You are on page 1of 29

vanguardias online review program

NURSING PRACTICE I
ASSESSMENT EXAM
Situation: Health Promotion is one of the significant Programs emphasized by the Department of Health
and any tertiary hospital to prevent illness.
1.

Health promotion is best represented by which activity?


A. administering immunizations
B. giving a bath
C. preventing accidents in the home
D. performing diagnostic procedures
Rationale: C. Health Promotion focuses on maintaining normal status without consideration of diseases.
Option A is an example of illness prevention. Option B is aesthetic (i.e., not needed for health promotion or
disease prevention). Option D focuses on disease detection.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
2.

Which of the following is an example of the emotional component of wellness?


A. The client chooses healthy foods
B. A new father decides to take parenting classes
C. A client expresses frustration with her partners substance abuse
D. A widow with no family decides to join a bowling league
Rationale: C. Frustration is an example of an emotion. The client who chooses health foods (option A)
represents the physical component, taking parenting classes enhances the intellectual component (option
B), and the bowling league (option D) enhances the intellectual component (option B), and the bowling
league (option D) enhances both the physical and social components.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
3.

Which individual appears to have taken on the sick role?


A. An obese client states, I deserve to have a heart attack.
B. A mother is ill and says, I wont be able to make your lunch today.
C. A man with low back pains misses several physical therapy appointments
D. An older adult states, My horoscope says I will be well again.
Rationale: B. The mother has taken on the sick role by expecting to be excused from her usual role
responsibilities. The sick role states that persons are not answerable for their illness, contrary to the obese
clients perspective (option A). In the sick role, the client tries to get better as opposed to the man who
misses his physical therapy appointments (option C). The older adult is not following the sick role
expectation to rely on component help (option D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
4.

Because a client recently diagnosed with diabetes mellitus is confident that blood sugar control can
be improved with diet and exercise alone and recently checked out a video on the management of
diabetes at the Health Maintenance Office education center, the clients actions are most
representative of which model?
A. Health belief model
B. Clinical model
C. Role performance model

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


D. Agent-host-environment model
Rationale: A. The behavior is most representative of health promotion, which is the central focus of the
health belief model. The clinical model focuses of the health on relieving signs and symptoms of illness
(option B). The role performance model emphasizes social activities such as fulfilling a particular role
(option C). The agent host environment model focuses on predicting illness (option D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.,
Situation: The Nursing Service of a hospital is observing and adopting the Model of Benners Clinical
Proficiency level.
5.

A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing
care demands is at which of Benners stages of nursing expertise?
A. advanced beginner
B. competent
C. proficient
D. expert
Rationale: B. Option A, the advanced beginner, demonstrates marginally acceptable performance. Option
C, the proficient practitioner, has 3 to 5 years of experience and has developed a holistic understanding of
the client. Option D, the expert practitioner, demonstrates highly skilled intuitive and analytic ability in new
situations.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
6.

Which provides the best explanation of describing nursing as a practice discipline?


A. nursing focuses on performing the professional role
B. it takes time and experience to become a competent nurse
C. research and theory development is a central focus
D. nurses function as a members of a team who form a practice group
Rationale: A. Practice disciplines are fields of study in which the central focus is performance of a
professional role. Time and experience are necessary for developing proficiency in any profession or career
(option B). Research and theory development do not have performance as their primary focus. The primary
focus of nursing is providing quality service to humans (option C). Team or group practice can be a part of
a career in humanities, computer science or rocket science (option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
7.

Person, environment, health, and nursing constitute the metaparadigm for nursing because they do
which of the following?
A. provide a framework for implementing the nursing process
B. can be utilized in any setting when caring for a client
C. can be utilized to determine applicability of a research study
D. focus on the needs of a group of clients
Rationale: B. Person/client, environment, health and nursing are relevant when providing care for any
client whether in the hospital, at home, in the community, or in elementary school systems. These elements
can be used to understand diseases, conduct and apply research, and develop nursing theories as well as
implement the nursing process.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
8.

Which is an accurate statement about the role of nursing theory?

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


A. practice theories assist nurse to reflect on the effectiveness of what they do
B. midlevel theories, describing the interrelationships among a broad range of concepts within
nursing, have been well tested through nursing research
C. all school of nursing in the United States are organized around one of the conceptual models
described in this chapter
D. nursing theory guides the direction of research but not that of education or practice
Rationale: A. Practice theories assist the nurse to reflect on nursing care. Theories describing the
interrelationships among a broad range of concepts within nursing care are grand theories, not midlevel,
and both require more testing through nursing research (option B). Schools of nursing in the United States
may or may not be organized around any theory or conceptual model (option C). Nursing guides the
direction of research and education practice (option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
9.

The client has difficulty in swallowing problem. Although the client refused the procedure, the nurse
insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides
to settle the lawsuit because the nurse is most likely to be found guilty of which of the following?
A. an unintentional tort
B. assault
C. invasion of privacy
D. battery
Rationale: D. Battery is the willful touching of a person without permission. Another name of an
unintentional tort is malpractice. This situation is an intentional tort because the nurse executed the act on
purpose. Assault is the attempt or threat to touch another person unjustifiably or without permission.
Invasion of privacy injures the feelings of the person and does not take into consideration how to revealing
information or exposing the client will affect the clients feelings.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
Situation: A male surgical nurse is preparing the post-operative orders.
10.

The staff nurse discovers that a Physician has prescribed an unusually large dosage of medication.
Which is the most appropriate action?
A. administer the medication
B. notify the prescriber
C. call the pharmacist
D. refuse to administer the medication
Rationale: B. The nurse should call the person who wrote the order for clarification. Administering the
medication is incorrect because knowing the dose is outside the normal range and not questioning the
order could lead to client harm and liability for the nurse. Calling the pharmacist is not the best answer it will
not solve the problem, and the nurse needs to seek clarification from the person who wrote the order. The
nurse should suspend administration but not refuse to administer the medication until that issue is resolved.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
11.

A Physician prescribes one tablet, but the nurse accidentally administers two. After notifying the
physician, the nurse monitors the client carefully for untoward effects of which there are none. Is the
client likely to be successful in suing the nurse for malpractice?
A. no, the client was not harmed

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


B. no, the nurse notified the primary care provider
C. yes, a breach of duty exists
D. yes, foreseeability is present
Rationale: A. All elements such as duty, foreseeability, causation, harm/injury, and damages must be
present for malpractice to be proven. The nurse is a licensed professional responsible for individual actions.
Notifying the primary care provider does not exempt the nurse from liability. Because it is apparent the
standard of practice was not performed, a breach of duty does exist. Violation/omission of the standard of
practice resulted in an excessive dosage. Therefore, foreseeability is present; however, no harm occurred
to the client.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
12.

The Physician consultant in a tertiary hospital wrote a do-not-resuscitate (DNR) order. The nurse
recognizes that which applies in the planning care for this client?
A. The client may no longer make decisions regarding his or her own health care
B. The client and family know that the client will most likely die within the next 48 hours
C. The nurses will continue to implement all treatments focused on comfort and symptom
management
D. A DNR order from a previous admission is valid for the current admission
Rationale: C. A DNR order only controls CPR and similar lifesaving treatments. All other care continues as
previously ordered. Competent clients can still decide about their own care (including the DNR order).
Nothing about the DNR order is related when the client may dies. Because clients medical conditions and
their views of their lives can change, a new DNR order is required for each admission to a health care
agency. Once admitted, that order stands until changed or until expires according to agency policy.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
13.

When an ethical issue arises, one of the most important nursing responsibilities in managing client
care situations is which of the following?
A. be able to defend the morality of ones own actions
B. remain neutral and detached when making ethical decisions
C. ensure that a team is responsible for deciding ethical questions
D. follow the client and familys wishes exactly
Rationale: A. A nurses action is an ethical dilemma must be defensible according to moral and ethical
standards. The nurse may have strong personal beliefs but distancing oneself from the situation does not
serve the client (option B). A team is not always required to reach decisions (option C), and the nurse is not
obligated to follow the clients wishes automatically when they may have negative consequences for self or
others (option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
14.

