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1 Rhonchi (gurgles) are continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality

. A nurse understands that the cause of this adventitious breath sounds is: Choose one answer. a. Rubbing together of inflamed pleural surfaces.

b. Air passing through a constricted bronchus as a result of secretions, swelling, and tumors. c. Air passing through fluid or mucus in any air passage.

d. Air passing through narrowed air passages as a result of secretions, swelling, and tumors. Question2 Because nursing research usually focuses on humans, a major nursing responsibility is to be aware of and to advocate on behalf of client's rights. Which of the following statements best describe the right to self-determination in research? Choose one answer. a. provision of complete information about the research/study

b. assurance of the anonymity of a study participant

c. freedom from constraints, or any undue influences to participate in a study d. avoidance of any exposure to the possibility of injury beyond everyday situations Question3 The research design is the overall plan for obtaining answers to the questions being studied and for handling some of the difficulties encountered during the research process. The purpose of the design is to maximize control over factors that can interfere in the validity of the findings. What type of research design is used wherein there is total control of the study? Choose one answer. a. pretest-posttest design

b. nonexperimental design

c. experimental design

d. quasi-experimental design Question4 When using an instrument or tool in quantitative research, it is important to ensure its reliability and validity. Reliabilityis the consistency with which it measures the target attribute, while validity refers to the degree to which an instrument measures what it is supposed to measure. Harry, a nurse researcher, has found an instrument to measure the level of self-esteem of school-age children. He wants to test its validity so he consults a panel of experts to evaluate the validity of the instrument. This is called: Choose one answer. a. Both content and face validity

b. content validity

c. face validity

d. None of the above Question5 Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. This phase includes establishing client goals and objectives. Which of the following objectives for the nursing diagnosis of Ineffective Airway Clearance related to poor cough effort is NOT properly stated? Choose one answer. a. The client will not experience aspiration.

6 Preoperative teaching is a vital part of nursing care to reduce clients' anxiety and postoperative complications and increases their satisfaction with the surgical experience." Question7 Assessment is a continuous process carried out during all phases of the nursing process. During the procedure. What is the main purpose why the client needs to holds his breath during needle insertion? Choose one answer. Which of these is the main difference between MIS and HIS? Choose one answer. you instruct the client to inhale and exhale deeply several times and to hold his breath after the final exhalation for up to 10 seconds as the needle is inserted. and information science to manage and communicate data." d. Comparing patterns with norms d. "After surgery. c. I can immediately resume the diet I had before I was operated. nurses. information and knowledge in nursing practice to support patients. c. Distinguishing relevant from irrelevant data b. Which of these is NOT part of the assessment phase? Choose one answer. MIS focuses on the types of data needed to manage client care activities and health care organizations. HIS focuses on the types of data needed to manage client care activities and health care organizations. "I will only do deep breathing exercises when I am experiencing pain. d. Holding the breath minimizes the pain experienced by the client as the needle is inserted. Which of the following statements by the client indicates that preoperative teaching regarding gallbladder surgery has been effective? Choose one answer. avoiding injury to the lung and liver. "I am not going to cough after surgery because if I do." b. b. MIS and HIS do not have any differences. computer science. "I cannot eat or drink anything at least 8 hours before my surgery. my wound will tear apart. The client will demonstrate effective coughing and increased air exchange within 24 hours after surgery. Validating data c. HIS is more general as MIS is more specific in managing data. 2001). . b. The two most common types of computer systems used by nurses are management information systems (MIS) and hospital information systems (HIS). The client will have lungs clear upon auscultation during entire postoperative period." c.b. a. This immobilizes the chest wall and liver and keeps the diaphragm in its highest position. MIS is designed to facilitate the organization and application of data used to manage an organization or management. and other providers in their decision-making in all roles and settings (ANA. HIS is designed to facilitate the organization and application of data used to manage an organization or management. For comfort purposes only c. a. Question9 Liver biopsy is the removal of a small amount of liver tissue. usually needle aspiration. a. Organizing data Question8 Nursing informatics is the specialty that integrates nursing science. d. The client will show no signs of pallor or cyanosis by 12 hours post-surgery. a.

Question12 Positioning a client in good body alignment and changing the position regularly (every 2 hours) and systematically are essential aspects of nursing practice. you know that the only possible way is to take it on his thighs. b. Question10 Nursing care oriented to health promotion.d. therefore you place him in a semi-Fowler's position. You are a nurse in the medical ward and you are assigned to a new patient for the shift. c. Place a pillow under lower legs. She has modified her lifestyle since then by quitting smoking. When taking his blood pressure. She has been taught at the health center about the possible complications of the disease if it is not managed properly and this includes stroke. Around his mid-thigh with the bladder over the posterior aspect of the thigh and the bottom edge around the knee c. c. A client is a known hypertensive for 5 years. . You want to know about the case of the patient and the kind of nursing care and therapeutic management already done to help her in her condition throughout her stay at the hospital. Around the upper portion of his mid-thigh with the bladder over the posterior aspect the thigh and the bottom edge in line with the knee. b. He has an AV fistula on his right arm and the client's chart reads "save both arms" for a possible creation of another fistula on his left arm. which should be looked at in total. A nurse performing internal examination of a woman during labor who experienced minimal vaginal bleeding during the second trimester. d. Secondary prevention b. Holding the breath contracts the abdominal muscles so that the contour of the liver will be well-defined for easier insertion of the needle. a. A possible problem of this position is the posterior flexion of the lumbar curvature which may be brought about by the unsupported portion of the upper part of the body elevated at 30-45 degrees commencing at the hips. a.Which of the following statements is NOT included in the scope of nursing? Choose one answer. These activities demonstrate: Choose one answer. A community health nurse teaching a group of hypertensive clients about regular monitoring of blood pressure. 9173 (The Philippine Nursing Act of 2002)defines the scope of nursing practice in the Philippines. Your client is experiencing difficulty of breathing. Question13 Vital signs. Place a pillow at the lower back. a. Place a pillow under the forearms to eliminate pull on shoulder. are checked to monitor the functions of the body. A client with end-stage renal disease is undergoing hemodialysis. Around his lower thigh with the bladder over the posterior aspect of the thigh and the upper edge around the knee d. neck and upper back. exercising regularly and by eating a balanced diet. Tertiary prevention d. A nurse providing oral hygiene to a bed-ridden patient. wellness.A. You therefore read the: Choose one answer. and illness prevention can be understood in terms of health activities on the different levels of preventive care. None of the choices 11 R. d. Around the knee of the client Question14 Nurses document evidence of the nursing process in a variety of forms throughout the clinical record. b. a. Primary prevention c. Where should you place the BP cuff? Choose one answer. Place a pillow to support the head. How will you make sure this problem is prevented? Choose one answer. A nurse administering an IV antibiotic after being ordered by the physician.

