NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice SITUATIONAL- 74/100 Situation 1 – Mr.

Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg subcutaneously. 1. The indication for epinephrine injection for Mrs. Simon is to: A. Reduce anaphylaxis B. Relieve hypersensitivity to allergen C. Relieve respiratory distress due to bronchial spasm D. Restore client‘s cardiac rhythm 2. When preparing the epinephrine injection from an ampule, the nurse initially: A. Taps the ampule at the top to allow fluid to flow to the base of the ampule B. Checks expiration date of the medication ampule C. Removes needle cap of syringe and pulls plunger to expel air D. Breaks the neck of the ampule with a gauze wrapped around it 3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to: A. Inject needle at a 15 degree angle over the stretched skin of the client B. Pinch skin at the injection site and use airlock technique C. Pull skin of patient down to administer the drug in a Z track D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: A. Syringe 3-5 ml and needle gauge 21 to 23 B. Tuberculin syringe 1 ml with needle gauge 26 or 27 C. Syringe 2 ml and needle gauge 22 D. Syringe 1-3 ml and needle gauge 25 to 27 5. The rationale for giving medications through the subcutaneous route is: A. There are many alternative sites for subcutaneous injection B. Absorption time of the medicine is slower C. There are less pain receptors in this area D. The medication can be injected while the client is in any position Situation 2 – The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials. 6. Martha wants to do a study on this topic: ―Effects of massage and meditation on stress and pain‖. The type of research that best suits this topic is: A. Applied research B. Qualitative research C. Basic research D. Quantitative research

7. The type of research design that does not manipulate independent variable is: A. Experimental design B. Quasi-experimental design C. Non-experimental design D. Quantitative design 8. This research topic has the potential to contribute to nursing because it seeks to A. include new modalities of care B. resolve a clinical problem C. clarify an ambiguous modality of care D. enhance client care 9. Martha does review of related literature for the purpose of A. determine statistical treatment of data research B. gathering data about what is already known or unknown about the problem C. to identify if problem can be replicated D. answering the research question 10. Client‘s rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT: A. right of self-determination B. right to compensation C. right of privacy D. right not to be harmed Situation 3 – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario‘s nursing care plan is to loosen and remove excessive secretions in the airway. 11. Mario listens to Richard‘s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be: A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position 12. When documenting outcome of Richard‘s treatment Mario should include the following in his recording EXCEPT: A. Color, amount and consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of client before and after the procedure D. Significant changes in vital signs 13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT: A. Amount of food and fluid taken during the last meal before treatment

B. Respiratory rate, breath sounds and location of congestion C. Teaching the client’s relatives to perform the procedure D. Doctor‘s order regarding position restrictions and client‘s tolerance for lying flat 14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. In both percussion and vibration the hands are on top of each other and hand action is in tune with client‘s breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air Situation 4 – A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client. 16. When doing an initial assessment, the best way for you to identify the client‘s priority problem is to: A. Interview the client for chief complaints and other symptoms B. Talk to the relatives to gather data about history of illness C. Do auscultation to check for chest congestion D. Do a physical examination while asking the client relevant questions 17. Upon establishing Mr. Regalado‘s nursing needs, the next nursing approach would be to: A. Introduce the client to the ward staff to put the client and family at ease B. Give client and relatives a brief tour of the physical set up the unit C. Take his vital signs for a baseline assessment D. Establish priority needs and implement appropriate interventions 18. Mr. Regalado says he has ―trouble going to sleep‖. In order to plan your nursing intervention you will: A. Observe his sleeping patterns in the next few days B. Ask him what he means by this statement C. Check his physical environment to decrease noise level D. Take his blood pressure before sleeping and upon waking up 19. Mr. Regalado‘s lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach? A. Moisturize lower extremities to prevent skin irritation B. Measure fluid intake and output to decrease edema

C. Elevate lower extremities for postural drainage D. Provide the client a list of food low in sodium 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: A. Making a final physical assessment before client leaves the hospital B. Giving instructions about his medication regimen C. Walking the client to the hospital exit to ensure his safety D. Proper recording of pertinent data Situation 5 – Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension. 21. Considering her level of anxiety, the nurse can best assist Nancy by: A. Giving her activities to divert her attention B. Giving detailed explanations about the treatments she will undergo C. Preparing her and her family in case surgery is not successful D. Giving her clear but brief information at the level of her understanding 22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of: A. bargaining B. denial C. anger D. acceptance 23. The nurse visits Nancy and prods her to eat her food. Nancy replies ―what‘s the use? My time is running out.‖ The nurse‘s best response would be: A. ―The doctor ordered full diet for you so that you will be strong for surgery‖ B. ―I understand how you feel but you have to try for your children‘s sake‖ C. ―Have you told your doctor how you feel? Are you changing your mind about your surgery?‖ D. “You sound like you are giving up.” 24. The nurse feels sad about Nancy‘s illness and tells her head nurse during the end of shift endorsement that ―it‘s unfair for Nancy to have cancer when she is still so young and with two kids‖. The best response of the head nurse would be: A. Advise the nurse to ―be strong and learn to control her feelings‖ B. Assign the nurse to another client to avoid sympathy for the client C. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her D. Ask the other nurses what they feel about the patient to find out if they share the same feelings 25. Realizing that she feels angry about Nancy‘s condition, the nurse learns that being selfaware is a conscious process that she should do in any situation like this because: A. This is a necessary part of the nurse – client relationship process

Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles B. Your instruction would focus on prevention of skin irritation and breakdown by: A. wipe from anal area up towards the pubis D. Which would you include? A. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues: . Mrs. 31. 26. After urination. Mrs. instruct client to start wearing thin adult diapers C. high fiber diet C. Drying the skin with baby powder to prevent or mask the smell of ammonia C. what physical changes predispose her to constipation? A. loss of tone of the smooth muscles of the colon D. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. prolonged use of laxatives 29. tell client to drink less fluids to avoid accidents B. Seva. Using thick diapers to absorb urine well B. drink pineapple juice C. teach client pelvic exercise to strengthen perineal muscles 30. Seva also tells the nurse that she is often constipated. Instruction on health promotion regarding urinary elimination is important. Making sure that linen are smooth and dry at all times Situation 7 – Using Maslow‘s need theory. inhibition of the parasympathetic reflex B. excessive exercise B. Tell client to empty the bladder at each voiding 27. Breathing and Circulation are the physiological needs vital to life. decreased ability to absorb fluids in the lower intestines 28. 52 years old. Your most appropriate instruction would be to: A. The nurse‘s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. rising and drying of skin area that get wet with urine D. The nurse is a role model for the client and should be strong C. Because she is aging. no regular time for defecation daily D.B. Thorough washing. How the nurse thinks and feels affect her actions towards her client and her work D. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. ask the client to bring change of underwear ―just in case‖ D. The nurse has to be therapeutic at all times and should not be affected Situation 6 – Mrs. If burning sensation is experienced while voiding. Mrs. asks you about possible problems regarding her elimination now that she is in the menopausal stage. The nurse understands that one of these factors contributes to constipation: A. Airway. weakness of sphincter muscles of anus C.

Anemia 33. Brigitte with diarrhea 32. Apnea B. Rotating catheter as it is inserter with gentle suction 35. Sonnyboy with a fracture in the femur D. Abad. Hypoxemia D. In your health education class for clients with diabetes you teach them the areas for . the distance from the tip of the nose to the tip of the ear lobe D. When taking blood pressure reading the cuff should be: A. the distance from the tip of the nose to the middle of the neck C. tip of the nose to the base of the neck B. Santos that he has reduced oxygen in the blood. 36. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. deflated quickly after inflating up to 180 mmHg C. eight to ten inches 34. You noted from the lab exams in the chart of M. asthma D. deflated fully then immediately start second reading for same client B. bronchitis C. Hypoxia C. The primary cause of COPD is A. The nurse documents this condition as: A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed B. Abad. large enough to wrap around upper arm of the adult client 1 cm above brachial artery D. While doing nasopharyngeal suctioning on Mr. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery 37. You will do nasopharyngeal suctioning on Mr. This condition is called: A. Cyanosis B. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death world wide and is a preventable disease. Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood pressure readings.A. Orthopnea C. Using gloves to prevent introduction of pathogens to the respiratory system C. Tachypnea Situation 8 – You are assigned to screen for hypertension. Theresa with anemia C. Your guide for the length of insertion of the tubing for an adult would be: A. tobacco hack B. Applying no suction while inserting the catheter D. cigarette smoking 38. Dyspnea D. the nurse can avoid trauma to the area by: A. Carol with tumor in the brain B.

After the treatment. Assist in the police investigation since she is a witness C. Nurse Rivera is assigned to attend to the client with lacerations on the arms. smoking C. You teach your clients the difference between. Clean the wound vigorously of contaminants C. Assess the extent of injuries incurred by the victims of the accident 42. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology C. genetics D. proper nutrition 39. Control and reduce bleeding of the wound D. Noel who has lacerations on the arms with mild bleeding D. is pale and with difficulty breathing C. Report the incident immediately to the local police authorities D. the client is sent home and asked to come back for follow-up care. Apply antiseptic to prevent infection B. Linda who shows severe anxiety due to trauma of the accident B. Andy whose left ankle swelled and has some abrasions 43. Your responsibilities when the client is to be discharged include the following EXCEPT: . Assess damage to property B. Type I (IIDM) is characterized by fasting hyperglycemia D. nutrition Situation 9 – Nurse Rivera witnesses a vehicular accident near the hospital where she works. These are the following except: A. physical activity B. Type I (IDDM) and Type II (NDDM) diabetes. The nurse applies dressing on the bleeding site. regular physical activity B. Her priority nursing action would be to: A. Ryan who has chest injury. This intervention is done to: A. The most immediate nursing action would be to: A. Priority attention should be given to which of these clients? A. Promote hemostasis 45. thorough knowledge of foot care C. Type II (NIDDM) is characterized by abnormal immune response 40. Lifestyle-related diseases in general share areas common risk factors. both types diabetes mellitus clients are all prone to developing ketosis B.control of Diabetes which include all EXCEPT A. Allow the pus to surface faster C. Bandage the wound and elevate the arm 44. Protect the wound from microorganisms in the air D. While assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. In the emergency room. Which of the following is true? A. prevention nutrition D. She decides to get involved and help the victims of the accident 41. Reduce the need to change dressing frequently B.

A. Encouraging the client to go to the outpatient clinic for follow up care B. Accurate recording of treatment done and instructions given to client C. Instructing the client to see you after discharge for further assistance D. Providing instructions regarding wound care Situation 10 – While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor‘s appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment. 46. The purpose of your initial nursing interview is to: A. Record pertinent information in the client‘s chart for health team to read B. Assist the client find solutions to he her health concerns C. Understand her lifestyle, health needs and possible problems to develop a plan of care D. Make nursing diagnoses for identified health prob;ems 47. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this pain occurs about an hour after taking black coffee without breakfast for three weeks now. You will record this as follows: A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics B. After drinking coffee, the client experienced severe abdominal pain C. Client complained of intermittent abdominal pain an hour after drinking coffee D. Client reported abdominal pain an hour after drinking black coffee for three weeks now. 48. Geline tells you that she drinks black coffee frequently within the day to ―have energy and be wide awake‖ and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning a healthy balanced diet with Geline, you will: A. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet and drink plenty of fluids B. Plan a high protein diet, low carbohydrate diet for her considering her favorite food. C. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level. D. Discuss with her the importance of eating a variety of food from major food groups with plenty of fluids. 49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following? A. Caffeine products affect the central nervous system and may cause the mother to have a ―nervous breakdown‖ B. Malnutrition and its possible effects on growth and development problems in the unborn fetus C. Caffeine causes a stimulant effect on both mother and the baby D. Studies show conclusively that caffeine causes mental retardation 50. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of non-communicable diseases that are influenced by her lifestyle. These include the following EXCEPT: A. Cardiovascular diseases

B. Cancer C. Diabetes Mellitus D. Osteoporosis Situation 11 – Management of nurse practitioners is done by qualified nursing leaders who had clinical experience and management experience. 51. An example of a management function of a nurse is: A. Teaching patient do breathing and coughing exercises B. Preparing for a surprise party for a client C. Performing nursing procedures for clients D. Directing and evaluating the staff nurses 52. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone without consulting anybody. This type of leadership is: A. Laissez faire leadership B. Democratic leadership C. Autocratic leadership D. Managerial leadership 53. When the head nurse in your ward plots and approves your work schedules and directs your work, she is demonstrating: A. Responsibility B. Delegation C. Accountability D. Authority 54. The following tasks 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 infusions C. Irrigation of a nasogastric tube D. Take vital signs 55. You made a mistake in giving the medicine to the wrong client. You notify the client‘s doctor and write an incident report. You are demonstrating: A. Responsibility B. Accountability C. Authority D. Autocracy Situation 12 – Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs. 56. You are to measure the client‘s initial blood pressure reading by doing all of the following EXCEPT: A. Take the blood pressure reading on both arms for comparison B. Listen to and identify the phases of Korotkoff‘s sound C. Pump the cuff to around 50 mmHg above the point where the pulse is

obliterated D. Observe procedures for infection control 57. A pulse oximeter is attached to Mr. Dizon‘s finger to: A. Determine if the client‘s hemoglobin level is low and if he needs blood transfusion B. Check level of client‘s tissue perfusion C. Measure the efficacy of the client‘s anti-hypertensive medications D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops 58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: A. inconsistent B. low systolic and high diastolic C. higher than what the reading should be D. lower than what the reading should be 59. Through the client‘s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client‘s blood pressure for accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes 60. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours Situation 13 – The nurse‘s understanding of ethico-legal responsibilities will guide his/her nursing practice. 61. The principles that govern right and proper conduct of a person regarding life, biology and the health professionals is referred to as: A. Morality B. Religion C. Values D. Bioethics 62. The purpose of having a nurses‘ code of ethics is: A. Delineate the scope and areas of nursing practice B. Identify nursing action recommended for specific health care situations C. To help the public understand professional conduct expected of nurses D. To define the roles and functions of the health care givers, nurses, clients 63. The most important nursing responsibility where ethical situations emerge in patient care is to:

A. Act only when advised that the action is ethically sound B. Not takes sides, remain neutral and fair C. Assume that ethical questions are the responsibility of the health team D. Be accountable for his or her own actions 64. You inform the patient about his rights which include the following EXCEPT: A. Right to expect reasonable continuity of care B. Right to consent to or decline to participate in research studies or experiments C. Right to obtain information about another patient D. Right to expect that the records about his care will be treated as confidential 65. This principle states that a person has unconditional worth and has the capacity to determine his own destiny: A. Bioethics B. Justice C. Fidelity D. Autonomy Situation 14 – Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you know that this entails quality assurance programs. 66. The following mechanisms can be utilized as part of the quality assurance program of your hospital EXCEPT: A. Patient satisfaction surveys B. Peer review to assess care provided C. Review of clinical records of care of client D. Use of Nursing Interventions Classification 67. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is? A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice B. It refers to the scope of nursing practice as defined in Republic Act 9173 C. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing practice D. The Standards of Care includes the various steps of the nursing process and the standards of professional performance 68. you are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone? A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours C. Have the registered nurse, family and doctor sign the order D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 Hours 69. To ensure client safety before starting blood transfusions the following are needed

Teaching strategies and approaches when giving nutrition education is influenced by age. limit use of table salt and use condiments instead C. take baseline vital signs B. harmful effects of drugs and alcohol intake C. commercial preparation of dishes D. sex and immediate concerns of the group. Check client’s pulse. 1 tsp of salt/day but no patis and toyo 72. Your best response to Mr. 1 tbsp of salt/day with some patis and toyo D. limit intake of preserved or processed food 73. report incidence of non-communicable diseases to community health center B. blood should be warmed to room temperature for 30 minutes before blood transfusions is administered C. Doctor‘s order for restraints should be signed within 24 hours B. Bruno is: A. use herbs and spices D. Bruno. proficiency in doing breast self-examination D. blood type. Part of standards of care has to do with the use of restraints. get consent signed for blood transfusion 70. have two nurses verify client identification. educate as many people about warning signs of non-communicable diseases . Offer food and toileting every 2 hours Situation 15 – During the NUTRITION EDUCATION class discussion a 58 year old man. 5 gms per day or 1 tsp of table salt/day C. Mr. unit number and expiration date of blood D. Your presentation for a group of young mothers would be best if you focus on: A.before the procedure can be done EXCEPT: A. 1 tsp of salt/day with iodine and sprinkle of MSG B. Cancer cure is dependent on A. blood pressure and circulation every 4 hours D. diets limited in salt and fat B. Your instructions to reduce or limit salt intake include all the following EXCEPT: A. Mr. early detection and prompt treatment 75. cooking demonstration and meal planning 74. watching out for warning signs of cancer C. Which of the following statements is NOT true? A. shows increased interest. Remove and reapply restraints every 2 hours C. The role of the health worker in health education is to A. Bruno asks what the ―normal‖ allowable salt intake is. use of alternative methods of healing B. 71. eat natural food with little or no salt added B.

Atienza has lost 250 ml of gastric fluid. you administer the ophthalmic drops by instilling the eye drops: A. pressing the lacrimal duct C. 81. 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. The plan of the nurse supervisor is an example of A. Patches may be applied to distal part of the extremities like forearm C. 76. After checking all the necessary information and cleaning the affected eyelid and eyelashes. 200 ml/hour 78. She wants to ensure that there are nurses available daily to do health education classes. 190 ml per hour 77. Apply to hairless clean area of the skin not subject to much wrinkling B. Change application and site regularly to prevent irritation of the skin D. 150 ml per hour D. He is also losing gastric fluid which must be replaced every two hours. 275 ml/hour C. from the inner canthus going towards the side of the eye 80. 350 ml/hour B. focus on smoking cessation projects D. 100 ml per hour B. At what rate should the IV fluid be flowing hourly? A. Felipe. squeeze about 2 cm of ointment and gently close but not squeeze the eye B. directly onto the cornea B. in service education process . Mr. into the outer third of the lower conjunctival sac D. Between 8 am and 10 am. You are to apply a transdermal patch of nitoglycerin to your client. Mr. 400 ml/hour D. The endorsement includes the IV infusion and medications for these clients. the following guidelines apply EXCEPT: A. hold the tube above the conjunctival sac. 210 ml per hour C. Wear gloves to avoid any medication on your hand 79. monitor clients with hypertension Situation 16 – You are assigned to take care of 10 patients during the morning shift. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of 1800ml. Mr. How much fluid should he receive at 11 am? A. do not let tip touch the conjunctiva Situation 17 – The staff nurse supervisor requests all the staff nurses to ―brainstorm‖ and learn ways to instruct diabetic clients on self-administration of insulin. You will be applying eye drops to Miss Romualdez. When applying eye ointment.C. apply the ointment from the inner canthus going outward of the affected eye C. The following are important guidelines to observe EXCEPT: A. discard the first bead of the eye ointment before application because the tube is likely to expel more than desired amount of ointment D.

most know how to perform task delegated 83. increasing human resources D.B. tell her to take the day off C. grievance B. empathize with the nurse and listen to her B. hospital extension program C. advance training D. delegates aspects of the clients care to the nurse-aide who is an unlicensed staff. collective bargaining D. The provision of health information in the rural areas nationwide through television and radio programs and video conferencing is referred to as: A. Mrs. height and weight measurement. makes the assignment to teach the staff member B. outreach program B. continuing education Situation 18 – There are various developments in health education that the nurse should know about: 86. Guevarra. primary prevention 82. This type of program is referred to as A. barangay health program D. efficient management of human resources C. appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. a nurse. arbitration C. does not have to supervise or evaluate the aide D. smoking cessation classes and aerobics class services. the new nurse. Community health program B. Wellness program D. inservice education C. Red Cross program 87. ask about her family life 84. Guevarra A. Connie. is assigning the responsibility to the aide but not the accountability for those tasks C. wellness program . The nurse supervisor should A. When Mrs. strike 85. Process of formal negotiations of working conditions between a group of registered nurses and employer is A. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. discuss how she is adjusting to her new job D. This is A. A nearby community provides blood pressure screening. professional course towards credits B. Telehealth program C.

‖ The most appropriate nursing response would be: A. Ronnie asks you ―Do I have a fracture? I don‘t want to have a cast. secondary prevention C. Poison Control 90. Nurse Beatrice is providing tertiary prevention to Mrs. 93. This statement shows that the nurse has correct understanding of the use of cold compress: . Ostrea has a schedule for Pap Smear. After cleaning the abrasions and applying antiseptic.88. Part of teaching client in health promotion is responsibility for one‘s health. primary prevention Situation 19 – Ronnie was in a vehicular accident where he sustained injury to his left ankle. An example of tertiary provestion is A. tertiary prevention B. Take him to the radiology section for X-ray of affected extremity B. the nurse applies cold compress to the swollen ankle as ordered by the physician. Self-examination for breast cancer C. ―Based on my assessment. Goals and intervention developed by the nurse and client should be approved by the doctor C. Allaying his anxiety by telling him that he only sustained a minor injury 94. ―You have to have an x ray first to know if you have a fracture‖. You establish rapport with him and to reduce his anxiety you initially: A. De Villa. Client will decide the goals and interventions required to meet her goals 89. In the Emergency Room. C. health screening D. there doesn‘t seem to be a fracture‖. “You seem to be concerned about being in a cast‖. Identify yourself and state your purpose in being with the client C. When Danica states she needs to improve her nutritional status this means: A. Nurse will decide goals and interventions needed to meet client goals D. The nurse can best assist him by: A. Do inspection and palpation to check extent of his injuries 92. Goals and interventions to be followed by client are based on nurse‘s priorities B. While doing your assessment. This is an example of A. Informing him that he is being treated by a very competent health team so he has nothing to worry about C. 91. She has a strong family history of cervical cancer. Asking the doctor to give an order for a sedative to call him down B. you notice how anxious he looks. ―Why do you sound so scared? It is just a cast and it‘s not painful‖. B. Talk to the physician for an order of Valium D. D. Mrs. Identifying complication of diabetes D. Marriage counseling B. Identifying his level of anxiety to determine how much information he can understand D. Ronnie is very anxious and is unaware of the extent of his injury.

The effects of regular nurse visits to client’s bedside on the number of client’s calls to the nurse C. Identifying clinical problem C. Developing guidelines for patient care D. It is safer to apply than hot compress C. Cold compress prevents edema and reduces pain D. She instructed the interviewees not to tell the interviewees that the data gathered are for her own research project for publication. A nurse preceptor observes that many clients are being readmitted in the ward for postoperative infections. Researchability 100. A study on benefits of pre-operative health instructions to client‘s feeling of anxiety D. She suggests to the students that they do a research on this topic. Disclosure C. Data analysis is to be done and the nurse researcher wants to include variability. she analyzes how much time.A. Ronnie is instructed to continue applying 30 minute cold at home and start 30 minute hot compress the next day. Before the nurse researcher starts her study. materials and people she will need to complete the research project. Variance . Reliability D. Feasibility C. Which of the following is based on quantitative research? A. Privacy D. What research activity is this? A. You explain that the use of hot compress: A. Produces anesthetic effect B. 96. Cold compress reduces blood viscosity in the affected area B. This analysis prior to beginning the study is called: A. Self-determination 97. Not be harmed B. Validity B. Increase oxygenation to the injured tissues for better healing D. This teacher has violated the student‘s right to: A. Data collection 98. A study on the effects of touch on the client‘s feelings of isolation 99. After receiving prescription for pain medication. Induces vasoconstriction to prevent infection Situation 20 – A nursing professor assigns a group of students to do data gathering by interviewing their classmates as subjects. money. A study on the effects of the white uniform of hospital personnel on pediatric patients B. Increases nutrition in the blood to promote wound healing C. Quantitative research involves numerical data. These include the following EXCEPT: A. Sharing research results with colleagues B. It eliminates toxic waste products due to vasodilation 95.

One centimeter above the symphysis pubis 5. Mean NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child SITUATIONAL—81/100 Situation 1 – Nurse Minette is an Independent Nurse Practitioner following-up referred clients in their respective homes. 350 kcal/day B. She sleeps as if exhausted from the effort of labor 4. She tells you she was in a lot of pain all during labor C. Within 1 hour after discharge D. At 6-week postpartum visit what should this postpartal mother‘s fundic height be? A. Drink more milk.B. Standards of Deviation D. She urges the baby to stay awake so that she can breast-feed him or her B. 200 kcal/day D. Inverted and palpable at the cervix B. She says that she has not selected a name for the baby as yet D. so she is reluctant to increase her caloric intake for breast-feeding. increased calcium intake prevents constipation D. 1. Within 24 hours after discharge C. No longer palpable on her abdomen D. Six fingerbreadths below umbilicus C. When is a first home-care visit typically made? A. Within 1 week of discharge 2. Walk for at least half an hour daily to stimulate peristalsis C. Range C. Here she handles a case of POSTPARTIAL MOTHER AND FAMILY focusing on HOME CARE. which of the following actions would alert you that a new mother is entering a postpartal taking-hold phase? A. By how much should a lactating mother increase her caloric intake during the first 6 months after birth? A. the professional growth and development of Nurses with specialties shall be addressed by a Specialty Certification . Leah is developing constipation from being on bed rest. This postpartal mother wants to loose the weight she gained in pregnancy. 500 kcal/day C. Nurse Minette needs to schedule a first home visit to OB client Leah. Within 4 days after discharge B. Drink eight full glasses of fluid such as water daily 3. What measures would you suggest she take to help prevent this? A. 1000 kcal/day Situation 2 – As the CPE is applicable for all professional nurse. Eat more frequent small meals instead of three large one daily B. If you were Minette.

