 Interpret the following order: VO ii gtts Isopto Atropine OD ac qd

Verbal order: two drops Isopto Atropine in right eye after meals every day
 SBAR stands for:
Situation, Background, Assessment, Recommendation
 Which of the following statements BEST describes POMR?
The data are arranged according to the problems
 POMR System has several advantages, EXCEPT which of the following?
Promotes continuity of care
 Which of the following part of the SBARR communication technique that briefly describes the
current situation of the patient?
Background
 The nurse would make which of the following inferences after performing the appropriate
patient assessment?
The patient is hypotensive
 An informal consideration of a subject by two or more health care personnel to identify and
resolve a client's problem, is termed as which of the following?
Discussion
 Which of the following part of the SBAR communication technique that states the pertinent
history and leads what got us to this point?
Background
 What are the benefits of SBAR?
A. Helps everyone to understand the overall picture of the patient's needs
B. Fosters the use of clear and unambiguous language to reduce confusion and
misinterpretation
C. Provides for an ongoing dialogue so that everyone is involved with the patient's care in
planning/thinking ahead
D. Provides for ongoing dialogue for the actress
E. Improved safety for the patient
E, C, A, B
 Once a nurse assesses a patient's condition and identifies appropriate nursing diagnoses, a:
Plan is developed for nursing care
 When are we going to use SBAR?
A. End of Shift
B. Transferred out of the unit
C. Transferred to other hospital
D. Transferred to other flat
 A, C, B
 Which of the following guidelines in documentation needs further attention:
Document interventions before carrying out
Before the shift endorsement, the allocated nurse will:
A. check the patient file
B. Make sure that all orders is on the chart
C. All physician orders are carried out
D. Planned care is ready for intervention
 C, A, D
 Which of the following data would you record as subjective?
Patient feels nauseated when moved suddenly
 Mr. Rando reports to his Nurse on Duty that he is experiencing nausea and constipation. Which
of the following would be the priority nursing action?
Complete an abdominal assessment
 Which of the following statements best describes the root cause of the incident?
A letdown in determining that a defective side-rail caused the patient's fall
 Which of the following guidelines in documentation needs a correction?
Indicate in each entry the date only
 After the nurse gives assessment findings on a client to the provider, the Nurse lets the provider
know it would be prudent to come and evaluate the client. What part of SBAR communication is
this?
Recommendation
 Which of the following basic components of POMR is data base which includes, EXCEPT:
Flow sheet
 Which of the following part of the SBAR communication technique that summarize the facts and
gives us best assessment, what's going on, using the best judgement?
Assessment
 The Nurse would do which of the following during the implementation phase of the nursing
process when working with a hospitalized adult patient?
Record in the medical record the distance a patient ambulates in the hall
 A legal or record that contains pertinent interactions and interventions with the patient is called
which of the following?
Documentation
 Which of the following part of the SBAR communication technique that entails what you can
suggest or what you want to happen next?
Recommendation
 The assigned nurse will:
A. initiate the complete report for each patient
B. His verbal report will reflect his bank account
C. His verbal report will reflect and reinforce appropriate information recorded in patient's
record
D. Initiate and complete your meals
A, D
 A PIE model documentation advantage is which of the following?
It promotes continuity of care
 A patient who complains of nausea and seems anxious is admitted to the nursing unit. The nurse
should take which of the following actions regarding completion of the admission interview?
Do the interview as soon as some uninterrupted time is available in order to address the
patient's concerns
 A patient on the nursing unit is terminally ill but remains alert and oriented. Three days adter
admission, the nurse observed signs of depression. The patient states "I'm tired of being sick. I
 wish I could end it all." What is the most accurate and informative way to record this data in a
nursing process note?
The patient states "I'm tired of being sick. I wish I could end it all."
 Collaborative interventions are therapies that require:
Multiple health care professionals
 Is a communication technique that provides an organized logical sequence and improved
communication process to ensure client safety.
SBAR
 During the shift change report, the incoming RN is repeatedly interrupting and criticizing the
outgoing RN's report. What is the best response using communication techniques to diffuse the
situation?
"I understand your concerns. Could we address them after we finish the report?
 The following statement appears on the nursing care plan for an immunosuppressed patient,
"The patient will remain free from infection throughout hospitalization." This statement is an
example of?
