Nursing Practice I -Foundation of

Professional Nursing Practice

1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking t
the nurse was negligent is:
a. The physicians orders.
b. The action of a clinical nurse specialist who is recognized expert in the field.
c. The statement in the drug literature about administration of terbutaline.
d. The actions of a reasonably prudent nurse with similar education and experience.

2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count
dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is schedul
medication, Nurse Trish should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C

3. Dr. Garcia writes the following order for the client who has been recently admitted Digoxin .125 mg P.O. onc
document this order onto the medication administration record?
a. Digoxin .1250 mg P.O. once daily
b. Digoxin 0.1250 mg P.O. once daily
c. Digoxin 0.125 mg P.O. once daily
d. Digoxin .125 mg P.O. once daily

4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should rec
a. Ineffective peripheral tissue perfusion related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.

d. A 63 year-old post operatives abdominal hysterectomy client of three days whose incisional dressing is satura

6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan sh
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows th
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records th
ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swe
which statement by Tony suggests that ice application has been effective?
a. My ankle looks less swollen now.
b. My ankle feels warm.
c. My ankle appears redder now.
d. I need something stronger for pain relief

10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that t
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the following
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

13.Which type of medication order might read "Vitamin K 10 mg I.M. daily 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nu
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a male client who is having external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.

17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:
a. Encourage the client to void following preoperative medication.
b. Explore the clients fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.

18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food a
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.

19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.

20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.

21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse tak
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.

22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladde
the care of this client?
a. Place client on reverse isolation.

b. Admit the client into a private room.

c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.

23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nur
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge

24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embo
a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.

25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed
trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma cen
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational

26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500
will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc

27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour

28.The nurse is aware that the most important nursing action when a client returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.

29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction
a. BP 80/60, Pulse 110 irregular
b. BP 90/50, Pulse 50 regular
c. BP 130/80, Pulse 100 regular
d. BP 180/100, Pulse 90 irregular

30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?

a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information i
b. Measure the clients arm, if you are not sure of the size of cuff to use.
c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
d. Document the measurement, which extremity was used, and the position that the client was in during the meas

31.Asking the questions to determine if the person understands the health teaching provided by the nurse would b
a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals

32.Which of the following item is considered the single most important factor in assisting the health professional
a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination

33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed
be to use:
a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.

c. Footboard
d. Hip-abductor pillow

34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV

35.When the method of wound healing is one in which wound edges are not surgically approximated and integum
is termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing

36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that
assessing him for dehydration, nurse Oliver would expect to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia

37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a clients pos
How many milliliters of meperidine should the
client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25

38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?
a. Its a common measurement in the metric system.
b. Its the basis for solids in the avoirdupois system.
c. Its the smallest measurement in the apothecary system.
d. Its a measure of effect, not a standard measure of weight or quantity.

39.Nurse Oliver measures a clients temperature at 102 F. What is the equivalent Centigrade temperature?
a. 40.1 C
b. 38.9 C
c. 48 C
d. 38 C

40.The nurse is assessing a 48-year-old client who has come to the physicians office for his annual physical exa
signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.

41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water
leaks by:
a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.

42.Nurse Trish must verify the clients identity before administering medication. She is aware that the safest way
a. Check the clients identification band.
b. Ask the client to state his name.
c. State the clients name out loud and wait a client to repeat it.
d. Check the room number and the clients name on the bed.

43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 d
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute

44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediate

a. Clamp the catheter

b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.

45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the
clients abdomen and notice that it is slightly concave. Additional assessment should proceed in which order:
a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.

46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand

47. Which type of evaluation occurs continuously throughout the teaching and learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective

48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John sh
mammogram how often?
a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline

49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HC
expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis

d. Metabolic alkalosis

50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?
a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal illness.
c. To ensure that the client gets counseling regarding health care costs.
d. To teach the client and family about cancer and its treatment.

51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following action
independently?
a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per day.