The Board of Nursing shall oversee the administration of the NSCP through the various Nursing Specialty Boards which will eventually be created C. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council. therefore. Which of the following serves as the legal basis and statute authority for the Board of Nursing to promulgate measures to effect the creation of a Specialty Certification Council and promulgate professional development programs for this group of nurse-professionals? A. The Board of Nursing at the time exercised their powers under R. B. R. A. The following questions apply to these special groups of nurses. and (c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge.D. R. and (b) As necessary consequence. 14 Series of 1999 entitled: ―Adoption of a Nursing Specialty Certification Program and Creation of Nursing Specialty Certification Council. Which of the following IS NOT a correct statement as regards Specialty Certification? A.A. which two (2) of the following serves as the strongest for its enforcement? (a) Advances made in Science and Technology have provided the climate for specialization in almost all aspects of human endeavor. and (d) Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care.‖ This rule-making power is called: A. b & c are strong justifications B. Executive/Promulgating Power 8. the PRC-Board of Nursing released Resolution No. a & d are strong justifications 9. Quasi-Judicial Power B. 6. P. Quasi-Legislative Power D. R. By force of law. industry and services imposed by the national laws of countries all over the world. . 223 C. The Board of Nursing consulted nursing leaders of national nursing associations and other concerned nursing groups which later decided to ask a special group of nurses of the program for nursing specialty Certification. a & c are strong justifications D.A. 9173 D. 7164 7. 7164 in order to adopt the creation of the Nursing Specialty Certification Council and Program D. 7610 B.A.A. The Board of Nursing intended to create the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals. there has emerged a new concept known as globalization which seeks to remove barriers in trade. Regulatory Power C. a & b are strong justifications C.Council.

Situation 3 –Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for Nurses in the Philippines. the application of professional judgment in estimating importance of facts to family and community B. a member from the Academe. evaluation B. chosen from among the Regulatory Board members. implementation D.1 MEMBER FROM PNA. and the last member coming from the Regulatory Board B. The chairperson and members of the Regulatory Board ipso facto acts as the CPE Council C. D. In community health nursing it is important to take into account the family health data coupled with an equally important need to perform ocular inspection of the area as activities which are powerful elements of: A. 11. In community health nursing. The extended members of every family C. The Family 13. goal-setting B. which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice. carrying out nursing procedures as per plan of action 14. which of the following is our unit of service as nurses? A. A Chairperson who is the President of the Association from the Academe. two other members also chosen atlarge. The individual members of the Barangay D. Prevention of illnesses C. The initial step in PLANNING process in order to engage in any nursing project or activities at the community level involves A. and one representing the consumer group. The community B. Which of the following is the primary focus of community health nursing practice? A. A very important part of the Community Health Nursing Assessment Process includes: A. Rehabilitation back to health D. A Chairperson who is the current President of the APO. assessment C. coordination with other sectors in relation to health concerns D. A Chairperson. Who shall comprise the NSCC? A. a Vice Chairperson appointed by the BON at-large. monitoring . Cure of illnesses B.10. 1 FROM ADPCN AND 1 FROM BON WHO WILL BE THE CHAIRPERSON. a member from the Regulatory Board. planning 15. The NSCC was created for the purpose of implementing the Nursing Specialty policy under the direct supervision and stewardship of the Board of Nursing. and the last member coming from the APO · NO CORRECT ANSWER : ANSWER IS . She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City. evaluation structures and qualifications of health center team C. Promotion of health 12.

Toxoplasmosis 19. . C. The nurse interprets this as: A. 16. Fetopelvic disproportion 18. Sperm can no longer reach the ova. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor? A. Hepatitis D. Only if there is a large viral load in the blood C. Contracted pelvis B. provision of data Situation 4 – Please continue responding as a professional nurse in these other health situations through the following questions. The nurse would anticipate that the client will have: A. Which would be the best answer? A. In all infants born to women with HIV infection 17. Dina. evaluation of data D. Frequent leg cramps D. Stimulate uterine contractions Situation 5 – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. the nurse determines that the client‘s fetus is in an occiput posterior position. A precipitous birth B. Cervical insufficiency D. Most commonly as a result of sexual contact D. After a vaginal examination. because the fallopian tubes are blocked D. Soften and efface the cervix B. Human papilloma virus C. Maternal disproportion C. Intense back pain C. Herpes-simplex virus B. Nausea and vomiting 20. The ovary no longer releases ova as there is no where for them to go. Transmission of HIV from an infected individual to another person occurs: A. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to: A. Sperm can not enter the uterus because the cervical entrance is blocked. The following conditions pertain to meeting the nursing needs of this particular population group. 21.C. 17 years old. Prevent cervical lacerations D. Most frequently in nurses with needlesticks B. asks you how a tubal ligation prevents pregnancy. The medical record of a client reveals a condition in which the fetus cannot pass through the maternal pelvis. Numb cervical pain receptors C. Prostaglandins released from the cut fallopian tubes can kill sperm B.

Lilia‘s cousin on the other hand. DPT 29. Measles vaccine B. Donor sperm are introduced vaginally into the uterus or cervix B. Lilia is scheduled to have a hysterosalphingogram. Tetanus toxoids C. The husband‘s sperm is administered intravenously weekly Situation 6 – There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION. a couple has wanted a child for 6 months 23. between -4 deg C and +8 deg C B. She will not be able to conceive for 3 months after the procedure B. the ovaries stop producing adequate estrogen D. between -8 deg C and 0 deg C D. A. This vaccine content is derived from RNA recombinants. endometrial implants can block the fallopian tubes B. Hepatitis B vaccines D. these include: 26. Infertility is said to exist when: A. Donor sperm are injected intra-abdominally into each ovary C. a couple has been trying to conceive for 1 year D.22. The Dators are a couple undergoing testing for infertility. Tetanus toxoids 28. This is the vaccine needed before a child reaches one (1) year in order for him/her to . This condition interferes with fertility because: A. pressure on the pituitary leads to decreased FSH levels 24. Many women experience mild bleeding as an after effect D. Which of the following vaccines is not done by intramuscular (IM) injection? A. a woman has no uterus B. Hepa-B vaccine D. Which of the following instructions would you give her regarding this procedure? A. Artificial sperm are injected vaginally to test tubal patency D. the uterine cervix becomes inflamed and swollen C. Another client named Lilia is diagnosed as having endometriosis. DPT C. Measles B. The correct temperature to store vaccines in a refrigerator is: A. She may feel some cramping when the dye is inserted 25. knowing nurse Lorena‘s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. between -8 deg C and +4 deg C 27. a woman has no children C. between 2 deg C and +8 deg C C. The sonogram of the uterus will reveal any tumors present C.

Tetanus toxoid 2 C. The nurse completes the information in this record particularly his/her basic personal data. primary medical diagnosis. Medicine and Treatment Record 34. This special form is used when the patient is admitted to the unit. Discharge Summary D. DPT B. health history of the family. These are sheets/forms which provide an efficient and time saving way to record information that must be obtained repeatedly at regular and/or short intervals of time. Tetanus toxoid 3 B. current orders of the physician to be carried out by the nurse. postoperative care. What is this? A. . Nursing records normally differ from institution to institution nonetheless they follow similar patterns of meeting needs for specific types of information. It has 2-parts: the activity and treatment section and a nursing care plan section. BCG 30. This does not replace the progress notes. Measles C. intake and output. These records show all medications and treatment provided on a repeated basis. nursing orders. This flip-over card is usually kept in a portable file at the Nurse‘s Station. post partum care. Tetanus toxoid 4 Situation 7 – Records contain those comprehensive descriptions of patient‘s health conditions and needs and at the same serve as evidences of every nurse‘s accountability in the care giving process. Nursing Kardex D. Nursing Health History and Assessment Worksheet C. Nursing Kardex B. Nursing Health History and Assessment Worksheet B. This carries information about basic demographic data. current illness. Discharge Summary C. Graphic Flow Sheets C. Hepatitis B D. instead this record of information on vital signs. Medicine and Treatment Record 33. A. Nursing Kardex B. etc. safety precautions in patient care and factors related to daily living activities. This is used whenever specific measurements or observations are needed to be documented repeatedly. emotional profile. environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record? A. treatment. Which of the following dose of tetanus toxoid is given to the mother to protect her infant from neonatal tetanus and likewise provide 10 years protection for the mother? A. scheduled tests and procedures. 31. Medicine and Treatment Record D. Discharge Summary 32. and diabetic regimen. written nursing care plan. Tetanus toxoid 1 D. previous health history. What do you call this record? A. The following pertains to documentation/records management.qualify as a :fully immunized child‖.

Accurate documentation of actions and outcomes 38. 39. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing accredited through the: . Nursing Health History and Assessment Worksheet Situation 8 – As Filipino Professional Nurses we must be knowledgeable about the Code of Ethics for Filipino Nurse and practice these by heart. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of Filipino Nurses? A. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. 37. time. The present code utilized the Code of Good Governance for the Professions in the Philippines D. what is regarded as the hallmark of nursing responsibility and accountability? A. Nursing Kardex 35. Health. Nursing Kardex C. Nurse Reviewers and/or nurse review center managers who pays a considerable amount of cash for reviewees who would memorize items from the licensure exams and submit these to them after the examination. D. being a fundamental right of every individual D. A nurse endorsing a person running for congress. A nurse withholding harmful information to the family members of a patient B. Medicine and Treatment Record C. What do you call this? A. What record is this? A. Medicine and Treatment Record D. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates C. Nursing Health History and Assessment Worksheet D. Discharge Summary B. Which of the following is TRUE about the Code of Ethics of Filipino Nurses? A. A nurse declining commission sent by a doctor for her referral C. 36. directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. Most nurses regard this conventional recording of the date. Based on the Code of Ethics for Filipino Nurses. The privilege of being a registered professional nurses C. Discharge Summary B. regardless of creed and gender B. The next questions pertain to this Code of Ethics. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. and mode by which the patient leaves a healthcare unit but this record includes importantly.This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated B. Human rights of clients.

maintain the patient‘s right to privacy Situation 9 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particular women with preexisting or Newly Acquired illness. What should Joanna educate her about in regard to this? A. The following conditions apply 41. safeguard the well being of every patient D. works in a nursing home. . Association of Deans of Philippine Colleges of Nursing D. Lacerations can provoke allergic responses because of gonadothropic hormone B. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed heparin sub-Q. Bernadette received a laceration on her leg from her automobile accident. Some infants will be born with allergic symptoms to heparin B. She has developed gestational diabetes 42. A woman is less able to keep the laceration clean because of her fatigue D. Nursing Specialty Certification Council C. I take an iron pill every day to help grow new red blood cells C.N. Which condition would make her more prone than others to developing a Candida infection during pregnancy? A. Aspirin can lead to deep vein thrombosis following birth B. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. She usually drinks tomato juice for breakfast D. Healing is limited during pregnancy. Mr. She was over 35 when she became pregnant C. Newbors develop withdrawal headaches from salicylates D. What statement signifies this fact? A. B. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. R. and he knows that one of his duties is to be an advocate for his patients. Why should she limit or discontinue this toward the end of pregnancy? A. I understand why folic acid is important for red cell formation 44. Her husband plays golf 6 days a week B. A. Heparin can cause darkened skin in newborns D. Santos knows a primary duty of an advocate is to. Newborns develop a red rash from salicylate toxicity C. so these will not heal until after birth. Why are lacerations of lower extremities potentially more serious in pregnant women than others? A. act as the patient‘s legal representative B.A. Santos. Heparin does not cross placenta and so does not affect a fetus 43. Increased bleeding can occur from uterine pressure on leg veins C. Bernadette is a 22-year old woman. Salicylates can lead to increased maternal bleeding at childbirth 45. complete all nursing responsibilities on time C. Philippine Nurse Association 40. Professional Regulation Commission B. Mr. I am careful to drink at least eight glasses of fluid every day D. I’ve stopped jogging so I don’t risk becoming dehydrated. Her infant will be born with scattered petechiae on his trunk C.

Wheezing B. Assess the patient using the chart on management of children with cough C. referral to the hospital is of the essence especially if the child manifests which of the following? A. Theresa. Teach the mother how to count her child‘s breathing 47. a mother with a 2 year old daughter asks. Teach mothers how to recognize early signs and symptoms of pneumonia B. Which of the following is the principal focus of the CARI program of the Department of Health? A. Seek assistance and mobilize the BHWs to have a meeting with mothers 50.Situation 10 – Still in your self-managed Child Health Nursing Clinic. Giving antibiotics B. The following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions. Teach other community health workers how to assess patients. Make home visits to sick children C. As early as 1 year old C. Give cotrimoxazole tablet or syrup B. Enhancement of health team capabilities B. When she‘s 3 years old**** . Refer to the doctor D. ―at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?‖ Your answer to this is: A. 46. you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS. Which of the following is the most important responsibility of a nurse in the prevention of unnecessary deaths from pneumonia and other severe diseases? A. Fast breathing D. 51. Teach mothers how to detect signs and where to refer C. You were able to identify factors that lead to respiratory problems in the community where your health facility serve. At 2 years you may B. Difficulty to awaken 48. Mortality reduction through early detection D. Josie brought her 3 months old child to your clinic because of cough and colds. Refer cases to hospitals D. Weighing of the sick child 49. Situation 11 – You are working as a Pediatric Nurse in you own Child Health Nursing Clinic. Taking of the temperature of the sick child C. Your primary role therefore in order to reduce morbidity due to pneumonia is to: A. Which of the following is your primary action? A. In responding to the care concerns of children with severe disease. Stop feeding well C. Provision of Careful Assessment D.

