NURSING PRACTICE I

SITUATION: A nurse utilizes the nursing process in managing patient care. Knowledge of this process is essential to deliver high quality care and to focus on the clients response to illness. 1. During the planning phase of the nursing process, which of the following is the product developed? A. B. C. D. Nursing care plan Nursing diagnosis Nursing history Nursing notes

2. Objective data are also known as? A. B. C. D. Covert data Inferences Overt data Symptoms

3. Data or information obtained from the assessment of a patient is primarily used by nurse to: A. B. C. D. Ascertain the patients response to health problems Assist in constructing the taxonomy of nursing intervention Determine the effectiveness of the doctors order Identify the patients disease process

4. What is an example of a subjective data? A. B. C. D. Color of wound drainage Odor of breath Respiration of 14 breaths/minute The patients statement of I feel sick to my stomach

5. Which statement is a difference between comprehensive and focused assessment A. B. C. D. Comprehensive assessments cant include any focus assessments Focused assessments are more important than comprehensive assessments Focused assessments are usually ongoing and concerning specific problems Objectives data are included only in comprehensive assessments

6. Two year old Bens mother states Ben vomited 8 ounces of his formula this morning. This statement is an example of: A. B. C. D. Objective data from a primary source Objective date from a secondary source Subjective data from a primary source Subjective data from a secondary source

7. Which expected outcome is correctly written? A. B. C. D. The patient will be less edematous in 24 hours The patient will drink a adequate amount of fluid daily The patient will identify 5 high-salt foods from a prepared list by discharge The patient will soon sleep well through the night

8. An expected outcome on a patients care plan reads: Patients will state seven warning signs of cancer by discharge. When the nurse evaluates the patient progress, the patient is able to state that a change in a wart of mole, a sore that doesnt heal and a change in bowel or bladder habits are warning signals of cancer. Which of the following be an appropriate evaluative statement for the nurse to place in the patients nursing care plan? A. Patient understands the warning signals of cancer B. Goal met: patient cited a change in wart of mole, sore that doesnt heal and a change in bowel or bladder habits as warning signals of cancer.

C. Goal not met D. Goal partially met

9. A quality assurance nurse sends questionnaire to patients after discharge to determine their level of satisfaction with the nurse care they received in the facility. What type of nursing audit is this? A. B. C. D. Concurrent Outcome Terminal Retrospective

10.The nursing makes the following entry in the patients record: Goal not met: patient refuses to attend smoking cessation. Because this goal hasnt been met, the nurse should: A. B. C. D. Develop a completely new nursing care plant Assign the patient to a more experienced nurse Critique the steps involved in the development of the goal Transfer the patient to another facility

SITUATION: Health care delivery system affects the health of every Filipino. As a Nurse, knowledge of this system is expected to ensure quality of life. 11.When should rehabilitation commence. A. B. C. D. The day before discharge When the patient desires Upon admission 24 hours after discharge

12.What exemplified the preventive and promotive programs in the hospital A. B. C. D. Hospital as a center to prevent and control infection Program for smokers Program for alcoholics and drug addicts Hospital Wellness Center

13.Which makes nursing dynamics A. B. C. D. Every patient is a unique physical, emotional and spiritual being The patient participate in the overall care plan Nursing practice is expanding in the light of modern development that takes place The health status of the patient is constantly changing and the nurse must be cogniza and responsive to these changes

14.Prevention is an important responsibility of the nurse in: A. B. C. D. Hospitals Community Workplace All of the above

15.This form of Health Insurance provides comprehensive prepaid health service to enrollees fixed periodic payment A. B. C. D. Health Maintenance Organization Medicare Philippine Health Insurance Act Hospital Maintenance Organization

SITUATION: Maslows hierarchy of needs is an integral component of prioritization. As a nurse, must know the clients needs that request for an immediate action. 16.The client with history of pulmonary emboli is scheduled for insertion of an inferior van cava filter. The nurse checks on the client 1 hour after the physician has explained the procedure and obtained consent from the client. The client is lying in bed, wringing the hands, and says to the

nurse. Im not sure about this. What if it doesnt work and Im just as bad off as before? the nurse addresses which of the following primary concerns of the client? A. Fear related tot the potential risk and outcome of surgery B. Anxiety related to the fear of death

