to the painful are by just one finger 19. 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. Sterilized B. Duration of disinfection and efficiency 23. should the nurse monitor when giving opioids especially among elderly clients who are in pain? A. By charting-it hurts all over C. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms Situation 5. it is known as the placebo effect . Real pain D. Nursing assessment and management of pin should address the following beliefs EXCEPT: A. Conscience C. I should not touch my surgical wound 15. Drug tolerance 18. How can you assist such client? A.

Situation 9-pain management is not limited to pharmacological means: 41. An example of collaborating effort on public service particularly during summer is: A.5 ml B. Supporting political candidates that advance nursing care issues B. Disinfected C. OR shoes. Mask. The doctor ordered to incorporate 1000 u insulin to the remaining ongoing IV.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Clean B. scrub suit. Joining the Mayo Uno Labor Union C. 10 ml C. Following the decision of CGFNS to retake Test III and IV to validate the visa screen for the U. you know that intact skin acts as an effective barrier to most microorganisms. What OR attires are worn in the restricted area? A. OR shoes C. The strength is 500 /ml. Scrub suit. OR shoes. gloves. items that come in contact with the intact skin should be: A. Prolong the exposure time according to manufacturer s direction 25. Alcoholized Situation 6-The OR is divided into three zones to control traffic flow and contamination 26. Collaborate with DOH regarding disposal or specimens 37. Boto mo. Vital signs including BP C. store in the freezer Situation 8-Collaborative planning is essential if nursing and health care are to be made available to all people. When the nurse communicates to the attending physician the desire of the patient to be seen by an urologist D. When does a nurse reject the interdependence of providers and patients in achieving access to health care? A. This is exemplified in: A. head cap B. Collaboration with other OR personnel regarding the practices of surgeons collecting exorbitant professional fees D. Multiple vial-dose-insulin when in use should be A. kept in the refrigerator D. mask. Operation Linis D. Clean and Green B. You questioned his treatment because: 24 . Nursing intervention for a patient on low dose IV insulin therapy includes the following. The doctor is not on duty today 40. Affiliating with the Healthcare Alliance 38. Communicate with other members of the health profession to improve the integrity B. mask. 36. shoes 33. Operation Tuli 39. Joining labor day rally to increase wages of healthcare workers and improve dilapidated health centers D. 5 ml 35. Ipatrol mo C. Elevation of serum ketones to monitor ketosis B. Test the potency of the high level disinfectant D. Individual patients and society as a whole benefit from nursing participation in decisions made about health care. The nurses collaborate with other members of the health profession to improve the integrity of the hospital working environment the following ways EXCEPT A. Elevation of blood glucose levels 34. Head cap. Perioperative examples of collaboration are the following EXCEPT: A. kept at room temperature C.S. EXCEPT: A. When the nurse replies to the client s relative You have the best doctor in town C. kept in narcotic cabinet B. Joining barangay health club projects B. Bringing the NCLEX in Philippines C. Cap. 0. Supporting the proliferation of colleges of nursing in the country D. Our hospital does not honor visiting doctors B. Sterile D. scrub suit D. Estimate serum potassium D.:273-2245 C. 2 ml D. As a nurse. Therefore. 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. How much should you incorporate into the IV solution? A. Communicate with health officials the incidence of Hepatitis B among OR personnel C.

D. Which action by a new nurse signifies a need for further teaching in infection control? A. Change the attendant s assignment C. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? A. Which action should you pursue? A. knee-chest exercise before menstruation and hot water bag application over lower abdomen during onset C. 47. The nurse colleague charting medication administration that she has not yet given 50. Try to explore the interaction with the nursing attendant concerned B. You saw one colleague charting medication administration that she has not yet administered. The client sleeps well D. You have been in the surgical ward for almost a year and have cared for a number of patients with CVP. C. Which of the following clients at the PACU will demonstrate the effectiveness of ? teaching? A. Initiate a group discussion with all other nursing attendants D. Monitor the situation and note whether any other items are reported missing. Charge the erring nurse with dishonesty D. Ignore the situation because you are busy C. You noted that the orderly was looking through the items of one of the patients. The nurse uses her bare hands to change the dressing D. The colleague instructs the clients to perform the valsalva maneuver during the CVP reading D. ice cold drinks 45. Terminate the nurse C. coughing. At 9:30 AM. Call the attention of the orderly in private B. He asked you for an eye ointment to relieve the pain and swelling. The nurse applies oxygen catheter to the mouth. After talking to her. Repot to the Board of Nursing Situation 11 You are assigned at the PACU. hot compress over the right eye C. The client demonstrated deep breathing. You are on PM shift and about 5 patients are of discharge. The client manifests normal temperature C. Report this behavior to the nurse in charge D.:273-2245 A. splintering and leg exercises. 48. Acupuncture uses variety of herbs and oils from wild plants C. The client has good balance I and O 25 . Knowledge deficit related to lack of information because patients are all sedated. The nurse places the side rails the time to an unconscious patient B. Menstrual pain and discomfort account for absences in schools and offices. You should offer: A.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. C. Require the staff to submit an incident report B. diet restriction on fatty foods and liberal fluid intake Situation 10 One learns by doing especially when you practice the best methods. Discuss the matter with the patient s family 49. A nonpharmacological remedy for menstrual pain is: A. The colleague turns the stop-cock to the off position from the IV fluid to the patient B. warm shower during onset of menstrual period D. Which nursing diagnosis has priority among client in the PACU? A. tetracycline ophthalmic ointment D. Ineffective airway clearance related to general anesthesia. you also report the incident to the charge nurse. Which observation from a colleague would indicate a need for further teaching? A. Body image disturbance because of wound dressing and drains. post-op clients started to be ? in from the OR 51. Acute pain related to discomfort off wound and immobility B. Acupuncture uses manipulation of the skeletal muscles to relieve stress and pain D. Acupuncture uses pressure from the fingers and hands to stimulate body responses 42. ice pack over the right eye B. The nurse colleague noted the level at the top of the meniscus C. Acupuncture uses needles to stimulate certain points on the body to treat pain B. 46. The nurse elevates the head of the bed to check the BP. B. The charge nurse should: A. Your younger brother came home with right black eye. 52. regular bowel movement B.

biomedical division C. While you were making your endorsement. A suction being too high C. inches 60. Which of the following condition is the possible cause of the malfunctioning sealed drainage? A. After an hour you noticed that the bubbling stops. What would your instruction to the family include to prevent accidents? A. The body has reached its new set point thus the absence of shivering D. amputated limbs) disposal should be coordinated with following agencies EXCEPT: A. If the wound is painful. Shivering normally disappears as temperature becomes higher C. Assist the client back to his bed and place him on the affected side B. The patients is feeling better Situation 12 Patients with chest tubes can be very challenging to new nurses. Keep the room lights on for 24 hours D. of Tirso s chest tube. chaplaincy services D. It is alright to use adhesive tape over the wound to keep it intact C.e. A. Report when the IV infusion is almost finished B. disconnected B. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. french C. milliliters B. infection control committee B. you found out the chest tube of a client was disconnected. Test the call system if functioning C. DOH D. Continuously breathe normally during the normal of the chest tube B. DILG 26 . I will say it is normal B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus.9°C and was shivering. Reconnect the tube to the chest tube system D. A tension pneumothorax 57. closed C. EXCEPT: A. placed lower than the patient s chest D. and healthcare providers. Crematorium C. MMDA B. the nurse collaborates with the following departments. A tube being too small B. exhale. Hold breath until the chest tube is pulled out 59. gauge D. What would be your appropriate action? A. Exhale upon actual removal of the tube D. It is ok for his pet to remain at his bedside to keep him company D. An air leak D. One of your post-op patients has a temperature of 37. When transporting clients with chest tube. Which of the following remark indicates that the client s relative understood the discharge instruction for wound care? A. To control environmental hazards in the OR. Reyes asked you to assist him with the removal. The nursing student asked you to explain the absence of shivering even if the temperature was higher. the system should be: A.9°C. I will report any redness or swelling of the wound 54. Put the end of the chest tube into a cup of sterile normal saline 58. and bear down C. Make sure the side rails are up 55. Chest tube diameter is measured or expressed in: A. Cover the end of the chest tube while sterilize gauze C. You covered him with a blanket and later took his temperature again and it is now 38. placed between the legs of the client to prevent breakage Situation 13 The preoperative nurse collaborates with the client significant others. Waste disposal poses a big problem for the hospital. Biological wastes (i. 56. Take a deep breath. Dr. You must transfer out a post-op client to her room. 61. The patient is no longer febrile thus he is no longer chilling B. You would instruct the client to: A. pathology department 63.:273-2245 53.

