NURSING PRACTICE I
Situation 1: Loss and grief affect not only the clients and their families but
also the nurses who care for them. It is essential for the nurse to have a
thorough understanding of a client’s loss and the meaning of the loss to the
client.
1. A 55-year-old client is terminally ill with advanced cancer of the
ovary. To assist and comfort her, the nurse should
A. Attend to her physical needs
B. Provide support to the client
C. Assess continuously the client’s condition
D. Assess the client’s understanding of her illness and
impending health
2. Upon learning about her condition, the client says to the nurse,
“Why me? I did not do anything wrong.” What response of the
nurse is most appropriate?
A. “You will be fine.”
B. “Death is a normal part of life.”
C. “This must be very difficult for you.”
D. “Everyone has to die sooner or later.”
3. The client is in severe pain and manifests signs of impending
death. The husband asks the nurse if his wife is going to die soon.
Which of he following is the most appropriate response of the
nurse?
A. “The signs do not predict the exact time frame of
death.”
B. “You are concerned that your wife will die?”
C. “Death is inevitable.”
D. “Are you worried that your wife will die?”
4. The client has just died with her family around her. What
appropriate nursing action should the nurse make?
A. Allow the family time to be with the deceased client
B. Allow the family to grieve
C. Give the personal belongings of the client to her family
D. Reassure the family that the body will be cared of
5. The body is being prepared for transfer to the mortuary. Which of
the following is the most appropriate action of the nurse?
A. Remove all contraptions.
B. Record the time of death
C. Secure all belongings in a plastic bag
D. Bathe the body and place identification tags
Situation 2: In teaching good sleep hygiene to adult clients, the nurse
encounters clients in variety of situations that need some guidance and
assistance
6. When talking to a client to assess her sleeping difficulties, the
nurse’s most therapeutic communication would be
A. “Is this room darkened at night?”
B. “Do you take naps during the day?”
C. “What do you do just before going to bed?”
D. “Do you take snacks prior to going to bed?”
7. To promote good sleep hygiene, the nurse teaches the client to
do the following except
A. Avoid a heavy meal 3 hours before bedtime
B. Use the bedroom only for resting and sleeping
C. Stay in bed if sleep does not come in 30 minutes
D. Limit the use of bedroom for intensive work, studying,
eating, or watching TV
8. The client is concerned that sleeping during the day and being
awake at night is abnormal and unhealthy. The nurse’s most
therapeutic response is
A. “Many people who work at call centers have the same
habits and they are alright.”
B. “People have different biological clocks. As long as
you sleep and function well, your habit is not abnormal
and unhealthy
C. “Would you like to change your sleeping habits at this
time?”
D. “What makes you think that your habit of sleeping
during the day and being up at night is unhealthy and
abnormal?”
9. Which of the following questions by the nurse will help identify
possible causes of client’s sleep problems?
A. “How long does it take for you to fall asleep after you
lie down?”
B. “What do you do to fall asleep at your desired
bedtime?”
C. “Have you changed your bedtime rituals lately?”
D. “What time do you usually sleep?”
10. The client has obstructive sleep apnea (OSA) and has disrupted
sleep. He asks the nurse about the possible serious
consequences of OSA. The nurse’s most appropriate response
would be the following except
A. Alzheimer’s disease
B. Cerebrovascular accident
C. Cardiac dysrhythmias
D. Hypertension
Situation 3: Total quality improvement is based on the premise that the
process is ongoing and that quality can be always improved.
11. While giving care to a client in a medical unit, the nurse observes
that a 65-year-old male bedridden client has a reddened area with
no break in the skin in his coccyx. A clean dressing has been put
over the site in order to
A. Protect the area from injury
B. Provide comfort to the client
C. Make healing faster
D. Allow light to get through
12. A bedridden client has nasogastric tube and an intravenous line.
The client appears disoriented and attempts to remove both
contraptions. What action should the nurse do to protect the client
from injuring himself?
A. Ask a family to stay with the client
B. Stay with the client
C. Apply restraint
D. Ask the physician for an order for wrist restraints
13. The nurse is caring for a client receiving chemotherapy. She is
concerned about the client’s nutritional status and aims to
improve the appetite of the client. The nurse should
A. Administer medications before meals
B. Improve the food flavor
C. Offer hot soup
D. Offer white meat
14. The nurse is evaluating the nutritional status of a client. Which of
the following parameters should be observed by the nurse?
A. Stable weight
B. Extent of nausea and vomiting
C. Improved appetite
D. Amount of food intake
15. While completing the final preparations for a 12-year-old who is
scheduled for appendectomy, the nurse sees the mother applying
hot water bag in the child’s abdomen for relief of pain. The nurse
should tell the mother that the hot water bag may
A. Arrest progression of the disease
B. Increase abdominal contraction
C. Increase abdominal peristalsis
D. Cause the appendix to rupture
Situation 4: The nurse is assigned to take care of a client with an
endotracheal tube. The nurse noticed thick secretions
16. Which of the following is the most appropriate nursing intervention
to loosen the secretions?
A. Instill Mucomyst into the endotracheal tube and
frequent turning of the client unless contraindicated
B. Perform chest physiotherapy and assess respiratory
status of the client
C. Administer humidified oxygen and place the client in
side-lying or prone position unless contraindicated
D. Increase fluid intake and frequent turning unless
contraindicated
 17. In performing endotracheal suctioning, the nurse should apply
suction while
A. Rotating the catheter gently for not more than 10
seconds
B. Observing the amount and character of the secretions
after each suctioning
C. Observing the client’s tolerance to the procedure
D. Assessing the client’s respiratory and circulatory status
18. The nurse is monitoring the cuff pressure. To minimize the risk of
tracheal tissue necrosis the nurse should maintain the pressure to
A. 10 – 15 mmHg
B. 20 – 25 mmHg
C. 30 – 35 mmHg
D. 40 – 45 mmHg
19. The nurse is providing oral and nasal care every 2-4 hours to the
client. As a precautionary measure for possible biting down of the
oral endotracheal tube, the nurse should