Which of the following situations is most clearly a violation of the underlying principles associated
with professional nursing ethics?
A. the hospital policy permits use of internal fetal monitoring during labor. However, there is
literature to both support and refute the value of this practice
B. when asked about the purpose of a medication, a nurse colleague responds, Oh, I never
look them up. I just give what is prescribed.
C. the nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by
fellow nurses at another facility

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


D. a client reports that he didnt quite tell the doctor the truth when asked is he was following this
therapeutic diet at home
Rationale: B. The nurse has an ethical responsibility to act only when actions are safe or risks minimized.
This nurse is putting the client at unnecessary risk for a medication error. Many medical practices are
controversial but not necessarily unethical (option A). The nurse should follow agency policy. Although
some may view nurses strikes as unethical, supporting others who are striking is a personal decision
(option C). Although a client in confidence to a nurse may have ethical overtones, it does not automatically
constitute an ethical dilemma. Since the assigned health care provider is a member of the team, principles
of confidentiality do not include him or her (option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
Situation: Maria is a Nurse Manager in St. Peters Hospital. One of the clients came to her seems confused
and asking if she can help her in her personal problems.
15.

Which of the following statements would be most helpful when a nurse is assisting clients in clarifying
their values?
A. That was not good decision. Why did you think it would work?
B. The most important is to follow the plan of care. Did you follow all your doctors orders?
C. Some people might have made a different decision. What led you to make your
decision?
D. If you had asked me, I would have given you my opinion about what to do. Now, how do you feel
about your choice?
Rationale: C. In values clarification, clients are assisted to think about the factors that influence their
beliefs and decisions. Any judgmental statement that reflects the rightness or wrongness of the clients
thoughts or actions will impede this process (options A, B, and D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
16.

Which of the following is an example of a primary prevention activity?


A. antibiotic treatment of a suspected urinary tract infection
B. occupational therapy to assist a client in adapting his or her home environment following a stroke
C. nutrition counseling for young adults with a strong family history of high cholesterol
D. removal of tonsils for a client with recurrent tonsillitis
Rationale: C. Actions such as diet modification that help prevent an illness or detect it in its early stages
are primarily preventions. Treatment of a disease such as with antibiotic therapy (option A) or surgery
(option D) is secondary prevention, while rehabilitation efforts following an illness (option B) are considered
tertiary prevention.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
17.

A client is seeking to control health care costs for both preventive and illness care. Although no
system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client
contribution would be seen with
A. Medicare
B. an individual fee-for-service insurance
C. a preferred provider organization (PPO)
D. a health maintenance organization (HMO)
Rationale: D. A health maintenance organization involves a set monthly membership fee and predictable
visit or deductable costs. Medicare covers minimal number of preventive and outpatient services so the
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

vanguardias online review program


cost is anticipated (option A). Individual fee for service insurance is perhaps the most costly to the
client, with potentially large differences between the amount of coverage the insurance company pays and
the provider charges (option B). PPOs are less costly than fee-for-service entities but more expensive than
HMOs (option C).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
18.

When performing collaborative health care, Nurse Manager Maria must implement which of the
following?
A. assume a leadership role in directing the health care team
B. rely on the expertise of other health care team members
C. be physically present for the implementation of all aspects of the care plan
D. delegate decision-making authority to each health care provider
Rationale: B. In collaboration, each member of the team, including the client, participates in sharing ideas
and reaching consensus on the best plan of care. The team is generally led by the health care professional
most skilled in the clients specific areas of need (option A). Once the plan is established, it may be
implemented by any member of the team or a designate at an appropriate time and place (option C). It is
not necessarily delegated by the nurse (option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
Situation: Sophie a Medical nurse is finally checking the discharge orders of a client Mr. George.
19.

The nurse concludes that effective discharge planning (hospital to home) has been conducted when
the client states which of the following?
A. As soon as I get home, the nurse will come out, look at where I live, and see what kind of care I
will need.
B. All I need are my medications and a ride home. Then Im all ready for discharge.
C. When I visit my doctor in 10 days, they will show me how to change my bandages.
D. I have the phone numbers of the home care nurse and the therapist who will visit me at
home tomorrow.
Rationale: D. Effective discharge planning would have included an assessment of home care needs prior
to the client leaving the hospital. The kind of care is determined before the client leaves the current setting.
That is why it is called discharge planning following through assessment, the client would be taught selfcare strategies and a basic plan of care for the coming days (option C). Obtaining medications and a ride
home does not indicate the client possesses the knowledge and skills needed to manage care after
discharge (option B). If the client will need care at home, those referrals would be made by the discharge
planner and communicated to the client. Option D indicates the client knows and accepts these referrals.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
20.

St. Peters Hospital a tertiary hospital is adopting the new modern system in their hospital. What is the
challenge most associated with the utilization of an electronic client record system?
A. cost
B. accuracy
C. privacy
D. durability
Rationale: C. Control over who has access to confidential computerized data is the greatest concern.
Computer hackers can bypass codes and gain access to personal information, which could result in identity
theft. The benefits often outweigh the cost (option A). Computerizes data can be much accurate than paper
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

vanguardias online review program


and pencil data (option B). Due to ease of making copies and backups, electronic data can last forever
(option D).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
21.

What is one disadvantage associated with electronic (e.g., Internet-based) courses?


A. they take longer
B. interpersonal communication is not possible
C. everyone has to log on at the same time
D. it is harder to establish a sense of community
Rationale: D. Since learners may do their online work at different times and do much of their work offline, it
may be harder for them to feel and act like a class group. The courses are often self-paced and thus, may
take a longer or shorter time to complete than on-campus courses (option A). Interpersonal communication
is possible through e-mail and chat, plus audio and video file sharing allow learners to see and hear the
faculty as well as each other (option B). For most web-based courses, learners may log on at their
convenience (option C).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
22.

What is the primary advantage of using computers while conducting nursing research?
A. locating potential participants
B. designing the steps of the research plan
C. analyzing the quantitative data
D. disseminating the research findings
Rationale: C. Although all steps of the research process can be accomplished with and without computers,
electronic analysis of quantitative data helps ensure accuracy and speeds the process immensely.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
Situation: One nurse expresses that the manager prepared the holiday work schedule unfairly. The
manager states that it is the same type of schedule used in the past and other nurses have no problems
with it.
23.

Which response indicates the nurse is displaying an attitude of critical thinking?


A. accepting the preferences of the other nurses since there are several of them
B. recognizing that the nurse must be researched a false conclusion
C. considering going to a higher authority than the manager for an explanation
D. continuing to query the manager until the nurse understands the explanation
Rationale: D. The critical thinking approach should include perseverance until a reasonable solution or
answer is determined. Giving in (option1), over questioning self, poor trust in ones own beliefs (option2), or
bypassing normal routes of authority (option 3)violates the desirable attitudes of integrity, intellectual
courage, and confidence in reason.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9 th Edition
24.

In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and
performs which of the following before implementing the plan?
A. reexamines the purpose for making the decision
B. consults the client and family members to determine their view of the criteria
C. identifies and considers various means for reaching the outcomes
D. determines the logical course of action should intervening problems arise

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


Rationale: D. It is important to project what problems might interfere with the plan and have appropriate
responses to prevent the interferences. The purpose for the decision should have been clear enough at the
outset as to not require reexamination at this point (option1). Clients and families should be consulted
early- in the purpose-setting and criteria-setting steps.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
25.

Which reasoning process describes the nurses actions when the nurse evaluates possible solutions
for care of an infected wound for optimal client outcomes?
A. intuition
B. research process
C. trial and error
D. problem solving
Rationale: D. A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition
(option A) is not a sufficient basis for implementing wound care when significant data on alternative care
strategies are available. Research (option A) is a more comprehensive rigorous process and not yet
typically implemented while caring for an infected wound. Trial and error (option C) is unsafe and
inappropriate for care of an infected wound.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
Situation: Every nurse must utilize a nursing tool which is the Nursing Process to determine the problems
of the clients and deliver safe patient care.
26.

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of
the nursing process to provide nursing care?
A. proposes hypotheses
B. generates desired outcomes
C. reviews results of laboratory tests
D. documents care
Rationale: C. During assessment, date are collected, organized, validated, and documented. Hypotheses
are generated during diagnosing; outcomes are set during planning; and documentation occurs throughout
the nursing process.
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
27.

Which of the following elements is best categorized as secondary subjective data?