Nurse supervisor C. It improves insulin utilization and lowers blood glucose C. who is diabetic is for debridement if incision wound. 6 cm B. Patient s chart 72. Deliver a pre-meal bolus dose of insulin before each meal. D. Communicate with the client to verify if insulin was incorporated D. emotional. Surgeon B. the PACU nurse. Prevent unexpected saving in blood glucose measurements. Rosie.:273-2245 64. It will make you fit and energized Situation 15. Progress notes B. You wrote an incident report to show: A. Presence of prosthetoid devices such as dentutes. B.g. Anesthesiologist D. It burns excess glucose B. and psychosocial data C. What is the effect of regular exercise to a diabetic client? A. Observed untoward signs and symptoms and interventions including contaminant intervening factors 73. Malou found out that she has an order of Demerol 100 mg I. Deltoid area C. Tess. prn for pain. The current insulin pumps available in the market have the following capability. Baseline physical. Mr. EXCEPT: A. You will recommend this technology in the following diabetic patients. 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.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Abdominal area 69. It lowers glucose. Incident report C. Double check the doctor s order and call the attending MD B. Tipol. Gluteal area B. Detect signs and symptoms of hypoglycemia and hypocalcaemia. When the circulating nurse checked the present IV fluid. she found out that there is no insulin incorporated as ordered. is in severe pain 3 hrs after cholecystectomy. this should document in the: A. 57. Incorporate insulin as ordered. It is critical also that a diabetic client should be educated in the possible sites if regular insulin injection. What should the circulating nurse do? A. 2. Document the incident 27 .M. 66.5 cm D. The fastest absorption rate happens at the tissue areas of: A. Intern on duty 65. Communicate with the ward nurse to verify if insulin was incorporated or not C. discovered that Malou. Unstable diabetes C. 71. streptomycin was given by IV not IM. Discharge plan of diabetic clients include injection-site-rotation. artificial limbs hearing aid. Nurse s not D. Anterior area D. It is necessary for a diabetic client to exercise regularly.RN s should always be conscious that the contents in charting are admissible in court as evidence. 4 cm 68. Abdominal renal glucose threshold 70. decrease total triglyceride levels D. Arguments between nurses and residents regarding treatments D. B. Hypoglycemia without warning D. Which of the following should NOT be included in the patient s chart? A. Self-monitoring of blood glucose (SMBG) is recommended for patient s use. Tess should verify the order with: A. EXCEPT: A.0 units per hour 67. improves insulin utilization. You should emphasize that the space between sites should be: A.0 units to 2. etc. 5 cm C. Deliver a continuous basal rate of insulin at 5.During your morning rounds. Upon checking the chart. The documentation of all nursing activities performed is legally and professionally vital. who weights 110 lbs prior to surgery. Situation 14 Technology and patient s education has dramatically improved the management of the diabetic client. If there is any deviation from normal practice or procedure e. Client with proliferative retinopathy B. C.

Decreasing systematic hydration C. Regularly administering prescribed vasoconstrictive medication B. For nurse to asses an upper respiratory tract infection. 76. age. eyes. Name. Name of the client. age. Refrigerate and send it along with the day s specimens B. sex. How will you label this specimen? What information was essential in the label? A. sex C. The following are some tips on how to do corrections EXCEPT: A. wants to read her chart. Insert additions or corrections D. Suggest a soft or liquid diet during acute stage B. Local heat application to promote drainage B. Present confidential report D. type of specimen. You will include the following measures EXCEPT: A. Instruct client about symptoms of secondary infections B. Evidence of the quality of care 74. Positional drainage D.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. One of your cases is with acute pharyngitis. nose. Her uncle. Increase humidity D. hospital number. Soak it in formalin 82. Kathy is one of your patient s. Name. Apply ice collar for sympathetic relief of severe sore throat 77. The ears. hospital number B. Among the patients with upper airway infection. Refer to the hospital director C. Cross out wrong word or phrase with one or two lines making the crossed out word discernible C. doctor D. Refer to the attending physician Situation 16. Soak it in NSS D. Your nursing management includes the following EXCEPT: A.:273-2245 B.During the month of July. The tracheal and nasal mucosa including the frontal sinuses 78. and additions in medical records and the nurse s notes can be avoided. Encourage bed rest during stage D. site. and throat B. Administer prescribed antibiotics C. who is a doctor. Cross out blank spaces B. Instruct Kathy s uncle to present a written authorization signed by the patient B. Be a part of the patient s chart C. doctor. Teach that the causative virus is contagious even before symptoms appear D. Humidifying inspired room air 79. you noticed that there is an incidence of upper respiratory Disorders. Nose and throat only D. Consult an ENT surgeon C. Your appropriate action would be: A. Advice adequate fluid intake Situation 17. She is scheduled in your room on 5 for frozen section. age. type of specimen. you should palpate the following: A. Send to pathology immediately without soaking solution C. Erasures. How will you prepare the specimen for laboratory? A. Name of the client. alterations. A friend asked you some nursing measures of uncomplicated common colds. Adenoids tonsils and nose C. The following are your nursing suggestions for a patient with acute or chronic sinusitis EXCEPT: A. airway clearance can be facilitated by the following EXCEPT: A. Encourage liberal amount of cold fruit juices C. hospital number 28 . State the reason for any deviation from normal procedure/practice 75. Carmen is suspected to have a left CA. Instruct Kathy s uncle to present a written request to the Medical Records Section of the hospital D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. 81. Suggest adequate of fluids and rest 80.

Temperature and humidity are set for patient and personnel safety and reduce bacterial contamination. You are the nurse in charge in Mr. Supine B.:273-2245 83. it is normal to observe one the following: A. seeds or bullets are also considered as a specimen. and urethral opening D. Santos.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. The OR is a restricted area where OR attire is worn. When asked what are the organs to be examined during cystoscopy. 86. you will position Mr. Trendelenburg 88. Signs of infection D. Nurse s station 85. contamination should be confined and contained within the immediate vicinity of the surgical field to prevent the spread of pathogenic microorganisms. 91. Mr. B. In the OR. blood. D. Santos who is cystoscopy in: A. Lithotomy C.Mr. After cystoscopy. A post dilation and curettage (D and C) client is for discharge. Semi-fowler D. Pink-tinged urine B. 89. The OR head nurse D. All blood tissue. Prolonged hematuria 90. You assisted in the multiple gun-shot wound exploration. Surgeons conduct their patient s rounds in scrub suit D. 50. is to undergo cystoscopy due to multiple problems like scantly urination. ureteral opening bladder 87. Follow-up of lab result should be part of the discharge plan. Within 24-48 hours post cystoscopy. Hot sitz bath Situation 19. During the surgery the specimen to: A. You will instruct the client to follow up result at the: A. trigone. Laboratory C. Collect all specimens and send to laboratory at the end of the day C. Send specimens to laboratory right away after the operation with the proper labels B. Urethral opening. bladder. Cystoscopy is done by using lasers on the urinary tract . Client s family 84.g. Nursing intervention includes: A. movement of personnel including the circulating nurse is: 29 . Bed rest B. ureteral opening C. Santos. Doctor s clinic D. During the surgery. Cystoscopy is direct visualization and examination by urologist . you will enumerate as follows: A. The national bureau of investigation C. Foreign body the extracted from the body like pins. and body fluid specimens should be placed in leak-proof containers C. urethra B.During the surgical procedure. Santos asked you to explain why there is no incision of any kind. Warm moist soak C. Urethra. Prompt cleanup of accidental spills of contaminated debris e. kidney. You have 4 thyroidectomy cases for the day. Bladder wall. Cystoscopy is an endoscopic procedure of the urinary tract . The following techniques illustrates the concept confine and contain EXCEPT: A. needles. Urethra. C. Medical record B. Cystoscopy is done by x-ray visualization of the urinary tract . Prepare 4 specimen vials first thing in the morning Situation 18. Early ambulation D. body fluids 92. hematuria and dysuria. What do you tell him? A. The department of pathology B. You are the circulating nurse in OR 2. Label specimen at once D. Distended bladder C. bladder wall. Contaminated items like sponges are handled using loves B. Leg cramps are NOT uncommon post cystoscopy. uterine wall. How do you prevent switching of specimens? A.

Bone fragments 30 . Radiation D. Shelf-life of a packaged sterile item is event related and depends on the following. Monitored 93. A. Yellow B.Nokia is so powerful to connect people from the continent to continent. Traffic patterns in the OR suite should. devices or supplies used in the OR for any surgical procedure. Is clean B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Assure that the personnel walk in the same direction D. What gauge spinal sets will make available in the OR suite? A. An instrument tray with black striped autoclave/steam chemical indicator tape communicates that the instrument tray. Prevent unauthorized personnel from entering the OR B. Eliminated when possible C. Medical gases are used a lo9t in the OR. Precaution recommends that the use of standard personal protective equipment (PPE) to prevent cross contamination. Gauge 18 and 16 C. Restricted D. Kept to minimum B.:273-2245 A. Is sterile D.. Has undergone the sterilization process 100. Eyewear C. 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as stand by. all through communication via the cellphone. Yellow bin B. In the field of healthcare. Gauge 16 and 22 B. Other ways of communicating to relay information or instructions exist even in the healthcare setting. Gauge 5 and 22 97. yellow means proceed with caution . Water and blood splashes B. Green bin D. The quality of packaging material used D. Cover gown B. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb. Storage conditions 94. Gloves D. Orange bin C. EXCEPT: A. Prevent transmission of pathogenic microorganisms C. What is the identifying color of the tank which contains laughing gas ? A. On the traffic light. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. Allows personnel to move freely between restricted and unrestricted areas Situation 20. Black bin 99. Amount of handling C. Blue 98. Which is NOT considered a piece of PPE? A. Green C. there is danger of exposure to: A. Sterile is the condition of almost all items. A. Gauge 16 and 20 D. Is ready for use in surgery C.. where do you discard your used tissue papers? A. Face shields 95. Type of sterilizer used to sterilize items B. Black D. In health care when lad apron is required in any procedure like orthosurgery. 96. Pseudomonas C.