A. Have an assistant to hold the client
B. Use an oropharyngeal airway
C. Provide humidified air prior to the procedure
D. Position the client to side-lying position
20. The head nurse reminds the staff nurse about measures that
must be strictly observed when suctioning the client with an
endotracheal tube. Which of the following is the most appropriate
measure during suctioning?
A. Using rubber gloves when doing suctioning
B. Suctioning while inserting the catheter
C. Suctioning 2-3 times before withdrawing the catheter
D. Hyperoxygenating the client before and after the
procedure
Situation 5: The following situations are opportunities for the nurse to give
health teachings to the client and his family members.
21. A client who had a cerebrovascular accident resulted in right-
sided weakness of the extremities and mild slurring of speech.
The nurse is assisting the client to ambulate. To prevent the client
from falling, the nurse should stand at the
A. Left side with one arm around the client’s waist
B. Right side and holding the client’s arm
C. Right side with one arm around the client’s waist
D. Left side and holding the client’s arm
22. The use of principles of body mechanics is important when taking
care of clients. To prevent injury to self and others, the nurse
teaches the family members to do which of the following?
A. Move about a feet away from the client if possible
B. Form a broad base of support, flex the knees and feet
wide apart.
C. Use back and arm muscles to support lifting or moving
objects
D. Bend from the waist with knees straight and feet wide
apart
23. The clinic nurse in a large factory teaches some exercises to
some office workers. Which of the following statements is the
most appropriate?
A. Exercises can easily burn and expend daily caloric
intake
B. The best cardiovascular activity is walking on a
treadmill
C. Less intense or not very tiring exercises should be
done frequently to be of value
D. Continuous activity for a long period of time is useful
as an exercise
24. An elderly client has been taught how to use crutches in going up
and down the stairway. You observe that the client’s use of
crutches is appropriate when he
A. Uses the crutch next of the affected leg when going up
or down the stairs
B. Advances the crutches first to go up the stairs then the
affected leg
C. Uses the stair banister for support while going up or
down the stairs
D. Advances the crutches to go down the stairs then
move the affected leg afterwards
25. A mother calls the emergency unit to ask for advice after she
found her child seated on the bathroom floor with cleanser around
her mouth and tongue. The appropriate advice given to the
mother would be to
A. Check if the child is breathing and if the airway is open
B. Give the child syrup of Ipecac to induce vomiting
C. Call the poison control of a general hospital
D. Remove cleanser from the mouth and tongue
Situation 6: A 21-year-old female is admitted to the Surgery Ward and is
placed in traction. She has been very frustrated because she cannot do her
usual daily activities.
26. The nursing diagnosis that is most appropriate for this client is
A. Potential for immobility
B. Impaired physical mobility
C. Activity intolerance
D. Risk for injury and pathologic fractures
27. Limitations in the activity – exercise routine of a client affect her
self – esteem. To help increase the client’s self – esteem, the
nurse understands that
A. Self – esteem depends upon having a feeling of
usefulness and independence
B. Being confined in bed with no productive activity
causes depression
C. Self – esteem is dictated by one’s state of physical
health and beauty
D. The current problem exacerbates the client’s already
low self-esteem
28. The nurse maintains the client’s good body alignment while she is
in traction in order to
A. Promote proper body balance and optimal brain
functioning
B. Maintain body posture and strength
C. Promote efficient circulation and enhance lung
expansion
D. Decrease workload of the heart
29. The nurse considers the following statements when taking care of
a client with traction except
A. Steady pull from both directions keep the fractured
bone in place
B. Weights should be kept resting on the floor
C. Clients on traction need adequate skin care and proper
positioning
D. Traction can be used to correct or prevent deformities
30. Part of nursing care for a client on traction is giving instructions for
isometric exercises in order to
A. Prevent decubitus ulcers
B. Improve lung capacity
C. Normalize blood pressure
D. Maintain muscle strength
Situation 7: An understanding of the infectious process and appropriate
methods to protect the health workers and client from disease is important.
The following questions pertain to preventing transmission of infection.
31. The nurse is explaining standard precaution to the client. This
includes which of the following actions?
A. Wearing protective equipment when doing any nursing
procedures
B. Handwashing using antimicrobial soap and water
C. Recapping of used needles with both hands then place
in puncture-resistance container
D. Using clean gloves to handle contaminated items,
blood and excretions
32. The nurse is changing the wound dressing of a client. The most
appropriate action of the nurse would be to
A. Remove old dressing with sterile gloves
B. Wear sterile gloves whenever in contact with the area
C. Open the sterile dressings with sterile gloves
D. Pour antiseptic solution out of the container with sterile
gloves
 D. Over-delegating, under-delegating and improperly
33. The client has an order for contact precaution. The nurse is to delegating
give her a bath. The precautionary measure that the nurse
observes is to use 40. A staff nurse in the emergency room is well-liked by her
colleagues because she could easily relate well with co-workers.
A. Face mask and gloves For the past 2 months, she has been absent 4-5 times. She had
B. Sterile gloves and cap been given a written admonishment for unexcused absences.
C. Gloves and gown Which of the following is the best course of action of the head
D. Cap and face mask nurse?
34. The clinical instructor in the surgical unit is teaching the nursing
students about the prevention of spread of diseases in the health A. Warning
care environment. Which of the following is the most important B. Suspension
practical way to prevent the spread of diseases? C. Dismissal
D. Verbal admonishment
A. Consistently washing hands
B. Isolating infected clients Situation 9: A nurse in the medical unit suspects that a colleague is abusing
C. Wearing gloves whenever giving care chemicals while on duty. Irregular reports on the narcotic medication sheet
D. Wearing cap and gown are noted when she is on duty.