C. Ineffective individual coping related to the therapeutic regimen D. Knowledge deficit related to the surgical procedure 17.A nurse I formulating a plan of care for a client receiving enteral feeding. The nurse identifies which nursing diagnosis as the highest priority for this client? A. B. C. D. Altered nutrition, less than body requirements High risk for aspiration High risk for fluid volume deficit Diarrhea

18.A home care nurse finds a client in the bedroom, unconscious with pill bottle in hand. The pill bottle contained the SSRI sertraline (ZOLOft). The nurse immediately assesses the clients: A. B. C. D. Blood pressure Respirations Pulse Urine Output

19.A nurse is caring for a client admitted to the hospital for a subclavian line replacement. Which psychosocial area of assessment should the nurse address with the client? A. B. C. D. Strict restrictions of neck mobility Loss of ability to ambulate Possible body image disturbance Continuous pain related to ongoing placement of the subclavian line

20.A hospitalized client who has a living will is being led through a nasogastric tube. During a bottle feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take? A. B. C. D. Clear the clients airway Make the client comfortable Start CPR Stop feeding and remove the NG tube

SITUATION: Health Promotion is the priority nursing responsibility. The nurse should be able to promote the clients wellbeing and identify ways on improving the clients quality of life. 21.The nurse is caring for a 16 year old female client who isnt sexually active. The client asks if she needs a Papanicolau test. The should reply: A. B. C. D. Yes, she should have a Pep test after the onset of menstruation No, because she isnt sexually active Yes, because shes 16 years old No, because she is not yet 21 years old

22.The nurse is assessing a client who complains of abdominal pain, nausea and diarrhea examining the clients abdomen, which sequence should the nurse use? A. B. C. D. Inspection, palpation, percussion, auscultation Inspection, auscultation, percussion, palpation Auscultation, Inspection, percussion, palpation Palpation, auscultation, percussion, inspection

23.The nurse is speaking to a group of woman about early detection on breast cancer. The average age of the woman in the group is 45. Following the Philippine Cancer Society guidelines, the nurse should recommend that the women;

A. B. C. D.

Perform breast self examination annually Have a mammogram annually Have a hormonal receptor assay annually Have a physician conduct a clinical examination every 2 years

24.The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following instructions should the nurse emphasize in her task? A. B. C. D. Stay out of the sun between 1pm and 3pm Tanning booth are a safe alternative for those who wish to tan Sun exposure is safe, provided the client wears protective clothing Examine skin once per month, looking for suspicious lesions or changes in moles

25.An employer establishes a physical exam area in the workplace and encourages all employees to use it. This is an example of which level of prevention? A. B. C. D. Primary prevention Secondary prevention Tertiary prevention Passive prevention

SITUATION: Basic nursing skills are essential for they are vital in many nursing procedures. Such skills are needed in order to promote health, prevent illness, cure a disease and rehabilitation infirmaries. 26.A nurse has just been told by the physician that an order has been written to administer injection to a client. The nurse plans to give the medication in the: A. B. C. D. Gluteal muscle using Z-Tract technique Deltoid muscle using an air lock Subcutaneous tissue of the abdomen Anterolateral thigh using 5/8-inch needle

27.A client has just been told by the physician that a cerebral angiogram will be obtained. The nurse then collects data from the client about which of the following pieces of information? A. B. C. D. Claustrophobia Excessive weight Allergy to eggs Allergy to iodine or shellfish

28.A client has an order for a wound culture to be performed with the next wound irrigation and dressing change. The nurse would plan to use which of the following solutions for irrigation before this particular procedure? A. B. C. D. Providone-iodine (Betadine) One-half-strength hydrogen peroxide Normal saline Acetic acid

29.Which of the following is the best indicator in determining that the clients airway needs suctioning? A. B. C. D. Oxygen saturation measurement Respiratory Breath sounds Arterial blood gas results

30.A nurse is planning to assist a diabetic client to perform self-monitoring of blood glucose level. The nurse should incorporate which of the following strategies to best help he client obtain an adequate capillary sample? A. B. C. D. Cleanse the hands beforehand using cool water Let the arm hang dependently and milk the digit Puncture the center of the finger pad Puncture the finger as deeply as possible

SITUATION: Mastery of intravenous therapy and all aspects that address the response of the complication related to it will help the new nurse in providing quality care.