You are assisting your client while she tries to ambulate after her surgery 2 days ago. A nurse should remember that the patient: Choose one answer. Progress notes Question15 Clients who have been immobilized for even a few days may require assistance with ambulation. and prognosis if not treated by a health care provider. Will most likely be unable to choose between alternatives when asked to consent Question17 Nursing practice is governed by many legal concepts and it is important for nurses to know the basics of legal concepts. All of the above . there is no nearby chair or wheelchair wherein you can lower the patient. she feels weak and seems to be fainting. c. and lower the person gently to the floor. Your client is to undergo thoracentesis and you assist him to assume a position that is indicated for the procedure. you are liable for: Choose one answer. battery Question18 Thoracentesis is used to remove the excess fluid or air to ease breathing. You can assist the client to a horizontal position on the floor before fainting occurs. Which of these can be his position during the procedure? 1 Sitting position with the arms above the head 2 Sitting position with the arm elevated and stretched forward 3 Sitting position in which the client leans over a pillow or overbed table 4 Sitting position with both arms crossed in front of the chest Choose one answer. however. assault d. alternatives to the treatment. You inserted a Foley catheter to a patient with urinary retention even though the patient refused to.a. Nursing discharge summary b. You informed the patient that this will benefit her. a. Is not able to make an acceptable or intelligent choice c. however. Even if you have a good intention. a. because nurses are accountable for their professional judgments and actions. 16 Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information. Allow the client to slide down your leg. Is able to give voluntary consent when his parents are not available d. Bring the client backward so that your body supports the person. EXCEPT: Choose one answer. Kardex c. a. unintentional tort c. there are no other significant others present during that time. d. Suddenly. b. You can do the following. invasion of privacy b. a. Assume a broad stance with both feet parallel to each other. including the benefits and risks of treatment. Does not have the legal capacity to give consent b. An informed consent needs to be acquired for the performance of endoscopy for a 17-year-old male adolescent. All of the above. Flow sheet d.

Fever. decreased PaO2. 1. Imogene King c. and increased pH. Decreased PaCO2. vomiting and chills d. Dorothea Orem d. increased PaO2. b. 21 Total parenteral nutrition (TPN) affords the provision of energy and nutrients intravenously and it is an important responsibility of the nurse to monitor the patient regularly for possible complications related to this therapeutic management. c. Martha Rogers b. 30 compressions:2 breaths b. asthma attack. Your client is experiencing a prolonged. d. Florence Nightingale Question23 Peplau's theory involves the use of a therapeutic relationship between the nurse and the client. Increased PaCO2. you are putting into practice the theory of: Choose one answer. Nausea. Cold clammy skin. and decreased pH. When the client assumes the dependent client role. Thirst. increased PaO2. Increased PaCO2.b. Based on the latest guidelines in CPR. vomiting Question22 Nurses should deliver holistic care to all clients across the lifespan. a. 5 compressions:1 breath d. and increased pH. 2. 2 and 3 d. You will note which of the following if your client is already hyperglycemic? Choose one answer. what is the compression-to-ventilation ratio for all clients except that of newborns? Choose one answer. nausea. a. which supplies oxygen to the lungs. 3 and 4 c. 15 compressions:2 breaths Question20 Arterial blood gases (ABGs) are performed to evaluate the client's acid-base balance and oxygenation. decreased PaO2. the nurse and client are on which phase of the therapeutic relationship? Choose one answer. and decreased pH. Which of the following ABG results would you anticipate? Choose one answer. which is intended to reestablish cardiac function and blood circulation. 10 compressions:2 breaths c. severe. increased urine output and warm flushed skin b. a. and external cardiac massage (chest compressions). 3 and 4 Question19 Cardiopulmonary resuscitation (CPR) is a combination of oral resuscitation (mouth-to-mouth breathing). Decreased PaCO2. a. You are regularly assessing your client who is receiving TPN for signs of hyperglycemia. . In doing this. sweating and weakness c.

customs. There is less control applied in terms of handling the subordinates. c. The leader acts primarily as a facilitator and a resource person. non-maleficence c. Exploitation Question24 It is important that nurses make nursing diagnoses with a high level of accuracy. a. Which of the following is NOT included in the nurses' code of ethics? Choose one answer. Resolution d. The hallmark of accurate documentation of actions and outcomes of delivered care is a nursing responsibility. b. Identification c. autonomy . c. a. Personal information acquired in the process of giving nursing care shall be held in strict confidence. a. d. Explanation by the attending physician of the important findings.a. alleviation of suffering. It is a set of ethical principles that is shared by members of the group. management. Word the diagnosis as generally as possible c. Question27 In health care delivery. and laissez-faireleadership. prognosis and evaluations to a newly-diagnosed breast cancer patient is an application of: Choose one answer. democratic. and serves as a standard for their professional actions. 26 The Nurses' Code of Ethics is a formal statement of a group's ideals and values. d. The leader leaves the decision-making up to the group. Word the statement so that it is legally advisable Question25 Leadership is commonly defined as a process of influence in which the leader influences others toward goal achievement. basic ethical principles assist the health professionals to determine the right or wrong in regard to value issues involving the pursuit of health. The leader decides for the whole unit by himself. Orientation b. Values. Three leadership styles are still widely recognized today: the autocratic. Use statements based on nurse's perception of the client's response d. Nurses are the advocates of the client. Use medical terminology rather than nursing terminology to describe the probable cause of the client's response b. and assisting patients toward peaceful death. b. beneficence b. and spiritual beliefs held by individuals are to be respected. Which of these guidelines should be followed when writing a nursing diagnostic statement? Choose one answer. a. reflects their moral judgments over time. A laissez-faire leader is differentiated from other types of leadership through which of the following? Choose one answer.