35. The nurse is to perform a sterile procedure while assisting in a 41. Which of the following should be the appropriate action of the
minor surgery. Which of the following actions of the nurse nurse?
maintains aseptic technique?
A. Report to the supervisor in a confidential manner
A. Keeping the sterile field in view B. Pretend not to know the situation
B. Handling the medicine to the physician over the sterile C. Personally call her attention in private
field D. Write an incident report and submit to administration
C. Talking to others over the sterile field
D. Using sterile gloves in opening sterile package 42. To be vigilant when a co-worker is suspected of abusing
chemicals, it is imperative for the nurse to assess which of the
Situation 8: Nursing interventions are sometimes complex and require following substance abuse indicators?
knowledge and skills. Other nursing interventions are relatively simple and
can be delegated to assistive personnel. One of the key skills of an effective 1. Defensive when questioned on the discrepancies in the
nurse leader is delegating tasks effectively. narcotic control sheet
2. Excessive work-related tardiness, absences and accidents
36. The head nurse is evaluating the performance of the nurses in all 3. Accurate but sloppy documentation
the service units. Which of the following is the key activity in 4. Social isolation
evaluating the performance of nurses?
A. Communicate clearly to the nurse the purpose of A. 1, 2, 3, and 4
performance appraisal at the time they are hired B. 1 and 3
B. Provide input to nurses in developing the standards in C. 2 and 4
which performance is judged D. 1, 2, and 3
C. Inform nurses in advance what happens if the
expected performance standards are not met 43. Health care agencies have policies in place for “Do Not
D. Reinforce the nurse’s prior achievement to help find Resuscitate” (DNR) decisions when the client is either comatose
new ways to excel or near death. In this situation, which of the following should be
the responsibility of the nurse?
37. Upon reporting to the unit, the head nurse of the morning shift is
overwhelmed with the following situations: failure of the staff to A. Know and follow the patient’s wishes regarding
carry out medication order 2 days ago, an elderly client pulled out resuscitation and the application of life support system
his central venous line and a client wishes to be discharged B. Ascertain that a written DNR order from the physician
immediately. Which of the following should be the course of action is in place
of the nurse? C. Explain to the family the consequences of DNR
A. Increase the scope and responsibility of the staff nurse D. Follow strictly the physician’s order
B. Recognize the capability of each team member and
delegate appropriately 44. Which of the following should the nurse take into consideration
C. Prepare an assignment of each team member and when the client has a DNR order?
delegate appropriately depending on the expertise of
the member A. The DNR order is not separate from other aspects of
D. Assess the situation and delegate appropriately client’s care
activities that recognizes the unique expertise of each B. The order of the physician is final and not subjected to
team member explicit discussion
C. The competent client’s values and choices should
38. Managers implement a variety of strategies to ensure effective always be given the highest priority
delegation. The following are strategies that ensure effective D. Consider the views of the family who are against DNR
delegation except
45. A nurse in the cancer unit is in a quandary in carrying out a DNR
A. Assess the situation and delineate expected outcome order due to personal beliefs. Which of these is an appropriate
B. Identify the skills and educational levels of the team nursing action in this situation?
necessary to complete the job
C. Empower the person to whom you delegate the job A. Seek counseling session with the nurse supervisor on
D. Create job description and scope of responsibility duty
B. Seek comfort and allay one’s fears through stress
39. The nurse manager delegates work to a subordinate. Which of management
the following is the frequent mistake made by the manager in C. Ignore personal beliefs and feelings in the situation
delegating? D. Consider a change of assignment