31.One hour after the IV was inserted, Nurse Net found out that the 1 liter of DSNSS was empty. Patient was in severe respiratory distress with pinkish frothy sputum. The most probable complication is A. B. C. D. Speed shock Renal failure Congestive heart failure Pulmonary edema

32.When an IV of DSW is not infusing well on patient, it is best to first: A. B. C. D. Pinch the rubber part of the flush out clogged blood Coil tube and squeeze hard Lower IV to check for return flow Restart the IV

33.The doctor ordered venoclysis of dextrose 5% in water one liter KVO for 24 hours as a vehicle for IV medications. How many drops per minute should the fluid be regulated? A. B. C. D. 20 drops per minute 5 drops per minute 10 drops per minute 15 drops per minute

34.The nurse is administering IV fluids to an infant. Infants receive IV therapy are particularly vulnerable to: A. B. C. D. Hypotension Fluid overload Cardiac arrhythmias Pulmonary emboli

35.A client with severe inflammatory bowel disease is receiving TPN. When administering TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause: A. B. C. D. Hyperglycemia Air embolism Constipation Dumping syndrome

SITUATION: teaching and learning is a nursing responsibility. The ability of a nurse to educate and change the clients behavior through health teaching is one important goal nursing. 36.A client hypertension has been recently diagnosed. The nurse would plan to do which of the following as the first step in teaching the client about the disorder? A. B. C. D. Gather all available resource material Plan for the evaluation of the session Assess the clients knowledge and needs Decide on the teaching approach

37.a diabetic client who is performing self-monitoring of blood glucose at home ask a clinic nurse why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate which of the following into a response. A. This laboratory test is done yearly to predict likelihood of long term complication B. This laboratory test gives an indication of glycemic control over the last 3 months C. It is done as a method of verifying the accuracy of the meter used at home

D. It is done to predict risk of hypoglycemia with the current diet and medication regimen 38.In teaching the sister of a diabetic client about the proper use of glucometer in determining the blood sugar level of the client. The nurse is focusing in which domain of learning according to bloom? A. B. C. D. Cognitive Affective Psychomotor Affiliative

39. Which of the following is the most important condition for diabetic client to learn how to control
their diet A. B. C. D. Use of pamphlets and effective teaching divides during health instruction Motivation to be symptom free Ability of the client to understand teaching instruction Language and appropriateness of the instruction

40.When you prepare your teaching plan for a group of hypertensive clients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds writing of learning objectives? A. B. C. D. Planning Implementing Evaluating Assessing

SITUATION: Nursing is a science. It involves a wide spectrum of theoretical foundation applied different health care situation. The nurse must use these theories in order to deliver the most needed quality care. 41.The theorist who believes that adaptation and manipulation of stressors are needed to foster change is: A. B. C. D. Betty Neuman Dorothea Orem Martha Rogers Sister Callista Roy

42.The theorist whose theory can be defined as the development of a science of humankind incorporated the concepts of energy fields, openness, pattern and organization is: A. B. C. D. Dorothy Johnson Hildegard Peplau Martha Rogers Myra Levine

43.A theorist whose major theme is the idea of transcultural nursing ad caring is: A. B. C. D. Dorothea Orem Madeleine Leininger Sister Callista Roy Virginia Henderson

44.Florence Nightingale was born in A. B. C. D. Italy, May 12, 1840 Italy, May 12, 1820 England, May 12, 1840 England, May 12, 1820

45.Smith conceptualizes this health model as a condition of actualization or realization of persons potential. Avers that the highest aspiration of people is fulfillment and complete developmental actualization. A. B. C. D. Clinical Model Role performance Model Adaptation Model Eudemonistic Model