While Jayvee. When a nurse volunteers to work in a hospital setting and she commits a mistake. which of the following will you do FIRST? A. Electrolyte imbalance D. Increase O2 flow rate D. volunteer nurse. You over0hear one of your co-staff nurse assigned to Aling Josie who is 78 years old say. you would assign the HIGHEST priority to the client with the: A. As his nurse. The nurse was proven guilty of negligence. Check the IV stand C. Assault D. Battery C. which of the following indicators will tell you that TPN was effective? A. You report your costaff s behavior as: A. As the triage nurse. Increased platelet count B. which of the following sources should you take into consideration when making effective assignments for the next shift? A. Upon assessment you observe that he is exhibiting sudden onset of crackles in the lungs. Which of the following did the nurse fail to do? A. Negligence B. Notify anesthesiologist C. that if she refuses to take her medications. severe head injury and no blood pressure B. Teach pain relief strategies D. weight gain D. seniority preferences B. diminish episode of nausea and vomiting 109. who is legally responsible? A. moist respiration and tachypnea. hospital and the nurse in charge B. Reduce IV rate 103. recent performance evaluation C. Hold the IV bottle B. While Mrs.:273-2245 101. Administer prescribed analgesic C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. If you will evaluate her nutritional status. Paras is receiving total parenteral nutrition (TPN). the professional organization which the volunteer nurse represents C. Which of the following will you do FIRST? A. Support position with pillow 107. He has an IV of Dextrose 5% Lactated Ringers Solution. Assess bone pain B. hospital D. enrich diet with red meats 31 . second trimester pregnancy with premature labor D. Enriquez is receiving chemotherapy which of the following will you include in the plan of care to address her nutritional needs? A. Jake is in the Post Anesthesia Care Unit follwing a colorectal resection. client classification data 104. volunteer nurse because there is no employer employee relationship 106. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. the IV bottle fell on Jayvee s head. Elevated erythrocyte sedimentation rate (ESR) 108. He sustained a laceration on his forehead. maxillofacial injury and gurling respirations C. Malpractice 102. As a head nurse of the unit. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Daniel with multiple myeloma complains of deep bone pain. adequate hydration C. Mrs. You are the nurse in an Adult Care Unit. Altered blood urea nitrogen (BUN) and creatinine levels C. administer Compazine before meals B. laboratory work up B. Restrain Jayvee 110. Which laboratory result should you expect to find? A. Place the IV stand on the foot part of the stretcher D. a burn patient is being transferred from the burn unit to the operating room. Place on Fowler s position B. she will not be given her favorite dessert. lumbar spinal cord injury and lower extremity paralysis 105. personality traits D.

her relative informed you that the bottle is empty. Tell her Hodgkin s disease is common among young adults like her D. Which of the following patients is most at risk for metabolic alkalosis? A. you accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. Which of the following procedures may be done through the said system? A. Tell her there is nothing to worry if it does not bother her B. inform the client s family D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Acetone D. What should you do as a nurse? A. Which of the following will you do first? A. Studies have shown that the highest incidence of Hodgkin s disease is common among young adults. Avoid applying creams and powders to the area 116. Palpate Juana s neck and explain the possible cause C. do nothing because the client s condition is stable 119. refer to nurse manager B. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: A. Grace. What should be included in the plan of care to minimize skin damage from the radiation therapy? A. Helen. Juana. 70 year old with altered level of consciousness who is unable to access water freely D. Cover the areas with thick clothing materials B. Knowledge and skills D. Nino is being treated with radiation therapy. 20 years old approaches you and tells you I am worried about the mass on my neck . ammonia B. During a meal.:273-2245 C. It was started at 8am. Inferential statistics 114. At 10am. increase the amount of spice in the diet 111. Standardized care plans are used on all of the nurse s clients. Frequency distribution B. Alcohol C. Measures of central tendency D. Apply a heating pad to the site C. Correct errors in the physician medication order 32 . C. call the hospital attorney C. assess Olga and check level of fluid left in the bottle C. Measures of variability C. Standards of care are developed by the hospital nursing service and should be followed D. Rachel a 55 year old who has just experienced a stroke C. A research study found out that 60% of patients complains were due to delayed responses of nurses in the emergency department. Client s care is planned based on the nurse s clinical expertise and latest research findings B. Although the client exhibits no adverse reactions to the larger dose. replace IV fluid with prescribed follow-up 113. Client s needs are assessed and individualized care plan are developed for each client. serve hot soup and food D. 120. a tertiary hospital utilized a computerized medication order system. Wash skin with water after the therapy D. 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. 30 year old post surgical patient who has continuous nasogastric suction B. Which of the following leadership characteristics exhibited by the nurse manager best describes this strength? A. Communication skills C. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. Interpersonal abilities 112. Because of increase incidents of medication error due to wrong transcription of physician medication orders by the nurse. You are assigned to the following patients. a client with hepatitis B dislodges her IV line and bleeds on the surface of the over-the-bed table. complete an incident report B. Vision and passion B. Which of the following measurement of data was used in this study? A. you should: A. Tell her to see a doctor 118. bleach 115. discontinue IV and assess Olga D. You are the nurse manager of the Medical Unit. As a nurse. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution 117. 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.

QRS interval C. 126. Pathologic Q wave Situation 2 To be able to help our clients with their psychological concerns. T wave C.her stamp collection with the nurse D. 33 . Radiation treatment of the breast D. Later in the acute phase of Myocardial Infarction. that a sudden change in body image would occur from: A. PR interval 122. 65 years old. joke with the client D. You are expected to recognize electrocardiographic readings on the cardiac monitor. Eliminate drug interaction C. Cruz.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. PR interval 124.20 sec 125. establish a therapeutic relationship C. greater than . Are your living accommodation all on one level? D. ST segment suppression C. It is important for you to remember. The most appropriate nursing intervention to facilitate client s acceptance of a change in body image would be to: A. End of ventricular depolarization B. 121.10 sec B. What are your hobbies? B. When assessing patient s body image.20 sec D. establish a social relationship 128. become aware of her own attitude toward mutilation and disfigurement C. Stating he/she is too tired to have visitors C.12 sec to . Discussing his. QRS complex B. Surgical removal of an eyeball 130. Ventricular repolarization D. P wave B. What kind of food do you like? 127. Side effects of medication on skin C. Which of the following represents ventricular repolarization? A. Weight gain B. . ST segment D. Which of the following represent the normal interval of QRS complex? A. be in agreement with the philosophy of therapy for the client B. Which of the following responses would indicate that the client is beginning to accept change in his/her body image? A. Venticular depolarization C. From an ECG reading. was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. Feeling of the dressing over the incisional site B. Document drug administration SITUATIONAL Situation 1 P.20 sec C. Before you can help Lorna accept a change in body image you must FIRST: A. Atrial depolarization 123. a QRS complex represents: A. which of the following typically appears as the first sign of tissue death? A. we have to explore how they view themselves and their body image. Prolonged PR interval B. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium? A. It is important that the nurse measures intervals of QRS complex. Short T wave D. accept the fact that a person can live with a body part missing Situation 3 Radiation therapy is another modality of cancer management. What kind of work did you do prior to this illness? C. . Provide a list of drugs with their generic name D. . encourage dependence B. be aware of the attitudes and feelings of the client and her family D. ST segment D. With emphasis on multidisciplinary management you have important responsibilities as nurse.:273-2245 B. Showing no interest in the dressing change 129. which of the following would be most important to ask? A.

You should prepare for which of the following FIRST? A. Inspect his skin for petechiae. Insert an oral or nasopharyngeal airway C. Albert is receiving external radiation therapy and he complains of fatigue and malaise.:273-2245 131. Which of the following independent nursing interventions nursing interventions is NOT suited for her? 34 . free from radiation 133. what will be your priority interventions A. Knowledge deficit regarding thrombocytopenia precautions B. enhance renal excretion of drugs 140. weakness. considered radioactive for 24 hrs B. Andrea s arterial blood gases reflect respiratory acidosis. easy fatigability. Ineffective tissue perfusion. CT scan of the head 139. placed on isolation for 6 hours D. Provide rest in between activities D. cerebral. This is most likely related to: A. Give 100% oxygen by mask 137. Andrea loses consciousness. As Andrea s nurse. bacteremia. Placement of a second IV line C. Head injury D. What nursing diagnosis should be of highest priority? A. renal 135. Activity intolerance C. Obtain arterial blood gases D. Pain 138. headache. As a nurse you should observe the following symptoms: A. bruising. correct acid-base imbalances D.25 g/kg IV bolus for increased ICP. peripheral. Reassure him that these feelings are normal D. Place Albert on strict isolation precaution C. promote renal perfusion C. This is given to: A. Immediately following the radiation teletherapy. Albert is admitted with a radiation induced thrombocytopenia. epistaxis B. hepatomegaly 134. Insert an intravenous catheter B. As Andrea s nurse your goal is to prevent increased intracranial pressure (ICP).Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Refer him to the physician C. Placement of a nasogastric tube B. Partially obstructed airway B. 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. Albert is A. promote cerebral-tissue fluid movement B. GI bleeding regularly B. Help him plan his activities 132. given a complete bath C. blurred vision D. Andrea s physician gives an order of Mannitol 0. dizziness. ecchymosis. Impaired tissue integrity D. gastrointestinal. Ineffective breathing pattern C. 136. She was brought to the ER by a police woman. Which of the following nursing interventions would be most helpful for Albert? A. cardiovascular. pallor C. Tell him that sometimes these feelings can be psychogenic B. Emergency measures were started. severe sore throat. petechiae. Endotracheal intubation or surgical airway placement D. What intervention should you include in your care plan? A.