caring. and. Delegation maximizes the use of talents of staff associates. It is the branch of medicine that deals with the physiological and psychological aspects of aging and with diagnosis and treatment of diseases affecting older adults. Documentation of nursing activities is included in which phase of the nursing process? Choose one answer. c. a. All of the choices. . cognitive. Implementation b. evaluating the effectiveness of such care. and comforting rather than merely the treatment of disease. a. Question30 The management theory developed by McGregor is the Theory X and Theory Y. c. 31 There is a need for recording of the accomplished nursing interventions and the client's responses for effective communication among the members of the health care team. When you refer to other health professionals those who have severe hypertension that are already at high-risk for stroke.d. you are doing which area of nursing practice? Choose one answer. Diagnosis Question32 The nurse-manager decides what task should be done. It is the study of all aspects of aging process and its consequences. a. This can be done throughdelegation. You are a nurse in the community taking care of residents with hypertension. b. Preventing illness c. It is concerned with the assessment of health and functional status of older adults. Restoring health d. Caring for the dying Question29 The nursing care of older adults poses special challenges because of great variation in their physiological. Promoting health and wellness b. They do not like the work that they are doing. This theory is about the two different ways to motivate or influence others based on underlying attitudes about human nature. and psychosocial health. planning and implementing health care and services. when. Evaluation d. d. a. Which of the following is NOT a reason for delegating? Choose one answer. a. diagnosis. Which of the following describes GERONTICS? Choose one answer. It considers the nursing care of older adults to be the art and practice of nurturing. They cannot offer creative solutions to help organizations advance. b. They like to be supervised and avoid added responsibilities. where and by whom. veracity Question28 Nursing practice involves all aspects of the health-illness continuum. Which of the following describe a Theory X nurse manager's perception of his/her nursing staff? Choose one answer. d. Assessment c.

The respondents are employees of the only private hospital in the municipality of San Juan in Batangas. Magnesium d. are present in all body fluids and fluid compartments. Administer the medication anyway because you might get reprimanded by the physician. d. b. when you arrived in your patient's room. c. The patient is L. you noticed the following signs and symptoms: numbness. d. A faculty in a college of nursing should have at least one (1) year of clinical practice in a field of specialization. d. licensing requirements. Wait until the patient experiences pain again then administer the medication. charged ions capable of conducting electricity. tingling of the extremities and around the mouth. Question33 Because of their unique position in the health care system. a.R. Inform the charge nurse of the condition. Withhold the medication. Calcium c. What will be your action? Choose one answer. Sodium b. nurses experience conflicts among their loyalties and obligations to clients. a. b. and standards of nursing care. EXCEPT: Choose one answer. a. However. none of the above Question35 Electrolytes. Delegation reduces managerial costs. Which of the following electrolytes is most likely to be imbalanced in your patient? Choose one answer. A member of the Board of Nursing should have at least ten (10) years of continuous practice of the nursing profession provided that the last five (5) years of which shall be in the Philippines.. The research study was done in the pediatric wards of a tertiary hospital in Manila. Delegation saves time and can help develop others. he seems to not be in pain. Question34 Confidentiality is the protection of the participants in a study such as that individual identities are not linked to information provided and are never publicly divulged. Delegation is an opportunity to transfer one's accountability to a task. muscle tremors. d. a. Which of the following statements best manifest confidentiality? Choose one answer. further assess the patient and inform the attending physician of your findings. The Board of Nursing shall designate the places and dates of the Nursing Licensure Examination. Potassium 36 Republic Act No. primary care providers. Makati. 9173. female of 5 Jupiter Street. When you are assessing your patient. and licensing bodies. The features of this Law include the following. The attending physician of your patient placed an order in the chart to administer a pain medication STAT. otherwise known as the Philippine Nursing Act of 2002 was implemented to define the scope of nursing practice. employing institutions. Question37 .C. families. The Certificate of Registration may be revoked or suspended if the nurse demonstrated unprofessional or unethical conduct. c. b. c. 34.b. c. cramps and hyperactive deep tendon reflexes.