A. the nurse measures a weight loss of 10 pounds since the last clinic visit
B. spouse states the client has lost all appetite
C. the nurse palpates edema in lower extremities
D. client states severe pain when walking up stairs
Rationale: B. Primary data come from the client (option D), whereas secondary data come from any other
source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be
measured or validated (weight option A, edema option C). If the spouse had stated that the client had
eaten only toast and tea, this would be secondary objective (measured data).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
28.

The use of conceptual or theoretical framework for collecting and organizing assessment data
ensures which of the following?
A. correlation of the data with other members of the health care team

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

vanguardias online review program


B. demonstration of cost-effective care
C. utilization of creativity and intuition in creating a plan of care
D. collection of all necessary information for a thorough appraisal
Rationale: D. Frameworks help the nurse be systematic in data collection. Other members of the health
care team may use very different conceptual organizing frameworks so data may not correlate (option A).
Cost-effective care (option B) is more likely to occur with systematic application of the nursing process, but
use of a framework for assessment alone may not accomplish this goal. Because the framework is
structured, and because of the nature of client needs/problems, creativity and intuition in care planning are
not assured (option C).
Reference: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice 9th Edition
29.

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client
with a seizure disorder. Which step exists between data analysis and formulating the diagnostic
statement?
A. Assess the clients needs.
B. Delineate the clients problems and strengths.
C. Determine which interventions are most likely to succeed.
D. Estimate the cost of several different approaches.
Rationale: B. In diagnosing, data from assessment (option A) are analyzed and problems, risks, and
strengths are identified before diagnostic statements can be established. Interventions (option C) are more
commonly part of the planning and implementing phases of the nursing process. Cost (option D) is an
important consideration but would be estimated in the phase.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
30.

In the diagnostic statement, Excess fluid volume related to decreased venous return as manifested
by lower extremity edema (swelling), the etiology of the problem is which of the following?
A. Excess fluid volume
B. Decreased venous return
C. Edema
D. Unknown
Rationale: B. Because the venous return is impaired, fluid is static, resulting in swelling. Therefore,
decreased venous return is the cause (etiology) of the problem. Excess fluid volume is the nursing
diagnosis, and edema of the lower extremity is the sign/symptom or critical attribute. The cause is known.
Reference: Kozier&Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
Situation: After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to
replace an arthritic hip was discharged from the post anesthesia recovery unit. The client has been on the
orthopedic floor for several hours.
31.

Which type of planning will be least useful during the first shift on the orthopedic unit?
A. Initial
B. Ongoing
C. Discharge
D. Strategic
Rationale: D. Strategic planning is an ongoing process focused on organizational change rather than
individual clients so it is least useful and not relevant in this case. The client requires initial planning
because he has just arrived on the orthopedic unit for the first time (option A). Of the three type of planning
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

vanguardias online review program


necessary to determine the care appropriate for this shift (option B). Discharge planning needs to start on
admission to ensure adequate client preparation for management of health needs outside the health
agency (option C).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
32.

The nurse recognizes which of the following as a benefit of using a standardized care plan?
A. No individualization is needed
B. The nurse chooses from a list of interventions
C. They are much shorter than nurse-authored care plans
D. They have been approved by accrediting agencies
Rationale: B. Standardized care plans provide a list of interventions from which the nurse can choose. The
plan must still be individualized (option A).Standardized plans could be longer or shorter than the nurseauthored ones (option C), but have not been approved by any outside accreditor (option D).
Reference: Kozier&Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.
33.

Which of the following is likely to occur if the goal statement is poorly written?
A. There is no standard against which to compare outcomes
B. The nursing diagnoses cannot be prioritized
C. Only dependent nursing interventions can be used
D. It is difficult to determine which nursing interventions can be delegated.
Rationale: A. Goal statements provide the standard against which outcomes are measured. Nursing
diagnoses are prioritized before goals are written (option A). Both independent and dependent interventions
may be appropriate for any goal (option C). Clarity of goal does not influence delegation of the intervention
(option D).
Reference: Kozier&Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
34.

Which of the following principles does the nurse use in selecting interventions for the care plan?
A. Actions should address the etiology of the nursing diagnosis
B. Always select independent interventions when possible
C. There is one best intervention for each goal/outcome
D. Interventions should be doing, not just monitoring
Rationale: A. Interventions should address the etiology of the nursing diagnosis. Both dependent and
independent interventions should be selected if appropriate (option B) and several interventions may be
needed for a single outcome (option C). Both action and assessment-type interventions can be used
(option D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed
35.

When initiating the implementation phase of the nursing process, the nurse performs which of the
following phases first?
A. Carrying out nursing interventions
B. Determining the need for assistance
C. Reassessing the client
D. Documenting interventions
Rationale: C. The first step of implementing is reassessing the client to determine that the activity is still
indicated and safe. The next action would be to determine if assistance is require, and then implement the
intervention (delegating if appropriate), and last, document the intervention.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.,
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

10

vanguardias online review program


36.

Under what circumstances is it considered acceptable practice for the nurse to document a nursing
activity before it is carried out?
A. When the activity is routine (e.g., raising the bed rails)
B. When the activity occurs at regular intervals (e.g., turning the client in bed)
C. When the activity is to be carried out immediately (e.g., a stat medication)
D. It is never acceptable
Rationale: D. It is never acceptable practice for the nurse to document a nursing activity before it is carried
out. This would be very unsafe because many things can cause an activity to be postponed or canceled
and prior charting would be inaccurate, misleading and potentially dangerous. In a few situations, it may be
permissible to chart frequent or routine activities some time following the activities such as at the end of a
shift or after a particular interval. (e.g. every 4hrs) rather than immediately following the activity.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
Situation: Nurses are always reminded to observe proper charting in documentation.
37.

Which action by a nurse ensures confidentiality of a clients record?


A. The nurse logs on to the clients file and leave the computer to answer the clients call light
B. The nurse shares her computer password
C. The nurse closes a clients computer file and logs off
D. The nurse leaves client computer worksheets at the computer work station
Rationale: C. All of the other answers endanger the clients confidentiality.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
38.

The case management model using critical pathways would be appropriate for a client with which
diagnosis?
A. Myocardial infarction (heart attack)
B. Diabetes, hypertension
C. Myocardial infarction, diabetes, hypertension
D. Diabetes, hypertension, an infected foot ulcer, senile dementia
Rationale: A. Critical pathways work best for clients with one diagnosis. Option 2 is a possibility; however,
there may be many individualized needs. Because that information is not available, the best answer is 1.
Options 3 and 4 have too many diagnoses to work well with a critical pathway.
Reference: Kozier&Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
39.

After making a documentation error, which action should the nurse take?
A. Use correcting liquid to cover the mistake and make a new entry
B. Draw a line through it and write error above the entry
C. Draw a line through it and write mistaken entry above it
D. Draw a line through the mistake and write mistaken entry with initials above it.
Rationale: D. It is the most complete answer. The clients record is a legal record and should not be altered
with correcting liquid. You may see error written above a mistake even though many authors suggest not
writing it. It is important to also put your name or initials next to the words of the mistaken entry.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

11

vanguardias online review program


Situation: The Pediatric Nurse is attending to the needs of the newly admitted children at different age
group. Significant principles are important to be considered to deliver safe patient care , The following refer
to these questions.
40.

The parents of a 5-month-old infant and a 3-year old child ask the nurse abut the sequence and
timing of developmental milestones for the infant. Which is the most appropriate response?
A. This infant should reach the milestones at the same time as your older child.
B. The infant may reach the milestones in a different order than your older child.
C. The sequence of reaching each milestone should follow the same pattern but may be at a
different rate.
D. There are no predictable patterns. Try to enjoy the uniqueness of each child.
Rationale: C. The sequence of each stage of development is predictable, although the time of onset, the
length of the stage, and the effects of each stage vary with the person.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
41.

The nurse knows that the study of growth and development is an exploration of which of the
following?
A. Physical changes of the growing child
B. Increasing complexity of function and skill progression of the growing child
C. Environmental factors such as family, religion and culture of the growing child
D. Physical developments and the increasing level and progression of function and skill of
the growing child
Rationale: D. The study of growth (physical) and development (function and skills) is correct because the
answer needs to have both components to be complete. Option A addresses only the growth aspects.
Option B addresses only developmental aspects and optionC addresses only the environmental factors that
might influence growth and development.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
42.

