RECALLS 8: NURSING PRACTICE 3

Situation: Ethical and moral issues are becoming a common
scenario in practice setting so heal care providers have to be
equipped with this competency.
1. In the clinical setting, when nurses are confronted with ethical
dilemmas the BEST practical guide, she can use of is____
A. PRC oath for professionals - to be dictated by the BON for
oath taking
B. code of ethics
C. theological doctrine - religious scriptures
D. Florence Nightingale oath
Rationale: guides us how to act accordingly
examinations the physician ordered him to undergo an
exploratory laparotomy. You are the nurse on duty day.
6. While performing your assessment you are guided that the
organs found in the epigastrium include which of the following?
A. Portion of duodenum & jejunum, left kidney, appendix &
ovary - left inguinal
B. Duodenum, pancreas, portion of the liver and pyloric
end of the stomach.
C. Stomach, spleen, tail, pancreas and adrenal gland. - left
hypochondriac
D. Gallbladder, duodenum and portion of the right kidney -
right hypochondriac

Rationale:
2. Mr. Rad is admitted to the hospital complaining of chest pain
due to clogging in his coronary arteries. He is diabetic
hypertensive and considered by the physician to be a high risk
for cardiovascular surgery. What PRIORITY actions should the
members of the health team do in this situation?
A. Consult the family members and let them give their
decision.
B. Proceed with the planned surgery, as this will save the
patient. - “just for the sake of saving the patient”
C. Consult the Ethics committee on what to do with the
patient.- no ethical dilemma present
D. Discuss with Mr. RAD his health status & let him decide

Additional Note: high risk patients (especially those who are Epigastric Area:
in the ICU) has separate consent → Aorta
→ Pyloric end of stomach
3. Mrs. Agnes, 77-year-old, is suffering from dementia and → Part of duodenum
demonstrates unruly behavior. When Nurse Gigi describes the → Pancreas
patients in her shift report, as “That’s awful, Dirty old woman In → Part of liver
bed 14” is an example of what ethical behavior is being
employed by the nurse? Right Hypochondriac Area:
A. Stigma - stereotyping on a certain condition (e.g. HIV → Right lobe of the liver
patients) → Gallbladder
B. Ageism - degrading of children/adolescents or according → Part of duodenum
to age → Hepatic flex of colon
C. Gender bias - degrading according to gender → Upper ½ of right kidney
D. Depersonalization - part of dissociative disorders; “out of → Suprarenal gland
body experience”; common on multiple personality
disorder Left Hypochondriac:
→ Stomach
Rationale: Alzheimer’s is the disease; dementia has → Spleen
forgetfulness; it is a symptom of Alzheimer’s not a disease → Tail of pancreas
itself; → Splenic flexure of colon
→ Upper half of left kidney
→ Adrenal gland
4. Mr. Rey, who is on an end-stage of life, has an order of “Do → Suprarenal gland
Not Resuscitate” and passes away in your shift. He was declared
dead by his physician at 8:30 AM. What should be your Right lumbar:
PRIORITY nursing action in this situation? → Ascending colon
A. Prepare the death certificate for the physician to sign → Lower half of right kidney
B. Request your nurse attendant to all the funeral parlor at → Part of duodenum and jejunum
once.
C. Allow the family to have private moments with the Left lumbar:
deceased. → Descending colon
D. Clean the body and remove all the IV lines, tubes and → Lower half of left kidney
other appliances. → Part of jejunum and ileum

Rationale: postmortem care should be the priority after a Right inguinal:

patient died → Cecum
→ Appendix
→ Lower end of ileum
5. When a nurse is in full support of a patient's care and
→ Right ureter
safety personal rights throughout her hospital stay, she is
→ Right spermatic cord/Right ovary
implementing what ethical principle?
A. Responsibility - duties
Left inguinal
B. Empathy - understanding what you’re going through
→ Sigmoid colon
C. Advocacy
→ Left ureter
D. Accountability - “pananagutan”
→ Left spermatic cord/ left ovary

Situation: A manager of an accounting firm is admitted to the

hospital due to an acute abdominal pain and passing out of
bloody stools. After several diagnostic and laboratory