9 c. which are any pathological skin changes. . c. moves to localized pain and makes sounds that are incomprehensible. Care plans are individualized according to the client's needs. 8 41 During physical assessment of the skin. d. a. You are a nurse-manager in the pay ward who uses evidence-based practice in planning care for your clients. Which of the following is your priority in planning for these clients? Choose one answer. Which of the following situations will most likely cause the nurse to be sued for negligence? Choose one answer. 11 b. 7. Question38 A physician orders Ceftriaxone (Rocephin) 2. b. Nurse Abby mixed a medication in the wrong kind of IV fluid during preparation in the medication room. the nurse assesses skin lesions. explicit. 5 ml d. a. 10 d.5 ml b. b. Nurse Pat gave the wrong antibiotic and after 30 minutes the patient experienced an anaphylactic reaction. that is 0. Nurse Cecille is about to administer an oral medication when the patient complained that it is not the one usually given to her. larger than 1-2 cm. Care plans are based on the nurse's clinical experience and from the latest research findings. 10 ml Question39 Negligence is defined as a misconduct or practice that is below the standard expected of an ordinary. Marie. An elevated solid mass. which is a component of the neurologic examination. The pharmacy sends a vial labeled 5g/10ml. the nurse should use: Choose one answer.5-2 cm. She opens her eyes to verbal command. When preparing the medication.5 ml c. c. the nurse may palpate it to locate skin lesions. will document on her chart? Choose one answer. What will be her score on the GCS that you. 2. During palpation of the skin. a. a. can be measured using theGlasgow Coma Scale (GCS). a. b. Care plans follow the standards of care established by the institution's nursing service.Evidence-based practice is the conscientious. Question40 The level of consciousness. Which of the following describes a nodule? Choose one answer.5 g given via IV piggyback every 8 hours for a client with severe infection. deeper and firmer than a papule. a 45-year-old woman. Care plans that are standardized are used on all patients. and judicious use of current best evidence in making decisions about the care of individual patients. as her nurse. and prudent person.5 ml in a syringe. which she documented in the client's chart as a nodule. was brought in at the Emergency Department after a vehicular accident. reasonable. Solid mass that may extend deep through the subcutaneous tissue. d. Nurse Anne noticed that she aspirated 1 ml of the medication instead of the prescribed 0.

c. A 28-year-old female client to undergo Caesarian section the next day c. Your client. A 5-year-old child with ascariasis d. thereby increasing peristalsis and the excretion of feces and flatus. Which of these is the correct scheme for the wound care using the RYB color code? Choose one answer. creating physical problems such as skin breakdown and possibly leading to psychosocial problems such as embarrassment. circumscribed. 46 To guide wound care. Reflex urinary incontinence . which is the independent variable? Choose one answer. the nurse can use the RYB color code of wounds. Irregularly shaped. or sneezes. which is based on the concept on the color of an open wound . yellow. hypertensive residents b.encourage timed verbal toileting reminders and positive social feedback for successful toileting b. Your client is terminally-ill and his family is saying that he has lived a good life and are considering ending his life. and social withdrawal. a.c. blood pressure c. It can have a significant impact on the client's life. Urge urinary incontinence . a.increase bladder's ability to hold urine and the client's ability to suppress urination. Which of these situations LEAST require the use of complex ethical decision-making skills in nurses? Choose one answer.regular periodic use of a catheter to empty the bladder d. Question42 Determining the different variables in research is an important task of the researcher. "What is the effect of progressive muscle relaxation on the blood pressure of hypertensive residents in an urban community in Metro Manila?". not a disease. In the research question. b. Functional urinary incontinence . elevated area or superficial localized edema that varies in size. isolation. Your patient is depressed and does not respond to any of your questions. A 45-year-old man who will undergo colonoscopy on the following day Question44 Urinary incontinence.red. or black (RYB) . Stress urinary incontinence . a. Question45 Nurses are almost often involved in the decision-making pertaining to some ethical issues. Your pregnant client is considering abortion due to financial constraints. solid elevation in the skin. Your client has just been recently diagnosed to be HIV-positive. smaller than 0. Melanie.5 cm. A palpable. d.rather than the depth or size of the wound. coughs. A client experiencing excessive flatus. is 8 months pregnant and she reports dribbling of urine whenever she laughs. or involuntary urination is a symptom. Which of the following clients is more likely to receive a retention enema? Choose one answer. progressive muscle relaxation Question43 An enema is a solution introduced into the rectum and the large intestine to distend the intestine and sometimes to irritate the intestinal mucosa. . a. What will be your appropriate nursing diagnosis and intervention for her? Choose one answer.encourage pelvic muscle exercises c. urban community in Metro Manila d. d. b.

a. AF. Once. protect yellow. Cleanse red. Protect red. Appeal to the child's belief in magic by using a "magic" blanket to take away pain. c. you have promised him that you will come back to talk to him and answer his questions after you have made your rounds to your other patients. there are no co-morbidities present.Mrs. a. cleanse black b. protect black d. AF to assume? Choose one answer. cleanse yellow. c. philosophical concepts that guide one's particular actions. autonomy Question50 Several positions are frequently required during the physical assessment. Play music or tapes of a heartbeat. general. Prone b. Never bend or break needles before disposal. 65 years old. however. a. and age. is diagnosed to have cervical cancer for 5 years already. cleanse yellow. b. debride black Question47 One of the most potentially hazardous procedures that health care personnel face is using and disposing of needles and sharps. Jenny. Sims . What position should the nurse ask Mrs. She is in the clinic for a follow-up and the nurse is to assess her genital area. Protect red. What bioethical principle have you ignored? Choose one answer. How will you best divert her attention from the pain experience? Choose one answer. a. however it is important to consider the client's ability to assume a position as well as their physical condition. Question49 Bioethical principles are statements about broad. You are the nurse of a chronically-ill patient. 5 years old. d. non-maleficence d. EXCEPT: Choose one answer. Use appropriate puncture-proof disposal containers to dispose of uncapped needles and sharps. fidelity b. is often crying because of pain. You are a nurse in the pediatric ward and your client. you have forgotten to keep your word because of the more critical conditions of your other patients. Question48 The age and developmental stage of a client is an important variable that will influence both the reaction to and expression of pain. energy level.a. use a one-handed "scoop" method. debride black c. justice c. debride yellow. Debride red. When recapping a needle. Clarify misconceptions on pain. d. Recap used needles. Provide a behavioral rehearsal of what to expect and how it will look and feel. Needlestick injuries can be prevented if these guidelines are followed. However. b.