The nurse examines a 2-year old child recently hospitalized with pneumonia. Which pattern of
behavior is most likely to be exhibited by the child?
A. Lies quietly while the nurse listens to the lungs
B. Asks many questions about what the nurse is doing and hearing
C. Fusses, cries and pushes the nurse away during assessment of the breath sounds
D. Enjoys playing nurse with the stethoscope, and listens t self and others breath sounds
Rationale: C. Toddlers typically demonstrates negative behavior and are hesitant around strangers,
resisting close contact with people they do not know well. They do not have sophisticated language skills
and often use crying or fussing to communicate. Older school-aged children and adolescents are likely to
cooperate without complaint in many health procedures.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
43.

A 14-year old is scheduled to have surgical repair of a spinal curvature (scoliosis). The adolescent
will be hospitalized for about two weeks. Which nursing intervention will be most helpful during the
hospital stay?
A. Have peers visit frequently during the day
B. Instruct parents to room-in with her
C. Encourage her to go to the recreation room
D. Encourage her to arrange for her teachers to provide her with homework

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

12

vanguardias online review program


Rationale: D. Adolescents need to establish identity, which involves developing a more mature sense of
independence and responsibility. Providing her with schoolwork keeps her connected to her peer group and
gives a sense of accomplishment. Also, it prevents the client from worrying about getting behind in school
assignments. Interaction with peers is very important during this stage, but they are likely to be attending
school during the day (option A); an infants sense of trust is reinforced if parents room-in, and older infants
and toddlers experience less separation anxiety if parents are nearby (option B); and pre-school and school
aged children would benefit from the distraction and social interaction of others in the recreation room
(option C)
Reference: Kozier&Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.
Situation: The parent of an 8-month old girl who has been admitted to the hospital with pneumonia is
worried about the infant having sudden infant death syndrome (SIDS).The parent stated that My sisters
baby died at the age of 2 months and all he had was a little cold.
44.

Which is the nurses best response?


A. You dont need to worry. Your daughter is too old for SIDS.
B. Girls are less likely to have SIDS than boys are.
C. We dont know what causes SIDS, so I would try not to worry about it.
D. You must be very anxious; lets talk about SIDS and what you are thinking.
Rationale: D. Providing opportunities for the parent to express worries and discuss facts about SIDS give
more control over the situation. The nurse can also provide her with information about the Back to sleep
campaign. Option A: The highest incidence of SIDS occurs between B and D months of age, but it does
occur in older infants. It is not the best response because it provides facts but does not address the
parents immediate concerns. Option B: SIDS affects boys more than girls. However, this information is
likely to increase anxiety and does not address the concerns of the patient. Option C: there is no known
cause of SIDS, although respiratory problems may be present in some infants. This response is sensitive to
the need of the mother.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.,
45.

Four-year-old Angie, whose grandmother recently died, tells the nurse, My grandma has wings just
like angels. She flew to heaven yesterday and tomorrow shell be back. Which is the nurses best
response?
A. Shes not coming back, honey.
B. It is normal for a little one to make believe.
C. You must miss your grandma a lot.
D. When people get old, they die.
Rationale: C. Pre-school age children use fantasy and make-believe to learn about, understand and
master their environment, including their concepts of death. The childs conceptualization of death is
consistent with her cognitive development. The response in option A negates the childs understanding and
limits her ability to develop fuller understanding and adapt to the loss. Option B negates the childs attempt
to understand and deal with the loss. Option D is incorrect because at 4 years of age, children can hear
explanations such as when people get old, they will die, but these children do not have firm grasp of the
meaning of time and age, and probably will not understand.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
46.

Which statement most accurately describes physical development during the school-age years?
A. Childs weight almost triples

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

13

vanguardias online review program


B. Child acquires stereognosis
C. Few physical changes occur during middle childhood
D. Fat gradually increases, which contributes to the childs heavier appearance
Rationale: B. School-age children acquire stereognosis, the ability to identify an unseen object simply by
touch. Option A: birth weight triples by about 12 months. Children enter school-age weighing about 45
pounds and gain about 5-7 pounds per year. Option C: Significant physical change occurs during the
school-age years. Option D: Fat deposits do not usually appear until puberty.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
47. The routine physical examination of a female client between the ages of 25 and 64 is most likely to
reveal that the client has which type of cancer?
A. Cervical cancer
B. Lymphoma
C. Lung cancer
D. Colon cancer
Rationale: C. Lung cancer, once primarily a mans disease, is now increasingly common in women.
Cervical cancer is more prevalent in younger women, and is detected with the Pap smear (option A).
Lymphoma and colon cancer are significant diseases for both men and women (options B& D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.,
48.

Which statement about moral development in adults is the most correct?


A. Moral development is completed during adolescence
B. Moral development continues throughout adulthood
C. Moral development is highly individualized
D. Moral development correlates to spiritual development
Rationale: B. Kohlbergs initial work indicated that moral development was completed by adulthood, but
more recent research demonstrated that moral development continues throughout adulthood. Moral
development refers to a decision-making process of right and wrong and proceeds in a series of predictable
stages (option C). Moral development and spirituality are unrelated, and represent very different spheres of
human thought and behavior (option D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
Situation: A nurse in tertiary hospital with a long-term care facility (Elderly Unit) is caring for several older
adults with noticeable hearing losses.
49.

Which is the best way for the nurse to communicate with these clients?
A. Speak slowly using the proper volume and as few words as possible
B. Write the information using large lettering
C. Speak in a low and distinct voice tone
D. Have the client increase the volume in the hearing aid
Rationale: C. Because the hearing loss occurs in the ability to distinguish high-pitched tones, speaking in a
low and distinctive voice tone is most appropriate method of communicating with the clients. Hearing loss in
the older adult includes the loss in the ability to discern higher frequencies, and speaking slowly at a
particular volume is not the best way to communicate with the clients (option A). The stem indicates the
clients have noticeable hearing loss, but does not indicate the clients are deaf; large lettering is appropriate
is the client has a visual problem. (Option B). Hearing aids are not usually effective when the problem is
related to neural damage (option D).
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9th Ed.,
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

14

vanguardias online review program


50.

While being admitted to rehabilitation unit an 82-year old woman mentions to the nurse that she has
trouble holding her water, adding if I could have that tube back in me like I had in the hospital, I
wouldnt have so many accidents. What is the nurses best response?
A. Dont worry, the staff will bring plenty of pads to keep you dry.
B. Ill put the tube back in you so you will stay dry.
C. Tell me more about your problem.
D. Just call the staff and we will help you to the bathroom in time.
Rationale: C. This option will provide the nurse with the most information for potential intervention. Options
A, B and D are incorrect because urinary incontinence is not normal and it is something the nurse should
investigate.
Reference: Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 9 th Ed.,
Situation: Assessment is one of the significant components of the nursing process. Gina a Novice nurse is
assigned in a Medical ward. She is preparing to continue the nursing assessment to several admitted
patients.
51.

When performing an initial assessment, what phrase validates the importance of collecting past
health history?
A. To determine both current and future health risks
B. To determine both allergies to food or drugs
C. To ensure the client receives any specific dietary needs
D. To ensure the client receives all prescribed medications
ANSWER: A - It is important to understand all elements of the client's past health history to provide an
accurate assessment of the client's health risks. Determining allergies and special dietary needs, and
reviewing all of the client's medications are also helpful in developing an individual health plan for the client,
but knowledge of the past medical history alerts the nurse to possible complications because the current
health problem interacts with the previous chronic health problems.
REFERENCE: Medical Surgical Nursing by: Joyce Black
52.

Gina is performing a psychosocial history on a 56-year-old woman with a history of diabetes and
hypertension being brought to the emergency room with multiple bruises after an argument with her
husband. In performing the psychosocial assessment, what action must Gina take?
A. Determine whether the client has allergies.
B. Determine what medications the client is taking.
C. Establish an atmosphere of trust.
D. Promote an environment of fun and harmony.
ANSWER: C - An atmosphere of trust encourages the client to divulge sensitive information, which is
needed for the nurse to be able to develop a plan of care. It is important that the nurse be able to establish
a therapeutic relationship in that the relationship between the nurse and the client affects the quality of the
data retrieved. The remaining options are constitute pieces of the assessment that are indeed needed and
helpful in developing a plan of care; however, the atmosphere of trust is the foundation for the entire
process.
REFERENCE: Medical Surgical Nursing by: Joyce Black
53.