52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf. He should apply the bandage beginnin
a. Knee
b. Ankle
c. Lower thigh
d. Foot

53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infu
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia

54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterw
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and n

to the clients room. Upon reaching the clients bedside, the nurse would take which action first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness

56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting
a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.

57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with b
been maintained if which of the following data is observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg

58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nu
specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.

59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretar
emergency phone call. The appropriate nursing action is to:
a. Immediately walk out of the clients room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the clients door open so the client can be monitored and the nurse can answer the phone call.

60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a produ
to obtain the specimen?

a. Ask the client to expectorate a small amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
d. Provide tissues for expectoration and obtaining the specimen.

61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker

a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the flo

62.Nurse Amy has documented an entry regarding client care in the clients medical record. When checking the e
documented. How does the nurse correct this error?
a. Erases the error and writes in the correct information.
b. Uses correction fluid to cover up the incorrect information and writes in the correct information.
c. Draws one line to cross out the incorrect information and then initials the change.
d. Covers up the incorrect information completely using a black pen and writes in the correct information

63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety
a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.

64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on c
use which of the following protective items when giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles

65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has r
the client use which of the following assistive devices that would provide the best stability for ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane

d. Walker

66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The clie
safe environment, the nurse assists the client to which position for the procedure?
a. Prone with head turned toward the side supported by a pillow.
b. Sims position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated 45 degrees.
d. Left side-lying with the head of the bed elevated 45 degrees.

67.Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers t
repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability

68.Harry knows that he has to protect the rights of human research subjects. Which of the following actions of H
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study

69.Patients refusal to divulge information is a limitation because it is beyond the control of Tifanny. What type
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical

70.Nurse Ronald is aware that the best tool for data gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation

71.Monica is aware that there are times when only manipulation of study variables is possible and the elements o

research is referred to this?

a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design

72.Cherry notes down ideas that were derived from the description of an investigation written by the person who
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes

73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing a
the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity

74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the ne
principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine

75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is:
a. The Board can issue rules and regulations that will govern the practice of nursing
b. The Board can investigate violations of the nursing law and code of ethics
c. The Board can visit a school applying for a permit in collaboration with CHED
d. The Board prepares the board examinations

76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked

c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing

77.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the follow
process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework

78. The leader of the study knows that certain patients who are in a specialized research setting tend to respond p
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect

79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?

a. Plans to include whoever is there during his study.

b. Determines the different nationality of patients frequently admitted and decides to get representations samples
c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.
d. Decides to get 20 samples from the admitted patients

80. The nursing theorist who developed transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy

81.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked i
a. Random
b. Accidental
c. Quota
d. Judgment

82.John plans to use a Likert Scale to his study to determine the:

a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance

83.Which of the following theory addresses the four modes of adaptation?

a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson

84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader

85.Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bio
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence

86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should i
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.

87.A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should inc
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties

88.The nurse prepares to administer a cleansing enema. What is the most common client position used for this pr
a. Lithotomy
b. Supine
c. Prone
d. Sims left lateral

89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first?
a. Arrange for typing and cross matching of the clients blood.
b. Compare the clients identification wristband with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the clients vital signs.

90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlie
a. Independent
b. Dependent
c. Interdependent
d. Intradependent

91.A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. T
redness or edema. The nurse's actions reflect which step of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

92.Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware th
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.

93.Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a b
a. Instructing the client to report any itching, swelling, or dyspnea.

b. Informing the client that the transfusion usually take 1 to 2 hours.

c. Documenting blood administration in the client care record.
d. Assessing the clients vital signs when the transfusion ends.

94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which interventi
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler's position while feeding.
d. Change the feeding container every 12 hours.

95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when administering oxygen by face mask to a female client?
a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
d. Loosen the connectors between the oxygen equipment and humidifier.

97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

98.Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse Monique ob
a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.

99.Nurse May is aware that the main advantage of using a floor stock system is:
a. The nurse can implement medication orders quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.

100. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries.