Promotion of wound healing C. On his back or on the side of surgery D. Horace underwent lobectomy. Peter will not be able to tolerate coughing B. Prone position B. Expansion of the remaining lung D. fever C. Administration of analgesic to the older persons requires careful patient assessment because older people: A. pain 35 . The most dependable cause of infection in the older person is A. providing rest for six hours before exercises 144. have increased sensory perception D. 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. placing him on his operative side during exercises B. mobilize drug more rapidly C. you can best help Horace to reduce pain during deep breathing and coughing exercises by: A. have increased hepatic. Pain in the older persons require careful assessment because they: A. increased glomerular filtration C. Peter underwent pneumonectomy. decreased breath sounds with crackles D. The tracheobrachial trees are dry C. change in mental status B. During the immediate postoperative period. On his abdomen or on the side opposite the surgery C. Keep head of bed 30-45 degrees elevated C. administering the prescribed analgesic immediately prior to exercises D. decreased bladder capacity D. renal and gastrointestinal functions B. Following lobectomy. 141. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration B. Maintain Andrea s head in straight alignment and prevent hip flexion D. Prevention of mediastinal shift 142. Which of the following observations indicates that the closed chest drainage system is functioning properly? A. deep tracheal suction should be done with extreme caution because: A. The remaining normal lung needs minimal stimulation D. You have important perioperative responsibilities in caring for patients with lung cancer.:273-2245 A. Which of the following is the purpose of Horace s closed chest drainage post lobectomy? A. Have a decreased pain threshold 147. Prevent constipation and increases in intra-abdominal pressure Situation 5 Specific surgical interventions may be done when lung cancer is detected early. Are expected to experience chronic pain B. Intermittent bubbling through the long tube of the suction control bottle 46 D. The fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration C. Facilitation of coughing B. are more sensitive to drugs 148. The bronchial suture line may be traumatized 145. Experienced reduce sensory perception C. The older person is at higher risk for incontinence because of: A. Less than 25 ml drainage in the drainage bottle 143. diuretic use B. On which of the following positions should you place Peter who just underwent pneumonectomy? A. Absence of bubbling in the suction-control bottle B. splinting his chest with both hands during the exercises C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. 146. dilated urethra 149. Have increased sensory perception D.

ensure accurate monitoring of intake and output 153. Irrigate his catheter C. breathing B. Knowing that proper documentation of assessment findings and interventions are important responsibilities of the nurse during first post operative day. 154. You decided to check on Mang Felix s IV fluid infusion. Activities of daily living started Situation 8 Many hospitals form bioethical review committees to ensure better quality of life of patients. Immediately after surgery. You noted that he has a 3-way indwelling urinary catheter for continuous fast drip bladder irrigation which is connected to a straight drainage. Autonomy B. breathing disability (neurologic) C. and consistency of bladder irrigation drainage D. tell him to Go ahead and void. What ethical principle did Zorayda and her family utilize as basis for their decision to sign a DNR. airway. Beneficence 36 . D. Daria who is admitted to the hospital with autoimmune thrombocytopenia and a platelet count of 20.:273-2245 150. Justice C. Daria states I don t need surgery. Pyrogenic reaction D. She decides to sign a DNR form. You are invited by the nursing service department to participate in their bioethical review committee. You noted a change in flow rate. Which of the following is the purpose of the ethical review committee? A. circulation D. Pinkish to red 152. Zorayda is terminally ill and is experiencing severe pain. Amber D. She as bone and liver metastasis. Light yellow C. circulation. color. She has been on morphine for several months now.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Decrease public scrutiny of health care provider s action 157. The purpose of the continuous bladder irrigation is to: A. Intravenous infusion rate C. Your priorities when caring for the older person who sustained traumatic injuries include: A. A. pallor and coldness around the insertion site. breathing Situation 7 Mang Felix. airways. allow continuous monitoring of the fluid output status B. allow for proper exchange of electrolytes and fluid D. What will be your most appropriate action? A. Remove his catheter then allow him to void on his own B.000/æL develops epistaxis and melena. What is your assessment finding? A. Zorayda is aware that they are having financial problems. Advocacy 158. Air embolism 155. what would you expect his urine to be? A. Justice D. In considering your response to Daria. disability (neurologic). Infiltration to subcutaneous tissue C. breathing. You have an indwelling catheter. which of the following is the LEAST relevant to document in the case of Mang Felix? A. Enhance health care provider s liability C. You are expected to know the purpose and apply bioethical principles. Phlebitis B. airway. Increase individuals responsibility for decision making D. you must depend on the ethical principle of: A. Chest pain and vital signs B. Beneficence C. Her physician recommended splenectomy. 151. This will go away on its own. Mang Felix informs you that he feels som discomfort on the hypogastric area and he has to void. Treatment with corticosteroids and immunoglobulin has not been successful. if there is a change refer to urologist for possible irrigation. provide continuous flushing of clots and debris from the bladder C. Amount. 156. a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. airway. assess color and rate of outflow. Bright red B. You are assigned to receive him. Promote implementation of general standards B.

observe the patient s vital signs 165. Autonomy D. Advocacy C. observe for symptoms of tightness of chest for bleeding C. Autonomy Situation 9 Ensuring safety before. 166. She goes out of her way to help other. which of the following complains to Fernan should be noted as a possible complication: A. weight 37 . Getty is receiving chemotherapy for cancer. You are commuting to work riding the LRT. You review Getty s laboratory report and note that he has anemia. assist the physician C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. She developed hypoglycemia. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease: A. holding his breath periodically for 30 seconds 162. cardiovascular. Hypertension C. You felt good. Impaired oral mucous membrane C. Autonomy D. cerebral. Activity intolerance B. you brought the patient to the nearest hospital. 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. What ethical principles is she practicing? A. sore throat and hoarseness 163. To help Fernan better tolerate the bronchoscopy. Beneficence C. you should instruct him to practice which of the following prior to the procedure? A. instruct the patient not to cough or deep breathe for two hours B. Beneficence D.:273-2245 B. Pain D. Impaired tissue perfusion. retrain from coughing and talking D. gastrointestinal D. hematuria B. breathe deeply C. place an ice pack to the puncture site D. tensing the shoulder muscles while lying on his back D. With help. Advocacy 159. You learned later that woman was diabetic. clenching his fist every 2 minutes B. Following a bronchoscopy. Advocacy B. clear his throat 164. Thoracentesis may be performed for cytologic study of pleural fluid. which of the following is most appropriate intervention? A. As a nurse your most important function during the procedure is to: A. Tricia. keep the sterile equipment from contamination B. breathing in and out through the nose with his mouth open C. She was on her way to the diabetes clinic to have her fasting blood sugar tested. Justice B. Immediately after bronchoscopy. An older person collapsed and nobody seem to notice her. What principle was applied? A. is considered a role model not only by her colleagues but also by her patients. Justice 160. Right after thoracentesis. You saw what happened and you decided to help. You were able to save a life. She is very active in their professional organization and she practices what she teaches. exercise the neck muscles B. blood tinged sputum and coughing D. 161. during and after a diagnostic procedure is an important responsibility of the nurse. The security guard tried to make her sit down but she remained unconscious. open and close the three-way stopcock D. To which nursing diagnosis should you give the highest priority? A. shortness of breath and laryngeal stridor C. a staff nurse working in a cancer unit. nausea and vomiting B. Impaired tissue integrity 167. you instructed Fernan to: A.

cardiogenic shock C. His daughter told you that he got out of bed to go to the toilet. bolus of Lidocaine D. Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. severe pain 169. Frank is admitted to the Intensive Care Unit with a diagnosis of acute respiratory distress syndrome. the call light at his room was on. manual cardiopulmonary resuscitation 174. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Your presence and critical decision making as a nurse are important. To immediate promote oxygenation and relief of dyspnea.8 deg C B. A. 171. pneumonia 175. He climbed over the side rail but his foot got caught in the beddings. After reporting this to the physician. Cardiogenic shock B. acute pulmonary edema B. you anticipate that the physician will order. You came in and saw Domingo slumped on the floor moaning.:273-2245 168.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Oral temperature of 38. Domingo. Call his physician 172. Side rails were placed to ensure that he will not fall from bed. The cardiac monitor indicates that Cedric s heart rate has increased to 150 beats per minute. alteration in body image C. place Lulu on high fowler s position D. insertion of a pacemaker C. maintenance of sterility D. Heart failure D. facilitate Frank s verbal communication B. When assessing Frank you would expect to find: A. Wound healing by first intention Situation 11 Nurses have important responsibilities when caring for hospitalized acutely ill patients. Which outcome criterion would be most appropriate for a client with a nursing diagnosis of ineffective airway clearance? A. you have to anticipate occurrence of complications. Heart rate of 88 beats/min C. His physician was considering dementia. assess his response to the equipment 38 . Breath sounds clear on auscultation C. administer oxygen Situation 12 Acute respiratory distress is life threatening. maintain sterility of the ventilation system C. perform chest physiotherapy B. A difficult problem to deal with when caring for a patient with partial-thickness burns sustained 3 days ago is: A. Respiratory rate of 24/min D. Continued use of oxygen when necessary B. frequent dressing change B. Which assessment would be most supportive of the nursing diagnosis. 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. have her take deep breaths and cough C. impaired skin integrity related to purulent wound drainage? A. the physician gave a diagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain. intracardiac epinephrine B. you notice Cedric is in ventricular tachycardia. Ensure airway. breathing. Based on the ECG obtained on admission at the ER and clinical findings. Transfer him to bed B. you should first: A. 176. right-sided heart failure D. circulation D. Apply restraints C. Take note that the major cause of death after an MI is: A. A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI. Which among the following will you do FIRST? A. You should recognize this as signs and symptoms of: A. He has an open wound on his forehead. At 2:00 AM. Shortly after this increase. Pulmonary embolism 173. As Aimee s nurse. You are caring for Lulu has acute pulmonary edema. Presence of congestion 170. Dry and intact wound dressing D. Cardiac arrhythmias C.