Which clinical scenario validates an appropriate question for a male patient to determine his mental
status?

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

15

vanguardias online review program


A. Asking an elderly man about "pop" singers
B. Asking a 23-year-old man about his education level
C. Asking a teenage girl about her cultural background
D. Asking an 80-year-old woman about sexual practices
ANSWER: B - The level and depth of questioning vary, depending on individual circumstances. Variables
may affect the client's ability to answer questions correctly, thereby leading the nurse to think that the client
has had a change in mental status when indeed the client is unfamiliar with the topic. It may be revealing to
ask a teenager about popular singers but inappropriate to ask the same question of an older person.
REFERENCE: Medical Surgical Nursing by: Joyce Black
54.

Gina is preparing a plan of care for an individual just admitted to the unit. She is assessing the client.
What data when analyzed would be the most significant?
A. The clients ability to utilize large words
B. The clients ability to speak logically
C. The clients ability to communicate in English
D. The clients ability to randomly speak his mind
ANSWER: B - When the nurse is attempting to establish whether the client is alert and oriented, some of
the data used to determine the client's orientation is the ability of the client to speak when asked and then
speak clearly and logically. It is important that the speech progresses logically and the stream of thought be
spontaneous, natural, organized, logical, relevant, and coherent.
REFERENCE: Medical Surgical Nursing by: Joyce Black
55.

If Gina is assessing a client's psychosocial development, what indicators would be relevant to


understanding the client's developmental stage?
A. The clients age
B. The clients race
C. The clients personal history
D. The clients current health status
ANSWER: D - Listening to the client's comments regarding his current health status or life goals will assist
the nurse in gaining insight into the current level of the client's psychosocial level of development. As an
individual experiences crisis, often the individual reverts to an earlier stage of development and needs to
rework the stage. It is true that, in the beginning, age certainly determines the stage, but not when the
individual is in crisis. The client's race or personal history, although nice to know, does not play a
contributing part in this question.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: Carlo an Out Patient nurse clinic nurse is conducting an interview to a 28-year-old healthy Asian
woman just moved to the city and is seeing the physician for the first time.
56.

What information would be beneficial as the nurse develops a relationship with the client?
A. Family health history
B. Past health history
C. Habits, customs, beliefs
D. Psychosocial history
ANSWER: C - A cultural assessment provides insight into the client's beliefs, values, and practices that
could affect health care and self-care behaviors. This information will help the nurse and the physician
develop a plan of care in the future if necessary. It is always good to know the client's past medical history,
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

16

vanguardias online review program


family history, and psychosocial history; however, this client is healthy, so there is no need for the past
medical history.
REFERENCE: Medical Surgical Nursing by: Joyce Black
57.

Carlo the nurse also admitted an 18-year-old woman brought to the clinic after falling down steps at
the high school and fracturing her right wrist. He uses inspection, percussion, and auscultation to
determine the client's respiratory status. With percussion, Nurse Carlo noted resonance. What action
should he take?
A. Alert the physician to the abnormal finding.
B. Teach the client to cough and deep breathe.
C. Document the results as a normal finding.
D. Instruct the client to breathe through her nose.
ANSWER: C - Resonance is a moderate to loud sound of low pitch and long duration, resulting from the
air-filled tissue of the normal lung and has a hollow quality. Resonance is a normal sound when percussing
the lung; therefore, no action is necessary other than to document the finding.
REFERENCE: Medical Surgical Nursing by: Joyce Black
58.

Carlo requested to a student nurse to listen to the heart of a 42-year-old man and notes an extra
sound. The student confirms the presence of the extra sound with Nurse Carlo and together it is
noted that the client has a murmur. Which characteristic is the best description of a heart murmur?
A. Pitch
B. Intensity
C. Duration
D. Quality
ANSWER: A - Heart murmurs can be either high-pitched or low-pitched, depending on the structural cause;
therefore, pitch is a diagnostic clue. The remaining options describe the sound waves that are heard when
auscultating, but the pitch is the best determining characteristic for heart murmurs.
REFERENCE: Medical Surgical Nursing by: Joyce Black
59.

A client is being admitted to the hospital from the physician's office. The orders will be faxed to the
hospital unit shortly. After Nurse Carlo completes the initial assessment and client history, develops a
plan of care based on the assessment, how often should Carlo complete a physical assessment on
the client?
A. Per physician orders
B. At the beginning of every shift
C. Before 0900 every day
D. Based on the clients condition
ANSWER: D - The condition of the client should dictate the frequency of assessment after following the
policies of the hospital. The hospital may state that every client is assessed at least once every shift;
however, the nurse has the responsibility to increase the number of assessments based on the condition of
the client. The policy represents minimum requirements.
REFERENCE: Medical Surgical Nursing by: Joyce Black
60.

Carlo admitted a 68-kg 65-year-old woman to the hospital this morning with a medical diagnosis of
dehydration. When taking the client's history, which information is most significant?
A. The client has noticed an increase in being thirsty over the last 2 weeks.
B. The client has lost 8 lb over 2 weeks using the same scale at home.

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

17

vanguardias online review program


C. The client's urine has been dark, yellow, and clear.
D. The client has had trouble swallowing, stating she does not have enough saliva.
ANSWER: B - A loss of 2.2 lb is equivalent to losing 1 L of fluid; that is, an 8-lb loss equals a loss of 3.5 L
of fluid. A 3-L loss of fluid equals moderate dehydration. Options a, c, and d are all signs that the fluid
volume is decreasing; however, option b is the most significant and needs to be addressed first.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: An Out Patient Clinic is conducting a Health Promotive lecture. The classic definition of
"wellness" is an integrated method of functioning that is oriented to maximizing the prospective of which the
individual is capable of achieving within his environment. The following questions refer to health promotion
and rehabilitation.
61.

A nurse would focus on which concept when promoting a client's well-being?


A. Being free of disease
B. Ongoing goal toward greater wellness
C. Prevention of illness
D. Being free of injury
ANSWER: B - Wellness is not a static state but rather a process of always working toward greater health
and well-being.
REFERENCE: Medical Surgical Nursing by: Joyce Black
62.

A male client who has been paraplegic since an accident 6 years ago is in for a follow-up visit for a
laceration on his lower left leg from a wheelchair basketball game he participated in last week. The
client is bright, cheery, and eager to get back to playing basketball. In revising the client's plan of
care, what model should the nurse use as the foundation?
A. Role-performance model
B. Reiterative model
C. Clinical model
D. Eudemonistic model
ANSWER: D - A client with exuberant well-being, or a client who strives to be all he can be best describes
a client with a perception of health, sometimes even in the presence of illness.
REFERENCE: Medical Surgical Nursing by: Joyce Black
63.

A nurse is working with a male client who has been noncompliant with treatment in the past. The
client has a long history of alcohol abuse and diabetes. Through discussion the nurse learns a great
deal about the client, his past, his beliefs and where he sees himself in the future. How will this
information assist the nurse?
A. Understanding why a client is seeking medical attention
B. Using the models to educate a client on illness prevention
C. Understanding the clients perceptions to aid in communication
D. Providing clients with motivators to improve their health
ANSWER: C - The models give an insight into how a client perceives their health status. Understanding the
client's perceptions of health will assist the nurse to identify the language to use to help communicate with
the client. Once communication is established, then a plan with mutually agreed upon goals can be
developed.
REFERENCE: Medical Surgical Nursing by: Joyce Black
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

18

vanguardias online review program


Situation: Fe is a Clinic Nurse in the Out-Patient Clinic. The following patients seek consultation. One is a
32-year-old female client who is overweight with a 2-year history of diabetes has had some issues with
controlling her blood sugar and another medication is being added to her regimen. Structuring a diet for the
client would not be as beneficial as having the client use self-management support strategies.
64.

Which strategy would benefit the client and assist in meeting the goal of controlling the blood sugar?
A. Behavior management
B. Role management
C. Emotional management
D. Physical management
ANSWER: A - Self-management support strategies are based on the fact that the client has day to day
responsibility for her actions and the self-management support strategies assist the client in problem
solving and making the best decisions possible. In this scenario, the nurse wants the client to change
behaviors and eat a healthy diet that corresponds to the diet necessary to control the blood sugar. The rest
of the strategies are valid but not in this particular scenario.
REFERENCE: Medical Surgical Nursing by: Joyce Black
65.