RECALLS 8: NURSING PRACTICE 3

 RECALLS 8: NURSING PRACTICE 3
7. When conducting the nursing history on the health
perception, health management pattern of function what is the
APPROPRIATE question to be asked pre-operatively?
A. Do you experience your wounds healing quickly?
B. Do you have shortness of breath when exercising?
C. Are you aware of risk factors for your disease?
D. Have you experienced weight change in the past?
Rationale: health perception assess the history/awareness of
risk factors
8. Patient was visited by the anesthesiologist and explained the
anesthesia for his surgery. Which of the following types of
anesthesia would you expect to be ordered?
A. Spinal
B. Caudal
C. Local
D. General
Rationale: Exploratory laparotomy needs general anesthesia
(major surgery); airway patency should be monitored
9. There are preoperative medications given to the patient.
Which of the following drugs are given in order to decrease
intraoperative anesthesia requirements and pain?
A. Celebrex (Celecoxib) - selective COX-2 inhibitor; NSAIDS;
inflammatory has effects on COX2 only
B. Ibuprofen (Motrin) - NSAID, non-selective; inhibits COX1
and 2; can cause bleeding and ulcer d/t antiplatelet and
antiprostaglandin
C. Acetaminophen (Tylenol) - paracetamol; mild analgesics
D. Demerol (Meperidine HC1)
Rationale:
10. Which of the following universal protocols are adopted and
validated prior to surgery?
I. Patient’s identity
II. Surgical procedure
III. Surgical site
IV. Surgical equipment - not included
A. II & III
B. I & II
C. I, II & IV
D. I, II, & III
Situation: Crisostomo, a 40 years old employee has been
complaining of difficult painful urination for almost a week
now. He saw some fresh blood in his urine but was afraid to
see a physician, instead he went to his neighbor who is a
herbalist. After a week his condition worsened and his wife
brought him to a community clinic.
11. A community clinic does primary care for patients. Most
often the one who manages this is which of the following?
A. Physician
B. Barangay health workers
C. Nurse
D. Midwife
Rationale: primary care refers to clinics established by MD
12. Upon assessment, the patient was referred immediately to a
25-bed-capacity hospital, which does not have any capacity to
do intensive diagnostic examinations. You are a nurse in this
hospital, which you know is at level___
A. 3
B. 1
C. 4
D. 2
Rationale:
I. Primary Level of Care
• is usually the first contact between the community
members and the other levels of the health facility.
• provided by center physicians, public health nurses,
rural health midwives, barangay health workers,
traditional healers
• Ex:
1. Rural Health Units
2. Community Hospitals and Health Center
3. Private Practitioners (Puericulture Centers)
4. Brgy. Health Stations
II. Secondary Level of Facility
• Serves as a referral center for the primary health
facilities are capable of performing minor surgeries
and perform some simple laboratory examination
• Ex:
1. Provincial/City Health Services and Hospitals
2. Emergency and District Hospitals
III. Tertiary Level of Facilities
• Serves complicated cases and intensive care
• Ex:
1. National and Regional Health Services
2. Teaching and Training Hospitals
• Diagnostic testing includes: MRI, PET Scan,
Neurosurgeon
• Quaternary Level
o Under tertiary
o More detailed
13. In the tertiary where the patient was again referred, he was
considered an emergency case. The nurse immediately call for
a specialist who is__
A. Neurologist - neurons and brain
B. Urologist - genitourinary e.g. impotence, premature
ejaculation
C. Phlebotomist - concerned with blood extractions
D. Nephrologist - kidney
Rationale: Patient has dysuria and hematuria (urination
problem)
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 RECALLS 8: NURSING PRACTICE 3
14. After a thorough assessment by the physician- specialist, an
order for an immediate sonogram was made. The nurse was
instructed to call which of the following sections of the hospital?
A. Operating room - surgery
B. Laboratory
C. Intervention - part of the nursing process to lol
D. Imagery
15. After the procedure, the patient was ordered for Lithotripsy,
under spinal anesthesia. The nurse has call to the department
of___
A. Internal medicine
B. Anesthesia
C. Surgery
D. Imagery
Rationale: Urolithiasis → ESWL → release of shockwaves to
crush stones until beach sand size → urinated by the patient
→ X-ray guided
→ Non-invasive
→ Nursing considerations:
• Increase fluid intake
• Filter/Strain urine to check if stones are excreted
→ Intracorporeal Lithotripsy → through surgery, with
anesthesia (invasive)
Situation: An alert 67-year-old woman with diabetes mellitus
is discharged from the hospital. A referral is made to a
community nursing agency. You are asked to reinforce the
teaching program started in the hospital. The patient is using
sulfonylurea compound tolbutamide (Orinase).
16. When the patient turned 69-year-old orinase was
discontinued and NPH insulin was prescribed for her. After
several months, she is determined to be suffering from the
somogyi effects. Which of the following conditions will most
likely result when the patient is receiving too much insulin?
A. Developing an elevation of the blood glucose level
B. Producing even more insulin
C. Becoming resistant to insulin
D. Conserving excessive amount of fluid
Rationale:
17. A few days later the patient comes into the emergency
department via ambulance stretcher and reveals a work-up of a
blood sugar level at 800 mg/dl, ketones are absent in the
urine, she is dehydrated, and has an altered mental status.
Based on the data, the patient is most likely suffering from what
specific medical condition?
A. Hyperosmolar nonketotic coma (HNKC) - complication of
type II DM
B. Diabetic retinopathy - high blood glucose → viscous blood
→ affects blood vessels of the eyes
C. Acute renal failure - nephropathy
D. Diabetic ketoacidosis (DKA) - complication of type I DM
18. Upon interview, the patient reported that she often felt
nauseated, restless, perspiring a lot, felt fatigued and was
often hungry when she was younger. What do these signs
indicate?
A. Diabetic nephropathy
B. Hyperglycemia
C. Hypoglycemia
D. Diabetic retinopathy
19. Upon further assessment you noticed had many scratches
on her right ankle, a resulting infection, and cellulitis. When
you ask her about the scratches the patient states “Oh my cat
must have been using my leg as a scratching post again and did
not even feel it.” Which diabetic complication suspect the patient
has?
A. Neuropathy
B. Macroangiopathy - large blood vessels are affected in the
lungs and heart
C. Retinopathy - eye; microangiopathy
D. Nephropathy - kidneys; microangiopathy
20. You should check the patient for suspect disturbed thought
processes related to depressed metabolism and altered
cardiovascular and respiratory status. What is the rationale for
orienting the patient to time, place, date and events?
A. Show improved cognitive functioning
B. Provides reality orientation to patient
C. Permits evaluation of the effectiveness of treatment
D. Let’s the patient identify the time, place, date, and events
correctly
Rationale: Options ACD evaluates the patient; patient has
altered mental status therefore orienting the patient to reality
is deemed important
Situation: Nurse Pat is a newly hired Registered Nurse
together with 5 licensed graduate nurses coming from
different regions. It is their first day of orientation in a big
health facility. The continuing nurse educator started the
session by projecting the organizational structure of the
medical center.
21. Which of the following is the MAJOR PURPOSE of an
organizational structure? It is the __.
A. blueprint representing committees for delegation of roles
and function
B. flow chart shows interaction among members of major and
minor groups
C. framework of relationship of units, departments and
channels of communication
D. design that identifies roles, collaboration, interdependence
between functions of people
22. Line and staff function are identified in the presented
organizational Chart. What does line authority mean?
A. Staff relationship in the organization is advisory in nature
B. Staff mix of personnel reporting to the “BOSS”
C. Decisions are made from bottom to top in an organization.
D. Design that identifies roles, collaboration, interdependence
between functions of people
Rationale: line authority are vertical
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 RECALLS 8: NURSING PRACTICE 3
23. Which of the following statements is CORRECT of the
nursing service system in health care?
A. Informal leaders are more effective than formal and with
less autonomy.
B. A shared governance tends to controlling and with less
autonomy - marami ang nagdedecide; more empowering
C. Institutional policies are a more powerful tool in nursing
practice than laws and regulations. - laws and regulations
are more powerful than institutional policies
D. A situational leadership style provides effective means
in achieving patient outcome.
Rationale: leadership style depends on the situation
24. Which of the following statements is CORRECT of the
nursing service system in health care?
A. Informed leaders are more effective than formal and with
less autonomy.
B. A shared governance tends to controlling and with less
autonomy
C. Institutional policies are a more powerful tool in nursing
practice than laws and regulations.
D. A situational leadership style provides effective means
in achieving patient outcome.
25. Budgeting is an important aspect of financial management.