The right to self-determination means that prospective participants have the right to decide voluntarily whether or not to participate in a study. or any undue influences to participate in a study. It can be best heard during expiration but can be heard on both inspiration and expiration.MIS is designed to facilitate the organization and application of data used to manage an organization or management. Comparing patterns with norms c. or social. objectives should be measurable and time-bound (Kozier). Typically. order entry and finance. Air passing through narrowed air passages as a result of secretions. The right to full disclosure is wherein the researcher should fully describe the nature of the study. (Kozier). and documentation of data.content validity. on the other hand.c. The right not to be harmed refers to avoidance of any exposure to the possibility of injury beyond everyday situations. HIS focuses on the types of data needed to manage client care activities and health care organizations. HISfocuses on the types of data needed to manage client care activities and health care organizations.comparing patterns with norms. Meanwhile. financial. observable criteria used to evaluate whether the goals have been met. This statement is more of a goal because goals are broad statements about the client's status while objectives are more specific." . experimental design b." There is aneed to restrict food and oral fluids (NPO) at least 8 hours before surgery to prevent aspiration during the operation. Crackles (rales) and crackles are caused by air passing through fluid or mucus in any air passage. The client should be taught how to splint his/her incision to reduce pain while coughing if the incision is near any of the breathing muscles (ie. "I cannot eat or drink anything at least 8 hours before my surgery. This immobilizes the chest wall and . freedom from constraints. high-pitched. and tumors. squeaky musical sounds and are best heard on expiration.content validity a. swelling. b. and tumors. swelling. without risking any penalty or prejudicial treatment. This kind of validity is necessarily based on judgment and it is becoming increasingly common to use a panel of substantive experts to evaluate and document the content validity of instruments.Holding the breath while inserting the needle during liver biopsy immobilizes the chest wall and liver and keeps the diaphragm in its highest position. Face validity. the researcher's responsibilities. thereby preventing atelectasis and pneumonia. . interrupted crackling sounds that are best heard on inspiration. A pretest-posttest design is an example of an experimental study. validation. avoiding c. legal. HIS is a type of MIS but is more specific to health care. It can be described as fine. The right to privacy and confidentiality is wherein participants have the right to expect that any data they provide will be kept in strictest confidence. Content validity concerns the degree to which an instrument has an appropriate sample of items for construct being measured. Also. The data gathered in the assessment phase are used in the next phase. "I will only do deep breathing exercises when I am experiencing pain. . A quasi-experimental design is an intervention study in which subjects are not randomly assigned to treatment conditions. clinical laboratory. an HIS will have subsystem in the areas of admission. organization. This involves avoidance of any risk that can be physical. dietary alterations are necessary post-operatively because some foods are not yet tolerated immediately after surgery.freedom from constraints. The client will not experience aspiration. c. An experimental design is used by a researcher wherein the researcher controls (manipulates) the independent variable and randomly assigns subjects to different conditions." ."I cannot eat or drink anything at least 8 hours before my surgery.experimental design. pharmacy. refers to whether the instrument looks as though it is measuring the appropriate construct (Polit & Beck). Anonexperimental design is wherein the researcher does no manipulation of the independent variable. and likely risks and benefits (Kozier and Polit & Beck). diagnosing wherein they are analyzed and synthesized into nursing problems (Kozier) . Meanwhile. In MIS. medical records.The primary cause of rhonchi (gurgles) is the passage of air through narrowed air passages as a result of secretions. Usually. c. Lithotomy d. or any undue influences to participate in a study c. assessment is the systematic and continuous collection. Deep breathing and coughing exercises post-op are needed to enhance lung expansion and mobilize secretions. Clients should also be encouraged to carry out deep breathing and coughing exercises at least every 2 hours. Rubbing together of inflamed pleural surfaces is the cause of pleural friction rubs which are superficial grating or creaking sounds that can be heard during inspiration and expiration (Kozier). and tumors. but the researcher exercises certain controls to enhance the study's validity by manipulating the independent variable. . c. . . (Kozier). Dorsal recumbent d. Wheezes are caused by air passing through a constricted bronchus as a result of secretions. short. MIS is designed to facilitate the organization and application of data used to manage an organization or management. emotional. all levels of management benefit from the ability to access data. This activity is included in the diagnosis phase of the nursing process. swelling. .the client will not experience aspiration. the person's right to refuse treatment. diagphragm). which can be described as continuous.