Short-term goal
 Which of the following is an example of a subjective data?
Cigarette smoking 2 PPD for 2 years
 Which of these statements is a correctly written outcome goal?
The patient will walk 3km daily by April 12
 After instructing the patient on crutch walking technique, the nurse should evaluate the
patient's understanding by using which of the following methods?
Return demonstration
 The Rehab Nurse wants to make the following entry into the patient's plan of care: "Patient will
be able to reestablish a pattern of daily bowel movements without straining within 3 months."
The Rehab Nurse will write this statement under which section of plan of care?
Long-term Goals
 The ANA code of ethics states which of the following ethical and legal considerations in
documenting?
The student nurse is bound by a strict ethical and legal responsibility of all client's information
 The incident should be notified immediately to the nursing office and an INCIDENT REPORT
should be submitted within 48 hours. The objective for the submission time frame is:
Incidents submitted over the time frame is considered void and invalid
 His/her responsibility is to ensure the compliance of the policy in his/ her department.
Head Nurse
 While assisting Ms. Marla with ambulating from bed to bedside chair, Nurse Wilkins observes
that Ms. Marla begins to look pale and is now perspiring heavily. Nurse Wilkins would do which
of the following activities as reassessment?
Observe Ms. Marla's skin color and take another set of vital signs
 The nurse writes an expected outcome statement in measurable terms. An example for this
would be:
The patient will report pain scale of less than 4 on a scale of 0 to 10
 Which desired outcome written by the student nurse is correctly written and is measurable?
The patient will lose 2kg within the next 14 days
 Which of the following action should the nurse take when a recording mistake has occurred?
Draw a line through the mistake and write mistaken entry and your initials above it
 The nurse informs the physical therapy department that the patient is too weak to use a walker
and needs to be transported by wheeled chair. Which step of the nursing process is the nurse
engaged in at this time?
Implementation
 Which of the following actions by a nurse ensures confidentiality of a client's computer record?
The nurse closes a client's computer file and logs off
 Which of the following charting entry would be the most defensible in court?
Notified Dr. Jones of BP of 90/40
 Which of the following statements is a data on FDAR method of documentation?
"I have difficulty swallowing my foods for 3 days now"
 The Planning step of the Nursing Process includes which of the following activities?
Setting Goals and Selecting Interventions
 The nursing diagnosis is Risk for Impaired Skin Integrity related to Immobility and Pressure
Secondary to pain and presence of cast. Which of the following desired outcomes should the
nurse include in the care plan?
Skin will remain intact and without redness during his hospital stay
 In the nursing diagnosis "Self-care Deficit: Feeding related to Bilateral Fractured Wrists in Casts,"
what is the major related factor or risk factor identified by the nurse?
Fractured wrists
 The Nurse on Duty needs to validate which of the following statements being made by their
assigned patients?
The patient reported an infected toe
 Which is NOT TRUE among the purpose of doing hand hygiene?
It is important to all HCWs and the patient's hands to facilitate transmission of
microorganisms.
 When should Nurse Klee clean her patient's dentures?
Clean dentures as frequently as natural teeth.
 Which of the following actions does the nurse maintain proper body mechanics when making a
bed?
Avoid twisting the body
 Which of the following factors may affect individual hygiene?
All of the above
 This pertains to the movement or the transmission of causative agents from a reservoir to a
susceptible host.
Route of Transmission
 Mr. Brown is assigned to room 8, but he is currently at physical therapy. Which of the following
bed making procedure applies?
Unoccupied; close bed
 Which of the following is a must before shaving your patient's beard?
Ask for the patient's consent before shaving his beard.
 Nurse Linda is tasked to shave her patient who is clinically depressed in preparation for her
scheduled surgical operation. The UAP has presented various types of razors ready to be used in
 shaving her patient. Which of the following razors would Nurse Linda choose in shaving her
patient?
Electronic razor
 It is a small sheet placed over the middle of the bottom sheet referred as:
Draw Sheet
 This bath is indicated for patients who are unconscious, paralyzed, in a cast or traction, and/or
weak from illness or surgery.
Complete bed bath
 Which of the following interventions are appropriate in maintaining respect for the patient
when making their bed?
All of the Above
 Which of the following is the purpose of surgical gloving procedure?
All of the Above
 This is a principle wherein it REDUCES the number of microorganisms and prevent their spread.