When a unit manager allocates expenses for unit supplies,
stocks and medical-surgical supplies. This is considered____
A. cash budget - contingency budget
B. operational budget
C. capital budget
D. flexible budget
Rationale:
→ Flexible budget - can be adjusted
→ Inflexible budget - cannot be adjusted
→ Personnel budget - has the biggest percentage in an
institutions budget
Situation: Mely 68 years old was admitted to the hospital
because of decreased appetite, easy fatigability, dehydration
and weight loss of about 15lbs for the past week. She was
examined by the physician and advised to be admitted. You
are the nurse assigned to take care of her.
26. The physician ordered Ms. Mely on total parenteral
Nutrition (TPN). What is your INITIAL step to be undertaken
PRIOR to this intervention?
A. Determine if the family can afford the whole treatment.
B. Evaluate the tolerance of the patient to glucose.
C. Identify allergies to supplemental nutrition - deadly if has
severe allergic reaction; order must be modified; protein
content of TPN causes most allergies
D. Assess the basic understanding of the patient regarding
TPN.
Rationale: TPN:
→ Directed to the veins
→ Central vein insertion (subclavian vein or jugular vein)
→ For long term use
→ Started gradually because patient would be prone to
hyperglycemia
→ WOF: infections → tubings and TPN bag must be
changed after 24 hours even if hindi pa ubos
→ Air embolism is another complication
→ Gradual discontinuation → titrating d/t risk of
hypoglycemia
→ Partial TPN:
• Inserted through peripheral veins
• For short term use
27. Choose from the following the primary goals of TPN?
I. promote weight gain
II. maintain muscle mass
III. establish nitrogen balance
IV. enhance healing process
A. I, II, & III
B. I, II, III, & IV
C. I & II
D. I, II, III, IV, & V
28. When a patient is undergoing TPN, you have to monitoring
closely for the___
A. serum creatinine level
B. potassium level
C. serum glucose level
D. sodium level
Rationale: d/t risk of hyperglycemia
29. While Mr. Mely is on TPN she suddenly complains of slight
chest pain, dyspnea and appears cyanotic. You suspect that
she is experiencing what possible IMMEDIATE complication?
A. Sepsis due to IV line - would take 2-3 days to develop
B. Air embolism - chest pain is present; left trendelenburg
position
C. Hyperglycemia - not signs of hyperglycemia
D. Allergic reaction to TPN - if anaphylactic reaction,
manifestations would include airway inflammation, difficulty
in breathing
30. What PRIORITY nursing action should you do with the
presenting clinical manifestations of the patient?
A. Report to the physician status of the patient at once.
B. take blood pressure and respiratory rate.
C. Stop temporarily the total parenteral nutrition - because
it is an emergency situation; D5W can be used to prevent
hypoglycemia if TPN is discontinued
D. Administer inhalation.
Situation: Ms. Monina is a retired community health nurse in
barangay San Pablo. Due to her commitment to the nursing
profession, she has volunteered in their community to
conduct health education classes. One Saturday morning,
several patients who are hypertensive and with pulmonary
health problems attended her session.
31. Mang Luis is a newly diagnosed patient with chronic
obstructive Lung Disease (COPD). Which of the following
PRIORITY teaching instructions should be given in relation to his
condition?
A. He should assume supine position when resting - should be
orthopneic
B. know early signs of respiratory infection.
C. He has to be taught how to Bronchial clapping. - the patient
should perform CPT not the patient
D. Family should be advised that the patient should sleep in a
warm room. - extreme temperatures should be avoided
because O2 demand adjusts or increases
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 RECALLS 8: NURSING PRACTICE 3
32. Which of the following health interventions should be
included in your teaching plan for Mang Luis?
A. Be on prolonged corticosteroid therapy.
B. Lung exercises must be done with longer inhalation that
exhalation
C. Reduce risk for infection.
D. have a high flow of oxygen administration - low flow; 1-2Lpm
only using venturi mask
33. Pulmonary Rehabilitation for COPD has a duration of at least
4 to 12 weeks. Which of the following should be avoided while
the patient is having this program?
A. Pursed lip breathing - prolonged expiration to release CO2
B. Smoking cessation
C. Aerobic, upper and lower body conditioning
D. Peripheral muscle wasting - iniiwasan natin ang pagpayat
Rationale: malnutrition is commonly observed in COPD; they
also have difficulty eating
34. Weight loss and malnutrition are commonly observed among
patients with COPD. They should be taught to avoid___
A. have full stomach even when in dyspneic condition
B. keeping body mass between 21-25 kg./m
C. a high caloric and a high protein diet
D. exercise one hour before and after eating - for pulmonary
rehab; deep breathing exercises
Rationale: would increase O2 demand → weight loss
35. Which of the following energy conserving strategies should
NOT be done by COPD patients?
A. Exhale when pushing or exerting effort when doing daily
activities
B. Assume tripod position with elbow supported on the table
when shaving or combing - allows easier breathing
C. Inhale when resting, sitting and lying down.
D. Stand in front of the mirror while shaving or combing
hair
Rationale: options AC are agreeing with each other
Situation: A housewife, appearing jaundiced, complaining of
abdominal pain, nausea and bloated sensation was rushed to
the hospital. The patient was examined by the physician and
ordered for admission due to suspected stone in the
gallbladder. You are the nurse on duty that day.
36. When performing an interview, which is the best initial
question you should ask when a patient is in pain?
A. How often do you feel the pain?
B. How would you describe your pain? - quality
C. Did you take any drug to relieve the pain?
D. When did you first feel the abdominal pain?
Rationale: in assessing pain use COLDSPA (characteristic,
onset, location, duration, severity, precipitating factors,
associated symptoms) or PQRST (pain, quality, does pain
radiates, severity, time [intermittent/continuous])
37. Which of the following imaging tests that use a transducer
will likely be ordered by the physician to detect gallstones?
A. Computed tomography
B. Abdominal X-ray
C. Abdominal Ultrasound
D. Doppler sonography
Rationale: abdominal UTZ is non-invasive, affordable,
efficient, and reliable (cna detect small stones)
38. The test revealed the presence of gallstone and inflamed
gallbladder. The patient was advised to undergo open
cholecystectomy. This operation compared to laparoscopic
cholecystectomy are____
I. Invasive
II. Less pain
III. Longer recover
IV. Shorter hospital stay
A. I II & IV
B. I & II
C. I , II & III
D. I & III
Rationale: Removal of the gallbladder (cholecystectomy)
through traditional surgical approaches has largely been
replaced by laparoscopic cholecystectomy (removal of the
gallbladder through a small incision through the umbilicus).
As a result, surgical risks have decreased, along with the
length of hospital stay and the long recovery period required
after standard surgical cholecystectomy. In relatively rare
instances, a standard surgical procedure may be necessary.
39. After 2 hours post- operatively the nurse observed reddish
drainage from the operative area of the patient. Which of the
following nursing actions should you perform FIRST?
A. Check if stitches from the operation have come apart -
dehiscence or evisceration doesn’t happen immediately
B. Check where is the source of possible bleeding
C. Cover the operative area with sterile gauze bandage.
D. Put your hand as a pressure on the operative area.
40. After several days in the hospital, the physician ordered for
the patient to be discharged. Which of the following is the
PRIORITY restriction that you should emphasize when he goes
home?
A. Stool softener to induce bowel elimination. - not restricted;
to prevent straining
B. Driving if not using a narcotic drug.
C. Take shower even if it is still with a surgical drain.
D. Lifting of objects more than 10 lbs.
Rationale:
Managing Self-Care After Laparoscopic Cholecystectomy
The nurse instructs the patient about pain management,
activity and exercise, wound care, nutrition, and follow-up
care as described below.
Managing Pain
→ You may experience pain or discomfort from the gas
used to inflate your abdominal area during surgery.
Sitting upright in bed or a chair, walking, or using a
heating pad may ease the discomfort
→ Take analgesic medications as needed and as
prescribed. Report to your surgeon if pain is unrelieved
even with analgesic use.
Resuming Activity
→ Begin light exercise (walking) immediately.
→ Take a shower or bath after 1 or 2 days.
→ Drive a car after 3 or 4 days.
→ Avoid lifting objects exceeding 5 pounds after surgery,
usually for 1 week.
→ Resume sexual activity when desired.
Situation: Sarah, a 38-year-old teller from a bank is admitted
to a tertiary hospital due to hypertension and frequent
hematoma of the lower extremities every time she bumps
herself in the workplace. The physician who examined her
gave an impression of Cushing disease.
41. Which of the following characteristics of Cushing disease is
TRUE?
I. The disease occurs in women between 20 to 40 year
of age
II. The use of Corticosteroids for multiple immune
conditions is a cause of the disease process -
prolonged steroid use
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 RECALLS 8: NURSING PRACTICE 3