the client becomes fatigued and there is the development of alveolar hypoventilation. 2 and 3 a. The Kardex reveals specific data about the client. including the therapeutic management done and a nursing care plan to be able to meet the goals and relieve the problems. making information quickly accessible to all members of the health team. however one foot should be in front of the other. c. decreased PaO2. These positions allow easy access to the intercostal spaces wherein the needle will be inserted to remove the excess fluid or air (Kozier). Primary prevention. thus preventing back strain. All the other choices are correct: a nurse can conduct essential health teachings. bringing the client's weight backward against your body allows gradual movement to the floor without injury to the client (Kozier). This position of the cuff should be done to ensure that the bladder is directly over the posterior popliteal artery if the reading is to be accurate (Kozier). This will prevent the posterior flexion of the lumbar curvature. meanwhile.does not have the legal capacity to give consent. Assault. The flow sheet enables nurses to record nursing data quickly and concisely to provide an easy-to-read record of the client's condition over time. Placing a supportive device such as a pillow on the lumbar region will support this part of the body when placed in a Fowler's position. The other choices are unrelated. neck and upper back will prevent hyperextension of the neck (Kozier). therefore the victim needs less ventilation than normal (Kozier). Kardex . 9173 because the law states that a nurse is only to do internal examinations during labor provided that there is an absence of antenatal bleeding and delivery. is aimed at health promotion that includes health education programs.a nurse performing internal examination of a woman during labor who experienced minimal vaginal bleeding during the second trimester. Other kinds of people who cannot sign an informed consent are those who are unconscious or injured in such a way that they are unable to give consent. Placing a pillow to support the head.a minor who is self-sufficient or married. and decreased pH. . d.) .around his mid-thigh with the bladder over the posterior aspect of the thigh and over the posterior aspect of the thigh and the bottom edge around the knee. Placing a pillow under the forearms will prevent shoulder muscle strain and possible dislocation of the shoulders. provide information about the progress a client is making.Assume a broad stance with both feet parallel to each other. Battery is the willful touching of a person (or the person's clothes or even something the person is carrying) that may or may not cause harm.increased PaCO2. thirst. Does not have the legal capacity to give consent d. with his arm elevated and stretched forward and in which he leans over a pillow or overbed table. . . it is the act that causes the person to believe a battery is about to occur. Tertiary prevention involves minimizing the effects of longterm disease or disability by interventions directed at preventing complications and deterioration. Progress notes. such as touching without permission or consent. . . 30 compressions:2 breaths d. Place a pillow at the lower back.A.place a pillow at the lower back. Lastly. A nurse performing internal examination of a woman during labor who experienced minimal vaginal bleeding during the second trimester. A broad stance widens your base of support while placing one foot behind the other allows you to rock backward and use the femoral muscles when supporting the client's weight and lowering the center of gravity. There are some situations wherein there is a need to take the blood pressure other than that in the arms. Based on the latest guidelines of the American Heart Association (2005). Assume a broad stance with both feet parallel to each other. This is also changed because of the rationale that blood flow to the lungs is less than normal during CPR. The pH also decreases because the hydrogen ions are also retained as the carbon dioxide is retained (Lippincott NCLEX. The only exceptionwherein a minor is allowed to sign a consent is when he/she is considered anemancipated minor . Placing a pillow under the lower legs will prevent pressure on the heels. this is changed from 15:2 (adults) and 5:1 (child and infant) to simplify training and to ensure a longer series of uninterrupted chest compressions. Around his mid-thigh with the bladder . An individual is legally unable to sign a consent until the age of 18 years. This can eventually lead to carbon dioxide retention (thus increased PaCO2) and hypoxemia (decreased PaO2). immunization and physical and nutritional fitness programs.battery. the nursing discharge summary is completed only when the client is being discharged (Kozier) . Assault precedes battery. a. avoiding injury to the lung and liver. on the other hand.Increased PaCO2.tertiary prevention. concise method of organizing and recording data about a client. c. and decreased pH. on the other hand. The client undergoing thoracentesis can assume the sitting position with his arms above the head.Kardex. . This is not included in the scope of nursing as defined by R. The Kardex is a widely used. focuses on individuals who are experiencing health problems or illnesses and includes screening techniques and treating early stages of disease to limit disability by preventing or delaying the consequences of advanced disease (Potter & Perry). Tertiary prevention injury to the lung and liver. Negligence and malpractice are examples of unintentional torts (Kozier). on the other hand. decreased PaO2. et al. administration of written prescription for medications and executing comfort measures (Bellosillo. 1. Secondary prevention. b. which is the one the bottom edge around the knee normally done. These are the main symptoms of b. increased urine output and warm flushed skin. can be described as an attempt or threat to touch another person unjustifiably.liver and keeps the diaphragm in its highest position. Meanwhile. penetration of the diaphragm is avoided when it is in its highest position and the risk of lacerating the liver is minimized (Kozier and Brunner). . b. Also. Kozier). battery c. Assuming a broad stance is correct. It may be actionable by law if the touching is done in a wrong way. and those who arementally ill persons who have been judged by professionals to be incompetent (Kozier and Mosby NCLEX) . As the severe asthma attack worsens.30 compressions:2 breaths.

accurate documentation is a nursing ACCOUNTABILITY. The leader leaves the decision-making up to the group. the organization. This can be achieved through immunizations. and nursing systems (Kozier). Chaos is likely to develop unless an informal leader emerges. The other choices are included in the nurses' code of ethics (Kozier and Balita). Lastly.a. . planning and implementing health care and services. Gerontological Nursing is concerned with the assessment of health and functional status of older adults. c. . When the client assumes this role. TIP: If it's hot and dry. and comforting rather than merely the treatment of disease.restoring health. or ensuring the total kcaloric load is not excessive (Goodner). the client assumes a position of dependence. veracity . Dorothea Orem's General Theory of Nursing included three related concepts of self-care. described the nature of and standard for nurse-patient interactions that lead to goal attainment (Goal Attainment Theory). Promoting health and wellness involves enhancing the individual's or community's lifestyle. Autonomy refers to the right to make one's own decisions. give some candy. The diagnosis should be specific and precise to provide direction for planning the nursing intervention. the bioethical principle of beneficencemeans "doing good" and it requires nurses to act in ways that benefit clients. caring. Laissez-faire leadership is passive and permissive and the leader defers decision-making. The statement shouldnot imply that d. but instead objective (Kozier). and minimal responsibility.Restoring health b. Martha Rogers b. Her Theory of Unitary Human Beings emphasized that the person is an irreducible whole and that the nurse should seek to promote interaction between two energy fields (human and environment) to strengthen the coherence and integrity of the person and to promote maximum health potential. All of the choices.Imogene King.word the statement so that it is legally advisable. . On the other hand.implementation. the sugar is high.the leader leaves the decision-making up to the group. self-care deficit. which is achieved in the exploitation phase. Cold and clammy. Theory Y's assumptions are that in the right conditions. a. d. makes the decisions. people enjoy their work. a. reducing the dextrose load.Implementation . or independence in relation to the nurse. caring. It also consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. Non-maleficence is the duty to "do no harm". Nurses who follow this principle should recognize that each client is unique. Authoritarian leadershipmaintains strong control. The Theory X view is that in bureaucratic organizations.veracity. .Identification . prenatal care. During the identification phase. evaluating the effectiveness of such care. or punishment are necessary because people do not like the kind of work that they are doing. Implementation is the phase in the nursing process wherein the nurse performs the nursing interventions. It considers the nursing care of older adults to be the art and practice of nurturing. Gerontology is the study of all aspects of aging process and its consequences (Potter & Perry). are able to contribute creatively and are motivated by ties to the group. etc. The most common metabolic complication in TPN is hyperglycemia.Gerontics considers the nursing care of older adults to be the art and practice of nurturing. Nursing diagnostic statements should not be judgmental. The answer is D . and gives the orders. and comforting rather than merely the treatment of disease. Meanwhile. does the planning. This requires nurses to act in such a way as to avoid causing harm to clients. Florence Nightingale stressed the importance of utilizing the environment in assisting the patient towards recovery. employees prefer security.Martha Rogers. ask questions and make suggestions rather than issue orders (Marriner-Tomey and KellyHeidenthal). can show self-control and discipline. Members may work independently and possibly at cross purposes because there is no planning or coordination and little cooperation. (Balita's Ultimate Learning Guide and Kozier). Metabolic complications in TPN is most common because metabolic requirements and warm flushed skin (electrolytes and energy) differ from patient to patient. Caring for the dying includes helping clients live as comfortably as possible until death and helping significant others cope with death (Kozier). Hyperglycemia can be treated by adding insulin to the solution. democratic leaders maintain less control. d. interdependence.the hallmark of accurate documentation of actions and outcomes of delivered care is a nursing responsibility. Nursing terminology should be used rather than medical terminology to describe the probable cause of the client's is legally advisable response.all of the choices. This area of nursing practice focuses on the ill client. maintenance of health through prevention of disease is the goal. he/she is completely dependent on his/her caregiver until he/she derives understanding of his/her condition. Geriatrics is the branch of medicine that deals with the physiological and psychological aspects of aging and with diagnosis and treatment of diseases affecting older adults. and it covers early detection of the disease to helping the client during the recovery period. In illness prevention. and. . Completion of the implementation phase is done by recording the interventions and the client's c. and the work itself (Kelly-Heidenthal). Thirst. . New needs and goals are adopted during the resolution phase (Kozier). diagnosis. The principle of veracity refers to the practice of telling the truth. direction. The hallmark of accurate documentation of actions and outcomes of delivered care is a nursing responsibility.identification. b. Word the statement so that it there is legal liability in the part of the health care team. Coercion. . on the other hand. threats. increased urine output hyperglycemia. Instead of responsibility. Meanwhile.