SITUATION: Oxygen is the most important physiologic requirement of the body. Absence of this vital element over 6 minutes leads to irreversible brain damage. A measure that promotes oxygenation is integral in successfully managing clients response to illness. 46.The primary effect of oxygen therapy is to: A. B. C. D. Increase oxygen in the tissues and cells Increase oxygen carrying capacity of the blood Increase respiratory rate Increase oxygen pressure in the alveolar sac

47.A nurse suctions a client who has an endotracheal tube in place. Following the procedure. Which of the following would indicate to the nurse that the client is expecting an adverse effect of this procedure? A. B. C. D. Hypertension Cardiac Irregularities A reddish coloration in the clients face Oxygen saturation level to 95%

48.The GAUGE size in ET tubes determines A. B. C. D. The external circumference of the tube The internal diameter of the tube The length of the tube The tubes volumetric capacity

49.The nurse is correct in performing suction when she applies the suction intermittently during A. B. C. D. Insertion of the suction catheter Withdrawing of the suction catheter Both insertion and withdrawing of the suction catheter When the suction catheter tip reaches bifurcation of the trachea

50.The purpose of the cuff in Tracheostomy tube is to: A. B. C. D. Separate the upper and lower airway Separate trachea from the esophagus Separate the larynx form the nasopharynx Secure the placement of the tube

SITUATION: To deliver a safe and quality care. Knowledge about wound care is necessary. The nurse will have to deal with different types of wound during practice. It is outmost important to apply this knowledge to ensure optimum wound healing. 51.Based on the nurses knowledge of surgical wounds, simple surgical incisions heal by A. B. C. D. Primary intention Secondary intention Tertiary intention Quatemary intention

52.The nurse documents that the wound edges are approximated. When the edges of an incision are said to be approximated, this means edges are: A. Brought together by sutures, tapes or staples

B. Erythematous and swollen C. Gaping and draining D. Necrotic and draining 53.Which vitamin is most essential for collagen synthesis? A. B. C. D. Vitamin Vitamin Vitamin Vitamin A B O C

54.When assessing the clients wound for sign of infection, the nurse should look for the present of which of the following? A. B. C. D. Granulation tissue Pink tissue Purulent drainage Well approximated edges

55.The nurse is changing dressing and providing wound care. Which activity should she perform first? A. Assess the drainage in the dressing B. Slowly remove the soiled dressing

C. Wash hands thoroughly D. Put on latex gloves SITUATION: Physical examination and health assessment are important in rendering care. The nurse must use assessment knowledge in order to determine and prioritize clients response to or her illness. 56.The component that should receive the highest priority before physical examination is the A. B. C. D. Psychological preparation of the client Physical preparation of the client Preparation of the environment Preparation of the equipments

57.When inspecting a clients skin, the nurse finds a vesicle on the clients arm. Which description applies to a vesicle? A. B. C. D. A flat, nonpalpable and colored Solid, elevated and circumscribed Circumscribed, elevated and filled with serous fluid Elevated, pus-filled and circumscribed

58.When assessing a client with abdominal pain the nurse should assess: A. B. C. D. Any quadrant first The symptomatic quadrant first The symptomatic quadrant last The symptomatic quadrant either second or third

59.To assess the clients dorsalis pulse, the nurse should palpate the A. B. C. D. Medial of the ankle Lateral surface of the ankle Ventral aspect of the top of the foot Medical aspect of the dorsum of the foot

60.Which of the following assessment would be a priority for a 2 ear old after bronchoscopy? A. B. C. D. Cardiac rate Respiratory quality Sputum color Pulse pressure changes

61. The nurse checks the clients gag reflex. The recommended technique for testing the gag reflex is to: A. B. C. D. Touch the back of the clients throat with a tongue depressor Observe the client for evidence of spontaneous swallowing when the neck is stroked Lace a few milliliters of water on the clients tongue and note whether or not he swallows Observed the clients response to the introduction for a catheter for endotracheal suctioning

62.The nurse is evaluating a clients lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields? A. B. C. D. Visiular Bronchial Bronchovesicular Adventitious