A. Lack of experience in delegating and trying to get Situation 10: A nurse is a member of the multidisciplinary health team. In
organized working with the team, client and family are important considerations in the
B. Delegating without adequate information formulation of goals and planning of care.
C. Feeling insecure in their ability in performing task
 46. Doctor’s orders are medical interventions that the nurse is
expected to implement. By education and training, the nurse may 52. You are administering soapsuds enema to a client. During the
choose not to follow doctor’s orders. Which of the following procedure, the client complains of abdominal cramping. Your
statements is not true? most appropriate initial nursing approach would be to

A. The nurse has less training than the doctor and A. Clamp the enema tubing to stop the flow of fluids
clarifying an order is against hospital protocol B. Push the tubing further by 2 inches
B. By carrying out a wrong order, the nurse is just as C. Ask the client to inhale and exhale slowly
liable as the person who wrote the order D. Lower the height of the enema container
C. Clarifying an order is competent nursing practice and
protects the client from potential harm 53. You are taking care of a client with fecal incontinence. You are
D. The knowledge base of the professional nurse allows aware that this client has a risk for injury due to
her to recognize errors and try to correct it
A. Falls when trying to go to the bathroom
47. The nurse carries out nurse-initiated interventions which are B. Dehydration and malnutrition
referred to as independent functions. These functions are C. Increased abdominal cramping
D. Perineal and anal skin breakdown
A. Actions based on nursing diagnoses for the benefit of
the client and not under supervision from other health 54. A client is brought to the hospital due to severe diarrhea. Which of
team members the following is a major problem of the client requiring immediate
B. Nursing orders that require specialization in certain management by the health team?
fields of nursing practice to implement
C. Focused only on health restoration and administration A. Excessive passing of flatus
of medications B. Irritation of the anal sphincter
D. Tasks performed by the nurses who have attained C. Severe abdominal cramping
higher degree of education and specialty training D. Severe fluid-electrolyte imbalance