As a nurse. expiration date 183. notify the blood bank and administer antihistamines D. Dyspnea. notify the blood bank 39 . serial number. a decrease in red blood cell formation Situation 13 As a nurse you have to be prepared to care for patients receiving blood transfusion. chills. an excessive drying of the respiratory mucosa B. serial number. headache. 1 hour D. assess his response to the equipment D. hyperoxygenate with 100% oxygen before and after suctioning D. Slow the blood transfusion and monitor the patient closely C. Check his vital signs every 15 minutes D. expiration date with another nurse D. What should you do FIRST before you administer blood transfusion? A. maintain sterility of the ventilation system C. use short and jabbing movements of the catheter to loosen secretions C. Immediately stop the blood transfusion. When suctioning the endotracheal tube. what will be your priority intervention? A. call the physician. The earliest signs of transfusion reactions are: A. Verify client identity and blood product blood product. cross matching results. bradypnea D. for early indications of respiratory acidosis. you should: A. blood type. Tiger with a pulmonary embolus is intubated and placed on mechanical ventilation. Check IV site and use appropriate BT set and needle B. You are preparing a unit of whole blood for transfusion. hypertension and flushing D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. rupture of emphysematous bullae D. Immediately stop the blood transfusion. who has a restrictive airway disease. Immediately stop the blood transfusion. infuse dextrose 5% in water and call the physician B. In case Diego will experience an acute hemolytic reaction. As Diego s nurse what will you do after the transfusion has been started? A. Add the total amount of the blood to be transfused to the intake and output 184. bradycardia B. blood type. oliguria and jaundice B. suction two to three timed in quick succession to remove all secretions 179. Diego is undergoing blood transfusion of the first unit. which include: A. Frank s respiratory status necessitates endotracheal intubation and positive pressure ventilation. 4 hours C. apply suction while inserting the catheter B. prepare him for emergency surgery 178. The physician orders low concentration oxygen to be given continuously for Kenneth who has a chronic obstructive pulmonary disease to prevent: A. Stay with Diego for 15 minutes to note for any possible BT reaction C. 6 hours 182. You re most immediate nursing intervention for Frank at this time would be to: A. 2 hours B.:273-2245 D. depression of the respiratory center 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. fever 185. From the time you obtain it from the blood bank how long should you infuse it? A. you should observe Bernard. Discontinue the primary IV of Dextrose 5% water B. infuse normal saline solution. facilitate Frank s verbal communication B. urticaria and wheezing C. restlessness 180. Flaring of the Nares 177. 181. cross matching results. prepare him for emergency surgery E. light-headedness C. Verify client identity and blood product. Verify physician s order C.

general pain management choices based on level of pain C. Which of the following statements does not apply to critically ill patients? A. Lack of privacy B. Adoloscent D. educational level D. developing tolerance to morphine D. Inadequate nursing staff 187. becoming psychologically dependent B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. skill of health professional 40 . It is now regarded as the 5th vital sign. constipation 193. Updated information on client s status D. Unresponsive patient 188. Emotional support C. Majority need extensive rehabilitation B. Most have chronic illness 190. As a nurse caring for patients in pain. nonpharmacologic interventions based on level of pain D.:273-2245 Situation 14 Based on studies of nurses working in special units like the intensive care unit and coronary care unit. medication C. it is important for nurses to gather as much information to be able to address their needs for nursing care. pruritus D. Assuming that nothing has changed in his condition. non-steroidal anti-inflammatory drugs enhance pain perception C. Are physically unstable D. Families of critically ill patients desire which of the following needs to be met first by the nurse? A. Hospital food C. pharmacologic and nonpharmacologic pain management choices B. You have collaboration as well as independent nursing interventions for pain. adjuvant medication such as steroids. opioids are drug of choice for severe pain D. All have been hospitalized previously C. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. needing to have morphine discontinued C. exaggerating his level of pain 195. Who of the following is at greatest risk of developing sensory problem? A. Jack has been on morphine on a regular basis for several weeks. physical dependence C. The guidelines for choosing appropriate nonpharmacologic interventions for pain include all of the following EXCEPT: A. pain problem identification B. Which of the following statements about cancer pain is NOT TRUE: A. previous knowledge of illness 189. type of opioid being used C. This strategy is used to give emphasis on how pain should be managed. specific pain management choices based on severity of pain 192. 191. pain associated with cancer and the terminal phase of the disease occurs in majority of patients 194. Spiritual counseling Situation 15 Pain is the most common reasons why people consult their physicians. Lack of blankets D. you would suspect that Jack is: A. anticonvulsants. gender B. Critically ill patients frequently complain about which of the following when hospitalized? A. Transplant patient B. Female patient C. Provision of comfortable space B. you should evaluate for opioid side effects which include the following EXCEPT: A. The WHO Analgesic ladder provides the health professional with: A. 186. Which of the following factors may inhibit learning in critically ill patients? A. Respiratory depression B. undertreatment of pain is often due to a clinician s failure to evaluate the severity of the client s problem B.

Wash the chemical off with cool water C. Administer the prescribed Furosemide (Lasix) C. serum Na 130 mEq/L.5 g/100 ml. 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. Mark accidentally spilled the whole can of corrosive chemicals all over his body. 196. Assess for associated injuries D. You noted that pulse could not be appreciated in his injured extremity. Increase the oral intake to 30/hr 199. Which of the following will you do FIRST? A. You are caring for Lenard who sustained severe burn injury and he is in the emergent phase of burn injury. Try to take the pulse in the uninjured extremity D. Check catheter for kinks D. Which of the following would you consider as the priority intervention in the emergency management of Mark? A. Which of the following will you do FIRST? A. Dino sustained circumferential thermal burns of the left upper extremity and chest. All the laboratory tests are within normal rage C. Avoid sunlight for the next three months D. who has partial-thickness burns on the face. effectiveness for patient Situation 16 The nurse s accurate assessment is very crucial in preventing complication during the severe post burn period. Maintain a patent airway B. Increase the rate of the IV fluid B. These are due to hemodilution from rapid IV fluid replacement B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. ***END*** 41 . They are slightly abnormal but will normalize once IV fluids have been started D. Continue to eat high caloric high food for the next month B. Avoid facial makeup for at least a year 200. Remove all clothing containing the chemical 198. Wear a pressure garment daily for one year C.:273-2245 D. Elevate the injured extremity to increase blood flow to the heart B. Hematocrit 50%. you gathered the following: Hemoglobin 13. Remove the dead tissues which impede circulation C. Which of the following should you include in your discharge teaching? A. As his nurse. These are due to a loss of serum and interstitial fluid through the burn wound. inquiries about skin care after discharge. Notify the physician immediately as this requires emergency intervention 197. Kathy. While unloading containers with chemicals from a truck. How will you explain the laboratory results? A.

Avoid relating with neighbors to minimize conflict C. Reyes remarked I am wary about people visiting. refer the matter to the police 5. Which of these nursing actions belong to the secondary level of preventive intervention? A. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents. Be assertive to express to express her individuality D. 1. marital crises D. and Mrs.:273-2245 NURSING PRACTICE V SET A Situation 1 The following questions refer to nurse s efforts to do collaboration and teamwork. the legal aspects of drug abuse B. Providing mental health education to members of the community 4. I acknowledge what you are saying. Keeping trust in the relationship B. Mrs. 7. Which of these symptoms if demonstrated by Mr. counsel the client C. Reyes often insists strict ways to a point of protectiveness from what he perceives as unsafe i. aged 7 and 4 years. empathy and compassion 9. consistency and predictability C. She is applying the principle of: A. Being politically active in relation to mental health issues D. Reyes would necessitate referral to a doctor? A. Providing emergency psychiatric services C. disciplining children at home and school C. C. The nurse diverts the attention to talk about non-threatening topics. Million therapy C. Mr. Upon her visit she observed that common areas of arguments between Mr.with all the media news about child kidnapping and robberies. Suspicious affect D. Behavioral therapy B. It must be distressing to think and feel the way you do. 6. responsibility and accountability B. The nurse s BEST response would be: A. Ignore the husband and just be supportive 8. Would you rather wish that I don t come and visit you may regard me as a stranger? B. Mrs. I get that. The most important role of the nurse as a member of the team is to: A. Hypervigilance C. meet the needs for the physical well being of patients C. honesty and integrity D. An appropriate topic would be: A. community and neighbors that cannot be trusted. the problems of out of school youth Situation 2 The nurse visited the Reyes family to check on their two growing children. loss of reality contact 42 .Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Reyes are about conflicting ways of bringing up their children. A biological/medical approach to patient care utilizes which of the following? A. 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. Which of the following would the nurse emphasize as basic? A.e. carry out medical orders B. Providing mental health consultation to health care providers B. Reyes expressed that her socializing with neighbors is limited because her husband thinks she is getting overly friendly with a guy next door. D. call a priest B. Psychotherapy 3. refer the client to the psychiatrist D. coordinate the psychological care and management of clients D. When the nurse identifies a client who has attempt to commit suicide the nurse should: A. Reyes is lax and tolerant while Mr. My concern is the health care of your family and information are strictly confidential. hypersensitive B. Somatic therapy D. Select the best answer. keep a 24 hour watch for the patients 2.