When delegating. on the other hand. and results of treatments so individuals can make informed decisions and choices to improve their quality of life (Kelly-Heidenthal). 9173. For this item. the nurse's first loyalty is to the client. flexes and withdraws-4. . solid elevation in the skin. c) foreseeability .5 cm and an elevated nevus is an example of which. risks. 1 to 3 . the selection of the person to complete it.the client must demonstrate some type of harm or injury (physical. Research provides evidence about benefits. A wheal is an irregularly shaped. It is the responsibility of the Professional Regulation Commission (PRC) to designate the places and dates of the licensure exam. with positive Trousseau's and Chvostek's signs and cardiac dysrhythmias are manifestations of hypocalcemia or decreased serum calcium. A 5-year-old child with ascariasis . The Board of Nursing shall designate the places and dates of the Nursing Licensure Examination.5 ml.the Board of Nursing shall designate the places and dates of the Nursing Licensure Examination. uses inappropriate words-3. Evidenced-based practice uses outcome research and other current research findings to guide the development of appropriate strategies to deliver quality. c. b. c. a. A comatose patient scores 7 or less (Kozier and Potter & Perry) . A retention enema introduces oil or medication into the rectum and sigmoid colon. A common example of a nodule is a wart. makes incomprehensible sounds-2 and no response-1). that is 0. TheBoard of Nursing is primarily responsible in the conduction of the licensure exam. to verbal command-3. disoriented and converses-4.withhold the medication.A nodule is an elevated solid mass.5-2 cm.responses in the nursing progress notes (Kozier). no response-1) and verbal response (oriented and converses-5. A tumor is a solid mass that may extend deep through the subcutaneous tissue. Numbness.progressive muscle relaxation .Delegation is an opportunity to transfer one's accountability to a task.5-2 cm.the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care. Withhold the medication. and. costeffective care. flexes abnormally-3. . Nurse Pat gave the wrong antibiotic and after 30 minutes the patient experienced an anaphylactic reaction.it must be proved that the harm occurred as a direct result of the nurse's failure to meet standard of care. larger than 1-2 cm and a common example of which is an epithelioma (Potter and Perry). we compute the amount to administer (x) by using 2. b) breach of duty there must be a standard of care that is expected in the specific situation but that the nurse did not observe.Nurse Pat gave the wrong antibiotic and after 30 minutes the patient experienced an anaphylactic reaction. tingling of the extremities and around the mouth. A papuleis a palpable. elevated area or superficial localized edema that varies in size and common examples of which are hives and mosquito bites. further assess the patient and inform the attending physician of your findings. . An assessment totaling 15 points indicates that the client is alert and completely oriented. and both the staff's and their own performance (Tomey). extends abnormally-2. . According to the nurses code of ethics. This c. or emotional) (Kozier). d. characteristic. the more improved or normal the level of functioning. Delegation is an opportunity to transfer one's accountability to a task. An act of negligence can be seen if the following are present: a) duty . motor response (to verbal command-6.a link must exist between the nurse's act and the injury suffered. The research study was done statement best manifests confidentiality as there were no specific information given to link in the pediatric wards of a the individual identities. All the other choices are features of R. .g. The amount of drug to be given is computed using the formula: amount to administer (x)=desired dose or dose ordered/dose on hand multiplied by the quantity on hand. . responsibility shared and accountability retained.the research study was done in the pediatric wards of a tertiary hospital in Manila. or outcome that the researcher wishes to explain or predict. Clients at greatest risk for hypocalcemia are those whose parathyroid glands have been removed.10. c. .10 b. the blood pressure is the dependent variable (Kozier).5 ml c. a. The answer will be therefore. An elevated solid mass. no response-1). Care plans are based on the nurse's clinical experience and from the latest research findings.Accountability is still retained by the nurse-manager even if tasks are delegated. smaller than 0. to pain-2.care plans are based on the nurse's clinical experience and from the latest research findings. 5 ml (Lippincott NCLEX Reviewer).5 g/5 g x 10 ml. c. The independent variable is the presumed cause of or influence on the dependent variable. deeper and firmer than a papule.A. further assess the patient and inform the attending physician of your findings. They are still accountable for the performance of the task. that is 0. to localized pain-5. The liquid is retained for a relatively long period (e. . In the statement above. Calcium. authority is transferred. The nurse's actions should always give the highest priority to the client's needs before that of other members of the health team (Kozier). Calcium c. The higher the score. code numbers or reporting only aggregate or group data in published tertiary hospital in Manila. Measures to be included to ensure confidentiality is the use of pseudonyms. financial. muscle tremors. research ((Kozier and Polit & Beck). is the behavior. deeper and firmer than a papule. cramps and hyperactive deep tendon reflexes.A 5-year-old child with ascariasis. Hypomagnesemia and chronic alcoholism also increase the risk of hypocalcemia (Kozier). e) injury . The dependent variable. circumscribed. The Glasgow Coma Scale tests three (3) major areas that determines the client's level of consciousness: eye opening (spontaneous-4. d) causation .progressive muscle relaxation.