48. A client sustained multiple injuries from a vehicular accident. To 55. A client had abdominal surgery under general anesthesia and is
maintain his level of health, he will need the health team. Which of still in the recovery room. You are aware that clients who went
the following illustrates this kind of interventions? through general anesthesia would most likely experience
A. Nurse-initiated A. Paralytic ileus
B. Collaborative B. Tolerance for solid food immediately after surgery
C. Support system C. Immediate return of gastrointestinal motility
D. Doctor-initiated D. Excessive flatus
49. A new staff nurse is attending an orientation program. The Situation 12: A researcher investigated the effect of crossing of a leg at the
supervisor emphasizes close collaboration with the heath team as knee during blood pressure measurement of a client’s blood pressure.
an important function of the nurse. The nurse demonstrates this Participants were recruited from the outpatients of a government training
when she hospital consisting of 50 males and 50 females, 21 to 70 years of age with a
diagnosis of hypertension.
A. Identifies the community health centers that the client
can visit when discharged 56. Which of the following describes this type of research?
B. Leaves the decision-making to the doctor who is the
recognized leader of the multidisciplinary team A. Qualitative research
C. Creates a discharge plan as soon as the client is B. Applied research
admitted to the ward C. Quantitative research
D. Shares her knowledge and expertise with other nurses D. Basic research
and solicits the expertise of others
57. The researcher explains to the participants the nature of the
50. A client is admitted with a medical diagnosis of acute study. Which of the following describes the action of the
gastroenteritis with severe dehydration. The nurse recognizes that researcher?
when caring for this client, she will be doing mostly
A. Full disclosure
1. Dependent nursing functions
2. Independent nursing interventions B. Informed consent
3. Discharge planning with the physician in charge C. Human dignity
4. Delegation of nursing functions to the nursing aide D. Self-determination

58. The research question for this study may be stated as follows:
A. 1, 2, and 3
B. 2 and 3 A. What is the blood pressure of the participants before
C. 1 only crossing a leg at the knee?
D. 2, 3, and 4 B. What is the effect of crossing a leg at the knee on the
blood pressure of the participants?
Situation 11: Problems with bowel movement may be experienced by people
of different ages. It can cause enough discomfort or health problems to C. What is the initial blood pressure of the participants
individuals that require nursing interventions. with a leg crossed at the knee?
D. What should be the position of the leg when measuring
51. An active woman in her mid-20s has been on weight loss diet of blood pressure?
low-carbohydrates and high protein diet. She is successful in
losing weight but is experiencing constipation. Which of the 59. Which of the following is the appropriate instrument in measuring
following should the nurse advice the client to avoid constipation? the dependent variable?

A. Take over-the-counter laxatives to ease bowel A. Self-report method

movement B. Participant observation
B. Try another type of diet that has less animal fat like C. Biophysiologic measures
fish, chicken, and low-carbohydrates D. Observational rating instrument
C. Eat nutrient-dense foods that are low-calorie but have
high nutrient value and fiber like broccoli and berries 60. The researcher found out that the blood pressure measurements
D. Increase exercise activities to improve peristalsis are higher when a leg is crossed at the knee and that the
 probability is less than 1 in 10,000. With these findings, the C. “Does the hear problem occur at any specific time of
researcher concludes that day?”
D. “How frequently does this episode of palpitation
A. There is an increase in blood pressure when a leg is happen to you?”
crossed at the knee
B. The blood pressure decreases when a leg is crossed 67. A female client is in the emergency room with chief complaint of
at the knee difficulty breathing and is receiving oxygen inhalation. To obtain a
C. There is no change in the blood pressure reading complete history of the client, the best nursing approach is to
when a leg is crossed at the knee
D. Crossing the leg at the knee is significantly related to A. Focus on the physical examination and obtain other
the blood pressure data from the client
B. Use the medical history taken by the physician
Situation 13: Teaching clients about healthy food intake for health promotion C. Have several short sessions with the client to gather
and disease prevention is an important function of the nurse. Nutritional data needed
deficiency is preventable if individuals and families have adequate D. Call family members to provide additional information
knowledge about normal nutrition. about the client

61. The nurse is teaching a family to take food with high protein 68. A client has just been transferred to the surgical unit after knee
content. She discovers that the family’s consideration is the high surgery. The nurse needs to assess the circulation of the right
cost of food. Which of the following affordable high protein foods lower leg. Which of the following is the initial approach of the
should the nurse recommend? nurse?

