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SITUATION: to prevent further injury to patients with problems of immobility/mobility, the nurse should observe certain principles of body


1. Which of the following is the CORRECT guideline when positioning patients? a. Put pillows above a joint to immobilize it b. Support the joints with pillows c. Patients position should be changed at least three or four times a day d. Position of the joints should be slightly extended

SITUATION: Nurses perception of pain influences the way they perceived and interact with clients pain.

2. Which of the following MOST appropriately describe pain sensation that has periods of remission and exacerbation? a. Psychosomatic b. Acute c. Intractable d. Chronic 3. Non-pharmacologic pain management includes all of the following EXCEPT: a. Body movement b. Use of herbal medicines c. Massage d. Relaxation techniques 4. Zacha is constantly asking to be relieved from pain. Since morphine is an addicting drug, which of the following is BEST for the patient? a. Give instructions on relaxation technique to reduce frequency of pain sensation b. Administer morphine on a routine schedule as ordered c. Administer morphine P.R.N. d. Divert his attention by not limiting visitors 5. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is? a. Instruct client to go to sleep and relax b. Advice the client to close the lips and avoid deep breathing and talking c. Offer hot and clear soup d. Turn to sides frequently and avoid too much talking

SITUATION: As a nurse, you are aware that proper documentation in the patient chart is your responsibility. 6. Delegation is the process of assigning tasks that can be performed by subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation? a. The RN must supervise all delegated tasks b. After a task has been delegated, it is no longer a responsibility of the RN

c. The RN is responsible and accountable for the delegated task in adjunct with the delegate d. Follow-up with a delegated task is necessary only if the assistive personnel is not trustworthy

SITUTATION: at the medical-surgical ward, the nurse must also be concerned about drug interactions.

7. You have a client with TPN. You know that in TPN, like blood transfusion, there should be no drug incorporation. However, the MDs order read: incorporate insulin to present TPN. Will you follow the order? a. NO. because insulin will induce hyperglycaemia in patients with TPN b. YES, because insulin is chemically stable with TPN and can enhance blood glucose level c. NO, because insulin is not compatible with TPN d. YES, because it was ordered by the MD

8. How can nurse prevent drug interaction including absorption? a. Always flush with NSS after IV administration b. Administering drugs with more diluents c. Improving on preparation techniques d. Referring to manufacturers guidelines

SITUATION: Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience.

9. The following task can be safely delegated by a nurse to a non-nurse health worker EXCEPT: a. Transfer a client from bed to chair b. Change IV infusion c. Irrigation of a nasogastric tube d. Take vital signs

SITUATION: Caring, even if it comes from the innermost desire of nurses to extend help and lend assistance in the area of health promotion, disease prevention, cure and rehabilitative health care, or even to the point of rendering assistance towards peaceful death still requires high degree of ethico-moral-legal considerations. The following conditions apply:

10. Legally speaking, the information in the medical record is owned by: a. The doctor b. The client c. The hospital d. The caregivers

11. Another similar institutional abbreviated order is DNT which means: a. Do not treat b. Do not touch c. Do not transfuse blood d. Do not resuscitate

12. A document which specifies the desired types of medical treatment is called: a. Living will b. A holographic will c. A last will d. A good will

SITUATION: nursing involves all aspect of care across lifespan. One unique aspect of Nursing is that, it extends up to giving respectful and dignified dying. Post mortem care concerns not only the deceased patient but the family as well.

13. Which of the following is true regarding a patient with DNR order? a. The patient may no longer make decisions regarding his or her own health care b. The patient and the family recognize that the patient will most likely die within the next 48 hours c. Nurses will most likely continue to implement all treatments focused on comfort and symptom management d. A DNR order in place from a previous admission is valid for this and subsequent admissions

14. The nurses most important legal responsibility after the patients death in a hospital is : a. Obtain a consent of an autopsy b. Notifying the corner or medical examiner c. Labelling the corpse appropriately d. Ensuring that the attending physician issues the death certification

SITUATION: nurse is caring Mang Teroy, 60yrs old who develops stage I pressure ulcer related to immobility. Mang Teroy also has an established colostomy.

15. When caring Mang Teroy with stage I pressure ulcer on a sacral area, which of the following actions can the nurse perform independently? a. Clean the ulcer using 0.9% NaCl an apply a protective dressing as needed b. Massaging the area with an astringent every 4 hours c. Applying an antibiotic cream to the area three times per day d. Using a betadine wash on the ulceration three times per day

16. Which of the following patients is at greatest risk for developing pressure ulcer? a. A disoriented 79 y/o patient with CHF who requires assistance to get out of bed b. A apathetic 61 y/o COPD client receiving nasal oxygen via nasal cannula c. A 90 y/o incontinent patient with gastric cancer who is confined to his bed at home d. At alert, chronic arthritic patient treated with steroids and aspirin.

17. Nurse Amy is assessing Mang Teroys abdomen. Which finding should nurse Amy report as abnormal? a. A bowel sound occurring every 10 seconds b. Dullness over the liver c. Vascular sounds heard over the renal arteries d. Shifting dullness over the abdomen

SITUATION: nurse Yuda passed the board examination and is ready to pursue her profession in the clinical setting. To prepare herself, she reviews some basic principles for her practice nursing competently.

18. Which of the following should the nurse AVOID doing in preventing spread of infection? a. Recapping the needle before disposal to prevent injuries b. Never pointing a needle towards a body part c. Using only standard precaution to AIDS patients d. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie , with Nuetropenia

SITUATION: oral care is important part of hygienic practices and promoting client comfort

19. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep moistened by using: a. Salt solution b. Petroleum jelly c. Water d. Mentholated ointment

SITUATION: Eileen, 45 y/o is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39c.

20. Give the above assessment data, most immediate goal of the nurse would be which of the following: a. Prevent urinary complication b. Maintains fluid and electrolytes

c. Alleviate pain d. Alleviate nausea

21. After IVP a renal store was confirmed, a left nephrectomy was done. Her post-operative order includes daily urine specimen to be sent to the laboratory. Eillen has a Foley catheter attached to a urinary drainage system. How will you collect the urinary specimen? a. Remove urine from drainage tube with sterile needle and syringe and empty urine to flow catheter into specimen container b. Empty sample urine from collecting bag into specimen container c. Disconnect the drainage tube from indwelling catheter and allow urine to flow from catheter into the specimen container d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container.

22. How will you prevent ascending infection to Eileen who has an indwelling catheter? a. See to it that the drainage tubing touches the level of the urine b. Change the catheter every eight hours c. See to it that the drainage tubing does not touch the level of the urine d. Clean catheter may be used since urethral meatus is not a sterile area.

SITUATION: Mrs. Perla is admitted to your ward. The attending physician ordered prepare for thoracentesis this PM.

23. Which of the following nursing responsibility is essential in Mrs. Perla who will undergo thoracentesis? a. Support, and reassure client during the procedure b. Ensure that informed consent has been signed c. Determine if client has allergic reaction to local anesthesia d. Ascertained if chest x-rays and other test have been prescribed

24. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis? a. Place flat in bed b. Turn on the unaffected side c. Turn on the affected side d. On bed rest

SITUATION: nurses are expected to attend to patient requiring acute and immediate care.

25. Nurse Roxy is assisting a female client named Karen for immediate surgery, the nurse in-charge is aware that she should: a. Encourage the client to void following preoperative medication b. Explore the clients fears and anxieties about surgery c. Assist the client in removing dentures and nail polish d. Encourage the client to drink water prior to surgery