Marasmus 57. When a child has symptoms of epiglottitis D. What is a method used to treat hyperbilirubinemia in a newborn? A. Morphine Sulfate C. They are more active than usual so throw off covers C. Baby John develops hyperbilirubinemia. When children are under 5 years of age 53. Administration of cardiovascular stimulant C. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor. You assessed a child with visible severe wasting. They are preterm so are born relatively small in size 55. edema B. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature? A. Their skin is more susceptible to conduction of cold D.D. Naloxone (Narcan) B. When she‘s 6 years old 52. Gentle exercise to stop muscle breakdown D. 56. When is it important NOT to elicit a gag reflex? A. do not give BCG if the child has known hepatitis C. do not give BCG if the child has known AIDS 58. Penicillin G 54. he has: A. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1 B. When a boy has a possible inguinal hernia C. The following questions apply. Which of the following statements about immunization is NOT true: A. do not give DPT to a child who has recurrent convulsion or active neurologic disease D. Kwashiorkor D. They do not have as many fat stores as other infants B. Keeping infants in a warm and dark environment B. when a girl has a geographic tongue B. What drug is commonly used for this: A. A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit . Early feeding to speed passage of meconium Situation 12 – You are the nurse in the Out-Patient Department and during your shift you encountered multiple children‘s condition. Sodium Chloride D. LBM C. Which of the following conditions is NOT true about contraindication to immunization? A. You typically gag children to inspect the back of their throat.

of the rapid growth of the fetus 64. Feeling fetal kicks . and fetal heart cannot be heard D. not very low weight no anemia Situation 13 – Nette. Spotting related to fetal implantation B. a nurse palpates the abdomen of Mrs. moderate anemia/normal weight B. The woman should lie in a supine position with her knees flexed slightly B. At the level of the umbilicus. There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center before referral are both correct D. A child has some palmar pallor can be classified as: A. and the baby is just about to move C. and the fetal heart can be heard with a fetoscope B. Symptoms of diabetes as human placental lactogen is released C. The nurse assesses the woman at 20 weeks gestation and expects the woman to report: A. a primigravida. moderate malnutrition/anemia B. severe malnutrition/anemia C. The obstetrician told that she appears to be 20 weeks pregnant. she is expressing pressure C. The hands of the nurse should be cold so that abdominal muscles would contract and tighten C. not very low weight no anemia D. Leopold‘s Maneuver is done. Be certain that your hands are warm (by washing them in warm water first if necessary) D. A child should be immunized in the health center before referral 59. She is unsure of the date of her last menstrual period. anemia/very low weight 60. In doing Leopold‘s Maneuver palpation which among the following IS NOT considered a good preparation: A. and fetal heart can be heard with a Doppler 62. The woman empties her bladder before palpation 63. she experienced fatigue and drowsiness. Nette explains this because the fundus is: A. of high blood pressure B. There is no contraindication to immunization if the child is well enough to go home C. 18 cm. Is just over the symphisis. A child with visible severe wasting or severe palmar pallor may be classified as: A. the fetus utilizes her glucose stores and leaves her with a low blood glucose D. In her pregnancy. 61. anemia/very low weight D. severe malnutrition/anemia C.B. 28 cm. This probably occurs because: A. Medina.

Hyperemesis Gravidarum D. fundic ht. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. Therapeutic or spontaneous abortion D. Cervix open.D. Medina comes to you for check-up on June 2. Hypoinsulinemia develops early in the first trimester C. When providing prenatal education to a pregnant woman with asthma. what do you expect during assessment? A. FH-midway between the umbilicus and symphysis pubis C. Butorphanol D. her EDC is June 11. There is progressive resistance to the effects of insulin 69. Glucose levels decrease to accommodate fetal growth B. 2 fingers below xyphoid process. which of the following would be important for the nurse to do? A. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child brought to your clinic? A. Diazepam 67. Abruprtion Placenta Situation 15 – One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital . Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy? A. Blood transfusion after hemorrhage C. engaged B. Fundic ht. Fundic height at least at the level of the xyphoid process. Phenobarbital B. Head injury from a car accident 68. Which of the following would the nurse include when describing the pathophysiology of gestational diabetes? A. Nausea and vomiting related HCG production 65. Mrs. Pregnancy fosters the development of carbohydrate cravings D. Demonstrate how to assess her blood glucose levels B. Unsuccessful artificial insemination procedure B. The nurse is aware that in addition to pregnancy. Ensure she seeks treatment for any acute exacerbation D. uneffaced. Nifedipine C. 66. engaged Situation 14 – Please continue responding as a professional nurse in theses varied health situations through the following questions. Teach correct administration of subcutaneous bronchodilators C. 2 fingers below xyphoid process. floating D. Rh-negative women would also receive this medication after which of the following? A. Placenta Previa C. Rh incompatibility B. Cervix close. Explain that she should avoid steroids during her pregnancy 70.

and in the implementation of health programs and projects you experience vividly as well the varying forms of leadership and management from the Barangay Level to the Local Government/Municipal or City Level. cleaning of the CHN bag D. contains basic medications and articles used by the community health nurse D. which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area? A. protection of the CHN bag B. meaning and direction to a company. Management is the process by which administration achieves its mission. a tool used by the Community health nurse is rendering effective nursing procedures during a home visit 72. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases D. goals. The community/Public Health Bag is: A. an essential and indispensable equipment of the community health nurse C. values give vitality. . arrangement of the contents of the CHN bag C. so the company becomes. Minimize if not totally prevent the spread of infection 74. Management effectiveness can be measured in terms of accomplishment of the purpose of the organization while management efficiency is measured in terms of the satisfaction of individual motives. The bag should contain all necessary supplies and equipment ready for use C. As the people of an organization value. Arrangement of the bag‘s contents must be convenient to the nurse B. and objectives. The upper tip D. In consideration of the steps in applying the bag technique. 76. It helps render effective nursing care to clients or other members of the family B. It should not overshadow concerns for the patient 73. Which among the following is important in the use of the bag technique during home visit? A. The outer surface C. a requirement for home visits B. Values make people persons. This is an important procedure of the nurse during home visits. An organization (or company) is people. The following statements can correctly be made about Organization and management: A. proper hand washing 75. It saves time and effort of the nurse in the performance of nursing procedures C. C. What is the rationale in the use of bag technique during home visits? A.facility for our practice?‘ 71. The lower lip B. A. B. The inside surface Situation 16 – As a Community Health Nurse relating with people in different communities. It should minimize or prevent the spread of infection from individuals to families D.

values. A and D are correct B. Only C and are correct C. national goals 78. B and C only C. Considers the achievement and advancement of the organization she/he represents as well as his people B. Which type of research inquiry investigates the issues of human complexity (e. and cognitive skills B. A. A. B and D only D.D.g. skills in fund-raising D. A. the Nursing sector is no except. Employee satisfaction B. one need not be concerned about peoples. Conceptual skills. budget and accounting skills. Logical position . Technical skills. C and D are correct D. Whether management at the community or agency level. organizational goals. technical skills. family goals C. culture. traditions and human relations. organizational goals. Considers its own recognition by higher administration for purposes of promotion and prestige. Organizational commitments. You learned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. Management principles are universal therefore. family goals D. technical skill. organizational objectives and employee satisfaction C. A and C only 77. Organizational objectives. understanding the human expertise)? A. Employee objectives/satisfaction. B is correct C. C and D are correct Situation 17 – You are actively practicing nurse who just finished your Graduate Studies. commitments and organizational objectives D. Since the advocacy for the utilization of Filipino value-system in management has been encouraged. Family goals. B. management needs to examine Filipino values and discover its positive potentials and harness them to achieve: A. organizational goals B. Considers the welfare of the organization above all other consideration by higher administration D. A is correct D. national goals. The following questions apply to research. there are 3 essential types of skills managers must have. and technical skills C. Manipulative skills. A. commitments and employee objective/satisfaction/ 79. these are: A. resource management skills A. B. Human relation skills. Management by Filipino values advocate the consideration of the Filipino goals trilogy according to the Filipino priority-values which are: A. 81. Considers the recognition of individual efforts toward the realization of organizational goals as well as the welfare of his people C. Family goals. national goals. A. A and D only B. Organizational goals. Only A and B are correct 80. human relation/behavioral skills. C and D are correct B. The following statements can correctly be made about an effective and efficient community or even agency managerial-leader. National goals.

Ronnie asks constant questions. An 85 year old client in a nursing home tells a nurse. The following conditions pertain to CARE OF THE FAMILIES WITH PRESCHOOLERS. Which client right is being violated? A. a concept C. Which of the following studies is based on quantitative research? A. Explain that new sisters grow up to become best friends . during and after a bone marrow Aspiration 83. Positivism D. A study measuring nutrition and weight loss/gain in clients with cancer C. Right not to be harmed 85. ―A supposition or system of ideas that is proposed to explain a given phenomenon‖. A study exploring factors influencing weight control behavior. How many does a typical 3-year-old ask in a day‘s time? A.B. C. Right of self determination B. ―I signed the papers for that research study because the doctor was so insistent and I want him to continue taking care of me‖. Naturalistic inquiry C. 300-400 87. 100-200 D. Less than 50 C. A study examining the bereavement process in spouses of clients with terminal cancer B. Which of the following studies is based on qualitative research? A. best defines: A. A study measuring differences in blood pressure before. during and after a Procedure 84. a conceptual framework Situation 18 – Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF Project for Children. A study examining oxygen levels after endotracheal suctioning D. Ronnie will need to change to a new bed because his baby sister will need Ronnie‘s old crib. a theory D.200 or more B. 1. Right to full disclosure D. What measure would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister? A. Quantitative Research 82. A study measuring the effects of sleep deprivation on wound healing D. A study examining clients reactions to stress after open heart surgery B. a paradigm B. A study examining client‘s feeling before. Move him to the new bed before the baby arrives B. Right to privacy and confidentiality C. 86.

Two. Check for ear discharge B. About 50 words D. complicate ear infection . About 12 words B. As a nurse. Tell him he will have to share with the new baby D. Falls and auto accidents C. Ask him to get his crib ready for the new baby 88. check for malnutrition 93. If discharge is present for how long? D. You reviewed infant safety procedures with Bryan‘s mother. acute ear infection D. What would you suggest? A. A child with ear problem should be assessed for the following. A ear discharge that has been present for more than 14 days can be classified as: A. mastoiditis B. chronic ear infection B. Check for ear pain D. EXCEPT: A. Ear pain 92. Poisoning and burns D. They give her ―timeout‖ when this begins 89. acute ear infection D. Aspiration and falls B. chronic ear infection C.C. Go to the next question. They refuse to allow him to watch television B. How many words does a typical 12-month-old infant use? A. The following questions apply 91. Twenty or more words C. An ear discharge that has been present for less than 14 days can be classified as: A. They remind him that some activities are private D. They schedule a health check-up for sex-related disease C. Check for tender swellings behind the ear C. What are two of the most common types of accidents among infants? A. mastoiditis C. what should you as the nurse do? A. complicated ear infection 94. Drowning and homicide Situation 19 – Among common conditions found in children especially among poor communities are ear infections/problems. is there any fever? B. Ronnie‘s parents want to know how to react to him when he begins to masturbate while watching television. If the child does not have ear problem. Ear discharge C. plus “mama” and “papa” 90. using IMCI.

A child who has had diarrhea for 14 days but has no sign of dehydration is classified as: A. refer urgently C. severe dehydration B. no dehydration C. some dehydration C. moderate dehydration C. dysentery C. There is no blood in the stool. persistent diarrhea 99. How will you classify Carlo‘s illness? A. Carlo has had diarrhea for 5 days. Which of the following is not included in the rules for home treatment in this case: A. no dehydration D. continue feeding the child B. give an antibiotic for 5 days D. he is irritable. If the child has sunken eyes. the classification would be: A. thirsty and skin pinch goes back slowly. moderate dehydration B. severe persistent diarrhea B. drinking eagerly.95. severe dehydration 97. no dehydration B. We can classify the patient as: A. gives oresol every 4 hours C. the nurse offers fluid to Carlo and he drinks eagerly. what would be the best thing that you as the nurse can do? A. moderate dehydration . severe dehydration 100. His eyes are sunken. know when to return to the health center D. some dehydration D. give the child extra fluids 98. If the child has severe classification because of ear problem. dry the ear by wicking Situation 20 – If the child with diarrhea registers one sign in the pink row and one in the yellow row in the IMCI Chart – 96. some dehydration D. The child with no dehydration needs home treatment. it goes back slowly. When the nurse pinched the abdomen. severe dysentery D. instruct mother when to return immediately B.