A. Peas and beans A. Check pedal pulse with your fingertips

B. Beef steak and vegetables B. Inspect color of the foot
C. Fried rice and dried fish C. Touch affected leg to check temperature
D. Spaghetti and bread D. Take blood pressure at the ankle

62. During the follow-up visit, the client asks the nurse foods that are 69. While performing a physical examination to an 82-year-old male
complete in protein. Which of the following should the nurse client, the nurse modifies her examination to consider the client’s
recommend? general weakness and reduced ability to move in bed. Which of
the following is the most appropriate nursing action?
A. Oatmeal with raisins
B. Toast with peanut butter A. Sequencing the examination to minimize changing
C. Eggs cooked in any style client’s position
D. Lentil soup B. Examining the client only in the position where he is
comfortable
63. A mother asks the nurse what finger food is safe for her toddler. C. Avoid touching the client so as not to alienate the client
Knowing that children can easily choke on food, the nurse should D. Speak loudly and close to the ear when talking to the
advice the mother to feed the toddler which of the following client
foods?
70. The nurse is auscultating the client’s heart. Which of the following
A. Caramelized popcorn is the best position of the client to enable the nurse all areas and
B. Cereals like cheerio high-pitched murmurs?
C. Grilled hotdog
D. Salted nuts A. Sitting and leaning forward
B. Left-lateral recumbent
64. A client diagnosed with peptic ulcer asks you what food is best to C. Supine
add to his diet so as not to exacerbate his symptoms. Which of D. Lying-in-bed
the following is the most appropriate food for this client?
Situation 15: A male nurse meets a 55-year-old client in his room. During
A. Citrus fruit juices interaction, the nurse feels drawn to the client and later looks forward to
B. Café latte and similar drinks seeing the client daily as does his rounds. The nurse realizes that the client
C. Green vegetable drinks looks and acts like his grade school teacher who was kind and fatherly
D. Frequent intake of milk towards him.

65. A mother asks if teenagers require special diet since teenagers 71. Which of the following best describes the feelings that the nurse
rapidly grow at this time. The nurse informs them other that experienced towards the client?

A. Boys need more fat and carbohydrates because they A. Counter-transference

are more active than girls B. Transference
B. Girls should increase intake of food rich in vitamins A, C. Denial
D, E, and K D. Idealization
C. Boys and girls should have food low in calories to
prevent adolescent obesity 72. The nurse utilizes the concept of therapeutic use of self when she
D. All teenagers need high-protein diet
A. Becomes self-aware and manages his feelings for his
Situation 14: Physical examination is performed to gather comprehensive clients
pertinent assessment data. Health history ascertains the client’s complaints B. Discusses his personal feelings with the client
and directs the focus of physical examination C. Asks to be assigned to another client
D. Ignores his feelings and continues to take care
66. While taking the health history of the client, she tells the nurse
that she has occasional episodes of palpitations that would last 73. The client is informed that he has stage IV colon cancer. He
for about 45 minutes to 1 hour. To further explore this information, realizes he is dying and his family has difficulty with his impending
the best question that the nurse should ask would be death. The nurse deals with his own personal feelings about
death and grieving in order to
A. “What are you doing or what’s going on around you
when this happens?” A. Discuss the family’s plan for the funeral and burial
B. “Are there other symptoms you experience along with services
this?” B. Assist the client and family express feelings on their
impending loss
 C. Remain objective and protect himself from the grieving
process
D. Shield his personal thoughts and feelings of loss and
grief
74. One afternoon the nurse enters the room and the client tells the
nurse, “Stop bothering me. Leave me alone. I don’t want anyone’s
pity.” The most appropriate response of the nurse is to say
A. “What did I do to upset you? Why are you angry with
me?”
B. “Alright, I understand and I will leave you for a while.”
C. “Are you upset because you don’t feel well?”
D. “You seem upset”, and remains with the client
75. A therapeutic relationship exists when the
A. CPE aims to improve and maintain safe nursing
practice
B. CPE assures that nurse possess a significant amount
of education
C. It is a response to scientific and technological
advances to make nurses globally competitive
D. It ensures professionalism in nursing and improves
personal qualities and professional behavior of the
nurse practitioner
Situation 17: The medical ward has clients with various disease conditions.
As a newly hired nurse, you are challenged to update knowledge and skills in
the provision of nursing care.
81. When administering oxygen therapy to a client, the least likely to
cause anxiety is the use of