Fe is also attending to the admission of a male client who is an account executive is in need of
reducing his blood pressure. He made some changes in his diet and state that he needs to exercise
but never seems to find time. Which of the following skill sets will be the most beneficial to the client
at this point in his treatment plan?
A. Problem solving
B. Decision making
C. Resource utilization
D. Client empowerment
ANSWER: A - Problem-solving skills will benefit the client the most in this situation. The client can identify
barriers that prevent him from following the plan. Once the barriers are identified then the client can take
action to remove the barriers. The nurse may play an important role in assisting the client to identify the
barriers and then assist in developing interventions. The rest of the options cannot be used until the client
completed the problem-solving stage.
REFERENCE: Medical Surgical Nursing by: Joyce Black
66. Nurse Fe is working with Lito a 32 year old, with low health literacy in the clinic this morning. The
nurse is providing education on his condition and how to improve his health. Which question should
the nurse expect Lito will ask to verify his understanding of the information provided?
A. How often should I exercise?
B. What is my main problem?
C. When is my payment due?
D. What do I need to do?
ANSWER: B - Low health literacy can have significant negative impact on health outcomes. Nurses need
to use strategies that overcome these problems, like using plain lay language when talking with a client,
limiting the amount of information presented at one time, and using "teach back," which requires the client
to teach back what he has learned. The best option then is the question that is the broadest and that
addresses the client's health condition. The rest of the questions are specific and only address a specific
aspect of the client's care.
REFERENCE: Medical Surgical Nursing by: Joyce Black
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

19

vanguardias online review program


67.

Nurse Fe is admitting with a client who is obese (>100 lb over ideal body weight). In order to promote
healthy living, which goal should the client work on?
A. Losing weight
B. Losing 100 pounds
C. Losing 50 pounds a year
D. Walking for 15 minutes three times this week
ANSWER: D - A goal should be small, specific, measurable, and short-term. Walking for 15 minutes three
times a week meets the requirements of small, specific, and measurable as well as short term. Just to lose
weight is not specific enough and to lose 100 lb is certainly not short term, nor is losing 50 lb a year.
REFERENCE: Medical Surgical Nursing by: Joyce Black
68.

A 51-year-old female is more than 50 lb overweight with a history of degenerative joint disease.
Nurse Fe is completing a nutritional assessment. What additional assessment data should Nurse Fe
collect?
A. Have the client keep a 3-day dietary log.
B. Have the client list her favorite foods.
C. Have the client bring in a copy of her grocery list.
D. Have the client write down the times she ate.
ANSWER: A - A dietary log is a comprehensive log including what food was eaten, when and why the
client ate, and how the client ate. This type of information is beneficial when determining a plan to reduce
weight. A listing of the client's favorite food and the times that the client eats could present additional
information that would be beneficial in tweaking the plan once developed. A grocery list is not specific
enough to provide support.
REFERENCE: Medical Surgical Nursing by: Joyce Black
69.

Nurse Fe is attending with a female client who is 5'2" and 170 lb with high cholesterol. Nurse Fe just
informed that she is a prime candidate for coronary artery disease (CAD). The client is aware that
diet, exercise, and a good mental attitude are necessary in order to promote health. Which health
care professional would benefit the client at this time?
A. Physical therapist
B. Cardiologist
C. Psychologist
D. Dietitian
ANSWER: D - Weight loss can greatly affect a client's health and well-being. Decreasing the risk for many
diseases can be achieved through a healthy eating plan. In this particular case, maintaining a healthy diet
would decrease the client's cholesterol, reducing the risk for CAD. With less weight on the client's frame,
she will feel better about herself and activity will be easier. Building and increased tolerance for activity will
assist her in the weight reduction.
REFERENCE: Medical Surgical Nursing by: Joyce Black
70.

Nurse Fe, conducts health assessment, to a male client tells her that since he was promoted but not
happy and just lounges on the couch after dinner. The nurse has noted the client's weight and blood
pressure are increasing. What prescription should the nurse expect the physician to write?
A. Nutritional consultation
B. Routine daily exercise
C. Blood pressure medication
D. Antidepressant medication

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

20

vanguardias online review program


ANSWER: B - Health y activity promotes a health lifestyle. Regular activity has many benefits, including
weight management, lower blood pressure, improved mood, and relief from depression. A well-balanced
diet is essential but may not curb the symptoms that the client is facing. The physician can add medication
to the regimen, but medication would not be the first step in management because every medication has
side effects.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: Kate is preparing the patients consultation list. During a routine office visit, a male client
mentions all his physical and mental problems are due to the increased stress in his life. The client
requests help in coping with stress.
71.

What should the Nurse Kate include in her assessment?


A. A history of the clients daily physical activity routines
B. An evaluation of the clients diet through the use of daily logs
C. An evaluation of the clients tobacco and alcohol use
D. A history detailing how the client feels and acts when stressed
ANSWER: D - The first step in intervention is the assessment of the problem, which includes a thorough
history of the problems or situations that seem to precipitate stress and the behavioral and emotional
responses. Afterward, looking at the strategies the client has used in the past to cope with the stress is
necessary, including activity, diet, and alcohol and tobacco use.
REFERENCE: Medical Surgical Nursing by: Joyce Black
72.

A female client complaining of increasing stress in her life visits the clinic. After the assessment and
the discussion, Nurse Kate and client develop a plan. Which intervention should the nurse include in
her instructions to the client?
A. Ensure 8 hours of sleep a night
B. Reduce exercise from five times a week to two times a week
C. Drink one glass of wine nightly before bed
D. Reduce intake of complex carbohydrates
ANSWER: A - Sleep and rest are natural forms of relaxation that are essential for healing and repairing.
Inadequate rest worsens stress, especially through impaired mental functioning. Physician activity improves
mental function, decreases depression, and increases physical endurance. Healthy eating can increase
resistance to stress. Complex carbohydrates provide a sustained source of energy and have a relaxing
effect.
REFERENCE: Medical Surgical Nursing by: Joyce Black
73.

A 45-year-old woman is visiting the clinic for her annual checkup. During the assessment the client
admits to drinking at least two alcoholic drinks a day. What additional health issue should Nurse Kate
assess for?
A. Drug abuse
B. Cirrhosis
C. Alcohol abuse
D. Stress
ANSWER: D - Problem drinking for women is considered as consuming two drinks per day. Clients often
use ineffective coping strategies designed to avoid problems; drinking alcohol is such a strategy. The client
is not drinking enough to make cirrhosis a concern yet; the better option is the stress and ineffective coping
mechanism. Drug abuse is more common among men, the unemployed and individuals without a high
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

21

vanguardias online review program


school education. According to the authors, there is no direct link between "problem drinking" and drug
abuse.
REFERENCE: Medical Surgical Nursing by: Joyce Black
74.

A 17-year-old male unemployed high school dropout is visiting the clinic for relief from a sinus
infection. Nurse Kate provides education on symptom management. What other topic of education
should the nurse address for this client?
A. Fast driving
B. Poor eating habits
C. Drug abuse
D. Unprotected sex
ANSWER: C - The client is in a high risk category for drug abuse. Drug abuse is more common among
men, the unemployed, and people without a high school education. Drug abuse is currently on the rise and
every opportunity should be taken to assess for drug abuse. The other options are important, but the
client's background puts him at higher risk for drug abuse.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: A client presents to the emergency department with shortness of breath. During the
assessment, the nurse discovers the client smokes. Nurse Barbie provides educational materials to the
client regarding smoking cessation.
75.

What statement validates the client's understanding of the risks involved with smoking?
A. I have tried many times to quit smoking.
B. I get so anxious, all I do is yell at the kids.
C. If I quit, I will put on unnecessary weight.
D. If I dont quit I am at risk for many diseases.
ANSWER: D - Smoking is directly linked to many forms of cancer, heart disease, and hypertension, and is
a risk factor in many diverse health problems. Smoking cessation is not easy and many individuals have
attempted to quit smoking several times and have not been completely successful. The remaining options
do not address the risks involved with smoking.
REFERENCE: Medical Surgical Nursing by: Joyce Black
76.