. Providing a behavioral rehearsal of what to expect and how it will look and feel is for the school-age children because at this age they already rationalize in an attempt to rationalize the pain (Kozier). This position.Autonomy refers to the right to make one's own decisions. Dorsal recumbent . Antihelminthics can be given through enema to kill helminths such as worms and intestinal parasites. the lithotomy position may be uncomfortable and tiring for elders and often embarrassing. it is of utmost importance during this time is to provide them with information and professional assistance. This requires nurses to act in such a way as to avoid causing harm to clients. Functional incontinence is the inability of the usually continent person to reach toilet in time to avoid unintentional loss of urine and this can be avoided through prompted voiding . fidelity d. therefore this strategy may succeed. cleanse yellow. The other 2 choices are other essential guidelines to prevent needlestick injuries (Kozier). b. Justice is fair. the principle of veracity refers to the practice of telling the truth (Balita and Kozier).g. rectum and the female reproductive tract. Preschool children develop the ability to describe pain and its intensity and location. Non-maleficence is the duty to "do no harm".g. d. The bioethical principle of fidelity means to be faithful to agreements and promises. has been inserted into a client)should NEVER be recapped except under special circumstances(e. However. Meanwhile.e. Reflex incontinence. there has been a strong social stigma and the moral obligation to care for this kind of client cannot be set aside unless the risk exceeds responsibility. Red wounds are usually in the late regeneration phase of tissue repair.Protect red. In end-of-life issues. Stress urinary incontinence encourage pelvic muscle exercises . such as that in pregnancy. a. nurses have no right to impose their values on a client but support clients' right to information and counseling in making decisions. Clients take such problems seriously and nurses should. remove feces in instances of constipation or impaction. on the other hand. However. Recapping a needle is also done only after drawing up a medication into a syringe prior to administration (hence. b. when transporting a syringe to the laboratory for an arterial blood gas or blood culture).appeal to the child's belief in magic by using a "magic" blanket to take away pain. are the most common positions to assume when assessing the female genitals. Those who will undergo surgery or have an invasive diagnostic procedure (e. is the involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached and this can be managed throughintermittent urinary catheterization. together with lithotomy. Concerning HIV and AIDS. Yellow wounds are cleansed to remove nonviable tissue. This is the least priority among all the choices. Playing music or tapes of a heartbeat is applicable for infants because of their need for tactile stimulation. use the one-handed "scoop" method). Stress urinary incontinence is the sudden loss of urine occurring with activities that increase abdominal pressure. or eschar.recap used needles. cleanse yellow.fidelity. Yellow wounds are characterized primarily by liquid to semiliquid "slough" that is often accompanied by purulent drainage or previous infection. Your patient is depressed and does not respond to any of your questions. Recap used needles.. . Appeal to the child's belief in magic by using a "magic" blanket to take away pain. colonoscopy) are more likely to receive a cleansing enema and this kind of enema is intended to remove feces. .protect red. as well as the highest quality of care and caring (Kozier). a. . debride black. They require debridement or removal of the necrotic material. debride black c. the bioethical principle of beneficence means "doing good" and it requires nurses to act in ways that benefit clients. Removal of nonviable tissue from a wound must occur before the wound can heal (Kozier). The main goal for this kind of incontinence is symptom control that may be done through strengthening and training the levator ani and urogenital muscles through repetitive contractions to decrease stress. too. Cleansing enemas are given chiefly to prevent the escape of feces during surgery. Urge incontinence is the involuntary passage of urine occurring after a strong sense of urgency to void and the best way to manage this is through urinary bladder training (Kozier).your patient is depressed and does not respond to any of your questions. Clarifying misconceptions on pain is for the elderly because they perceive pain as part of the aging process. urge or mixed types of incontinence (pelvic muscle exercises). Preschoolers are magical thinkers. . .encourage pelvic muscle exercises.stress urinary incontinence . Other types of enema includecarminative (to expel flatus) and return-flow (used occasionally to expel flatus and is repeated several times until it is expelled) enemas (Kozier). and appropriate treatment according to what is due or owed to persons. Lastly. Black woundsare covered with thick necrotic tissue. Abortion is a highly publicized issue about which many people feel very strongly.dorsal recumbent position. Theprone position is often not tolerated by elders and the sim position may be difficult for them because of limited joint movement (Kozier). and may consider pain as a punishment therefore reasoning with a child at this stage is not always successful. prepare the intestine for certain diagnostic tests such as x-ray or visualization tests. equitable. and. They need to be protected to avoid disturbance to regenerating tissue. Nurses who follow this principle should recognize that each client is unique. The dorsal recumbent position is contraindicated only to those with cardiopulmonary problems. Used needles (i.hours).