Medical Asepsis
 Student Nurse Marie is asked to define Chain of Infection. She is correct if she responds with
which of the following statements?
The spread of an infection within a community; several interconnected steps that describes
how a pathogen moves about.
 Prior to the implementation of bed making procedure to an occupied bed. The student nurse
should check first for which of the following?
Client's chart to check for limitation on the client's physical activity.
 Patient Yza is suddenly manifesting hair loss after undergoing multiple sessions of
chemotherapy. Patient Yza experiencing which of the following skin and scalp
conditions?
Alopecia
 This type of isolation is used to protect the patient whose resistance is low from acquiring an
infection.
Reverse isolation
 This type of bath includes medicated solutions and may contain cornstarch, oatmeal, aveno,
and/or alcohol which may relieve patient's signs and symptoms.
Therapeutic Bath
 These are entities, be it biological, chemical, or physical agents that are capable of causing
disease.
Causative Agent
 Principles of Bed making are the following EXCEPT:
Spread linens to remove wrinkles using your palms.
 A member of a species population who is at risk of becoming infected with a certain disease due
to a variety reasons.
Susceptible Host
 There are various procedures in controlling the spread of infections. Which of the following
procedure pertains to sterilization using steam under pressure to kill all organisms?
Autoclaving
 This pertains to the invasion of a host organism's bodily tissues by disease-causing organisms,
their multiplication, and the reaction of host tissues to these organisms and the toxins they
produce.
Infection
 Which of the following is INCORRECT when performing the procedure of assisting elimination of
the patient?
Cool the bedpan if it is metal.
 This type of isolation is used to prevent transmission of microorganisms spread by direct or
indirect contract with the source.
Contact isolation
 When doing Eye Care for your patient, which of the following principle must be observed?
Clean from the inner canthus to the outer canthus of the eye.
 Which of the following is TRUE of making a closed or unoccupied bed starting with the bottom
sheet?
When unfolding the bottom sheet, the center fold should be align with the center of the bed.
 Which of the following are the Key Moments of Hand Hygiene? SELECT ALL THAT MAY APPLY.
1. Before touching a patient.
2. Before Clean/Aseptic Procedure.
3. After Body Fluid Exposure Risk
4. After touching a patient.
5. After touching patient surroundings.
1, 2, 3, 4, 5
 This type of isolation is used to prevent transmission of microorganism spread by large, moist
droplets inhaled by or landing on the mucous membranes of the susceptible host.
Droplet precaution
 Mitered corners is used to which of the following reason?
To hold the linens under mattress and in place firmly
 Which of the following describes a closed bed?
A bed that is not in use and is not assigned to a client
 A student nurse is having a return demonstration in an occupied bed. The student nurse
understands the principle of medical asepsis in which of the following?
Never shake or fan the linens.
 Which is NOT TRUE in the Infection Control Principles?
Microorganisms are transferred by gravity when one item is held above another, thus passing
dirty items over clean items is a must.
 Which of the following is INCORRECT when performing Handwashing procedure?
You may not remove your jewelry when doing the procedure. The hand motions during
handwashing will wash the dirt and organisms trapped in the rough edges and places in the
jewelry.
 The patient is in surgery and will return to his bed via stretcher. The nurse plans ahead by
making which type of bed and placing it in which position?
An open bed in low position
 At which part of the bed is the top sheet tucked under the mattress?
Foot of the bed
 Which of the following statements is CORRECT when performing female perineal care?
Always cleanse from the urinary meatus towards the anus.
 When cleaning their patient's dentures, which of the following procedure will the nurse do prior
to cleaning their patient's dentures on the sink?
Place wash cloth or paper towel in sink to line it while you are cleaning the dentures.
 Which of the following procedures in doffing of gloves is INCORRECT?
Insert fingers of the gloved hand between the cuff of the glove and the wrist to roll glove off.
 This pertains to self-care by which people attended to such function as bathing, oral care,
grooming hair, cleaning fingernails, genital area, ear, and eye care.
Hygiene
 What measures should the nurse implement to ensure the safety and comfort of the client
when in bed:
All of the Above
 In making unoccupied bed linens were prepared and assembled in order of use (Bottom to top):
Pillow case, top sheet, draw sheet, under pad, and bottom sheet
 A 29 year old female patient was admitted at the ER and is scheduled for caesarian section. The
NOD will prepare which of the following bed in receiving the female patient?