III. Condition is aggravated by excessive production of

→ Fragile skin, slow healing of minor cuts and bruises
ACTH - d/t pituitary tumors
→ Lassitude
IV. The surgical of treatment of choice is Transsphenoidal
→ muscle wasting and osteoporosis
hypophysectomy
→ Retention of sodium and water
A. II & III
→ Libido is lost in men and women
B. I , II, & III
→ Hirsutism , virilism- breasts atrophy, menses cease, the
C. I , II, III & IV
clitoris enlarges, and the voice deepens
D. I & II

44. The attending physician ordered a Magnetic Resonance

Rationale: Women between the ages of 20 and 40 years are
Imaging (MRI) to patient Sarah in order to validate the medical
five times more likely than men to develop Cushing syndrome.
impression. This imaging technique is done to detect___
In females of all ages, virilization may occur as a result of
excess androgens. Virilization is characterized by the A. hemorrhagic injury in the brain
appearance of masculine traits and the recession of feminine B. Electrical impulse in the brain - EEG can detect electrical
impulses
traits. There is an excessive growth of hair on the face
C. level of oxygen in the brain - PET Scan (red - good
(hirsutism), the breasts atrophy, menses cease, the clitoris
perfusion; blue - poor perfusion)
enlarges, and the voice deepens. Libido is lost in men and
women. Distress and depression are common and are D. non-hemorrhagic injury in the brain - hemorrhagic injuries
increased by the severity of the physical changes that occur
45. While patient Sarah is confined in the hospital, the safety
with this syndrome. If Cushing syndrome is a consequence of
measure to be observed by the nurses is prevention from fall.
pituitary tumor, visual disturbances may occur because of
This is brought about by the patient being prone to fracture as a
pressure of the growing tumor on the optic chiasm.
result of__
Medical Management A. aging process
B. change in vision
→ If Cushing syndrome is caused by pituitary tumors rather
C. osteoporosis
than tumors of the adrenal cortex, treatment is directed
D. hematologic condition
at the pituitary gland. Surgical removal of the tumor by
transsphenoidal hypophysectomy is the treatment of
choice and has an 80% success rate. Radiation of the Rationale: d/t altered calcium metabolism
pituitary gland also has been successful, although it may
take several months for control of symptoms.
Adrenalectomy is the treatment of choice in patients with Situation: Mr. Alda, a 50-year-old company driver, is admitted
unilateral primary adrenal hypertrophy. Medical to the emergency room (ER) because of the pain in his left
management is recommended for bilateral adrenal chest and difficulty of a pack of cigarettes per day,
dysplasia. especially when he goes on overtime. Vital signs: BP is
150/90, PR - 110bpm, RR 38cpm. Has clammy perspiration
and quite restless. The physician ordered a chest X-ray and
42. When one has a Cushing disease the focal structure affected
revealed the patient has Pneumothorax. You are the nurse in
is the ___
charge of the patient.
A. hypothalamus
→ Pneumothorax occurs when the parietal or visceral
B. pituitary gland
pleura is breached and the pleural space is exposed to
C. adrenal gland
positive atmospheric pressure. Normally, the pressure in
D. parathyroid gland
the pleural space is negative or subatmospheric; this
negative pressure is required to maintain lung inflation.
Rationale: excessive secretion of ACTH → adrenal glands When either pleura is breached, air enters the pleural
would also increase secretion of GMA. space, and the lung or a portion of it collapses

Cushing syndrome results from excessive, rather than

deficient, adrenocortical activity (Porth, 2015). Cushing
syndrome is commonly caused by the use of
corticosteroid medications and is infrequently the result
of excessive corticosteroid production secondary to
hyperplasia of the adrenal cortex. However, overproduction
of endogenous corticosteroids may be caused by several
mechanisms, including a tumor of the pituitary gland that
produces ACTH and stimulates the adrenal cortex to increase
its hormone secretion despite production of adequate
amounts. Primary hyperplasia of the adrenal glands in the
absence of a pituitary tumor is less common. Another less
common cause of Cushing syndrome is the ectopic
production of ACTH by malignancies; bronchogenic
carcinoma is the most common type.
43. Which of the following clinical manifestations will NOT be a
complaint from Sarah’s condition?
A. Edema of the extremities
B. Poor wound healing
C. Decreased libido
D. Absence of growth in the public area
Rationale: d/t increased androgen productions, clitoris
grows, breasts ay lumiliit
Cushing Syndrome Manifestation
→ arrest of growth
→ Central-type obesity
→ Kyphosis, backache, and compression fractures of the
vertebrae
→ glucose intolerance, Hyperglycemia or overt diabetes
46. As a nurse you are guided that pain is usually described
BEST as a phenomenon WHICH is a____
A. neurologic activation of nociceptors - one type of pain only
B. subjective unpleasant experience
C. adaptive mechanism to a stimulus
D. creation of one’s imagination
Rationale: Pain is an unpleasant and highly personal
experience that may be imperceptible to others, while
consuming all parts of an individual's life. The best definition
of pain comes from Margo McCaffery, an internationally
known nurse expert on pain. Her often-quoted definition of
pain states, "pain is whatever the person says it is, and exists
whenever he says it does" (Pasero & McCaffery, 2011, p. 21).
This definition certainly portrays how subjective pain is.
Another widely agreed-on definition of pain is "an unpleasant
sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such
damage" (American Pain Society. 2016. p. 2)
47. When a patient has a pneumothorax, the nurse assessment
findings will likely reveal___.
I. absent breath sounds on an affected side - because
of shift from negative pressure to positive pressure
II. decreased chest expansion unilaterally - on the
affected side only
III. sharp chest pain
IV. burning chest - felt in heartburn, pyrosis, GERD
A. I, II, III
B. III, IV
C. I, II IV
D. I, II

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 RECALLS 8: NURSING PRACTICE 3

Rationale: In assessing the chest for any type of Rationale:

pneumothorax, the nurse assesses tracheal alignment,
expansion of the chest, breath sounds, and percussion of the
chest. In a simple pneumothorax, the trachea is midline,
expansion of the chest is decreased, breath sounds may be
diminished or absent, and percussion of the chest may reveal
normal sounds or hyperresonance depending on the size of
the pneumothorax. In a tension pneumothorax, the trachea is
shifted away from the affected side, chest expansion may be
decreased or fixed in a hyperexpansion state, breath sounds
are diminished or absent, and percussion to the affected side
is hyperresonant. The clinical picture is one of air hunger,
agitation, increasing hypoxemia, central cyanosis,
hypotension, tachycardia, and profuse diaphoresis.