anxious. Projection D. Reduces the production of aqueous humor D. rigid. sudden loss of eyesight B. gradual diminution of the retina C. Patient with Parkinson s disease B. Constricts the pupil B. loss of night vision C. downward D. Cancer patients C. The premorbid personality of a person with a non-psychotic maladaptive response to anxiety may most accurately be described as: A. Reaction formation Situation 3 Mr.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Aggressiveness B. Sison has been diagnosed as having early chronic glaucoma. aggressiveness B.:273-2245 10. Introducing him to female clients his own age C. The appropriate method of instilling eye drops is: Instilling into an opened eye. The nurse identified a nursing problem of disturbed sensory perception: visual impairment characterized by: A. Ignoring his flirtatious and provocative behaviors 17. The paranoid client utilizes which of the following defense mechanisms? A. insensitive and self-absorbed 18. suspiciousness Situation 4 SEXUAL DISORDER 16. pessimistic and moody D. difficulty relating with adults B. Hopelessness D. Which of these is the effect of this drug? A. The nurse can respond MOST therapeutically by doing which of the following? A. 11. it is important for the nurse to know that glaucoma is usually caused by: A. Diamox is a drug used in the treatment of glaucoma. opacity in the lens B. feelings of tenderness toward children C. He has been admitted to the hospital for treatment. damage to the proteins in the lens D. preferred for a passive sexual role 43 . Patient with COPD 15. The pedophile s choice of a sex object is primarily based on: A. impulsive and aggressive B. Public health nurses should identify which of these patients as a risk group for development of glaucoma. Facilitates outflow of aqueous humor 14. In order to understand the rationale for drug therapy. Suspiciousness 19. fears of incestuous impulses D. dependent. with the head held back and with the eye looking: A. Upward C. Encouraging him to watch TV in his room D. A hospitalized male adolescent flirts with and is sexually provocative toward a female nurse. insecure and conforming C. Sublimation C. An oral-dependent personality is characterized by which of the following? A. Diabetic and hypertensive patients D. loss of central vision 12. increase production of aqueous fluid 13. loss of peripheral vision D. Acts as osmotic diuretic C. Rationalization B. Telling him she is married and too old for him B. unpredictable. Helplessness C. hence the need for annual eye examinations: A.

Interaction Process Analysis D. In order to assess Reliability as a behavioral characteristic. You are here and I am ready to listen. Ineffective coping D. She inquires about personal information about the nurse D. developmental crisis C. Social crisis D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. nausea. initially she was just crying. Anita is experiencing: A. Trust D. Are the nursing history and psychosocial assessment accurate? 28. felt she was in a nightmare and she was at a loss. humiliation. Which of these behaviors of Anita signal her readiness to proceed to the working phase of the nurse-patient relationship? A. Algorithms 27. Did the history of the present problem correlate with the review of growth and development? B. She states she trusted the nurse B. anger D. Tell me when you are ready and I ll come back to you. When the nurse approached Anita. Follow the problem solving approach B. nightmare and muscle tension. Has the possibility of enhancing intra professional respect C. Nursing Care Process C. D. showered for an hour and still did not feel clean. Sexual violence C. guilt C. the nurse would ask herself which of the following questions regarding her recording: A. Which of these communicate unconditional acceptance of Anita and hr situation? A. Do not pass judgment on the ideas presented 44 . intimacy Situation 5 Anita is experiencing rape-trauma syndrome in an acute phase. Why did you date a guy you hardly knew? C. Provide an evaluation of the nurse s abilities 29. She wants to be told what her rights are Situation 6 The psychiatric mental health nurse adheres to standards that ensure quality improvement. 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. How long did it take to complete the nursing data base? C. This is a process wherein the client s chart is reviewed to compare criteria for quality care with actual practice: A. The following situations and behaviors are means to achieve this goal. frustration 25. The appropriate nursing diagnosis is A. She wants to talk to a lawyer C. It requires the development of standards for quality care D. One of the most important ground rules is: A. She had too much drink and she has feelings of mnanger. 24. industry B. Demands accountability for nursing actions B. Autonomy C. Sexual dysfunction 22. helplessness.:273-2245 20. 21. Psychiatric Audit B. Is the nursing data base complete? D. All of these are the advantages of peer review EXCEPT: A. denial B. I would be best of help if you stop crying. 26. vomiting. frustration 23. The nursing team leader wants to involve all the nurses in participating in their own personal and professional growth through a brainstorming session. B. Anita expressed to the nurse that she douched. Anita is experiencing: A. maturational crisis B. She had been invited to a fraternity party. Situational low self-esteem B.

case study 34. thoroughness C. the youngest participant is 86 years old C. Mr. the oldest participant is 86 years old D. Which of the following protocol would be considered unethical? A. Did the nurse perform in the best possible manner without waste? aims to describe the nurse s: A. Get another nurse for help B. institutionalized people? 31. It is easy to get data 35. The action of this drug is effective when it: A. Such studies have the advantages EXCEPT: A. What nursing action should be BEST when the client begins to faint? A. Instruct the patient to move from side to side 38. After the procedure. Recording interaction with the elderly with their permission B. Possibility of memory bias and distortion of fact C. elderly. Verbal permission from the subject is unnecessary C. Inform the client that he should be in supine position C. the nurse must include which of th following nursing action in his care? A. Mr. reliability D. Assess for movement and sensation of the lower extremity B. the sum ages divided by total number of participants B. 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. most of the number participant is 86 years old Situation 8 Mr. There is much material available D. Assess the sensory loss in his legs D. Interviewer is not held to any specific question C. Ideas must be feasible D. Suggestions must be cost effective 30. David is scheduled for lumbar laminectomy. H is scheduled for myelogram. 36. A written consent from the institution and a significant other 32. experimental B.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. David is to ambulate for the first time following surgery. Logroll the client with the help of another nurse B. The average age of the respondents was 86. This means that: A. controls edema 39. Controls nausea C. Assist the client to form a wide base of support and lean against the nurse 45 . A semi-structured interview was conducted. efficiency B. Lying supine with heels flexed D. Subject is allowed to express without any suggestion from interviewer D. Get back to his bed and place in side lying position D.:273-2245 C. Controls pain D. Interviewer is free to probe beyond a number of specific major questions 33. Trimethobenzamine Hydrochloride (Tigan) was administered postoperatively. David is brought to the hospital due to pain radiating to the hip and leg. The review of literature included reference to retrospective studies. Data are inexpensive to obtain B. Post operatively the nurse should: A. Quasi-experimental D. Descriptive C. Data coded and recorded solely by the investigation D. The type of study conducted is: A. Maneuver the client to a sitting position C. He is diagnosed with a herniated lumbar disk. controls muscle spasm B. Bed rest with bed elevated at 45 degrees 37. Place the client in most comfortable position C. Interview is conducted precisely in the same manner B. this represents: A. Investigation of cognitively impaired individual presented some ethical dilemmas.

NIcanor was readmitted with an entirely different behavior. Huwag po kayong mag-aalala. pare-pareho lang kayo ng mga ibang pasyente dito. Take him away form the group until he manages to have control of himself. Which of these drugs is likely to indicate to Nicanor? A. Immediately restrain him and put him on isolation to protect other patients.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. lying on his side in bed B. Masama and pakiramdam ko. Nagagalit ka sa nurse at nawawala ka ng control sa sarili mo. D. C. the nurse intervenes utilizing effective communication techniques. David has to wear back brace. B. Ikaw. C. B. she expresses. Lahat naman po tayo ay doon ang patutunguhan. galit ka sa nurse pero hindi tama na naninigaw ka. admonishing him with. Prevent him from becoming more furious by giving an extra PRN dose of sedative. 43. D. Nalulungkot ba ang pakiramdam mo? B. Nicanor was provoked. Ayaw nila ako. Valium (Diazepam) C. Which position is recommended when the brace is applied? A. D. A therapeutic response of the nurse would be: A. Sinabi mo sana sa nars nabigyan ka ng sedative mo. Ako ang nurse dito. Ang mahalaga ay ang palagay mo sa sarili mo. Sino ang nila na tinutukoy mo? D. Baka ini-istorbo ka na naman ng mga boses. he was very depressed. He says. displacement B. put him in his right senses . Huwag mong isipin yan. The patient verbalizes. Tofranil (Imipramine HCl) D. Hindi ako nakatulog kagabi. 45. During socialization. compensation D. Andito po ako at puwede tayong mag-usap. nurse. Camilia verbalizes. Relax lang! Huwag ka masyadong mag-iisip ng mga problema mo. 44. Maari mo bang sabihin sa akin and mga naiisip at nararamdaman mo? 42. B. Andito naman ako para makausap ninyo. narcissistic personality 48. A therapeutic response is: A. Serenace (Haloperidol) B. Wala na yata akong pagasang mabuhay pa. This is BEST demonstrated in: A. 46. Ano ba ang ipinagmamalaki mo! The nurse responds therapeutically by: A. B. Sitting position C. Mr. Looking sad. The following are varied situations in a psychiatry ward. Oo nga. Hayaan mo sila. Trilaton (Pherpenazine) 49. weak super-ego C. Therapeutic use of self is essential in relating with psychiatric patients. Respond with. supine position in bed Situation 9 Through the nurse-patient relationship. C. The defense mechanism utilized by manic patients to cover up depression is: A. denial 47. The psychodymanics of depression is: A. Nicanor becomes verbally assaultive to the nurse. reaction formation C. C. Standing position D. however. 41. Soledad is terminally ill of cancer. A response which fosters hope is: A. sympathizing with the miserable feelings of Nicanor 46 . Hindi tama yan. Nicanor. Mukhang napakabigat ang dinaramdam ninyo. wala kanga lam! Marunong pa ako sa iyo e. Dapat sumunod ka sa akin. became furious and started shouting Walang hiya kayo! Ako ang bida dito! The nurse s action is: A. D. Ignoring the behavior of the patient Situation 10 Nicanor was discharged form the hospital and recovered from a manic episode of Bipolar Disorder.:273-2245 40. Acknowledging his behavior and respond. Huwag po ninyong isipin ang sakit ninyo. C. Acknowledging his behavior. lax super-ego B. Lakasan ang loob ninyo. Bale wala yon. respond with. Gagaling din po kayo. internalized hostility feelings D. Pinag-uusapan nila ako.