63.The nigh nurse informs the primary nurse that a client receiving intermittent gavage feeding is not tolerating them. The primary nurse should first A. B. C. D. Change the feeding schedule to omit nights Request that the type of solution be changed Observe the night nurse administering a feeding Suggest that the prescribed antiemetic be given first

64.A client has a chest tubes attached to a pleural drainage system. When caring for this client, the nurse should. A. B. C. D. Palpate the surrounding are for crepitus Clamp the chest tubes when suctioning the client Change the dressing daily using aseptic technique Empty drainage chamber at the end of the shift

65.The nurse, aware of the 25 year history of excessive alcohol use, would expect the physical assessment to reveal a: A. B. C. D. Liver infection Low blood ammonia Small liver with a rough surface High fever with a generalized rash

SITUATION: Nursing is a profession. Miss Linda is a newly appointed nurse in a hospital in Manila. Born May 1985, her knowledge of nursings professional development is required in order to project the profession in a way that it lifts the standards of nursing. 66.Mrs. Linda defined nursing as one of the following except: A. B. C. D. Assisting individual, family and community in attaining health Assisting basic health needs Establishing nursing diagnosis and implementing nursing care Diagnosing, treating, prescribing medication and doing minor surgery

67.PNA was established in: A. 1922

B. 1926 C. With Mrs. Francisco Delgado as first president D. With Mrs. Anastacia Tupas as first president 68.As national nurses association, it is characterized as follows except A. B. C. D. Both a professional body and labor union Affiliated with the international Council of Nurses Advocating for improved work and life condition of Nurses Accrediting body for continuing education program

69.CPE unit per year is needed for license renewal. The number of CPE units per year should be A. B. C. D. 20 units 30 units 60 units 100 units

70.As a nurse, R.A. 1080 exempts her from: A. B. C. D. Paying her professional tax Exemption for civil service eligibility Qualifying for the CGFNS Paying business permit

71.In resigning for her job as a staff nurse, she must gives advance notice of A. 15 days B. 30 days

C. 45 days D. 60 days 72.Why is there an ethical dilemma? A. B. C. D. Because the law do not clearly state what is right from what is wrong Because morality is subjective and it differs from each individual Because the patients right coincide with the nurses responsibility Because the nurse lacks ethical knowledge to determine what action is correct and what action is unethical

73.Who among the following can work practicing nurse in the Philippines without taking the Licensure examination? A. B. C. D. Internationally well known experts which services are for a fee Those that are hired by prestigious hospitals Expert nurse clinicians hired by prestigious hospitals Those involved in medical mission whos services are for free

74.The nurse is correct in determining that a License is: A. B. C. D. A personal property Can be revoked by the Board of Nursing A Right Can be revoked by the PNA

75.A license is renewed every A. B. C. D. 1 2 3 4 year years years years

76.Which of the following persons cannot have free access to a patients record?

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A. B. C. D.

The The The The

patient Physical therapist pharmacist lawyer

77.Ms. Lindas license will explain in 2007. She must renew her license when? A. B. C. D. January 2007 December 2007 May 2007 May 2008

78.The practice of Nursing in the Philippines is regulated by: A. B. C. D. RA RA RA RA 9163 9173 7164 7146

79.The quality is being demonstrated by a nurse who raises the side rails of a confused and disoriented patient? A. B. C. D. Autonomy Responsibility Prudence Resourcefulness

80.Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the study. The case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstance of crime. They are correct in identifying which of the following circumstances that will be best applied in this case A. Justifying B. Aggravating

C. Mitigating D. Exempting SITUATION: This is the first day of Mark, R.N. to report as a staff nurse in the tertiary hospital. A morning duty nurse, he is about to chart his nursing care 81.Which of the following is not a acceptable medical abbreviation? A. B. C. D. NPO PRN OD NON

82.Communication is best undertaken if barriers are first removed. Considering this statement, which of the following is considered as deterrent factor in communication? A. B. C. D. Not universally accepted abbreviation Wrong number Poor penmanship Old age of the client

83.Which of the following chart entries are not acceptable? A. B. C. D. Patient complained of chest pain Patient ambulated to B/R Vital signs 130/70; 84; 20 Pain relived by Nitroglycerine gr 1/150 sublingualy

84.Which of the following indicates narrative charting?