48. Which of the following statements is NOT true of

Pneumothorax?
A. Atmospheric air within pleural space can result in a rise in
intra thoracic pressure and reduce vital capacity in the
lungs.
B. The loss of positive intrapleural pressure can produce
pneumothorax - positive pressure is gained
C. The loss of negative intra pleural pressure can result in the
collapse of the lungs.
D. A spontaneous pneumothorax can occur with the rupture of
pulmonary bleb.

49. The physician inserted a chest tube drainage to Mr. Alda in

order to help re-expand the lungs. Which of the following should
you prepare FIRST as a nurse in case of emergency when the
tube is accidentally disconnected?
A. sterile clamps - if disconnected from the tube and there is
no bottle of sterile water prepared yet as long as for short
period only
B. Another chest tube
C. Sterile dressing
D. A bottle of sterile water
Rationale: If the tube becomes disconnected from the
collecting system, submerge the end in 2.5 cm (1 in.) of sterile
saline or water to maintain the seal. If the chest tube is
inadvertently pulled out, the wound should be immediately
covered with a dry sterile dressing (non-occlusive).
→ Disconnect - from the tube
→ Dislodge - pulled out from the chest
→ Milking is avoided d/t accidental disconnection
• Pinching would be allowed
50. In order to relieve Mr. ALda of pain the physician prescribed
morphine So4 2 mg/IV PRN for intolerable pain. The goal of the
healthcare professional is to provide adequate control so the
patient can breathe easily. Which of the following would indicate
successful attainment of this goal?
A. Anxiety level of the patient will be reduced.
B. Respiratory rate will decrease to 20 breaths/min.
C. Oxygen saturation is at 76% level.
D. Pain scale will show 1 to 2, in a rating scale of 10 (10-
highest, 0,-lowest).
Situation: Nurse Rachel is assigned in a medical unit of a
tertiary hospital where most of the patients admitted are
suffering from Endocrine disorders. She is currently assigned
to patients: Claire, 54-year-old, married with hyperthyroidism,
Aster 66, year old has an impression of Cushing syndrome
while Sonia, 48-year-old is suffering from hypothyroidism.
51. While you are doing physical assessment to patient Aster,
she has bees exhibiting a UNIQUE clinical manifestation
different from patients Claire and Sonia which is characterized
by____
A. cyanosis, increasing growth of hands and feet - acromegaly
B. anemia, weight loss and presence of acne. - walang ganern
C. moon face, purple striae on trunk and buffalo hump
D. moon face, easy fatigability and peripheral edema - general
52. Which of the following diagnostic tests do you expect NOT
to be ordered by Dr. Lim to patient Aster who is suspected to
have Cushing Syndrome?
a. 24-hour urine cortisol level - increased cortisol
b. C reactive protein level - inflammatory marker together
with ESR
c. ACTH serum concentration - increased ACTH from
pituitary gland
d. Computerized tomography on the brain, chest and
abdomen - to check for pituitary gland and chest (tumor
might be the cause)
Rationale: Overproduction of endogenous corticosteroids
may be caused by several mechanisms, including a tumor
of the pituitary gland that produces ACTH and stimulates the
adrenal cortex to increase its hormone secretion despite
production of adequate amounts. Primary hyperplasia of the
adrenal glands in the absence of a pituitary tumor is less
common. Another less common cause of Cushing
syndrome is the ectopic production of ACTH by malignancies;
bronchogenic carcinoma is the most common type.
53. Which clinical manifestation should Nurse Rachel watch for
patient Claire if she is suffering from hyperthyroidism?
A. Cold extremities
B. Increased weight
C. Decreased bowel movement
D. Fine motor tremor
Rationale:
→ Options ABC are manifestations of hypothyroidism
→ Hyperthyroidism happens d/t increased T3 and T4 →
increased metabolism and heat intolerance;
→ Calcitonin calcium to bone
→ PTH calcium to blood
• Tip: H = hemo
54. Patient Sonia who has hypothyroidism is given. Which one
of the following drug therapy?
the following drug therapy?
A. Iodine
B. Propranolol
C. Iron pills
D. Levothyroxine

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 RECALLS 8: NURSING PRACTICE 3

Rationale: levothyroxine is T4; a weaker version of T3; given

for maintenance

57. She started to create her personal and professional

portfolio as a preparation for her application to a university
55. Which of the following should be AVOIDED by patient Sonia medical center in metro manila. Which of the following is NOT a
while she is being treated for hypothyroidism? major purpose of keeping a portfolio?
A. Use of warm blankets A. Keep on going records of skills development.
B. Light activities done at home B. Create a system for documenting accomplishment
C. Taking foods low in fiber C. Set career and educational goals.
D. Exposure to cold temperature D. Set system for a possible shift to another job.

Rationale: A professional portfolio, which all nurses should

Situation: Nurse Eileen has just passed the board
examination for nurses and set her goals for her nursing
career for the next 5 years. She is aspiring to become a
diabetes Nurse Educator after completing her 2 years as a
bedside nurse.
56. Which of the following can Nurse Eileen adopt to visualize
her future?
A Flow chart - contains yes and no; has pathway
B. Decision tree - contains yes and no; has pathway
C. Gantt chart
D. Decision grid - alternatives
Rationale:
Flow chart:
maintain, can be described as a collection of materials that
document a nurse's competencies and illustrate the expertise
of the nurse. The professional portfolio typically contains a
number of core components; biographical information,
educational background, certifications achieved and
employment history; a one- to two-page resumé; a
competency record or checklist; personal and professional
goals; professional development experiences, presentations,
consultations, and publications; professional activities;
community activities; honors and awards; and letters of thanks
from patients, families, peers, organizations, and others
(Sherrod, 2007). The individual needs to be selective in
collecting best-work documentation and only include those
materials that illustrate competency and highlight
achievement.
All nurses should maintain a portfolio to reflect their
professional growth throughout their career.
58. One area of the professional portfolio is to indicate one’s
philosophy of life. Which of the following workplace values
should Nurse Eileen consider as NOT favorable to be written in
her portfolio?
A. Customer service based on acceptance, empathy and
selfless duty.
B. Time and compensation Limiting her pursuit of
excellence in her job.
C. Commitment to continue lifelong and self-directed learning.
D. Challenge which can lead to growth, responsibility and
accountability.

59. In order for Nurse Eileen to be active as a bedside nurse, she

has to comply with the renewal of PRC ID by undertaking
continuing professional development (CPD) as mandated by the
CPD law. The purposes of which are development (CPD) as
mandated by the CPD law. The purpose of which are___
I. promote and upgrade the practice of the professional
II. improve the competence of the professional
III. international alignment of competence
IV. develop quality assurance for accreditation
A. II & III
Decision grid: B. I, II, III
C. I, II, III, & IV
D. I, & II

Additional Note: RA 10912 (CPD Act of 2016) → 45 Units

2017 → 15 Units 2019

60. Nurse Eileen is aware that her personal and professional

Gantt chart: portfolio has to include and keep up to date the following
EXCEPT___.
A. Certificate of CPD attended
B. Letters of reference
C. Photograph
D. Confidential information from past employers - red flag,
no!no!no!