Biomedical technician C. Anaesthesiologist D. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. In massive blood loss. who monitors the status of the client like urine output. Radiology department 4. Anaesthesiologist C. Circulating Nurse B. Security Division B. Which of the following observation would prompt you to call the doctor? . Chaiplaincy C. Surgeon C. Laboratory department C. For orthopedic cases.NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part A)---79/100 SITUATIONAL Situation 1 – Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure. Rehabilitation department B. Circulating Nurse 3. Laboratory technician 5. who else has to be present when a client undergoes laparoscopic surgery? A. Electrician D. The sterile nurse or sterile personnel touch only sterile supplies and instruments. blood loss? A. who hands out these items by opening its outer cover? A. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. Information technician B. what department is usually informed to be present in the OR? A. Aside from the usual surgical team. When there is a need for sterile supply which is not in the sterile field. 6. 1. What department needs to be alerted to coordinate closely with the patient‘s family for immediate blood component therapy? A. prompt replacement of compatible blood is crucial. Social Service Section D. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. Minimally invasive surgery is very much into technology. Pathology department Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. While the surgeon performs the surgical procedure. Nursing Aide 2. Maintenance department D. Surgeon D. Scrub Nurse B.

Explain all the possible interventions that may cause the client to worry B. Promote client’s sense of control and participation in control by listening to his concerns 10. Instruct client to observe strict bed rest B. The client reports pain reduction and decreased activity B. When the medical record is inaccurate. Department of Interior and Local Government (DILG) B. The next dose of Demerol 50 mg I. 11. When can the medical record become the doctor‘s/nurse‘s worst enemy? A. In some hip surgeries. Metro Manila Development Authority (MMDA) C. The client reports independence from watchers 9. Left foot is cold to touch and pedal pulse is absent C.M. When the patient is in severe pain C. The patient‘s medical record can work as a double edged sword. pulse of 82 beats/minute 7. Pain in ortho cases may not be mainly due to the surgery. Check for epidural catheter drainage C. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? A. When the client asks for the next dose B. When it is missing D. and inadequate 12. At 12 pm 8. When the record is voluminous B. There might be other factors such as cultural or psychological that influence pain. Which of the following behaviors indicate appropriate adaptation? A. is given: A. Assess respiratory rate carefully Situation 3 – Records are vital tools in any institution and should be properly maintained for specific use and time. How can you alter these factors as the nurse? A. Administer analgesia through epidural catheter as prescribed D. When a medical record is subpoenaed in court C. You injected Demerol at 5 pm. BP 114/78. incomplete. There is an order of Demerol 50 mg I. Left leg in limited functional anatomic position D. Dressing is intact but partially soiled B. Establish trusting relationship by giving his medication on time C. The client can distract himself during pain episodes D. now and every 6 hours p r n.A. Records Management Archives Office (RMAO) . At 11 pm D. You continuously evaluate the client‘s adaptation to pain.M. The client denies existence of pain C. What is your nursing priority care in such a case? A. Stay with the client during pain episodes D. an epidural catheter for Fentanyl epidural analgesia is given.

Your hospital is considered tertiary B. D. there are safety protocols that should be followed. In the hospital. You readmitted a client who was in another department a month ago. manicure. Doctor in charge B. According to the surgeon‘s preference 18. Assess level of consciousness B. Department of Health (DOH) 13. when you need the medical record of a discharged patient for research you will request permission through: A. Verify patient identification and informed consent C. The hospital director C. 16. Records Management and Archives Office of the DOH is responsible for implementing its policies on record disposal. The nursing service D. When are these procedures best scheduled? A. It obtained permit to operate from DOH D. Your hospital is PhilHealth accredited Situation 4 – In the OR. According to availability of anaesthesiologist D. the surgeon and anesthesiologist are in tandem C. from whom do you request the old chart? A. Central supply section B. Medical records section 15. the surgeon greets his client before induction of anesthesia B. As the circulating nurse. Previous doctor‘s clinic C. In between cases C. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‗dirty cases‘. and dentures 17. Check for jewelry. you make certain that throughout the procedure… A. You know that your institution is covered by this policy if: A. Last case B. Medical records section 14. Assess vital signs D. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. gown. Client is monitored throughout the surgery by the assistant anesthesiologist . Which of the following should be given highest priority when receiving patient in the OR? A. Department where the patient was previously admitted D. Since you will need the previous chart.D. strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board. OR nurses should be aware that maintaining the client‘s safety is the overall goal of nursing care during the intraoperative phase. Your hospital is in Metro Manila C.

As a perioperative nurse. Evaluate the type of anesthesia appropriate for the surgical client 22. Separation of the incision D. Which of the following role would be the responsibility of the scrub nurse? A. Draped B. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. supplies. Put side rails up and ask the client not to get out of bed B. Ensure that the airway is adequate C. The perioperative nurse should observe for what signs of impending infection? A. Obtain consent form 23. It is also the nurse‘s function to determine when infection is developing in the surgical incision. Clipped D. 21. Which of the following nursing interventions is done when examining the incision wound and changing the dressing? A. Account for the number of sponges. used during the surgical procedure. delayed wound healing D. how can you best meet the safety need of the client after administering preoperative narcotic? A. Blood clots and scar tissue are visible 25. check for presence dentures C. Assess the readiness of the client prior to surgery B. Localized heat and redness B. Allow client to get up to go to the comfort room D. Some lifetime habits and hobbies affect postoperative respiratory function. what should be done to make suturing easy and lessen chance of incision infection? A. check patient‘s ID D. Send the client to OR with the family C. postoperative respiratory function Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. Pulled C.19. Another nursing check that should not be missed before the induction of general anesthesia is: A. check for presence underwear B. Observe the dressing and type and odor of drainage if any B. check baseline vital signs 20. needles. D. perioperative anxiety and stress B. If your client smokes 3 packs of cigarettes a day for the past 10 years. delayed coagulation time C. Serosanguinous exudates and skin blanching C. If hair at the operative site is not shaved. you will anticipate increased risk for: A. Shampooed 24. Get patient‘s consent .

you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of: A. dust. The health instruction will include the following. Implement a regular inventory of supplies and equipment C. Sit-up with shoulders back C. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. Prevent thickening of secretions D. Avoid pollution like smoking C. Push on abdomen during exhalation D. Administer bronchodilator by nebulizer 27. Relax smooth muscles of the bronchial airway B. The mother asked the nurse. Limit suppliers to a few so that quality is maintained B. a case of bronchial asthma. Implement a regular maintenance and testing of alarm systems . You will give health instructions to Carlo. As the head nurse in the OR. Avoid pollens. seafood D. Sit in high-Fowler‘s position with extended legs B. 31. Lean forward 30-40 degrees with each exhalation 30. As a nurse. Wash hands D. Suction the client every 30 min D. Aminophylline was ordered for acute asthmatic attack. Which of the following nursing actions should be initiated first? A. Practice respiratory isolation 29. respiratory alkalosis D. Administer oxygen at 6L/min C. Suppress cough 28. 16 years old. EXCEPT: A. the nurse will say: A. Request the client to expose the incision wound Situation 6 – Carlo.C. What will be the best position? A. comes to the ER with acute asthmatic attack. metabolic alkalosis B. 26. Adherence to manufacturer‘s recommendation D. how can you improve the effectiveness of clinical alarm systems? A. Promote expectoration C. Promote emotional support B. Avoid emotional stress and extreme temperature B. metabolic acidosis Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility. what is its indication. respiratory acidosis C. RR is 46/min and he appears to be in acute respiratory distress.

Instrument technician and circulating nurse B. Take a video of the entire intra-operative procedure D. Scrub and circulating nurses 38. nurse assistant. In the OR. As a staff. Who comprise this team? A. Nurse anesthetist. radiologist. Who is your internist B. how can you improve the safety of using infusion pumps? A. the nursing tandem for every surgery is: A. and wrong procedure/surgery includes the following. call the client by his/her case and bed number D. Assess and periodically reassess individual client‘s risk for falling 35. identify client by his/her wrist tag and call his/her by name C. and assistant D. identify the client by his/her wrist tag and verify with family members B. orderly . While team effort is needed in the OR for efficient and quality patient care delivery. anesthesiologist. wrong person.32. Verify the flow rate against your computation 33. EXCEPT: A. EXCEPT: A. If you are the nurse in charge for scheduling surgical cases. Who is your assistant and anesthesiologist. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site. Check the functionality of the pump before use B. we should limit the number of people in the room for infection control. Who are your anesthesiologist. Who is your anesthesiologist 37. and instrument technician C. Allow the technician to set the infusion pump before use D. To reduce the risk of patient harm resulting from fall. Take action to address any identified risks through Incident Report (IR) C. what important information do you need to ask the surgeon? A. Allow client to walk with relative to the OR D. Select your brand of infusion pump like you do with your cellphone C. EXCEPT: A. and what is your preferred time and type of surgery? C. Conduct pre-procedure verification process C. As a nurse. 36. you know you can improve on accuracy of patient‘s identification by 2 patient identifiers. internist. Mark the operative site if possible B. you can implement the following. Assess potential risk of fall associated with the patient‘s medication regimen B. Surgeon. Conduct ‗time out‘ immediately before starting the procedure 34. Scrub nurse and nurse anesthetist D. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps. call the patient by his/her name and bed number Situation 8 – Team efforts is best demonstrated in the OR. scrub nurse. You identified a potential risk of pre-and postoperative clients. sphygmomanometer and similar devices/machines.

assistant surgeon. After ileostomy. Irrigate after lunch everyday B. Nurse Supervisor C. It can be temporary or permanent. Surgeon. Anesthesiologist 40. EXCEPT: A. including the family? A. intern. Increased weight B. Urge to defecate . who coordinates the activities outside. Establishment of regular bowel movement 44. Clean the area daily with soap and water before applying bag D. Liquid stool D. Electricity B. Surgeon. anesthesiologist C. The following are appropriate nursing interventions during colostomy irrigation. anesthesiologist. Circulating Nurse D. Orderly/clerk B. Communication Situation 9 – Colostomy is a surgically created anus.B. circulating nurse. The breakdown in teamwork is often times a failure in: A. Increase the irrigating solution flow rate when abdominal cramps is felt B. Hang the solution 18 inches above the stoma 45. Inadequate supply C. Sensation of taste B. Insert 2-4 inches of an adequately lubricated catheter to the stoma C. scrub nurse. What health instruction will enhance regulation of a colostomy (defecation) of clients? A. Eat fruits and vegetables in all three meals C. Which of the following is not indicated as a skin care barriers? A. Irritation of skin around the stoma C. Position client in semi-Fowler D. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained? A. scrub nurse. Apply talcum powder twice a day 42. Apply liberal amount of mineral oil to the area B. scrub nurse 39. anesthesiologist. assistant surgeon. assistants. pathologist D. Leg work D. Eat balanced meals at regular intervals D. Skin care around the stoma is critical. 41. Sensation of smell D. When surgery is on-going. Surgeon. which of the following condition is NOT expected? A. Restrict exercise to walking only 43. Use karaya paste and rings around the stoma C. depending on the disease condition. Sensation of pressure C.

Situation 10 – As a beginner in research. the circulating and scrub nurses have critical responsibility about sponge and instrument count. When is the first sponge/instrument count reported? A. Representativeness 48. 51. Purposive B. Study subjects C. Been selected based on set criteria D. Before closing the subcutaneous layer B. Control group B. Random sampling ensures that each subject has: A. Peritoneum . You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. Muscle C. Snow-ball D. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture? A. Appropriate number D. What should be the appropriate method ofor you to use in this care? A. Convenience C. Before peritoneum is closed C. 46. An equal chance of selection C. Which of the following methods allows the use of any group of research subject? A. Been selected systematically B. General population D. Before the fascia is sutured 52. Randomization B. Cluster sampling B. What is the most important characteristic of a sample? A. Startified ampling D. Universe 47. Characteristics that match other samples 49. Appropriate location C. What does a sample group represent? A. Quota 50. Fascia B. Before closing the skin D. you are aware that sampling is an essential elements of the research process. Random sampling C. Systematic sampling Situation 11 – After an abdominal surgery.

Patient’s advocate B. counts should be documented. your primary focus in the workplace is the client‘s safety. Text messaging and e-mail 58. Educator C. Tapered needle 54. what needle would you prepare? A. As a nurse. Another alternative ―suture‖ for skin closure is the use of ____________ A. Formal training B. needles also vary in shape and uses. Atraumatic needle C. You can communicate hazards to your co-workers through the use of the following EXCEPT: A. Round needle B. Circulating nurse Situation 12 – As a nurse. acronyms. Absorbent dressing D. Anesthesiologist B. Use of reminders of ‗what to do‘ B. Skin 53. Like sutures. and symbols C. you can help improve the effectiveness of communication among healthcare givers by: A. personal safety is also a concern. Reverse cutting needle D. One-on-one oral endorsement D. Surgeon C. Use of labels and signs 59. Like any nursing interventions. OR nurse supervisor D. 56. However. Invisible suture 55. Using standardized list of abbreviations. As a nurse. Staple B. Patient‘s arbiter 57. Posting IR in the bulletin board D. As a nurse. Therapeutic glue C.D. what is one of the best way to reconcile medications across the continuum of care? . If you are the scrub nurse for a patient who is prone to keloid formation and has low threshold of pain. Patient‘s Liaison D. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? A. Posters C. you should be aware and prepared of the different roles you play. What role do you play when you hold all client‘s information entrusted to you in the strictest confidence? A.