An open bed, fan folded top sheets.
 This means a population or a tissue which is chronically infested with the causative agent of a
disease and can act as a source of further infection.
Reservoir
 Nurse Klee is providing oral care to a patient who is unconscious. Which of the following would
Nurse Klee position her patient to avoid aspiration?
Head turned to the side or side lying.
 Which of the following procedure is INCORRECT regarding shaving the patient?
Shave against the direction of hair growth.
 Which of the following procedures in donning of gloves in INCORRECT?
Touch the inside and outside of the glove packaging.
 This refers to the practice that keeps an area or object FREE FROM ALL MICROORGANISMS,
including practices that destroys ALL microorganism spores.
Surgical Asepsis
 Which of the following is not an indication for Handwashing procedure?
None of the above
 Which of the following are the purpose of hygiene? SELECT ALL THAT MAY APPLY.
1. Remove microorganisms
2. Do physical assessment
3. Increase circulation.
4. Improve self-image.
5. Provide comfort.
6. Provide breaktime for the patient.
7. Increase the lifespan of the patient.
All of the above
 What is the following is a description of the Fowler's position?
 Client is sitting in a semi-sitting position (45 to 60 degrees) with his head and shoulders
elevated.
 Nurse Lindo is assisting his patient in her walk. Nurse Lindo is CORRECT if he positions himself
where?
At his patient's side and slightly on the back holding her arms or on the transfer belt.

 The only reason why the nurse positions the body of a deceased client is because of which of the
following reasons?
The body should appear in a natural position
 Which of the following would be the most important care a nurse can provide for the terminally
ill client?
Caring and touching
 Which of the following is the correct method for determining the vastus lateralis site for I.M.
injection?
Divide the area between the greater femoral trochanter and the lateral femoral condyle into
thirds, and select the middle third on the anterior of the thigh.
 What is the most important role of the nurse in preventing drug errors?
Always following the "rights" of drug administration
 Your patient Mrs. Linda is scheduled to have her morning walk on the next hour. As her nurse,
what intervention/s will you do to prepare her for her morning walk?
Offer her as needed pain medications 30 minutes before the scheduled walk.
 A sublingual drug is administered by placing the drug in what part of the body?
Under the tongue
 Immediately after a client's death, a nurse performs post mortem care. Correct care would
include which of the following?
Bathing the body and removing all tubes, unless autopsy might be ordered.
 A nurse understands that when a terminal client states, "No, I don't need anything. What would
you get me anyway?" He or she is most likely in which of the following stages of grief?
Anger
 A nurse is caring for a client who just passed away for more than an hour ago. As she was
performing post mortem on the client, she understands that the stiffening of the body muscles
of the dead client is typically a post mortem physiologic change known as which of the
following?
Rigor mortis
 Nurse Marie is assisting her patient to transfer from bed to the bedside chair. She is correct
when she holds the patient on where?
Transfer belt
 Where should the nurse place the load when carrying heavy objects?
Close to the body midline
 A client is dying of colon cancer tells a nurse that he is sure that he can beat the cancer if he
changes his eating habits. The nurse understands that the client is likely in which of the
following stages of grief by Kubler-Ross?
Bargaining
 A nurse explains to a family that research supports that the last sense to leave a dying client is
which of the following?
Hearing
 The patient's family has asked the nurse on what is the reason behind frequently changing their
patient's position. Which of the following statements indicates that the nurse is in need of
further education?
The nurse may use special devices such as splints and tractions even though it was not
ordered by the physician.
 After post mortem care, the nurse expected to perform which of the following action?
All of the above
 The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the
rationale for this instruction?
It distributes workload more evenly.
 This type of care's goal is to give patients with life threatening illnesses the best quality of life
they can by providing aggressive management of symptoms such as pain, etc.
Hospice care
 The nurse must verify the client's identity before administration of medication. Which of the
following is the safest way to identify the client?
Check the client's identification band.
 The nurse asks his patient on what is the importance of maintaining proper body alignment even
though he is lying on his bed. Which of the following statements indicates that the patient is in
need for further teaching?
"The footboard should not be used as this will case my foot to drop."
 What implementation might the nurse use to improve safety during a transfer?
Using a transfer (gait) belt
 Back injuries are a common cause of disability for emergency medical services professionals.