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 RECALLS 8: NURSING PRACTICE 3
Situation: Mr. Reynaldo is tasked to conduct a study to
determine the level of patient satisfaction on the care they
received from the hospital. He plans to include; all adult
patients admitted from May-October, first admission with an
average length of complications. of hospital confinement of 4-
5 days, and with no complications.
61. Which of the following is an EXTRANEOUS variable of the
study?
A. Age of patient.
B. Absence of complications.
C. Length of stay 4-5 days.
D. Date of admission January-March.
Rationale: extraneous variable - not included in independent
and dependent variables but needs to be controlled because
it can affect the variables; contaminating variables
62. Which of the following variables will he likely EXCLUDE in
his study?
A. Salary of nurses
B. Caring attitude of nurse
C. Responsiveness of staff
D. Competence of nurses
63. He plans to use a Likert Scale to determine:
A. compliance to expected standards
B. degree of agreement and disagreement
C. level of satisfaction
D. degree of acceptance
Rationale: Likert scale is a composite measure of an attribute
involving the summation of scores on a set of items that
respondents typically rate for their degree of agreement or
disagreement.
64. Which criterion refers to the ability of the instrument to detect
fine differences among the subjects being studied?
A. Reliability
B. Sensitivity
C. Objectivity
D. Validity
Rationale:
OBJECTIVITY
→ The extent to which two independent researchers would
arrive at similar judgments or conclusions (i.e., judgments
not biased by personal values or beliefs).
RELIABILITY
→ The reliability of a quantitative measure is a major
criterion for assessing its quality. Reliability is the
consistency with which an instrument measures the
attribute. If a scale weighed a person at 120 pounds one
minute and 150 pounds the next, we would consider it
unreliable. The less variation an instrument produces in
repeated measurements, the higher its reliability.
→ Reliability also concerns a measure's accuracy. An
instrument is reliable to the extent that its measures
reflect true scores—that is, to the extent that
measurement errors are absent from obtained scores. A
reliable instrument maximizes the true
VALIDITY
→ The second important criterion for evaluating a
quantitative instrument is its validity. Validity is the degree
to which an instrument measures what it is supposed to
measure. When researchers develop an instrument to
measure hopelessness, how can they be sure that
resulting scores validly reflect this construct and not
something else, such as depression?
SENSITIVITY
→ The ability of a measure to identify a case correctly, that
is, to screen in or diagnose a condition correctly. A
measure's sensitivity is its rate of yielding “true positives.”
Specificity is the measure's ability to identify non-cases
correctly, that is, to screen out those without the
condition. Specificity is an instrument's rate of yielding
“true negatives.” To determine an instrument's sensitivity
and specificity, researchers need a reliable and valid
criterion of “caseness” against which scores on the
instrument can be assessed.
65. This technique refers to the use of multiple referents to
draw conclusions about what constitutes the truth.
A. Delphi technique - uses expert panels and is asked for
consultation
B. Meta-analysis - multiple studies is used (research of
different studies)
C. Triangulation
D. Experiment - has manipulation, randomization, control
group
Rationale: Triangulation - can change method (can change
sample, method of data collection, etc.); qualitative research;
to know the reality
→ Delphi survey: A technique for obtaining judgments from
an expert panel about an issue of concern; experts are
questioned individually in several rounds, with a
summary of the panel's views circulated between rounds,
to foster consensus.
→ Meta-analysis is a technique for integrating quantitative
research findings statistically. In essence, meta-analysis
treats the findings from a study as one piece of
information. The findings from multiple studies on the
same topic are combined and then all of the information
is analyzed statistically in a manner similar to that in a
usual study. Thus, instead of study participants being the
unit of analysis (the most basic entity on which the
analysis focuses), individual studies are the unit of
analysis in a meta-analysis. Meta-analysis provides a
convenient, objective method of integrating a body of
findings and of observing patterns that might not have
been detected.
Situation: Nurse Tarly, the research coordinator of a Tertiary
hospital where there was a growing concern of patients and
family complains that Nurses are “rude and cranky.” In
response to this she organized a core group to conduct a
study on the “caring behavior of staff nurses and
Satisfaction of women with Ostomy.
66. Based on the research statement, what is the independent
variable in the study?
A. staff-nurse
B. caring behavior
C. women with ostomy
D. satisfaction
Rationale: independent variable is the variable that is
believed to cause or influence the dependent variable; in
experimental research, the manipulated treatment variable.
67. What is the dependent variable in the study?
A. staff-nurse
B. ostomy
C. degree of satisfaction
D. caring behavior
Rationale: dependent variable is the variable hypothesized
to depend on or be caused by another variable (the
independent variable); the outcome variable of interest.
68. What are the relevant related literatures that Nurse Tarly
and her group mates can utilize in this study?
I. Caring behavior
II. ostomy pathogenesis
III. contentment and satisfaction
IV. concept of body image
A. III and IV
B. I, II and III
C. I and II
D. I, II, III and IV
RECALLS 8: NURSING PRACTICE 3
 RECALLS 8: NURSING PRACTICE 3
Rationale: Basis will be the keywords on the title: “caring
behavior of staff nurses and Satisfaction of women with
Ostomy.”
69. If Nurse Tarly and her core group decide to formulate a
directional hypothesis it will be___
A. There is an increased relationship between the caring
staff nurses and degree satisfaction of ostomized
patients.
B. The caring behavior of staff nurses is related to increased
satisfaction of ostomized patients. - vague
C. The staff nurse's behavior has an effect on the patient's
satisfaction on an ostomized patient.
D. A significant relationship exists between the caring of
ostomized patients
Rationale: Directional hypothesis is a hypothesis that makes
a specific prediction about the direction of the relationship
between two variables
70. Based on the research problem, what is the research design
of the study?
A. Quasi-experimental
B. Descriptive - describing the phenomena, variables
C. Ex Post-facto - “after the fact”
D. Experimental - no need for manipulation, and control group
Situation: Nurse Virgo admits Benito, 67-year-old, due to
severe abdominal and back pain and vomiting after attending
a party he had positive alcohol breath and was tentatively
diagnosed with pancreatitis. He was scheduled for diagnostic
laparotomy to further confirm the diagnosis.
Self-digestion of the pancreas by its own proteolytic enzymes,
principally trypsin
→ undiagnosed chronic pancreatitis
→ bacterial or viral infection
→ Spasm and edema of the ampulla of Vater, caused by
duodenitis
→ Blunt abdominal trauma
→ peptic ulcer disease
→ ischemic vascular disease
→ hyperlipidemia, hypercalcemia
→ alcohol consumption, use of tobacco products
→ corticosteroids, thiazide diuretics, oral contraceptives
71. Nurse Virgo gathers more appropriate data from patient
Benito. Which of the following APPROPRIATE questions should
Nurse Virgo ask?
1. “Can you describe your pain?”
2. “Is your urine yellow?” - the question should be “is your
urine dark yellow in color”
3. “Is your stool clay colored?” - d/t obstruction in bile
duct, bile cannot pass thru
4. “Do you drink alcohol often?” - frequency should be
asked and the amount
A. 2 and 4
B. 1 and 3
C. 1, 2, and 4
D. 1, 2, and 3
72. Patient Benito asks Nurse Virgo “Why can’t the surgeon just
take out my pancreas?” The BEST response of Nurse Virgo
is___
A. “your body needs function well with your pancreas”
B. “your attack will soon be overcome when you are at rest” -
concern is not addressed