Advising the client. The client complained of abdominal distention and pain. As a nurse. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Offer hot and clear soup D. Medicate client as prescribed B. Provide information to clients about a variety of services that can help alleviate the client‘s pain and other conditions B. Appropriate preparation for the scheduled procedure C. Advice the client to close the lips and avoid deep breathing and talking C. Endorse in writing D. Your nursing intervention that can alleviate pain is: A. Encourage client to do imagery C. Surgical pain might be minimized by which nursing actionn in the O. Explain the proper use of PCA to alleviate anxiety C. more importantly RR 63. Proper positioning and draping of clients 65. Communicate a complete list of the patient’s medication to the next provider of service C. Which will be your priority nursing action? A. Pain as you know. you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT: A. Your assessment revelas bowel sounds on all quadrants and the dressing is dry and intact. 61. is very subjective. Call surgeon stat 62.A. Instruct client to go to sleep and relax B. Use of modern technology in closing the wound D. Encourage deep breathing and turning D. Health education among clients and significant others regarding the use of chemical disinfectant D. that which can contribute to the client‘s well-being C. A. One very common cause of postoperative pain is: .R. Endorse on a case-to-case basis B. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Skill of surgical team and lesser manipulation B. Endorse the routine and ‗stat‘ medications every shift 60. Avoid overdosing to prevent dependence/tolerance D. Turn to sides frequently and avoid too much talking 64. Endorsement thru trimedia to advertise your favorite disinfectant Solution Situation 13 – You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. by virtue of your expertise. Check abdominal dressing for possible swelling B. What nursing intervention would you take A. Monitor VS.

providing a cool. Prolonged surgery C. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following? A. Hypoglycemia 70. Determine if client has allergic reaction to local anesthesia . Activity intolerance related to tiredness associated with disorder B. iodine Situation 15 – Mrs.A. and comfortable environment D. cold intolerance. The MD ordered ―Prepare for thoracentesis this pm to remove excess air from the pleural cavity. you know that the most common type of goiter is related to a deficiency of: A. Your independent nursing care for hypothyroidism includes: A. Levophed 68. A. As the nurse. Lipitor D. you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism? A. thyrotropin C. Which of the following nursing responsibilities is essential in Mrs. Forceful traction during surgery B. Break in aseptic technique D. Hyperthermia D. thyroxine B. quiet. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics. As a nurse. Pichay is admitted to your ward. Hypothermia C. encourage to drink 6-8 glasses of water 67. iron D. Lidocaine C. and weight gain. Imbalance nutrition to hypermetabolism D. Risk to injury related to incomplete eyelid closure C. administer sedative round the clock B. administer thyroid hormone replacement C. Ensure that informed consent has been signed C. Pichay who will undergo thoracentesis? A. Hyperglycemia B. the doctor‘s diagnosis was hypothyroidism. constipation. Inadequate anesthetic Situation 14 – You were on duty at the medical ward when Zeny came in for admission for tiredness. Deficient fluid volume related to diarrhea 69.‖ 71. Upon examination. Levothyroxine B. Support and reassure client during the procedure B. 66.

Volumetric chamber D. Provide a glass of fruit juice every meal . Turn on the affected side D. You are to initiate an IV line to your patient. Kyle is diagnosed to have measles. you will explain: A. to rule out any foreign body Situation 16 – In the hospital. who is febrile. Mrs. Dorsal Recumbent position D. how will you position the client after thoracentesis? A. Orthopneic position 73. Place patient in a quiet and cool room B. During thoracentesis. Ascertain if chest x-rays and other tests have been prescribed and Completed 72. Chest x-ray was ordered after thoracentesis. Macroset C. Face mask D. Kyle. Place flat in bed B. Apply pressure over the puncture site as soon as the needle is withdrawn 74. who is febrile. What IV administration set will you prepare? A. Gloves 78. On bed rest 75. Blood transfusion set B. 5. Gown B. What will you do to ensure that Kyle. you are aware that we are helped by the use of a variety of equipment / devices to enhance quality patient care delivery. which of the following nursing intervention will be most crucial? A. to decongest D. What will your protective personal attire include? A. Microset 77. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions? A. to rule out any possible perforation C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest D.D. Maintain strict aseptic technique C. will have a liberal oral fluid intake? A. Eyewear C. Supine position C. to rule out pneumothorax B. When your client asks what is the reason for another chest x-ray. Turn on the unaffected side C. 76. Trendelenburg position B. To prevent leakage of fluid in the thoracic cavity.

Reverse trendelenburg with extended neck 85. hemorrhage B. Lock the doors 80. Test the call system D. anesthesiologist‘s preference C. balanced diet when fully awake B. general anesthesia 82. hot soup when awake C. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. soft diet when fully awake 83. How to lock side rails B. endotracheal tube perforation C. You are the nurse of Tony who will undergo T and A in the morning. The PACU nurse will maintain postoperative T and A client in what position? A. Regulate his IV to 30 drops per minute C. What do you teach the watcher and Kyle to alert the nurses for help? A. epiglottis 84. local anesthesia D. Your teaching will focus on: A. Put the lights on B. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask what food to prepare and give their children after surgery. Put the side rails up C.B. You as the nurse will say: A. Provide a calibrated pitcher of drinking water and juice at the bedside and monitor intake and output D. You as the RN will make sure that the family knows to: . Remote control Situation 17 – Tony. ice cream when fully awake D. 81. Supine with neck hyperextended and supported with pillow B. You will do which of the following: A. His mother asked you if Tony will be put to sleep. osopharyngeal edema D. Call system D. you went to ensure Kyle‘s safety in bed. Semi-fowler‘s with neck flexed D. 11 years old. The RR nurse should monitor for the most common postoperative complication of: A. spinal anesthesia B. has ‗kissing tonsils‘ and is scheduled for tonsillectomy and adenoidectomy or T and A. Before bedtime. Kyle‘s room is fully mechanized. Prone with the head on pillow and turned to the side C. Provide a writing pad to record his intake 79. Number of the telephone operator C.

Instruct the client not to exercise the arm with the shunt C. She was advised to undergo IVP by her physician. Which of the following action would be of highest priority with regards to the external shunt? A. 86. first morning urine C. As the nurse you will collect… A. offer clear liquid for 3 days to prevent irritation Situation 18 – Rudy was diagnosed to have chronic renal failure. The nutrition instructions should include: A. who has acute renal failure is low-protein. Avoid taking BP or blood sample from the arm with the shunt B. You are assisted by a nursing aide with the care of the client with renal failure. offer soft foods for a week to minimize discomfort while swallowing C. maintain aseptic technique throughout the hemodialysis 89. cantaloupe. Which delegated function to the aide would you particularly check? A. Recommend protein of high biologic value like eggs. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. offer osterized feeding B. 91. Bananas. Heparinize the shunt daily D. and tomatoes C. Hemodialysis is ordered so that an A-V shunt was surgically created. 24 hour urine specimen D. Diet therapy for Rudy. poultry and lean meats B. supplement his diet with Vitamin C rich juices to enhance healing D. He asked you how this can be prevented. maintain fluid and electrolyte balance C. maintain a conducive comfortable and cool environment B. 48 hour urine specimen B. Allowing the client cheese. A renal failure patient was ordered for creatinine clearance. cabbage. Change dressing of the shunt daily 87. Obtaining vital signs D. Encourage client to include raw cucumbers. Monitoring diet 90.A. canned foods and other processed food D. orange and other fresh fruits can be included in the diet 88. Checking bowel movement C. initial hemodialysis shall be done 30 minutes only so as not to rapidly remove the waste from the blood than from the brain D. Fe was so anxious about the procedure and particularly expressed her low pain threshold. random urine specimen Situation 19 – Fe is experiencing left sharp pain and occasional hematuria. low potassium and low sodium. carrot. Nursing health instruction will include: . Monitoring and recording I and O B. Your response is: A.

increase fluid intake B. because insulin will induce hyperglycemia in patients with TPN B. You instructed the family to include more vegetables in the diet and: A. Increased fluid intake D. Observe NPO for 6 hours C. The presence of calculi in the urinary tract is called A. Yes. Nephrolithiasis C. Ambulate more C. Post IVP. Fe should excrete the contrast medium. The RN should also know that some drugs have increased adsorption when infused in the PVC container. Report signs and symptoms for delayed allergic reaction B. barium enema C. You know that in TPN like blood transfusion. 96. No. Monitor intake and output 93. Administer by fast drip B. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. Will you follow the order? A. Strain all urine D. However the MD‘s order read. assure the client that the pain is associated with the warm sensation during the administration of the Hypaque by IV B. No. these should be no drug incorporation. What will the nurse monitor and instruct the client and significant others post IVP? A. assure the client that x-ray procedure like IVP is only done by experts 92. Bed rest 95. nitroglycerine hydralazine to promote better therapeutic drug effects? A. because insulin is chemically stable with TPN and can enhance blood glucose level C. You have a client with TPN. the nurse must also be concerned about drug interactions. assure the client that the procedure painless C. Use volumetric chamber . Urolithiasis Situation 20 – At the medical-surgical ward. because it was ordered by the MD 97. gastric lavage 94. Inject the drugs as close to the IV injection site C. cleansing enema D. because insulin is not compatible with TPN D. Yes. To increase the chance of passing the stones. Balanced diet B. Incorporate to the IV solutions D.A. incorporate insulin to present TPN. you instructed her to force fluids and do which of the following? A. Ureterolithiasis D. Colelithiasis B. assure the client that contrast medium will be given orally D. How will you administer drugs such as insulin.

4. Hypertonic solution D. Shade only one (1) box for each question on your answer sheets. Isotonic solution C. After excitement B. After a good night‘s rest C. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor‘s order? A. In insulin administration. After ingestion of food NURSING PRACTICE IV – SET B—71/100 NURSING PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations (Part B) GENERAL INSTRUCTIONS 1. This test booklet contains 100 test questions 2. . Improving on preparation techniques D. Two or more boxes shaded will invalidate your answer.98. it should be understood that our body normally releases insulin according to our blood glucose level. AVOID ERASURES. When is insulin and glucose level highest? A. Administering drugs with more diluents C. Any IV solution available to KVO B. After an exercise D. Always flush with NSS after IV administration B. 3. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. Referring to manufacturer’s guidelines 100. Hypotonic solution 99. How can nurses prevent drug interaction including adsorption? A. One patient had a ‗runaway‘ IV of 50% dextrose.

hyperkalemia and hyponatremia D. calculate the extent of his burns D. Teddy. 3. Write the subject title ―Nursing Practice IV‖ on the box provided. right upper extremities and right lower extremities. Once the flames are extinguished. . Dermis is partially damaged C. metabolic acidosis B. Cerebral hypoxia C. Sergio is brought to Emergency Room after the barbecue grill accident. Structures beneath the skin are damage B. pour cold liquid over the flames 2. His wife asks what that means? Your most accurate response would be: A. You have to be prepared to handle situations with ethico-legal and moral implifications. assess the Sergio’s breathing 3. Set Box ―B‖ if your test booklet is Set B. Based on the assessment of the physician. management requires a multidisciplinary approach. you should asses Sergio for: A. Epidermis and dermis are both damaged D. give him sips of water C.INSTRUCTIONS 1. Epidermis is damaged 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. You have important responsibilities as a nurse. whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. it is most important to: A. remove the burning clothes D. Hypervolemia D. Renal failure Situation 2 – You are now working as a staff nurse in a general hospital. cover Sergio with a warm blanket B. 2. his shirt burns into flames. hypokalemia and hypernatremia B. slap the flames with his hands C. During the first 24 hours after the thermal injury. While Sergio was lighting a barbecue grill with a lighter fluid. The most effective way to extinguish the flames with as little further damage as possible is to: A. You recognize that this most likely indicates that Teddy is developing: A. 1. who sustained deep partial thickness and full thickness burns of the face. hypokalemia and hyponatremia C. Sergio sustained superficial partial thickness burns on his trunk. hyperkalemia and hypernatremia 5. MULTIPLE CHOICE Situation 1 – Because of the serious consequences of severe burns. log roll on the grass/ground B. Shade Set Box A on your answer sheet if your test booklet is Set A.

Write an incident report and refer the matter to the nursing director B. Which among the following activities will you do first? A. is admitted to the CI. Report the matter to your supervisor D. You found out that what is on record does not tally with the drugs used. Which among the following will you do first? A. Call security officer and report the incident C. Report the matter to your head nurse Situation 3 . Call security to report the incident C. The mother of your patient who is also a nurse. Write an incident report D. Go to see Fiolo and assess for airway patency and breathing problems 10. Keep this matter to yourself C. During your endorsement rounds. Take note of it and plan to endorse this to next shift B. You saw the policeman trying to hit Martin. You are admitting Jorge to the ward and you found out that he is positive for HIV. He is being guarded by policeman from the local police unit. You were asked to check the narcotics cabinet. Find out from the endorsement any patient who might have been given narcotics 9. You are assigned in the cancer institute to care of patients with this type of cancer. Which among the following will you do first? A. Larry. You are on morning duty in the medical ward. You are on duty in the medical ward. During your rounds you heard a commotion. Call for the Code C. He denied the matter. You are in night duty in surgical ward. Keep your findings to yourself C. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer. 55 years old. Report the incident to your supervisor 8.6. Make an incident report B. Wait for 2 hours before reporting D. came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest. You are on duty in the medical ward. You have 10 patients assigned to you. Start basic life support measures B. Bring the crush cart to the room D. You asked why he was trying to hit Martin. 11. . Surgical procedures and other modes of treatment are done to ensure quality of life. The patient next to him informed you that he went home without notifying the nurses. who is suspected of having colorectal cancer. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound.Colorectal cancer can affect old and younger people. A. Write an accident report B. Which among the following will you do first? A. Call your nurse supervisor and report the incident D. Call the physician on duty 7. you found out that one of your patients was not in bed.