engaging Nicanor in productive activity C. Intiative 57. Basically. one of the children requests that he be the one to sign the consent in behalf of their mother. Make self available while maintaining distance until patient shows readiness to interact D. thought or impulse and attributes it to someone else B. 51. justifies behavior. consensus building 53. Right to privacy C. Seclusion 55. She is demonstrating a sense of: A. unusual because action of antidepressant drug is immediate B. When she resists taking her medication. Autonomy B. Physical restraint B. Nicanor still manifests depression. This means that she: A. allowing the medical staff to decide in their behalf D. They differ in their opinion whether or not to allow their mother to decide for her. ineffective because perhaps the drug s dose is inadequate Situation 11 . unexpected because it takes within one week for the medication to be effective D. unconsciously refuses to accept a feeling. Beneficence C.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. She claims that the medications being given her are meant to poison her. Right of habeas consent 54. majority of the children to decide C. Trust B. Fidelity D. 56. attitudes and feelings with excuses C. The nurse explains that Purita is rational in her thinking and which of this client s right must be regarded? A. Which of these etical principles can guide the nurse in her action? A. involuntarily refuses to acknowledge reality D. involuntarily excludes wishes. Marina utilizes projection by being suspicious. let her read the drug literature to convince her that it is therapeutic 47 . it is best to: A. impulses. the eldest child s opinion to be given priority B. She refuses to wear it continuously though she fully understands the medical indication for it. Which of these nursing approaches is MOST appropriate for the nurse to begin with? A.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. Engage Marina for at least one hour in a one-to-one interaction daily B. autonomy Situation 12 Marina.:273-2245 B. generativity B. ego integrity C. Invite her to socialize with other patients C. Generativity D. Intimacy C. memories and feelings from awareness 58. Right to refuse treatment B. Refer her for activity therapy 59. In anticipation that Purita might refuse. Marina is suspicious because of her inability to develop a sense of: A. expected because it takes about two weeks for the medication to be effective C. Use of on site guard/watcher D. Which of these would be the nurse s priority following the treatment principle of least restrictive alternative? A. Purita has six children who are already adults. Nonmaleficence 52. One of one staffing C. Right to informed consent D. Purita talks about her joy in having responsible and accomplished children and recalls challenging career as a lawyer. industry D. The nurse would encourage family conference for: A. engaging NIcanor in introspective thinking D. suppressing her own feelings toward NIcanor 50. The nurse evaluates this as: A. Breathing treatments are to be given to Purita. 26 years old. Dinio. is aloof in relating with other patients and members of the staff. She is also suspicious about the food being served for her. After three days of antidepressant medication.

Coupled with poor work performance. anger. and even indifference toward clients and co-workers. Given this example of a problem. psychotic anxiety B. request the doctor to give her medication 60. Identify how he can prepare for the job interview. address her physical well-being B. behavior modification Situation 14 The purpose of the nursing care plan is to identify the care for an individual patient based on his problems. call the nurse for a one on one conference 62. Another reason why she refuses to take Thorazine is because she complains of robot like movement and slurred speech. The initial action of the supervisor would be to: A. Given this example of an expected outcome: Openly verbalize anxiety about job interview. administrator by relieving her of responsibilities B.:273-2245 B. analyze the problems as concisely as possible 67. An expected outcome is stated in terms of what the patient will do B. avoid giving foods that are rich in tyramine D. group dynamics and team building D. help her find value and meaning in her work 65. administer the drug D. personality maladjustment D. the nurse can be said to be suffering from: A. who she interacts with regularly. counselor by actively listening D. The due to or the reason for the problem should be included if it is known. The nurse s action is: A. boost her self-confidence C. stress management C. post guidelines on proper decorum of nurses in the bulletin board B. request anecdotal report form nurse s co-workers D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Anxiety due to a job interview . The initial step in identifying problems is: A. The nurse writes a nursing care plan for a patient based on nursing care standards. force her to take the drug to maintain therapeutic effectiveness of the drug C. The following are reasons for setting deadlines within which to achieve outcomes of care EXCEPT: 48 . 61. withhold medication until referral is made to the doctor Situation 13 The supervising nurse received report that a staff nurse is displaying frequent irritation. staff burnout C. Which of these is not a criterion of expected outcomes? A. decrease the dosage of thorazine B. educator by reorienting her of her role as a nurse 63. An expected outcome is stated in terms of what the nurse will do C. assertiveness training B. Every outcome must be measurable D. The nurse expressed increasing feelings of dissatisfaction. explain the extrapyramidal side effects and administer Benadryl C. gather data about the patient B. The supervising nurse intervenes therapeutically by taking the role of: A. neurotic depression 64. 66. have the same nurse. Every outcome answers the question How will you know when the problem is resolved? 68. A priority in the nurse s personal development would be to: A. determine if the problems are usual or unusual C. analyze the data D. mental and physical fatigue and actual withdrawal from client contact and nursing duties. provide social support D. therapist by delving into the nurse s internal conflicts C. The most relevant professional program for her would be: A. write a memo of warning to the nurse C.

Which of these is not a relevant nursing order? A. D. C. the sole responsibility of the primary nurse C. Encouraging the client to speak slowly D. Mr. Using paper and pencil in communicating with the client C. To prevent contracture D. To provide corrective emotional experiences through a one-to-one intensive relationship. Which of the following responses of the nurse is MOST appropriate? A. Ask the patient what he is feeling about the job interview 70. Does not allow plans to be changed C. Which of these practices on evaluation support nursing care? Review of care plan is: A. As part of the rehabilitation planned for Alma. To prevent decubitus ulcer C. to improve muscle tone B. A with myasthenia gravis is having difficulty speaking. Santos was unable to stand and is having difficulty swallowing and talking. a nursing team responsibility B. Ask the patient any untoward side effects of medications he is taking B. Indicate specific times to review progress or lack of progress B. He has changed drastically. establish good health habits 74. The accurate information of the nurse of the goal of desensitization is: A. Let us walk and find a quiet place where we can talk. establish routine C. To help clients in a group therapy setting to take on specific roles and reenact in front of an audience. 49 . 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. Santos? A. The physician and the staff will make sure that your husband will be comfortable and safe here. To prevent bladder distention B. Have patient role play interview situation C. to treat the disease D. Discuss with a patient with specific means he might prepare for the job interview D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. the responsibility of peers D.:273-2245 A. to help the clients relax and progressively work up a list of anxiety provoking situations through imagery. C. Which of the following is the priority of the nurse in assisting Mr. Repeating what the client says for better understanding B. strengthen muscle coordination B. Alma. which of the following goals would be MOST appropriate? A. When planning for nursing care for Mr. 42 years old. On his second day of hospitalization. situations in which interpersonal conflict is involved. B. Situation 16 Annie has a morbid fear of heights. to maintain optimal body function 73. Allow plans the need to be changed D. He will soon recover in his condition. She asks the nurse what desensitization therapy is: 76. What communication strategies should the nurse avoid when interacting with Mr. To prevent aspiration pneumonia 75. 71. Set the time by which the expected outcome should be reached 69. has had multiple sclerosis. B who has Parkinson s disease. the nurse suggested therapy and hobbies to help her: A. For the past 10 years. Clients with multiple sclerosis experience many different symptoms. You need not worry. develop perseverance and motivation D. Ma. This has been a difficult time for you. A? A. we are doing the best we could. The wife of a seventy two (72) year old male with a diagnosis of Alzheimer s disease begins to cry and tells the nurse. B. I could not understand my husband anymore. to start rehabilitation as much as possible C. Encouraging the client to speak quickly 72.