C. “if your pancreas is removed, you can never eat fat and fried
foods again”
D. “antibiotic will relieve sign of infection”
73. Before Surgery, patient Benito is on nothing per formed
status (NPO). She tells Nurse Virgo that he is thirsty and hungry.
Which of the following is the BEST response of Nurse Virgo?
a. “You can sip only this amount of water to moisten your
mouth.”
b. “An NGT will be inserted to removed gastric secretions and
alleviate your thirst”
c. “I will give you ice stimulate your thirst”
d. “oral and fluid intake stimulates pancreatic enzymes
and pain” - will stimulate pancreatic enzymes
74. Nurse Virgo asks Patient Benito how can help to reduce pain
while waiting for his operation. Which is the most appropriate
question of Nurse Virgo?
A. “Are you ready for the operation? The pain will be soon over.”
B. “After operation everything will be alright”
C. “ Is your present position reducing pain?”
D. “Does exercise reduce your pain?”
75. Which of the following statements of patient Benito will
convince Nurse Virgo that his instructions for the prevention of
pancreatitis were understood by the patient? I will____
A. “increase my intake of high protein products - would lead to
increased production of pancreatic enzymes
B. “try to stop drinking alcohol”
C. “follow a high fat diet faithfully” - incorrect
D. “be careful of exposing myself to infections” - viral/bacterial
does not cause pancreatitis
Situation: The Department of Health (DOH) is an agency that
sets standards for safe and quality health care together with
Philhealth insurance which takes care accreditation and
reimbursement of cost of health care service.
76. The professional conduct of doctors, nurses and other
health care providers in the health facilities belong to which of
the following quality standards?
A. Improving performance
B. Organizational ethics
C. Patient care standards
D. Leadership and management
Rationale: conduct refers to behaviors and attitudes
77. The positive practice environment (PPE) is part of the
quality standards of every health facility in the country today.
Which of the following is NOT a component of PPE in the work
setting?
A. waste management
B. peer view
C. electrical wires
D. infection control
Rationale: performance evaluation of the staff; for human
resource management
→ Options ACD is for PPE
78. When a health facility formulates its Vision-Mission to guide
management and health personnel in the workplace is what part
of quality standards?
A. Human resource management - staff
B. Patient care standards
C. Leadership and management
D. Organizational ethics
79. When Nurse Sarah distributed a patient satisfaction survey
to be filled by the consumer upon discharge in a hospital
setting is in compliance to what quality standards?
A. Organizational structure standards
B. Identification of patient rights and welfare
C. Improving performance of health care personnel.
D. Human resource management and staffing pattern.
80. When an accurate documentation whether manually or by
electronic by what quality standards in a health care delivery
system?
A. Patient care management
B. Information management
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 RECALLS 8: NURSING PRACTICE 3
C. Leadership and management
D. Human resource management
Situation: Mr. Lam, a 44-year-old, male obese, married was
rushed to the Emergency room because of feeling nauseated,
with shortness of breath and severe chest pain radiating
to the back.
→ Acute Coronary Syndrome - PRIORITY
81. As a nurse, what is your PRIORITY step to be done in this
situation?
a. Palpate the point of maximal impulse - apical pulse;
palpated when patient has arrhythmias
b. Inspect the nail bed if cyanotic - late sign of hypoxia
c. Peaked P wave
d. Minimal ORS wave
Rationale: problem is in circulation → hypoxia
82. The physician confirmed that the patient is suffering from MI.
She was advised to be hospitalized and was given
streptokinase. Which of the following is the DESIRED effect of
the drug?
A. Dissolve clot formation
B. Reduce tissue damage of the heart.
C. Prevent dysrhythmia.
D. Reduce edema formation.
Rationale: Thrombolytics (Fibrinolytics)
Thrombolytic (fibrinolytic) therapy is initiated when primary
PCI is not available or the transport time to a PCI-capable
hospital is too long. These agents are administered IV
according to a specific protocol. The thrombolytic (fibrinolytic)
agents used most often are alteplase (Activase), reteplase
(Retavase), and tenecteplase (TNKase). The purpose of
thrombolytics (fibrinolytics) is to dissolve (i.e., lyse) the
thrombus in a coronary artery (thrombolysis), allowing blood
to flow through the coronary artery again (reperfusion),
minimizing the size of the infarction and preserving ventricular
function.
83. A 12 lead EKG was ordered by the physician. Which finding
in the EKG is suggestive evidence that the patient has
myocardial infarction (MI)?
A. Prominent segment elevation.
B. ST segment elevation.
C. Peaked P wave.
D. Minimal ORS wave.
Rationale:
→ >1 mm elevation: indicative of acute MI
84. As a nurse you are aware that a heart muscle damage after
an attack without treatment becomes permanent within____
hours?
A. 7-9
B. 10-12
C. 4-6
D. 1-3
85. In designing a care plan, which modifiable risk factors have
to be emphasized to the patient to prevent another heart attack
from happening?
1. Smoking
2. High blood pressure
3. High cholesterol
4. Overweight
A. 1, 2, & 3
B. 3 & 4
C. 1 & 2
D. 1, 2, 3, & 4
Situation: Ms. Nilda is a new graduate with a bachelor of
science degree which she acquired from a university. She is
determined to pass the national Licensure Examination (NLE)
to be administered by the board of nursing.
86. The licensure which is the administered by the professional
Regulation Commission, Board of nursing given to ___
A. apply the theory learned from the classroom to practice
settings
B. protect the public from incompetent practitioners
C. apply the scope of nursing practice
D. demonstrate expected competency standards
87. The PRC-Board of Nursing (PR-BON) has the power to
regulate Nursing Practice in the Philippines. The regulatory
function include the following except____
A. enforce and monitor quality standards of nursing practice in
the country
B. issue, suspend, revoke or reissue licensure in the country
registered nurses.
C. ensure proper conduct of nurse’s licensure in the country
D. issue permit from the opening of nursing programs in
the country - function of CHED
88. Ms. Sanchez is a new nursing graduate and in dire need for
the hospitalization of her ailing mother. She is being offered to
endorse a detergent product on a TV commercial wearing a mini
skirt and a plunging neckline shirt. In doing this performance
Ms. Sanchez is violating the___
A. oath of professional for a new nurse
B. nursing practice act 7164
C. code of ethics for nurses
D. core competency standards
Rationale: SECTION 10. Guidelines to be observed:
REGISTERED Nurses must:
a. perform their professional duties in conformity with
existing laws, rules regulations, measures, and generally
accepted principles of moral conduct and proper
decorum.
b. not allow themselves to be used in advertisement that
should demean the image of the profession (ie,
indecent exposure, violation of dress code, seductive
behavior, etc.).
c. decline any gift, favor or hospitality which might be
interpreted as capitalizing on patients.
d. not demand and receive any commission, fee or
emolument for recommending or referring a patient to a
physician, a co-nurse or another health care worker, not
to pay any commission, fee or other compensations to
the one referring or recommending a patient to them for
nursing care.
e. avoid any abuse of the privilege relationship which exists
with patients and of the privilege access allowed to their
property, residence or workplace.
89. Nurse Rey with the team of a tertiary hospital is going for
their annual outreach program “Operation TULI”. There were
300 patients who came in the morning with only 4 doctors, 3
nurses and 1 pharmacist. Due to the volume of patients Nurse
Rey, was asked to participate in performing circumcision
with the rest of the doctors. Nurse Rey can be liable of
committing___
A. assault
B. invasion of privacy
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 RECALLS 8: NURSING PRACTICE 3