At least 2 hours before visiting hours C. Proctosigmoidoscopy C. Carcinoembryonic antigen B. hematemesis. After Fermin accepts alteration in body image 18. blood in the stools. Genetic factors-familial adenomatous polyposis 14.A. The stools starts to become formed. anorexia. Inflammatory bowels B. To confirm his impression of colorectal cancer. You are participating in the OSTOMY CARE CLASS. reduce the bacterial content of the colon C. Symptoms associated with cancer of the colon include: A. Abdominal computed tomography (CT) test 13. Fermin can lie on the side comfortably. around the 7th postoperative day 17. ascites and mucus in the stool B. and “pencil shaped” stools D. Larry may be given sulfasuxidine and neomycin primarily to: A. heart burn and eructation C. Several days prior to bowel surgery. and increased peristalasis 15. 16. Larry will require which diagnostic study? A. High fat. constipation. high fiber diet C. empty the bowel of solid waste D. anemia. When Fermin would have normal bowel movement B. Stool hematologic test D. Annual digital rectal examination D. Prior to breakfast and morning care D. When preparing to teach Fermin how to irrigate colostomy. soften the stool by retaining water in the colon Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. Carcinoembryonic antigen C. diarrhea. The perineal wound heals And Fermin can sit comfortably on the commode B. Proctosigmoidoscopy 12. When observing a return demonstration of a colostomy irrigation. The abdominal incision is closed and contamination is no longer a danger D. you should plan to do the procedure: A. Smoking D. The following are risk factors for colorectal cancer. promote rest of the bowel by minimizing peristalsis B. you know that more teaching is required if Fermin: . Barium enema B. about the 3rd postoperative day C. You plan to teach Fermin how to irrigate the colostomy when: A. EXCEPT: A.

‖ D. empty the drainage system at the end of the shift B. When caring for him you should: A. 21. You are aware that teaching about colostomy care is understood when Fermin states. To prevent recurrent attacks on Terry who has acute glumerulonephritis. a reddened area at the ankle D. He verbalized his concern regarding his laryngectomy tube being dislodged. Food low in fiber so that there is less stool.‖ C. What should you teach him first? . You would know after teaching Fermin that dietary instruction for him is effective when he states. If I noticed a loss of sensation to touch in the stoma tissue.‖ B. Herbert had a laryngectomy and he is now for discharge. Soft food that are easily digested and absorbed by my large intestines. came in from PACU after pelvic surgery. change the dressing daily using aseptic techniques 22. pruritus on the calf and ankle 23. Everything that I ate before the operation. take showers instead of tub bath C. Bland food so that my intestines do not become irritated. Clamps of the flow of fluid when felling uncomfortable 19. ―I will contact my physician and report: A. ―It is important that I eat: A. Randy has chest tubes attached to a pleural drainage system. When mucus is passed from the stoma between the irrigations. painful area on the leg B. As Fanny‘s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be: A. seek early treatment for respiratory infections B. a tender. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. palpate the surrounding areas for crepitus D. You will need to provide instructions and information to your clients to prevent complications. Fanny. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled D.” B. clamp the chest tube when suctioning C. avoid situations that involve physical activity 24. If I have any difficulty inserting the irrigating tub into the stoma.‖ C. The expulsion of flatus while the irrigating fluid is running out. you should instruct her to: A.” Situation 5 – Ensuring safety is one of your most important responsibilities. Lubricates the tip of the catheter prior to inserting into the stoma B. a pitting edema of the ankle C.A. continue to take the same restrictions on fluid intake D.‖ 20. while avoiding foods that cause gas.‖ D.

Dakin‘s solution B. Keep calm because there is no immediate emergency C. ―Don‘t worry your husband‘s type of hepatitis is no longer communicable‖ B. his wife asks you about gamma globulin for herself and her household help. supplementary oxygen B. Recognize that prompt closure of the tracheal opening may occur B. Half-strength hydrogen peroxide C. Notify the physician at once 25. Betadine 30. 26.‖ D. Honrad. Reinsert another tubing immediately D. hepatitis C. dysrhythmia D. “You acquired the infection after you have been admitted to the hospital. “You should contact your physician immediately about getting gammaglobulin.‖ C. ventilation exchange C. after a workup he is diagnosed of having Hepatitis A. ―As a result of medical treatment. A solution used to treat Pseudomonas wound infection is: A.‘ 28. Which of the following is the most reliable in diagnosing a wound infection? A. He ask you what that means? Your best response would be: A. infection 29. Culture and sensitivity . Acetic acid D. ―This is a highly contagious infection requiring complete isolation. stomatitis B. When caring for Larry after an exploratory chest surgery and pneumonectomy. develops jaundice. blood replacement Situation 6 – Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. you have acquired a secondary infection. ―A vaccine has been developed for this type of hepatitis‖ 27.” B.” D. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is: A. Your most appropriate response would be: A. ―Gamma globulin provides passive immunity for hepatitis B‖ C. Infection control is one important responsibility of the nurse to ensure quality of care. who has been complaining of anorexia and feeling tired. chest tube drainage D. your priority would be to maintain: A. ―The infection you had prior to hospitalization flared up. Voltaire develops a nosocomial respiratory tract infection.A.

. stiff neck and photophobia. Place June on an upright lateral position B. While waiting for surgery. dimming the light in her room D.000/μL D. has received a significant brain injury Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. what should you do? A. you can provide a therapeutic environment by doing which of the following? A. When performing a neurologic assessment on Walter. Tell her family that probably she can‘t hear them B. There are frequently encountered situations and issues relevant to the older patients. placing her bed near the window C. Talk loudly so that Wendy can hear you C. probably has meningitis B. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke? A. Ivy. you find that his pupils are fixed and dilated. Maintain a patent airway 32. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. Preserve muscle function C. 31. Use hand rolls or pillows for support 34. Tell her family who are in the room not to talk D. Purulent drainage from a wound C. as Judy‘s nurse. Gram stain testing Situation 7 – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented. allowing the family unrestricted visiting privileges 35. infusion was started. was admitted to the hospital with a severe headache. Wendy is admitted to the hospital with signs and symptoms of stroke. is permanently paralyzed D. honoring her request for a television B. A central venous catheter was inserted an I. Her Glasgow Coma Scale is 6 on admission. Perform range of motion exercises C. Prevent skin breakdown B. Knowing that for a comatose patient hearing is the last sense to be lost. WBC count of 20. This indicated that he: A.B. Speak softly then hold her hands gently 33. Apply antiembolic stockings D. is going to be blind because of trauma C.V. age 40. As a nurse assigned to Wendy what will be your priority goal? A. Promote urinary elimination D.

The older patient is at higher risk for incontinence because of: A. Merle. decreased breath sounds with crackles Situation 9 – A ―disaster‖ is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation. Decreased alveolar surfaced area C. Acute confusion 40. The most dependable sign of infection in the older patient is: A. This may indicate: A. and recovery). dementia B.36. is complaining of dizziness when she stands up. change in mental status B. Disaster preparedness is crucial and is everybody‘s business. Cardiac ischemia in an older patient usually produces: A. fever C. Hyperventilation 37. man-made. preparedness. Very high creatinine kinase level C. pain D. Mitigation C. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging. functional decline D. ST-T wave changes B. Decreased anterior-posterior chest diameter D. a visual problem C.‖? A. There are agencies that are in charge of ensuring prompt response. Ineffective airway clearance B. Chest pain radiating to the left arm D. response. age 86. decreased bladder capacity 38. drug toxicity 39. increased glomerular filtration rate C. Response D. Preparedness . for all types of emergencies and disasters (natural. and attack) and for all levels of government and the private sector. A. Recovery B. dilated urethra B. 41. diuretic use D. Which of the four phases of emergency management is defined as ―sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.

Alcohol C. You are a member of the infection control team of the hospital. Ammonia D. Secondary prevention 43. 46. Debfriefing D. Which of the following terms refer to a process by which the individual receives education about recognition of stress reaction and management strategies for handling stress which may be instituted after a disaster? A. Emergent C. Blood oozes on the surface of the over-bed table. Primary prevention C. During the disaster you see a victim with a green tag. organizing counseling debriefing sessions and securing physical care are the services you are involved with. organizing support for the family. Finding safe housing for survivors. Clinical incident stress management B. Non-acute D. Tertiary prevention B. you know that the person: A. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment: A. has injuries that are life threatening but survival is good with minimal intervention C. has injuries that are minor and treatment can be delayed from hours to Days 44. Defusion Situation 10 – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.42. has injuries that are significant and require medical care but can wait hours with threat to life or limb B. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. It is most appropriate that you instruct the housekeeper to clean the table with: A. Follow-up C. Urgent 45. While eating his meal. Based on a feedback during the meeting of the committee there is an increased incidence . Bleach 47. Matthew accidentally dislodges his IV lines and bleeds. Immediate B. indicates injuries that are extensive and chances of survival are unlikely even with definitive care D. Acetone B. Aggregate care prevention D. To which type of prevention are these activities included: A.

How would you start prioritizing your activities? A. chart review. You now feel that Irma‘s family could be helpful if they knew what Irma has told to you. illness. Find out how many support groups there are in the hospital and get the contact number of their president 50. Contact the nurse in-charge and find out from her the reason for the referral C. You are assigned to contact the various cancer support groups in your hospital. Assign point persons who can implement policies. Irma is terminally ill. Involve the whole family in the teaching class 49. That way we can help our patients cope with death and dying.of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). What will be your most important role where you can demonstrate the impact of nursing in health? A. Conduct health education on healthy life style B. Find out if there is a budget for this activity B. Determine their learning needs then prioritize D. Your committee has 4 months to plan and implement the plan. Clarify objectives of the activity with the task force before contacting the support groups C. Be a triage nurse C. Prior to discharge today. pain. Determine the VIPs and Celebrities who will be invited D. Meet with the nursing group working in the burn unit and discuss problem with them. What is your priority activity? A. It is important for us nurses to be aware of how we view suffering. D. Act as a coordinator Situation 11 – One of the realities that we are confronted with is our mortality. Part of your responsibility as a member of the diabetes core group is to get referrals from the various wards regarding diabetic patients needing diabetes education. C. You are invited to participate in the medical mission activity of your alumni association. 51. What will be your priority activity? A. You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Tell the physician who in turn could tell the family . Establish policies for surveillance and monitoring B. 48. Bring your diabetes teaching kit and start your session taking into consideration their distance from your office B. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. Take the initial history and document findings D. and even our death as well as its meaning. Do data gathering about the possible sources of infection (observation. What should you do first? A. she speaks to you in confidence. You thought it is also your chance to share what you can do for others. interview). 4 patients are referred to you.

has serious management implications. Avoidance of the true situation C. Encourage coughing and deep breathing 57. who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves. financially and emotionally. Ruby who has been told she has terminal cancer. Leo. socially. Provide sensory stimulation D. ―What‘s the use?‖ D. has accepted his impending death? A. You can best help her by: A. Acceptance that death is inevitable B. Make an appointment to discuss the situation with the family 52. Leaving her alone because she is uncooperative and unpleasant to be with D. This is recognized as: A. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). is depressed. Sit down and talk with him for a while C. Keeping Conrad‘s head and neck alignment results in: A. As a nurse. Awareness that death will soon occur Situation 12 – Brain tumor. you should be able to understand the consequences of the disease and the treatment. who is dying. Tell Irma that she has to tell her family what she told you D. 90 years old has planned ahead for her death-philosophically. ―I have resigned myself to dying. Which of the following statements would best indicate that Ruffy. Which of the following would best help him during his depression? A. Denial with planning for continued life D. Insisting that Ruby should talk with you because it is not good to keep everything inside C. Arrange for visitors who might cheer him B. “I’m ready to go. turns away and refuses to respond to you.” B. ―I‘m giving up‖ 55. Administer bowel softener B. 56. increased inthrathoracic pressure . Encouraging her to be physically active as possible 53. Coming back periodically and indicating your availability if she would like you to sit with her B. Marla. whether malignant or benign.‖ C.B. Which intervention should you include in your plan to reduce ICP? A. Encourage him to look at the brighter side of things D. Position Conrad with his head turned toward the side of the tumor C. Obtain Irma‘s permission to share the information in the family C. Sit silently with him 54.

