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NURSING PRACTICE I SET A

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NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice

GENERAL INSTRUCTIONS:

1. This test booklet contains 100 test questions.
2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded
will invalidate your answer.
4. AVOID ERASURES.
5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is
punishable by law. Per RA 8981.
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INSTRUCTIONS:

1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet
Set .
2. Write the subject title “Nursing Practice I” on the box provided.
3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test
booklet is Set B.

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.”

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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 that
harms the client
D. totally responsible for the negligence

8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards
started singing prayerful hymns. What is the BEST response of Edna?

A. Ignore the incidence
B. Report the incidence to the head nurse
C. Respect the client’s actions as this provides structure and support to the
client
D. Call her attention so she can go to sleep

9. A client asks for advice on low cholesterol food. You advise the client to eat the following:

A. 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 of
dyspnea
B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two
tablets into the client’s medicine cup
C. As the nurse was about to administer medication, the client questioned why the
medication is still given when in fact the physician discontinued it.
D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient
noticed the error and complained.

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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 himself. 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
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

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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

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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

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

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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?

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 choose to be at home with his family. What nursing
action are 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.

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41. In both quantitative and qualitative research, the used of a frame of reference is required.
Which of the following items serves as the purpose of a framework?

A. Incorporates theories into nursing’s body of knowledge
B. Organizes the development of study and links the findings to nursing’s body
of knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts

42. Myrna need to review relevant literature and studies. The following processes are undertaken
in reviewing literature EXCEPT:

A. locating and identifying resources 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 can not pay his hospital bills and professional fees.
You refer him to a:

A. Nurse supervisor C. bookkeeping department
B. Social worker D. physician

47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the
oncology nurse to a self-help group of clients with cancer to:

A. receive emotional support C. provide financial assistance
B. to be a part of a research study D. assist with chemotherapy

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status.
She should be referred to a:

A. nutritionist C. physician
B. dietitian D. medical pathologist

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

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C. she listens to the individual views of the team members
D. helps client set goals of care and discharge

50. Nurse Rita is successful in collaborating with health team members about the care of Mr.
Linao. This is because she has the following competencies:

A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust

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

51. To provide safe, quality nursing care to various clients in any setting, the most important tool of
the nurse is:

A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs

52. You ensure the appropriateness and safety of your nursing interventions while caring for
various client groups by:

A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation

53. The effectiveness of your nursing care plan for your clients is determined by

A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care

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

A. Blood pressure measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty food
D. Complaint of frequent bouts of dizziness

55. While talking with Mrs. Amado, it is most important for the nurse to:

A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent

Situation 9 – Oral care is an important part of hygienic practices and promoting client
comfort.

56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive
dryness and presence of sores. Which of the following is BEST to use for oral care?

A. lemon glycerine C. Mineral oil
B. hydrogen peroxide D. Normal saline solution

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57. When performing oral care to an unconscious client, which of the following is a special
consideration to prevent aspiration of fluids into the lungs?

A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression

58. The advantages of oral care for a client include all of the following, EXCEPT:

A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal
mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food

59. A possible problem while providing oral care to unconscious clients is the risk of fluid
aspiration to lungs. This can be avoided by:

A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid
rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity

60. Your client has difficulty of breathing and is mouth breathing most of the time. This causes
dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in
addition, you will keep the mouth moistened by using:

A. salt solution C. petroleum jelly
B. water D. mentholated ointment

Situation 10 – Errors while providing nursing care to patients must be avoided and minimized at
all time. Effective management of available resources enables the nurse to provide
safe, quality patient care.

61. In the hospital where you work, increased incidence of medication error was identified as the
number one problem in the unit. During the brainstorming session of the nursing service
department, probable causes were identified. Which of the following is process related?

A. interruptions C. lack of knowledge
B. use of unofficial abbreviations D. failure to identify client

62. Miscommunication of drug orders was identified as a probable cause of medication errors.
Which of the following is safe medication practice related to this?

A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication
Administration Method
C. Only officially approved abbreviations maybe used in prescription orders
D. Encourage clients to ask question about their medications.

63. The hospital has an ongoing quality assurance program. Which of the following indicates
implementation of process standards?

A. The nurses check client’s identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room

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64. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of
quality care?

A. Interviews nurses for comments regarding staffing
B. Measures waiting time for client’s per nurse’s call
C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment every shift

65. 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. Which of the following is the most appropriate
action of the nurse supervisor?