C. tort
D. malpractice

Rationale: out of the nurse’s scope

Unintentional Torts
Negligence and professional negligence are examples of
unintentional torts that may occur in the healthcare setting.
Negligence is misconduct or practice that is below the
standard expected of an ordinary, reasonable, and prudent
individual. Such conduct places another individual at risk for
harm. Both nonmedical and professional individuals can be
94. Nurse Gladys, who is on morning shift, was making her
liable for negligent acts. Gross negligence involves extreme
lack of knowledge, skill, or decision making that the individual sounds when she observed Mr. Joe, who is suffering from
congestive heart failure, complaining of heaviness of his legs.
clearly should have known would put others at risk for harm.
She observed the patient to have an edema of his lower
Malpractice is "professional negligence," that is, negligence
extremities. If the edema is 3 plus, what do you expect the nurse
that occurred while the individual was performing as a
to write in her assessment findings?
professional. Malpractice applies to primary care providers,
A. Deeper pit, in 30 seconds.
dentists, and lawyers, and generally includes nurses. In some
B. Barely the pit is not perceptible.
states nurses cannot be sued for malpractice, only
C. Deeper pit, rebounds in only a few seconds.
professional negligence. The terms malpractice and
D. Deep pit, rebounds in 10-20 seconds.
professional negligence are often used interchangeably. Six
elements must be present for a case of nursing professional
negligence to be proven: Rationale:

90. Which of the following actions is likely to constitute

Negligence?
A. Complied with the request of a bedridden patient not to be
turned because of pain.
B. A nasogastric feeding is not given on time because the
patient is feeling nauseated. - possible of aspiration
C. A patient suffering from bleeding having to report to the
attending physician.
D. Urine output that has not been measured because of an → Grade 1 - returns immediately
emergency admission. → Grade 2 - returns <15 secs
→ Grade 3 - up to 30 secs
→ Grade 4 - >20 seconds
Situation: Documentation is a basic competency expected of
a graduate nurse when performing her role in the clinical
setting. 95. When auscultating the breath sounds of patients with
respiratory disorders they are instructed to breathe through their
mouth. A possible complaint the nurse has to watch and be
91. Mr. Rey had his insulin therapy on the day of his admission.
written in her documentation when performing this procedure is
On the second day he developed allergic reactions do you
which of the following?
expect the nurse to administration. What clinical manifestations
A. Palpitation
do you expect the nurse to write in her documentation as a
B. Dizziness
reaction to this drug?
C. Tachycardia
1. Redness
D. Bradycardia
2. Swelling
3. Tenderness
4. Induration Rationale: d/t too much loss of oxygen
A. 1, 2, & 3
B. 2 & 4
C. 1, 2, 3, 4 Situation: Mary, a hairstylist is experiencing periumbilical
D. 1 & 2 pain feeling feverish and nauseated while at work. She was
rushed to the hospital as the pain came intense at the right
92. Mr. Rey has been anxious regarding his diagnosis as well as lower quadrant of the abdomen. She was advised by the ER
the recent reaction to overcome this anxiety behavior is to__ physician to be admitted for further work-up.
A. conduct a family conference for the concern of the patient
B. refer to the physician for an order of tranquilizer 96. Nurse Ella admitted the patient and started to do her
C. express your empathy and respect for his feelings assessment. What sign is elicited by the nurse when a deep
D. take time to explain his disease process and effects of insulin palpation of the left iliac fossa is done and causes pain on the
right iliac fossa of the patient?
Rationale: Always choose the option “Kind and safe nurse” A. Obturator sign
B. Blumberg sign - rebound tenderness
93. When a patient a suffering from Ketoacidosis, you expect
C. Psoas sign
that the entry of nurses assessment findings in the chart will
D. Rovsing sign
include the following clinical manifestations EXCEPT___
A. kussmaul’s - releases CO2 to compensate for acidosis
brought by DKA Rationale:
B. cheyne stokes breathing - hypoventilation →
hyperventilation → apnea; heart failure and stroke
C. lethargy - the glucose is not used by the body
D. acetone breath odor - fruity odor

Additional Note: biyots: apnea → hyperventilation

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 RECALLS 8: NURSING PRACTICE 3

97. After a thorough physical examination, laboratory and

diagnostic test the physician ordered an emergency open
appendectomy due to prevent which of the following, MAJOR
complication?
A. Thrombosis
B. Sepsis
C. Perforation
D. Bleeding

Rationale: Complications
The major complications of appendicitis are gangrene or
perforation of the appendix, which can lead to peritonitis,
abscess formation, or portal pylephlebitis, which is septic
thrombosis of the portal vein caused by vegetative emboli that
arise from septic intestines. Perforation generally occurs
within 6 to 24 hours after the onset of pain and leads to
peritonitis (Craig, 2015; Saccomano & Ferrara, 2013).

98. The Nurse prepares the patient for surgery. The overall goals
by the surgical team for the patient going for operation include
which of the following?
1. Relief of pain
2. Preventing fluid volume deficit
3. Eliminating infection
4. Reducing anxiety reaction
A. I, II, III, & IV
B. I, II, & III
C. III, & IV
D. I, & II

99. As a safety alert, which of the following nursing measures

should be AVOIDED by the nurse prior to appendectomy?
A. Observe nothing by mouth
B. Administration of enema
C. Removal of nail polish
D. Instruct to urinate.

Rationale: Enema can lead to perforation

100. In wound care management, the nurse is aware NOT to

perform which of the following interventions?
A. Allow the wound to drain freely.
B. Maintenance of an acidic or neutral - alkaline is a fave of
bacteria
C. Application of cold pack solutions - to release inflammation
and has vasoconstrictive effect to reduce bleeding
D. Maintenance for a moist wound environment.

Rationale:
→ Airing out most wounds isn't beneficial because wounds
need moisture to heal. Leaving a wound uncovered may
dry out new surface cells (cleveland clinic. org)
→ Since then, moist dressings have become the standard
method for care for chronic wounds. A moist
environment has been proven to facilitate the healing
process of the wound by preventing dehydration and
enhancing angiogenesis and collagen synthesis together
with increased breakdown of dead tissue and fibrin ncbi
. nim. nih . gov 2013

RECALLS 8: NURSING PRACTICE 3