Nursing Practice I -Foundation of Professional Nur

1. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience.
Rationale: The standard of care is determined by the average degree of skill, care, and diligence by nurses in sim

2. Answer: (B) I.M

Rationale: With a platelet count of 22,000/l, the clients tends to bleed easily. Therefore, the nurse should avoid
can bleed readily when penetrated by a needle. The bleeding can be difficult to stop.

3. Answer: (C) Digoxin 0.125 mg P.O. once daily

Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure, whic
a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a t

4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion.

Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because
a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately
heart is avoided.

6. Answer: (C) Check circulation every 15-30 minutes.

Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to the dista
every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs

7. Answer: (A) Prevent stress ulcer

Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This results in a decreased pr

best treatment for this prophylactic use of antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine output
Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's
action is warranted.

9. Answer: (B) My ankle feels warm.

Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased war
application

10. Answer: (B) Hyperkalemia

Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokal
11. Answer:(A) Have condescending trust and confidence in their subordinates
Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.
12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.
Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.

13. Answer: (B) Standard written order

Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A
medications given immediately for an urgent client problem. A standing order, also known as a protocol, establ
particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may ins
a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stools

Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the
with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. Th
to defecate (although they can't pass stool) and a decreased appetite.

15. Answer: (C) Pulling the helix up and back

Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up
grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straigh

16. Answer: (A) Protect the irritated skin from sunlight.

Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approa

17. Answer: (C) Assist the client in removing dentures and nail polish.
Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can b

18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and
back pain reflects the inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet.

Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to
day.

20. Answer: (A) Blood pressure and pulse rate.

Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to t

21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse s
and call for a physician for the hospitalized client.

22. Answer: (B) Admit the client into a private room.

Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visito

23. Answer: (C) Risk for infection

Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (n
because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of th

24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg po
amount of blood pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is a task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr.

28. Answer: (B) Assess the client for presence of pain.

Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of com
provide for the clients comfort.
29. Answer: (A) BP 80/60, Pulse 110 irregular
Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold,

30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropria
Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic idea

31. Answer: (B) Evaluation

Rationale: Evaluation includes observing the person, asking questions, and comparing the patients behavioral r

32. Answer: (C) History of present illness

Rationale: The history of present illness is the single most important factor in assisting the health professional i

33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will allowed to heal by secondary intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart,

37. Answer: (A) 0.75

Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method i
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ml) = X
38. Answer: (D) Its a measure of effect, not a standard measure of weight or quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs
quality or quantity.
39. Answer: (B) 38.9 C
Rationale: To convert Fahrenheit degreed to Centigrade, use this formula
C = (F 32) 1.8
C = (102 32) 1.8
C = 70 1.8
C = 38.9

40. Answer: (C) Failing eyesight, especially close vision.

Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 6
(ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all connections
Rationale: Air leaks commonly occur if the system isnt secure. Checking all connections and taping them will
promote drainage not to prevent leaks.

42. Answer: (A) Check the clients identification band.

Rationale: Checking the clients identification band is the safest way to verify a clients identity because the ba
it is removed, it must be replaced). Asking the clients name or having the client repeated his name would be ap
understand what is being said, but isnt the safe standard of practice. Names on bed arent always reliable

43. Answer: (B) 32 drops/minute

Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the numbe
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheter

Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter cla
sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solut
infusion.

45. Answer: (D) Auscultation, percussion, and palpation.

Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, a
intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can al

46. Answer: (D) Ulnar surface of the hand

Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibra
fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth.

47. Answer: (C) Formative

Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning proc
necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching
48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at age 40 and continue for
as long as the woman is in good health. If health risks, such as family
history, genetic tendency, or past breast cancer, exist, more frequent
examinations may be necessary.

49. Answer: (A) Respiratory acidosis

Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arter
In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acid
In metabolic alkalosis, the pH and Hco3 values are above normal.

50. Answer: (B) To provide support for the client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesnt fo
referred to hospices have been treated for their disease without success and will receive only palliative care in t

51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary
Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurse
povidone-iodine wash and an antibiotic cream require a physicians order. Massaging with an astringent can fur
52. Answer: (D) Foot

Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method promote
the bandage at the clients foot. Beginning at the ankle, lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia.