A. Assign another nurse to perform the procedure
B. Ask the nurse to find way to learn the procedure
C. Tell the nurse to read the procedure manual
D. Do the procedure with the nurse

Situation 11 – Mr. Jose’s chart is the permanent legal recording of all information that relates to
his health care management. As such, the entries in the chart must have accurate data.

66. Mr. Jose’s chart contains all information about his health care. The functions of records include
all except:

A. means of communication that health team members use to communicate their
contributions to the client’s health care
B. the client’s record also shows a document of how much health care agencies will
be reimbursed for their services
C. educational resource for student of nursing and medicine
D. recording of actions in advance to save time

67. An advantage of automated or computerized client care system is:

A. The nursing diagnoses for a client’s data can be accurately determined
B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated
D. The number of people to take care of the client will be reduced

68. Information in the patient’s chart is inadmissible in court as evidence when:

A. The client’s family refuses to have it used
B. The client objects to its use
C. The handwriting is not legible
D. It has too many abbreviations that are “unofficial”

69. Nursing audit aims to:

A. provide research data to hospital personnel
B. study client’s illness and treatment regimen closely
C. compare actual nursing done to established standards
D. provide information to health-care providers

70. A telephone order is given for a client in your ward. What is your most appropriate action?

A. Copy the order on to the chart and sign the physician’s name as close to his
original signature as possible
B. Repeat the order back to the physician, copy onto the order sheet and
indicate that it is a telephone order
C. Write the order in the client’s chart and have the head nurse co-sign it
D. Tell the physician that you can not take the order but you will call the nurse
supervisor

Situation 12 – Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in
another unit. She will take care of clients with various conditions.

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71. Which of the following client conditions should be Miss Roque’s priority in the pediatric unit?

A. The baby whose fantanelle is bulging and firm while asleep
B. The infant who is brought in for upper respiratory tract infection whose
temperature is slightly elevated
C. A baby who is wailing after being awakened by the banging door
D. A baby boy whose circumcision has yellowish exudate

72. When suctioning the endotracheal tube, the nurse should:

A. Explain procedure to patient; insert catheter gently applying suction. Withdrawn
using twisting motion
B. Insert catheter until resistance is met, then withdraw slightly, applying
suction intermittently as catheter is withdrawn
C. Hyperoxygenate client insert catheter using back and forth motion
D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling
motion as catheter is withdrawn

73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a
sponge bath. While Doris is doing spone bath, what action of Doris needs correction?

A. Answering the phone while wearing gloves used for sponge bath
B. Rolling the patient like a log to do back rub
C. Lining the rubber mat with bed sheet as incontinence pad for the patient
D. Turning the patient on the left side with head slightly elevated

74. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before
cast application is most important for Nurse Roque to do?

A. Use baby powder to reduce irritation under the cast
B. Assess sensation of each arm
C. Evaluate skin temperature in the area
D. Check radial pulses bilaterally and compare

75. To obtain specimen for sputum culture and sensitivity, which of the following instruction is
best?

A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing
C. Save sputum for two days in covered container
D. After respiratory treatment, expectorate into a container

Situation 13 – Infections are quite commonly the reasons for a client’s hospitalization. Appropriate
interpretation of diagnostic tests and measures for infection control are helpful in the
management of patient care.

76. Dorothy underwent diagnostic test and the result of the blood examination are back. On
reviewing the result the nurse notices which of the following as abnormal finding?

A. Neutrophils 60%
B. White blood cells (WBC) 9000/mm
C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr
D. Iron 75 mg/100 ml

77. Surgical sepsis is observed when:

A. inserting an intravenous catheter
B. disposing of syringes and needles in puncture proof containers
C. washing hands before changing wound dressing
D. placing dirty soiled linen in moisture resistant bags

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78. A client with viral infection will most likely manifest which of the following during the illness
stage of the infection?

A. Client was exposed to the infection 2 days ago but without any symptoms
B. Oral temperature shows fever
C. Acute symptoms are no longer visible
D. Client “feels sick” but can do normal activities

79. Which of the following laboratory test result indicate presence of an infectious process?

A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18,000/mm3
C. Iron 90 g/100ml
D. Neutrophils 67%

80. Among the clients you are assigned to take care of, who is the most susceptible to infection?

A. Diabetic client C. client with pulmonary emphysema
B. Client with burns D. client with myocardial infarction

Situation 14 – You are a newly hired nurse in a tertiary hospital. You have finished your
orientation program recently and you are beginning to assimilate the culture of the
profession.

81. Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will
rank yourself as a/an:

A. competent nurse C. proficient nurse
B. novice nurse D. advanced beginner

82. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the
context of having:

A. the ability to organize and plan activities
B. having attained an advanced level of education
C. a holistic understanding and perception of the client
D. intuitive and analytic ability in new situations

83. As you become socialized into the nursing “culture” you become a patient advocate.
Advocacy is explained by the following EXCEPT:

A. respecting a person’s right to be autonomous
B. demonstrating loyalty to the institution’s rights
C. shared respect, trust and collaboration in meeting health needs
D. protecting and supporting another person’s rights

84. Modern day nursing has led to the led development of the expanded role of the nurse as seen
in the function of a:

A. Clinical nurse specialist C. community health nurse
B. Critical care nurse D. staff nurse

85. You join a continuing education program to help you:

A. Earn credits for license renewal
B. Get in touch with colleagues in nursing
C. Enhance your basic knowledge
D. Update your knowledge and skills related to field of interest

Situation 15 – When creating your lesson plan for cerebrovascular disease or STROKE. It is
important to include the risk factors of stroke.

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86. The most important risk factor is:

A. Cigarette smoking C. binge drinking
B. Hypertension D. heredity

87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based
on cause are the following EXCEPT:

A. Embolic stroke C. diabetic stroke
B. Hemorrhagic stroke D. thrombotic stroke

88. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of
hemorrhage, EXCEPT:

A. phlebitis C. damage to blood vessel
B. trauma D. aneurysm

89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug
is closely linked to this?

A. Amphetamines C. shabu
B. Cocaine D. Demerol

90. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:

A. “More red blood cells thicken blood and make clots more possible.”
B. “Increased RBC count is linked to high cholesterol.”
C. “More red blood cell increases hemoglobin content.”
D. “High RBC count increases blood pressure.”

Situation 16 – Accurate computation prior to drug administration is a basic skill all nurses must
have.

91. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm
daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of
the drug that the client will received per oral administration?

A. 1,000 mg tid C. 1,500 mg tid
B. 500 mg tid D. 50 mg tid

92. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day.
The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each
oral dose?

A. 0.5 ml C. 2.5 ml
B. 1.5 ml D. 10 ml

93. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for
Mrs. Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous
pump. Which of the following should Nurse Robert do to safely administer this drug?

A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard

94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician:
“give 3.00 cc of Lanoxin today for 1 dose only”. Which of the following is the most appropriate
action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin

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95. When Nurse Norma was about to administer the medications of client Lennie, the relative of
Lennie told the nurse that they buy her medicines and showed the container of medications of
the client. Which of the following is the most appropriate action by the nurse?

A. Hold the nurse administration of the client’s medication and refer to the head nurse
B. 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. Bring the medications of the client to the nurse’s station and prepare accordingly

Situation 17 – You are taking care of Mrs. Santillan a 48 year old woman who is unconscious
after a cerebrovascular accident. You are aware that there are many physical
complications due to immobility.

96. You should be alert for the following complications she may experience EXCEPT:
A. Impaired mobility C. hypostatic pneumonia
B. Contractures and muscle atrophy D. pressure sores

97. Proper positioning of an immobilized unconsciousness client is important for the following
reasons EXCEPT:

A. Maintain skin integrity
B. Promotes optimal lung expansion
C. Prevent injuries and deformities of the musculo-skeletal system
D. Facilitates rest and sleep

98. When positioning your client, you should observe good body mechanics for yourself and the
client. This means that the nurse:

A. Uses back muscles
B. Assumes correct body alignment and efficient use of muscles to avoid injury

C. Observes rhythmic movements when moving about
D. Uses large muscles only

99. You are going to move Mrs. Santillan, a 150 lbs unconscious woman. Some principls to use
when moving the client include the following EXCEPT:

A. prepare to move client by taking deep breath and tightening abdominal and gluteal
muscles
B. maintain wide base of support with feet and with knees flexed
C. push and pull using arms and legs instead of lifting
D. move close to the object to be moved leaning or bending at the waist

100. After moving Mrs. Santillan to the desired position, which action will you avoid?

A. Avoid friction between bony prominences
B. Place pillows to position client’s extremeties
C. Apply restraints
D. Raise bed rails

SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR
WATCHERS. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A
GROUND FOR CANCELLATION OF YOUR EXAMINATION.

***END***

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