A. Nurse and client work together to talk about how A. Face mask
client’s needs may be met B. Oxygen tent
B. Nurse informs the client the goals and priorities for his C. Nasal catheter
care after a thorough assessment D. Nasal cannula
C. Nurse explores the client’s thoughts and actions for the
client’s benefit 82. Which of the following is a major consideration in determining the
D. Various nursing procedures are used to help meet the method of oxygen administration to a specific client?
client’s needs
A. Pathologic condition of the client
Situation 16: Continuous personal and professional development of the B. Facial anatomy of the client
nurse is expected to provide safe quality care to clients C. Age of the client
D. Mental capacity of the client
76. A post-surgical client assigned to the nurse has an order of pain
medication through a patient-controlled analgesia (PCA). The 83. The nurse is assisting a client who has an order for postural
nurse has no prior experience in the use of PCA with clients. drainage. To help the client obtain maximum benefits after the
Considering the time frame, which of the following is the most procedure, the nurse should
appropriate action of the nurse?
A. Encourage the client to cough deeply
A. Read the literature for directions
B. Allow the client to rest in a sitting position
B. Secure assistance before implementation C. Elevate the head of the bed to promote comfort
C. Observe other clients with similar situations D. Allow the client to stay in his position for 30 minutes
D. Interview nurses about their experiences with the PCA
pump 84. When doing postural drainage for the client, measures should be
taken to minimize which of the following conditions?
77. The focus of care is to shorten hospital stay by moving clients
from an acute care setting to a community-based care setting. 1. Fatigue and pain
Which of the following are the components of health care delivery 2. Dsypnea
that are important to improve the health of the general public? 3. Anxiety and discomfort
4. Coughing
A. Community health nursing and community-based
nursing A. 1 and 2
B. Hospital-based nursing and community health nursing B. 1, 2 and 3
C. Acute care and community health care setting C. 1, 2, 3 and 4
D. Acute care in the hospital based setting D. 1, 3 and 4
78. When a nurse acts “professionally”, it implies that she 85. The nurse is taking care of a client with asthma. During
auscultation, she expects to hear wheezing sound which would
A. Is dedicated and committed in the practice of her sound like
profession
B. Considers health care cost and provides that best A. Grating sound
evidence-based practice B. Coarse crackles or rales
C. Is knowledgeable, conscientious and responsible to C. High pitched musical sounds
self and others D. Loud low pitched sounds
D. Uses clinically documented evidences in decision-
making Situation 18: A 73-year-old client is brought to the emergency room for
passing fresh blood upon defecation. The client is actively bleeding and his
79. Nursing as a profession requires its members to possess a blood pressure drops to 80/50 mmHg. Fluids and blood transfusion of
significant amount of education. The route for an individual to packed RBC are ordered immediately.
become an RN in the Philippines is through completion of a
86. This is the first time that the client will have blood transfusion. He
A. Basic science including theoretical and clinical courses and his family are very worried about the procedure. Your most
B. Degree of Bachelor of Science in Nursing and eligible appropriate nursing intervention would be to
to take the Nurse Licensure Examination
C. Formal four-year course leading to Bachelor of A. Talk to the client and family and inquire what their
Science in Nursing fears are about blood transfusion
D. Bachelor degree in a hospital setting and eligible to B. Reassure the client and family that blood transfusion is
take the Nurse Licensure Examination a simple low risk procedure
C. Tell the client that he will be closely observed for the
80. To remain current in nursing skills, knowledge and theory, a nurse first hour so he will be safe
who works in a geriatric unit plans to attend a continuing D. Request the doctor to explain to the client why blood
education program (CPE) in the care of elderly clients. The transfusion is necessary
following statements about CPE are true except
 87. The nurse prepares the following equipment for blood transfusion D. “I understand how you feel but it is my responsibility to
except take care of you.”