Another client a 67-year-old female client who lives alone was admitted to the hospital complaining of
pain and bruising on her left leg. The client is being discharged this morning. What action should the
Nurse Barbie take in preparation for the client's discharge?
A. Review the clients home environment with the client.
B. Instruct the client on how to take the pain medication.
C. Recommend the client buy new shoes that are light.
D. Recommend the client keep her left leg elevated.
ANSWER: A - Adults older than age 65 are at increased risk for a variety of accidents not seen in younger
adults. Older adults are more likely to fall and are more likely to fracture bones; therefore fall prevention is
important. One method to prevent falls is to assess the client's living space, especially because the client
has been admitted to the health care system because of an injury. The remaining options are valid, but the
main objective is to prevent injury.
REFERENCE: Medical Surgical Nursing by: Joyce Black
77.

Nurse Barbie is presenting to a community group on the topic of health and wellness, especially early

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

22

vanguardias online review program


detection. The nurse emphasizes the need for individuals to be aware of chronic diseases like
hypertension, coronary artery disease, cancer, and diabetes. Which intervention should the nurse
stress?
A. Adopt a healthy diet.
B. Exercise regularly.
C. Schedule screening tests.
D. Quit smoking.
ANSWER: C - Screening tests can provide early detection of many diseases including coronary heart
diseases, cancer, and type 2 diabetes. When these are detected early, then interventions can be put into
place that maximizes the health of the client. It is important that individuals eat healthy, exercise regularly,
and quit smoking, but screening for disease is still the number one intervention.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: Mae is a new graduate nurse for one year. She just finished her 6 months voluntary training
program in a secondary hospital.
78.

Which of these actions is most typical of a novice nurse?


A. Assesses the most important client problems first
B. Prioritizes assessments based on the clients diagnosis
C. Independently implements nursing actions based on the client assessment
D. Follows the assessment checklist carefully when doing client assessments
ANSWER: D - Because of lack of experience, the novice nurse follows rules when caring for clients rather
than adapting care to individual client needs.
REFERENCE: Medical Surgical Nursing by: Joyce Black
79.

Which of these nursing actions indicate that Nurse Mae is using evidence-based nursing practice?
A. The nurse follows the hospital policy when doing a wound dressing change.
B. The nurse studies current nursing journals for data to use in client teaching.
C. The nurse checks medications carefully before giving them to a client.
D. The nurse uses a computerized documentation system for charting care.
ANSWER: B - Evidence-based practice includes applying information from current literature in
implementation of client care. The other actions are also appropriate, but are not indicators of evidencebased practice.
REFERENCE: Medical Surgical Nursing by: Joyce Black
80.

A client tells the Nurse Mae about taking large amounts of vitamins to help maintain health. Which
information should the Nurse Mae include in client teaching?
A. Vitamins from established pharmaceutical companies are safe to take.
B. Vitamin supplements are ineffective in treating health problems.
C. It is important to discuss the use of vitamins with the physician.
D. An adequate amount of vitamins can be obtained from food.
ANSWER: C - The use of vitamin supplements should be discussed with the physician so that adverse
effects of the supplements and/or interactions between prescribed treatments and the supplements can be
minimized. The therapeutic and adverse effects of vitamins are dose related, not simply related to the
manufacturer of the supplement. Vitamin supplements are used to treat some health problems such as
macular degeneration and coronary artery disease. Some clients may not obtain adequate amounts of
vitamins from diet alone.
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

23

vanguardias online review program


REFERENCE: Medical Surgical Nursing by: Joyce Black
81.

A new client asks the Nurse Mae, "What do you think about using herbal treatments instead of
prescribed medications for treating health problems?" Which response by the nurse is most
appropriate?
A. "Which types of herbal remedies are you using?"
B. "Are you currently taking any herbal medications?"
C. "Do you believe that herbal therapies can be helpful?"
D. "Are you aware that herbal drugs can have many side effects?"
ANSWER: C - The client's question may indicate that the client is "testing the waters" to determine the
nurse's attitude about herbal treatments. Asking about the client's beliefs about herbal treatments is
nonjudgmental and encourages the client to share information about possible use of herbal treatments. The
other responses are less open-ended or imply the nurse has negative views about herbal treatments and
will be less likely to lead to client trust and disclosure.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: Another Novice Nurse just finished her training period and is assigned in an Out Patient
department. As a routine preparation for consultation she is conducting interview with patients.
82.

Which action should the Nurse working in a outpatient care clinic take first in order to be most
effective in assisting a patient to achieve blood pressure control?
A. Educate the patient about the consequences of hypertension.
B. Provide patient teaching about diet and high blood pressure.
C. Determine the patients beliefs about health and wellness.
D. Schedule the patient for frequent clinic appointments
ANSWER: C - Since collaboration and compliance with wellness behaviors are based on client choice for
the client in an ambulatory setting, the initial action by the nurse should be to assess the patient's
perspective on health and illness. Education, patient teaching, and frequent appointments are also
appropriate actions, but the initial action should be a multidimensional assessment of the client.
REFERENCE: Medical Surgical Nursing by: Joyce Black
83.

Which of the following actions is most appropriate for the Head Nurse working in a Physician's office
to delegate to a nursing Staff Nurse?
A. Teach a patient about a newly ordered medication.
B. Assess a patients understanding of a disease process.
C. Call a patient to follow up about a medication change.
D. Set up equipment for a minor surgical procedure.
ANSWER: D - Activities such as setting up rooms can be delegated to staff members with less education
and scope of practice. Activities such as teaching, assessment, and telephone follow-up are high level
professional functions that should be performed by the RN.
REFERENCE: Medical Surgical Nursing by: Joyce Black

84.

When orienting a nurse with extensive hospital experience working in an Out Patient Clinic setting,
the nurse manager plans to assist the nurse in learning techniques for:
A. focused assessment.

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

24

vanguardias online review program


B. holistic assessment.
C. head-to-toe assessment.
D. multidimensional assessment.
ANSWER: A - In an ambulatory (Out-patient department) care setting, the client is seen for brief visits, so
there is not enough time available for an extensive assessment with each visit. A nurse with hospital
experience will already be familiar with more detailed assessments, but these are not usually appropriate
for the ambulatory care setting.
REFERENCE: Medical Surgical Nursing by: Joyce Black
85.

To ensure that a 72-year-old client in the clinic takes ordered antibiotics appropriately, the most
important nursing intervention is to:
A. call the antibiotic order to the clients pharmacy.
B. give the client samples of the antibiotic.
C. provide medication teaching to the client and family.
D. be sure the client has the prescription.
ANSWER: C - Because the client and family/caregivers in an ambulatory/ out patient clinic care setting
ultimately decide whether to comply with therapies, the nurse's role as an educator is essential in assuring
compliance. Providing education to the client and family will improve the compliance with the antibiotic
regimen. Calling the prescription to the pharmacy, giving the client samples, and being sure the client has
the prescription will assure that the client has the antibiotics, but will not assure compliance with taking the
medication.
REFERENCE: Medical Surgical Nursing by: Joyce Black
86.

An example of primary preventive care provided by the nurse in the outpatient clinic is:
A. encouraging a 22-year-old to exercise several times weekly.
B. screening a 50-year-old for prostate cancer.
C. teaching a newly diagnosed diabetic to self-administer insulin.
D. checking blood pressure for an obese client.
ANSWER: A - Primary prevention is focused on prevention of health problems. Screening and monitoring
of clients at risk for health problems are examples of secondary prevention. Teaching a client with a
disorder such as diabetes about self-management is an example of tertiary prevention.
REFERENCE: Medical Surgical Nursing by: Joyce Black
87.

Which of these nursing actions for a client with high blood pressure is most appropriate for the nurse
working in the out- patient clinic setting to delegate midwives?
A. Education about symptoms of hypertension
B. Weekly monitoring of blood pressure (BP)
C. Referral to a dietitian for dietary teaching
D. Assessment for possible complications
ANSWER: B - Unlicensed assistive personnel such as medical assistants are educated to obtain vital
signs, so this task can be delegated. The medical assistant will be instructed to report weekly BP
measurements to the nurse. Client education, referrals, and assessments are higher level skills that require
more education and scope of practice.
REFERENCE: Medical Surgical Nursing by: Joyce Black
88.