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A. B. C. D.

Written descriptive nurses notes Date record on nurse activity sheets Use of checklist Use of flow sheet

85.Being a new staff nurse, Mark remembers that information needed for daily nursing care of clients are readily available in which of the following? A. B. C. D. Kardex Order sheet Admission notes Nurses notes

SITUATION: Mr. Orlando is assigned to Mang Carlos, a 60 years old, newly diagnosed diabetic patient. He is beginning to write objectives for his teaching plan. 86.Which of the following is written in behavioral term? A. Mang Carlos will know about diabetes related foot care and the techniques and equipme necessary to carry it out B. Mang Carlos sister will be able to determine his insulin requirement based on blood glu levels obtained from glucometer in two days C. Mang Carlos daughter should learn about diabetes mellitus within the week D. Mang Carlos wife needs to understand the side effects of insulin 87.Which of the following is the best rationale for written objectives? A. B. C. D. Document the quality of care Facilitate evaluation of the performance of the nurse Ensure learning on the part of the nurse Ensure communication among staff members

88.Mang Carlos has bee terminally ill for 5 years. He ask his wife top decide for him when h longer capable to do so. As a Nurse, you know that this is called: A. B. C. D. Last will and testament DNR Living will Durable Power of Attorney

89.Which of the following behavior of Mang Carlos least indicates readiness to learn? A. B. C. D. Talking with the nurse in charge and doctor Reading brochures and pamphlets about diabetes Inquiring about date of discharge Asking question about diabetes mellitus

90.Which of the following behaviors best contribute to the learning of Mang Carlos regarding disease condition? A. B. C. D. Drawing him into discussion about diabetes Frequent use of technical terms Loosely structured teaching session Detailed lengthy explaination

SITUATION: Mrs. Purification is now the Chief Nurse of a hospital in manila. She is clinically reviewing different management styles and theories that will best help her in running the nursing services in the hospital. 91.Which leadership style best empower the staff towers excellence?

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A. B. C. D.

Autocratic Situational Democratic Laissez Faire

92.A nurse manager, DSJ enjoys his staff of talented and self motivated individuals. He knew leadership style to suit the needs of this kind of people is called: A. B. C. D. Autocratic Participative Democratic Laissez Faire

93.A fire has broken in the unit of DSJ R.N. the best leadership style suited in cases of emergencies like this is: A. B. C. D. Autocratic Participative Democratic Laissez Faire

94.Mrs. Purification is thinking of introducing the Primary Nursing Model Approach. You understand that this nursing model is: A. B. C. D. The nurse manager assigns tasks to the staff members Critical paths are used in providing nursing care A simple registered nurse is responsible for planning and providing individualized nursing Nursing staff are led by an RN leader in providing care to group of clients

95.Structure, Process and Outcome are components of which step of the management process? A. B. C. D. Planning Organizing Directing Controlling

SITUATION: Nursing research is the term used to describe the evidence used to support nursing practice. Nursing, as evidence based area of practice, has been developing since the time of Florence Nightingale to the present day, where many nurses now work as researchers based i universities as well in the health care settings. 96.Mr. DSJ plans to undertake a research of Community 1 and 2 on how they manage their he using Primary health care after a organization and training seminars. This type of research is: A. B. C. D. Experimental Historical Descriptive Basic

97.The independent variable is: A. B. C. D. Primary Health Care Community 1 and 2 Organization and training seminars Management of their health

98.In this design, the variable that us being manipulated is 1) Independent 2) Organization and training seminars 3) Dependent

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4) Management of Primary Health Care A. B. C. D. 1,2 1,4 2,3 3,4

99.In general, the research process follows the following ordered sequence 1. 2. 3. 4. 5. B. C. D. E. 2,5,3,1,4 3,5,4,1,2 2,5,3,4,1 2,5,1,3,4 determination of Design statement of the problem definition of variables Collection and analysis of data review of related literature

100. Studies done in natural setting such as this one, possess difficult of controlling which variable A. B. C. D. Independent Dependent Extraneous Organismic

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