54. Answer: (A) Throbbing headache or dizziness

Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. Howeve

55. Answer: (D) Check the clients level of consciousness

Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in ventricu
However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output

56. Answer: (B) On the affected side of the client.

Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security belt in
position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that ther
outward rather than at his or her feet.

57. Answer: (A) Urine output: 45 ml/hr

Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as
adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators
adversely affects all body tissues.

58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes whi
client status. In addition, it may become contaminated with bacteria from opening the system.

59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call.
Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate actio
of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the cli
the room curtains pulled around the bathing area.

60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques bec
the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would

61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then
Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed
floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in the walke
walk into it.

62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change.
Rationale: To correct an error documented in a medical record, the nurse draws one line through the incorrect in
and correction fluid is never used in the medical record.

63. Answer: (C) Secures the client safety belts after transferring to the stretcher.
Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should avoid expo
Hurried movements and rapid changes in the position should be avoided because these predispose the client to
the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move sel
stretcher.

64. Answer: (B) Gown and gloves

Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Gogg
nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are no

65. Answer: (C) Quad cane

Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is
side. However, the quad cane would provide the most stability because of the structure of the cane and because

66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the be
stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the research instrument. It refers to
the repeatability of the instrument in extracting the same responses upon
its repeated administration.

68. Answer: (A) Keep the identities of the subject secret

Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder p
source.

69. Answer: (A) Descriptive- correlational

Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables
nosocomial infection.

70. Answer: (C) Use of laboratory data

Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, parti
essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when randomization and control of the variables are not possible.

72. Answer: (C) Primary source

Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator
someone other than the original researcher.

73. Answer: (A) Non-maleficence

Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/c
74. Answer: (C) Res ipsa loquitor

Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the

75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of th
duces tecum as needed.

76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that th
the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed

77. Answer: (B) Review related literature

Rationale: After formulating and delimiting the research problem, the researcher conducts a review of related li
study by previous researchers.

78. Answer: (B) Hawthorne effect

Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an interventi
their productivity. It resulted to an increased productivity but not due to the intervention but due to the psycholo
because they were under observation.

79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get represen
Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about

80. Answer: (B) Madeleine Leininger

Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the b

81. Answer: (A) Random

Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of th
82. Answer: (A) Degree of agreement and disagreement
Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement

83. Answer: (B) Sr. Callista Roy

Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concep
84. Answer: (A) Span of control
Rationale: Span of control refers to the number of workers who report directly to a manager.

85. Answer: (B) Autonomy

Rationale: Informed consent means that the patient fully understands about the surgery, including the risks invo
with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be

86. Answer: (C) Avoid wearing canvas shoes.

Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspi
irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut
clippers.

87. Answer: (D) Ground beef patties

Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdow
Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, maki

88. Answer: (D) Sims left lateral

Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema bec
the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent o
positions are inappropriate and uncomfortable for the client.

89. Answer: (A) Arrange for typing and cross matching of the clients blood.
Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility w
although appropriate when preparing to administer a blood transfusion, come later.

90. Answer: (A) Independent

Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug
independent intervention, whereas consulting with the physician and pharmacist to change a client's medication
intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent

91. Answer: (D) Evaluation

Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show tha
consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering as
diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action.

92. Answer: (B) To observe the lower extremities

Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once per day t
Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can s

93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea.
Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic
Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the
and should document its administration, these actions are less critical to the client's immediate health. The nurs

94. Answer: (B) Decrease the rate of feedings and the concentration of the formula.
Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Dec
formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize
head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding contain

95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing
medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if possible.
Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breath
band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nu

the chin not vice versa. The nurse should check the connectors between the oxygen equipment and humidifie
loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for
increases after that time. Discard or return to the blood bank any blood not given within this time, according to

98. Answer: (B) Immediately before administering the next dose.

Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therap
level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on
levels typically are drawn after administering the next dose.

99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for p
reinforce accurate calculations.

100. Answer: (C) Shifting dullness over the abdomen.

Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are nor