Which action by a new nurse orienting to work in the outpatient clinic indicates a need for more
education about the professional role in an Out Patient Clinic care?

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

25

vanguardias online review program


A. The nurse asks the nursing assistant to schedule a client for the next appointment.
B. The nurse instructs a client to call the clinic if medication side effects occur.
C. The nurse calls a client on the telephone to ask about daily sodium intake.
D. The nurse leaves a message about a laboratory test on the clients phone recorder.
ANSWER: D - Because other family members may hear the message left on a message machine or voice
mail, leaving a message does not protect the client's confidentiality. The other actions are appropriate.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: In the Nursing Unit Charge Nurses must be aware of the different procedures to be delegated to
Novice nurses and other members of the health team.
89.

Which nursing activity is appropriate for the Charge Nurse to delegate to a Novice Nurse working in
an ambulatory care setting?
A. Performing telephone triage
B. Assisting with procedures
C. Developing treatment protocols
D. Coordinating client care
ANSWER: B Novice nurses are educated and licensed to assist with office procedures. Telephone triage,
development of treatment protocols, and coordination of client care are high-level professional functions
that should be done by the RN.
REFERENCE: Medical Surgical Nursing by: Joyce Black
90.

Charge Nurses are working in a clinic with a Novice nurses. Which of these activities is most
appropriate for the staff nurses to do?
A. Take vital signs as clients arrive for appointments.
B. Schedule follow-up appointments as clients leave.
C. Administer immunizations and vaccinations.
D. Teach clients about new medications or treatments.
ANSWER: D RN/ staff nurse education and scope of practice includes client education; LPN/LVNs and
medical assistants do not have sufficient education or scope of practice to develop individualized client
teaching plans. The other activities are appropriate for the medical assistant or LPN.
REFERENCE: Medical Surgical Nursing by: Joyce Black
91.

A client who is newly enrolled in a health maintenance organization (HMO) tells the nurse, "I don't
understand exactly what an HMO is." The nurse explains that HMOs:
A. offer only health promotion services.
B. are designed to help contain health care costs.
C. allow clients more flexibility in choosing their physicians.
D. provide ambulatory care services rather than inpatient services.
ANSWER: B - A major goal of HMOs is to lower costs through the use of gatekeeper providers,
coordination of services, and elimination of unnecessary services and procedures. HMOs do place a high
value on health promotion, but these are not the only services they provide. Because clients must use a
primary care provider before seeing specialty providers, there is less flexibility in physician choice. HMOs
provide both ambulatory care and inpatient services.
REFERENCE: Medical Surgical Nursing by: Joyce Black
92.

Which of these nursing activities is an example of the case management role of the nurse who is

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

26

vanguardias online review program


working in a university student health clinic?
A. Referrals to appropriate services such as mental health and nutrition
B. Administration of meningococcal immunizations
C. Telephone triage of clients to determine the need for clinic services
D. Use of standardized protocols to order medications
ANSWER: A - Case management includes the coordination of multiple health care providers for a client.
Vaccine administration, telephone triage, and use of standardized protocols are all appropriate activities for
the nurse in a student health clinic, but they are not examples of case management.
REFERENCE: Medical Surgical Nursing by: Joyce Black
Situation: A Charge Nurse needs to delegate some patient care activities to a Novice Nurse.

93.

Which care is most appropriate to delegate?


A. Pre-meal blood glucose monitoring for a client with diabetes
B. Ambulation of a client who has been complaining of dyspnea
C. Assistance with feeding for a client who has difficulty swallowing
D. Vital sign checks for a client who has just been admitted with chest pain
ANSWER: A - Although all the tasks listed are appropriate skills for a nursing Novice Nurse, the client with
diabetes is the most stable of the four clients. The other clients all should be monitored by the RN when
doing the listed activities.
REFERENCE: Medical Surgical Nursing by: Joyce Black
94.

Which of the following tasks is most appropriate for the Charge nurse to delegate to a Novice nurse
working on the general medical unit?
A. Assessment of a newly admitted client
B. Insertion of a nasogastric tube for a nauseated client
C. Administration of insulin to a diabetic client
D. Education of a client about risk factors for heart disease
ANSWER: C - LPN education and scope of practice includes administration of medications such as insulin.
There is no indication that the diabetic client is unstable and needs assessment by an RN. Although LPNs
are educated to insert nasogastric tubes, because this client is acutely nauseated and needs assessment,
it is preferable that the RN insert the tube. Admission assessments and client teaching are higher level
skills that should be done by an RN.
REFERENCE: Medical Surgical Nursing by: Joyce Black
95.

For physiologically unstable clients, such as those in the intensive care unit, the optimal model for
organizing nursing care is:
A. primary nursing.
B. functional nursing.
C. case management.
D. team nursing.
ANSWER: A - Clients who are more critically ill require RN level assessment, planning, and intervention
skills, which are available using a primary nursing model. The other models are appropriate for delivery of
nursing care to more stable clients.
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

27

vanguardias online review program


REFERENCE: Medical Surgical Nursing by: Joyce Black
96.

When the nurse manager is making hospital staffing assignments based on acuity, which factor is
most important to consider?
A. The number of clients on each nursing unit
B. The medical diagnoses of the clients on each unit
C. The recent results from client satisfaction surveys for each unit
D. The amount of time that each client is likely to require for nursing care
ANSWER: B - The medical diagnoses indicate how stable or unstable clients on the various nursing units
are likely to be, which impacts acuity. Although the number of clients, client satisfaction, and the amount of
time required to provide care to clients are all factors to consider when making staffing decisions, they do
not necessarily impact client acuity.
REFERENCE: Medical Surgical Nursing by: Joyce Black
97.

When a medication error occurs, the nurse should complete an incident report in order to:
A. identify the staff member who is responsible for the error.
B. assist with changes to improve future medication safety.
C. assure that the error is documented in the client record.
D. meet the requirements of most regulatory agencies.
ANSWER: B - Incident reports serve as a means of quality improvement and risk management; they help
identify system problems or patterns that may lead to client injury. They should not be used as punishment
of individuals. They are not considered a part of the client's permanent record. Although regulatory
agencies do require hospitals to have quality improvement/risk management procedures, this is not the
reason to complete incident reports.
REFERENCE: Medical Surgical Nursing by: Joyce Black
98.

Which of these categories of risk is most likely to increase hospital liability and patient injury?
A. Early hospital discharges
B. Lack of availability of medications
C. Unsigned treatment consent forms
D. Early hospital discharges
ANSWER: C - Unsigned treatment consent forms and refusal of treatment are among the five highest risk
categories for liability. The other responses may indicate problems that increase liability and the possibility
for client injury or dissatisfaction, but they are not the most likely categories.
REFERENCE: Medical Surgical Nursing by: Joyce Black
99.

Based on the five rights of delegation, which task is appropriate for the nurse to delegate to nurse
trainee?
A. Dressing change
B. Intravenous line discontinuation
C. Reviewing discharge instructions
D. Ambulating a client
ANSWER: D Nurse Trainee are educated in basic client care such as ambulation. Dressing changes,
discontinuing IV lines, and reviewing discharge instructions with a client are higher level actions that require
more education and scope of practice and should not be delegated to unlicensed personnel.
REFERENCE: Medical Surgical Nursing by: Joyce Black
National Library of the Philippines, April 2015
Reproduction of any kind/form is punishable by law.

28

vanguardias online review program


100. In planning for the future of acute health care, nurse managers should anticipate:
A. more emphasis on use of nursing research to improve client care
B. decreased use of emergency departments as access to care improves
C. the lower incidences of chronic illness will change demand for nursing services
D. improved funding for hospital care as the boomer population ages
ANSWER: A. The current focus on evidence-based practice is likely to increase interest in and
implementation of nursing research. Emergency departments are likely to continue to be overcrowded due
to the growing population and lack of nursing staff of care for acutely ill clients after admission. As the
population ages, it is likely that the incidence of chronic illness will increase. Although it is likely that need
for hospital care will increase as the boomers age, there is no evidence that funding will improve.
REFERENCE: Medical Surgical Nursing by: Joyce Black

National Library of the Philippines, April 2015


Reproduction of any kind/form is punishable by law.

29