descriptive report B. Bear weight on the plaster cast for one hour. 86. The nursing management of anxiety related with post traumatic stress disorder includes all of the following EXCEPT: A. develop the art of public speaking B. encourage participation in recreation or sports activities B. Josephine appears to be anxious. The program inspired me a lot. Leave the cast uncovered to promote drying. I learned a lot. survey D. It is essential in desensitization for the patient to: A. Which of these feedback from individual participants indicate maximum gain from the staff development program? A. The victims were brought to the nearby hospital. Parkinsonian like syndrome B. project a positive image of the nursing profession C. remain with the client while fear level is high Situation 17 For personal and professional development. Some of the victims suffered injuries in the different part of their bodies. use deep breathing or another relaxation technique C. Physical signs of anxiety become more pronounced.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. Focus becomes limited and client experiences tunnel vision. severe anxiety C. One of the victims. panic D. While waiting for the plaster cast to be applied. moderate anxiety 79. cognitive capacity diminishes. to approach my clinical supervisor regularly to discuss nursing care of our clients. 50 . B. To help clients cope with their problems by learning behaviors that are more functional and be better equipped to face reality and make decisions. 81. individual interviews 85. Hepatic failure D. Josephine was confirmed to have a fractured left arm. A stockinet will be placed over the left arm to be placed in cast. which of the following topics should NOT be included in the teaching plan? A. A. In this level of anxiety. B. Antianxiety medications should be used with extreme caution be cause long term use can lead to: A. return demonstration C. role play 84. I have a Do it Now project for myself i. reassure client s safety while touching client C. D. work through unresolved unconscious conflicts 78. C. I feel very good. assess one s self for the need of an anxiolytic drug D. the nursing staff decided to hold a staff development program. group discussion and report B. The most effective way to practice assertiveness skills is through: A. brainstorming session 82. attendance D. process recording D. interview of nurses C. mild anxiety B. develop art and skills of therapeutic use of self D. have rapport with the therapist B. Self-enhancement through Assertiveness . Hypertensive crisis C. The least satisfactory method to evaluate the effectiveness of the program is through: A. Risk of addiction 80. I hope to have more seminars of its kind. An appropriate assessment tool to maximize gathering of needs of nurses is through: A. earn continuing education units 83. To reduce anxiety. written evaluation form C. Situation 18 A vehicle hit some pedestrians while waiting for a bus ride. observation B. 77.:273-2245 D. I will write a plan for personal development program. speak in a calm soothing voice D. the nurse teaches the procedure to the client. A priority objective of the program is: A.e.

box of cake D. The MOST effective way to deal with Carlo s behavior is initially to: A. Which of the following items will the nurse not allow to be brought inside the ward? A. Which of the following must be considered while planning activities for the depressed patient? A. Anger is incompatible with love D. Handle hardening cast with palm of hands D. Swelling of the fingers C.:273-2245 C. Mrs. Prior to surgery. activities which require exertion of energy B. clean the extremity and keep the skin dry B. Phillip was placed in skeletal leg traction with an overbed frame. Nail bed capillary refill time of 10 seconds 88. bottle of coke B. Pain on the left arm B. Which of the following nursing interventions is useful in maintaining effective traction? A. Frustration develops in response to unmet needs. assess any skin and circulatory disturbances C. give client support and positive feedback for controlling use of obscene language D. Assist the client by holding the trapeze and raising the hips off the bed. reduces muscle spasms and helps to immobilize the fracture B. a Buck s extension traction is to be applied. Support the affected extremity while the weights are removed. All of the following concepts are true EXCEPT: A. wants and desire C. if the client is agitated. variety of structured activities D. variety of unstructured activities Situation 20 . insist to stop obscene language by verbal reprimand C. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward? A. age 25. In assessing the neurovascular status of the client. 90. allows reduction of the fracture site for bone healing. recalled that his problem began around age 15-16. There are many things Jim seems he has to do to keep himself from feeling: 51 . Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. the nurse should A. Provide a punching bag as an alternative to express upset emotions 95. string rosary bracelet C. He is not allowed move from side to side. The rationale of traction is primarily based on the understanding that Buck s extension traction: A.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. 87. clean the pin sites as necessary D. 96.Jim. Secures the fracture site for rigid immobilization 89. C. B. Aggression can be expressed in a constructive as well as a destructive manner. challenging activities to get him out of his depression C. a sixty year old woman sustained hip fracture. 92. He would count pencils in a mug over and over with the thought that stopping could result in something bad happening. provide high fiber small meals 91. Suspend the trapeze within easy reach of the client D. Dizon was visiting her son at the Psychiatry Ward. Hostility is destructive B. One of the victims. Trim and reshape finish cast with knife or cutter. rubber shoes 94. To prevent complications when a child is in Buck s traction. Secures the fracture site to prevent damage to the muscle tissues D. Check the apparatus. discuss the feelings especially anger B. that weights hang free and knots in the rope are tied securely C. Skin abrasions on the edges of the plaster cast D. set limits on the behavior by verbal command B. which of the following assessment findings should be reported to the physician? A. Cast was applied on Josephine s left arm. remove the chairs from the room D. restrain the patient and place him in the Isolation Room 93. administer PRN tranquilizer C.

facilitate self-expression 100. The objective of nursing care for Jim is to develop or increase feelings of: A. self-determination 99. excited D. denial and projection C. self worth D. self-mastery C. rationalization and over reaction 98. suspicious C. This is a pattern of: A. psychosis D. He has change clothes 20 times before work. assign task that can be done repetitively D.Allan Ocampo Tutorials Mobile:0920-5583476 Bus. chew each bite he east 24 times and go up and down the stairs four to five times before it feels right. He is demonstrating: A. impose limits every time the behavior becomes repetitive B. confused B. Jim is aware of his behavior yet realizes that it is very disturbing to him.:273-2245 A. habitual disorder ***END*** 52 . self-actualization B. obsession and compulsion D. neurosis B. All of these are therapeutic interventions EXCEPT: A. anxious 97. ideas of reference B. personality disorder C. establish a routine for him C.

Allan Ocampo Tutorials Mobile:0920-5583476 Bus.:273-2245 Set 1 1 2 3 4 5 6 7 8 9 10 B B A D B B C C B B 11 12 13 14 15 16 17 18 19 20 A C C A D A B A A C 21 22 23 24 25 26 27 28 29 30 D A C B C C A A C C 31 32 33 34 35 36 37 38 39 40 D C A B A C A A D B 41 42 43 44 45 46 47 48 49 50 B C D C B B A A C A 51 52 53 54 55 56 57 58 59 60 A C D A B D A B D C 61 62 63 64 65 66 67 68 69 70 D C A A D C C B C B 71 72 73 74 75 76 77 78 79 80 B B C C A C A B B B 81 82 83 84 85 86 87 88 89 90 B C B A D B C A B A 91 92 93 94 95 96 97 98 99 100 B A A A C A D B D C Set II 1 2 3 4 5 6 7 8 9 10 D D B D A A D C D B 11 12 13 14 15 16 17 18 19 20 A D B C C A A C C A 21 22 23 24 25 26 27 28 29 30 C D C C C B B B A D 31 32 33 34 35 36 37 38 39 40 B D A B D D A D B C 41 42 43 44 45 46 47 48 49 50 D D D C A D A B D c 51 52 53 54 55 56 57 58 59 60 B D D D D C C B B 61 62 63 64 65 66 67 68 69 70 D B A D A C D A C C 71 72 73 74 75 76 77 78 79 80 B A B C A B B D B D 81 82 83 84 85 86 87 88 89 90 C C D C B A A A B D 91 92 93 94 95 96 97 98 99 100 C C C B B C A A D C 53 .

Allan Ocampo Tutorials Mobile:0920-5583476 Bus. c B C C C A B A C B D A A B C A A A Set IV 1 2 3 4 5 6 7 8 9 10 B D D B A A D C C A 11 12 13 14 15 16 17 18 19 20 C C D D D A D A A A 21 22 23 24 25 26 27 28 29 30 B A A C D A B A D B 31 32 33 34 35 36 37 38 39 40 D D A C A C B C A A 41 42 43 44 45 46 47 48 49 50 B B B D C B D B A C 51 52 53 54 55 56 57 58 59 60 D B D B D A C B A B 61 62 63 64 65 66 67 68 69 70 B B B D B C B D B C 71 72 73 74 75 76 77 78 79 80 C A C C C E D C D B 81 82 83 84 85 86 87 88 89 90 A B B D D C D B B B 91 92 93 94 95 96 97 98 99 100 B A B C B D D C C D 54 .:273-2245 Set III 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 A C C B C C B D D 21 22 23 24 25 26 27 28 29 30 C A D D A B 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 A A 51 52 53 54 55 56 57 58 59 60 C A D D C B C B A C 61 62 63 64 65 66 67 68 69 70 B B C A B C D A C 71 72 73 74 75 76 77 78 79 80 B C A C A B B B B A 81 82 83 84 85 86 87 88 89 90 B D A C A B B D A B 91 92 93 94 95 96 97 98 99 100 C A A A B A D A D C B C.

:273-2245 Set V 1 2 3 4 5 6 7 8 9 10 C B B C B C A C D B 11 12 13 14 15 16 17 18 19 20 C D C C A D D D A D 21 22 23 24 25 26 27 28 29 30 C A A C A A D C B C 31 32 33 34 35 36 37 38 39 40 B D A B A D C A D D 41 42 43 44 45 46 47 48 49 50 D A C A C A C C D B 51 52 53 54 55 56 57 58 59 60 C D A A A C A C C D 61 62 63 64 65 66 67 68 69 70 D C B D B A B B A A 71 72 73 74 75 76 77 78 79 80 D D A B D 81 82 83 84 85 86 87 88 89 90 A C D C D B D A B B 91 92 93 94 95 96 97 98 99 100 C A C C C D C A C C 55 .Allan Ocampo Tutorials Mobile:0920-5583476 Bus.

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