A. 0.9% normal saline solution 95. The client agrees to take a shower. While the client is being
B. IV infusion set with gauge 22 needle assisted to the bathroom, she begins to fall. Which of the
C. Blood product properly typed and cross-matched with following should be the initial action of the nurse?
the client
D. Y-type filter transfusion set A. Call for immediate help
B. Quickly assist the client in a nearby chair and lower the
88. The nurse understands that normal saline solution is used to head between the knees
initiate the intravenous infusion rather than dextrose solution C. Call the relatives to get back the client to bed
before blood transfusion to D. Refer the client to attending physician

A. Avoid cardiac overload Situation 20: Understanding client’s needs depends upon the ability of the
B. Maintain adequate hemoglobin content nurse to communicate therapeutically.
C. Prevent increasing the blood sugar
D. Avoid hemolysis and clumping of RBC 96. A client in her early 20s was recently diagnosed with breast
cancer. She says to the nurse, “Why did this happen to me? Do I
89. The nurse stays and observes closely the client after the start of deserve this when I have been very good to others?” Which of the
the blood transfusion for possible transfusion reaction which following should be the appropriate action of the nurse?
includes the following except
A. Provide comfort by telling her that she doesn’t deserve
this
A. Hypovolemic reaction
B. Provide reassurance by recognizing how difficult her
B. Febrile reaction
situation must be
C. Hemolytic transfusion reaction
D. Allergic reaction C. Call the chaplain to assist the client in accepting her
fate
90. After starting blood transfusion, the nurse should make sure that D. Encourage her to seek another opinion
the blood is transfused to the client within how many hours from
the time it started? 97. The nurse found a 28-year-old client who had hysterectomy
crying while alone in her room. What should be the nurse’s initial
A. 12 hours approach?
B. 10 hours
C. 8 hours A. Ask her what seems to be troubling her
D. 4 hours B. Reassure her that crying is a normal reaction
C. Reassure her that her attending physician will order
Situation 19: The nurse is assigned to take care of elderly clients with hormonal replacement therapy
different needs while in the medical ward. D. Leave the room quietly

91. While examining an elderly female client, the nurse notes musky 98. The doctor orders the insertion of a nasogastric tube for a client
sour body odor of the client indicating poor hygiene. Which of the who refused to eat. She has severe weight loss. She removed the
following is the most appropriate action of the nurse? tube and says, “I don’t need that thing.” The most appropriate
nursing response is
A. Give alcohol rub to cleanse the skin and reduce body
odor A. “Do you want your condition to deteriorate further?
B. Assist the client to apply moisturizing lotion daily Why did you pull out the tube?”
C. Obtain prescription for antifungal skin medication B. “You should not have done that. You need to improve
D. Help client bathe several times weekly your condition.”
C. “Your doctor will be upset and order reinsertion of the
92. The client is weak and needs to be moved up in her bed. To tube.”
reduce shearing force when moving the client, the nurse should D. “Tell me what you don’t like about the tube.”

A. Apply lotion to body parts in contact with bed sheet 99. A client is admitted to the hospital for diabetes accompanied by
B. Give the client a thorough explanation of the process her son. The son is telling the nurse about his difficulty in taking
C. Ask for staff assistance when lifting the client care of his mother. The nurse is using non-therapeutic
D. Use a draw sheet to put the client in correct position communication when she says

93. The client has been on bed rest and has reddening of the skin of A. “Maybe putting her in a home for the elderly people will
bony prominences. When moving the client up in bed, the nurse be best for her.”
places her arms across her chest. This is done to B. “Let’s look more closely about your concern.”
C. “It appears that you are concerned with your mother.”
A. Make the client’s body more aligned D. “You seem to be anxious about this. Tell me more
B. Protect the client’s extremities during the procedure about your concerns.”
C. Reduce the surface area that will come in contact with
the bed 100. The nurse is establishing her presence as part of her nursing
D. Make the body more compact to facilitate the move care. This is best interpreted as

94. The nurse reports that a client appears uncomfortable and covers A. Being with the client always
herself with bed sheets on a warm day. The nurse asks B. Offering of closeness with the client physically,
permission to pull out the sheet but noted urine smell and wet bed psychologically and spiritually
sheets. She persuades the client to get up and shower. The client C. Personally performing nursing care activities for the
refuses and becomes teary-eyed. The most appropriate client
therapeutic statement by the nurse would be: D. Sharing vital information with the client

A. “Just allow me to clean you up and you will see how

good I am at this kind of nursing procedure.”
B. “You should not be embarrassed since I am used to
taking care of clients who are incontinent.”
C. “I am here to make you feel comfortable.”