Which of the following statements represent guidelines for safe lifting?
Bend at your knees and hips, and keep your back straight.
 This is a technique wherein the nurse rolls the patient like a log to keep his patient's back in
straight alignment.
Logrolling
 Which of the following instances does Nurse Apple correctly demonstrates proper body
mechanics?
She raises the bed to an appropriate height when doing the bed making procedure.
 When providing supportive care for the dying or grieving client. Which of the following
assessments should be considered?
All of the above
 Which of the following best describes the way a gait belt is used when helping a client walk?
The belt is worn at the base of the client's ribs so that the nurse has a way to hold unto him.
 The only authorized person to declare client's death is which of the following healthcare
professional?
Physician
 Which of the following actions should the nurse do when moving a client from the bed to the
stretcher?
 Make sure the bed and the stretcher are the same height
 A patient is in the bathroom when the nurse enters to give a prescribed medication. What
should the nurse in charge do?
Return shortly to the patient's room and remain there until the patient takes the medication.
 The nurse is administering an antibiotic to her pediatric patient. She checks the patient's
armband and verifies the correct medication by checking the physician's order, medication
Kardex, and vial. Which of the following is NOT considered one of the ten "rights" of drug
administration?
Right effect
 A nurse has just witnessed a terminally ill client telling the physician that he does not wish to
have his life prolonged as stated in his living will. Which of the following actions by the physician
will the nurse expect to happen next?
Speak to the client's family before writing a DNR order.
 How frequent should an immobile client should be repositioned?
At least every 2 hours
 A client who is in shock is placed on the stretcher. Which of the following positions would be
most effective for this client?
Supine
 Before administering the evening dose of a prescribed medication, the nurse on the evening
shift finds an unlabeled, filled syringe in the patient's medication drawer. Which of the following
is the most immediate action should the nurse in charge do?
Discard the syringe to avoid a medication error.
 The patient is able and is doing the exercises while the nurse supervises and gives direction on
how to move and what positions to assume during their exercise time. The patient is doing what
king of range of motion exercises?
Active Range of Motion
 When transferring a client from bed to their bedside chair, the Nurse on Duty should use which
muscles to avoid back straining and injury?
Leg muscles
 Purposes of Post Mortem Care is which of the following?
All of the Above
 The nurse is moves the patient's joints and is positioning them in various positions. The nurse is
doing what kind of range of motion exercises?
Passive Range of Motion
 The family of a terminally ill client asks the nurse what they should expect when she dies. Which
of the following responses by the nurse to the family is most appropriate?
"Her breathing will stop, and her heart will cease beating within a few minutes."
 Which of the following is the most important instructions a nurse can give a patient regarding
the use of an antibiotic like Ampicillin?
Take all of the medication prescribed even if the symptoms stop sooner.
 A wife is extremely upset about her husband's respirations. A nurse explains that this type of
breathing is a symptom of end-stage disease. The breathing is called cheynes-stokes. Which of
the following best describes what Cheynes-Stokes breathing is?
A cycle of shallow and deep respirations
 Which of the following refers to the correct and efficient use of your body to facilitate lifting and
moving?
Body mechanics
 Nurse Lindo is assisting his patient on her transfer from her bed to her wheeled chair. Which of
the following statements indicates that Nurse Lindo is CORRECT while doing the transfer?
Nurse Lindo sets the height of the bed at the lowest setting, keeping his patient's knees
between his legs.

 The nurse is ordered to administer Amoxicillin 500 mg capsule TID p.o. The nurse should give the
medication by which of the following frequency?
Three times a day orally
 Mr. Rex wants to have his evening walk. As the nurse reviews his chart, it was documented
there that Mr. Rex had complained dizziness and weakness at the previous shift. What will the
nurse do?
Let Mr. Rex sit on the edge of the bed and dangle his feet for a few minutes, then assist him
during his evening walk.
 What administration technique does the nurse use to give a 2 yr. old child ear drops?
Pull the earlobe down and back
 Which of the following statements is CORRECT?
A person or an object is more stable if the center of the gravity is closed to the base of
support.
 To ensure stability and balance, the nurse must position his feet where?
One foot slightly positioned in front of the other foot while maintaining a wider base of support.
 Which of the following actions is appropriate if a client is falling to the ground?
Lower the client to the ground