61. Coordination 62. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg B. Manual hyperventilation C. who has cholelithiasis and is for operation on call. to manage time wisely? A. C. Which of the following activities may increase intracranial pressure (ICP)? A. B. The essential components of professional nursing practice are all the following EXCEPT: A. Practical planning . 64. Your most appropriate respiratory goal is to: A. Which of the following patients should you give first priority? A. Valsalva’s maneuver 59. Which statement accurately reflects the accountability of the nursing supervisor? A. Use of osmotic diuretics D. Although Brenda is not on duty. you know that drainage on a craniotomy dressing must be measured and marked. Bloody drainage Situation 13 – As a Nurse. lower arterial pH C. Yellowish drainage C. increased intrabdominal pressure 58. You are assigned to care for four (4) patients. Aris. you have specific responsibilities as professional. promote CO2 elimination 60.B. Emy. Conrad underwent craniotomy. Claire. After you asses Conrad. Raising the head of the bed B. As his nurse. who was previously lucid but is now unarousable. Foul-smelling drainage B. Brenda should be informed when she goes back on duty B. D. the Nursing Supervisor of the intensive care unit (ICU) is not on duty when a staff nurse committed a serious medication error. increased venous outflow C. Brenda. You have to demonstrate specific competencies. you suspected increased ICP. Grace. The nursing supervisor on duty will notify Brenda at home D. Brenda is not duty therefore it is not necessary to inform her. Which findings should you report immediately to the surgeon? A. who is newly admitted and is scheduled for an executive check-up. Care C. who is terminally ill with breast cancer. prevent respiratory alkalosis D. decreased venous outflow D. Greenish drainage D. Culture B. 63. the nursing supervisor on duty decides to call her if time permits C. Cure D. Which barrier should you avoid.

How can you allay his fear? A. efficient and effective care to your patients. pigmentation 70. Which of the following can be used on the irradiated skin during a course of radiation therapy? A. 66. erythema C. Paresthesia of the lower extremities D. Realistic personal expectation 65. Earliest sign of skin reaction to radiation therapy is: A. Assign the same nurse to him when possible C. Emphasis on the therapeutic value of the treatment D. atrophy D. Map out the precise course of treatment 67. desquamation B. Move his bed to a room far from nurse‘s station to reduce B. You are caring for Vincent who has just been transferred to the private room. Abnormal vaginal or perineal discharge C. you have to be prepared to provide safe. He is anxious because he fears he won‘t be monitored as closely as he was in the Coronary Care Unit. Identify the nurse who is assigned to care for such a patient B. Talcum powder D. Nausea and vomiting and diarrhea 68. Limit Vincent‘s visitors to coincide with CCU policies Situation 14 – As a nurse in the Oncology Unit. Allow Vincent uninterrupted period of time D.B. Adhesive tape B. Zinc oxide ointment 69. Urinary retention B. Prevent radiation-induced sterility C. Offer tranquilizers and antiemetics B. What is the purpose of wearing a film badge while caring for the patient who is radioactive? A. Protect the nurse from radiation effects D. Setting limits D. Measure the amount of exposure to radiation Situation 15 – In a disaster there must be a chain of command in place that . What side effects are most apt to occur the patient during radiation therapy to the pelvis? A. Which one of the following nursing interventions would be most helpful in preparing the patient for radiation therapy? A. Procrastination C. Mineral oil C. Instruct the patient of the possibility of radiation burn C.

smoking 77. Lower gastrointestinal problems C. Which of the following categories of conditions should be considered first priority in a disaster? A. sex at an early age. Morgue management B. EXCEPT: A. respiration B. Respiratory infections D. The following principles should be observed in disaster triage. any disaster plan should have resources available to triage at each facility and at the disaster site if possible B. multiple partners. male partner‘s sexual habits C. A guideline that is utilized in determining priorities is to asses the status of the following. Treatment group C. Late signs and symptoms of cervical cancer include the following EXCEPT: . 71. The following are risk factors for cervical cancer EXCEPT: A. immunosuppressive therapy B. You are assigned to take charge of the women to make them aware of cervical cancer. training on the disaster is not important to the response in the event of a real disaster because each disaster is unique in itself D. mentation 75. Within the health care group there are pre-assigned roles based on education. make the most efficient use of available resources C. viral agents like the Human Papilloma Virus D. Transport group 72. Triage group D. locomotion D. pupil reactivity B. As a nurse to which of the following groups are you best prepared to join? A. experience and training on disaster. exposure to socially transmitted disease. do the greatest good for the greatest number of casualties 73.defined the roles of each member of the response team. 76. There are important principles that should guide the triage team in disaster management that you have to know if you were to volunteer as part of the triage team. EXCEPT: A. Trauma 74. Intracranial pressure and mental status B. The most important component of neurologic assessment is: A. level of consciousness/responsiveness Situation 16 – You are going to participate in a Cancer Consciousness Week. vital sign assessment C. You reviewed its manifestations and management. cranial nerve assessment D. perfusion C.

The primary modalities of treatment for Stage 1 and IIA cervical cancer include the following: A. A crush cart with bed board D. tubes and ovaries D. uterine bleeding D. the uterus. As Leda‘s nurse. and two-thirds of the vagina C. the uterus. Support head with the hands when changing position 82. B. Perform range and motion exercise on the head and neck B. You should include: A. A tracheostomy set and oxygen C. atelectasis D. Two ampules of sodium bicarbonate 83. cervix. A common complication of hysterectomy is A. you plan to set up an emergency equipment at her beside following thyroidectomy. radiation therapy and hormone therapy B. thrombophelbitis of the pelvic and thigh vessels B. When a panhysterectomy is performed due to cancer of the cervix.A. Apply gentle pressure against the incision when swallowing C. surgery and radiation therapy 80. Keep you patient in a high-fowler’s position. Raise the knee-gatch to 30 degrees C. . leg or flank C. Which of the following nursing interventions is appropriate after a total thyroidectomy? A. diarrhea due to over stimulation C. You have to understand how management of these conditions are done. which of the following organs are removed? A. and one ovary B. pain in pelvis. wound dehiscence Situation 17 – The body has regulatory mechanism to maintain the needed electrolytes. Cough and deep breath every 2 hours D. 81. you should instruct Leda to: A. Prior to total thyroidectomy. radiation therapy D. the uterus and cervix 79. Place pillows under your patient‘s shoulders. urinary/bowel changes B. cervix. However there are conditions/surgical interventions that could compromise life. cervix. the uterus. surgery. You are caring for Leda who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. An airway and rebreathing tube B. lymph edema of lower extremities 78. surgery C.

sodium bicarbonate 88. Calcium gluconate C. Induction of vomiting is indicated for the accidental poisoning patient who has ingested. Support the patient‘s head and neck with pillows and sandbags. A. Show acceptance of the body by touching it and giving the family permission to touch D. Secondary blood stream infections B. a through soap and water wash and rinse of the patient C. gasoline C. Dyspnea C. This is part of quality care management. tingling and muscle twitching and spasm. Tetany 85. Nosocomial infection C. Potassium chloride Situation 18 – NURSES are involved in maintaining a safe and healthy environment. to immediately apply a chemical decontamination foam to the area of contamination B. Which of the following guidelines is not appropriate to helping family members cope with sudden death? A. colloidal (oatmeal C. Inform the family that the patient has passed on Situation 19 – As a nurse you are expected to participate in initiating or . Which of the following term most precisely refer to an infection acquired in the hospital that was not present or incubating at the same time of hospital admission? A. aspirin 89. removal of the patients clothing and jewelry and then rinsing the patient with water 87. 84. to immediately apply personal protective equipment D. Respiratory failure D. A. saline D. Provide details of the factors attendant to the sudden death C. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develop postoperatively? A. toilet bowl cleaner D. Magnesium sulfate B. 86. Obtain orders for sedation of family members B. What would you anticipate to administer? A. water B. you recommend which type of bath. The first step in decontamination is: A. Potassium iodide D. rust remover B. Primary blood stream infection 90. After surgery Leda develops peripheral numbness. Cardiac arrest B. Emerging infectious disease D. For a patient experiencing pruritus.D.

Which of the following questions will you not use in critiquing the Likert Scale? A. You also have to understand the rationale of the treatment. You are interested to study the effects of meditation and relaxation on the pain experienced by cancer patients.participating in the conduct of research studies to improve nursing practice. 91. A Descriptive Study To Compare The Support System Of Patients With Chronic Illness And Those With Acute Illness In Terms Of Demographic Data And Knowledge About Interventions. 93. Is the instrument clearly described? 95. You would like to compare the support system of patients with chronic illness to those with acute illness. Dependent B. D. Correlational C. A Study To Compare The Support System Of Patients With Chronic Illness And Those With Acute Illness. B. Correlational B. Descriptive C. If the Likert scale is to be used for a study. . Assurance of anonymity and confidentiality Situation 20 – Because severe burn can affect the person‘s totality it is important that-you apply interventions focusing on the various dimensions of man. C. Consent to incomplete disclosure B. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession. You would like to compare the support system of patients with chronic illness to those with acute illness. In any research study where individual persons are involved. was the development process described? D. Descriptions of benefits. What type of variable is pain? A. Experimental D. Are the reliability and validity information on the scale described? C. The following are essential information about the consent that you should disclose to the prospective subjects EXCEPT: A. risks and discomforts C. A Comparative Analysis Of The Support System Of Patients With Chronic Illness And Those With Acute Illness. Explanation of procedure D. Demographic 92. You are shown a Likert Scale that will be used in evaluating your performance in the clinical area. Independent D. Quasi-experimental 94. it is important that an informed consent for the study is obtained. How will you best state your problem? A. The Effect Of The Type Of Support System of Patients With Chronic Illness And Those With Acute Illness. What type of research it this? A. Are the techniques to complete and score the scale provided? B.

Care of Clients with physiologic and Psychosocial Alterations (Part C). Oral analgesics are most frequently used to control burn injury pain: A. patient discomfort D. after hospital discharge D.---66/100 NURSING PRACTICE V. delayed epithelialization 99. Mechanical C. excessive manpower requirement 100. during the emergent phase C. Chemical 97. Hypertrophic burn scars are caused by: A. SITUATIONAL Situation 1 – Jimmy developed this goal for hospitalization. wound ischemia D. He realized he needed help. exaggerated contraction B. What type of debridement involves proteolytic enzymes? A. ―To get a handle on my nervousness.96. cross contamination of wound C. . Silver sulfadiazine D. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. Silver nitrate C. upon patient request B.‖ The nurse is going to collaborate with him to reach his goal. patient hypothermia B. Which topical antimicrobial is most frequently used in burn wound care? A. during the acute phase *** END *** SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. Neosporin B. Interventional B. random layering of collagen C. Surgical D. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. The major disadvantage of whirlpool cleansing of burn wound is: A. Sulfamylon 98.

While Jimmy was discussing the signs and symptoms of anxiety with his nurse. The process recording was the principal tool for data collection. Verbal narrative account . mild anxiety 4. agreeing to contact the staff when he is anxious B. help the client to communicate 2. case study B. progress notes Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy‘s coping reaction pattern during stress. he recognized that complete disruption of the ability to perceive occurs in: A. cross-sectional study D. Non verbal narrative account B. panic state of anxiety B. subjective idea of the range of mild to severe anxiety C. writing out a list of behaviors that he identified as anxious 5. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is: A. A. 6. problem list D. help the client to plan alternatives C. help the client cope with the present problem D. initial plans or orders B. database C. The nurse is guided that Jimmy is aware of his concerns of the ―here and now‖ when he crossed out which item from this ―list of what to know‖. Which of the following is NOT a part of a process recording? A.1. Analysis and interpretation C. becoming aware of the conscious feeling C. The nurse notes effectiveness of interventions in using subjective and objective data in the: A. moderate anxiety D. evaluative study 7. physiologic indices of anxiety 3. severe anxiety C. This study which is an in depth study of one boy is a: A. help the client find meaning in his experience B. anxiety laden unconscious conflicts B. assessing need for medication and medicating himself D. early signs of anxiety D. longitudinal study C. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT: A. Audio-visual recording D.

Participant-observer B. ―Regina. C. Before approaching Regina. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an: A. Observer researcher C. Guided by a medication teaching plan. was given Flurazepam (Dalmane) 15mg at 10:00pm because she had trouble going to sleep. tell me what happened before you were finally able to sleep and how was your sleep?” B. Exploration of relationship between two or more phenomena. Which of these responses indicate that Regina needs further discussion regarding special instructions? . Which of these does NOT happen in a descriptive study? A. go over with her the purpose. C. D. That pill you were given last night is effective isn‘t it?‖ C. 13. “I learned that you were up till ten last night. ―Regina. Have an informal conversation about the medication and its effects D.. the nurse read the observation of the night nurse. cope with her present problem D. Explanation of relationship between two or more phenomena. Regina is a high school teacher. Which of the following approaches of the nurse validates the data gathered? A. subjected to an inter-observer agreement D. the outgoing nurse informed the nursing staff that Regina. about the medication and provide her a checklist B. the investigator‘s analysis and interpretations were: A. 35 years old. correlated with a list of coping behaviors C. You look like you had a very sound sleep. Provide a drug literature. Caregiver D.8. Which of these information LEAST communicate attention and care for her needs for information about her medicine? A. conceptualize her problem C. B. face emerging problems realistically B. how are you?‖ 12. did you sleep well?‖ D. Investigation of a phenomenon in real life context. 11. scored and compared standard criteria Situation 3 – During the morning endorsement. Manipulation of variable 9. To ensure reliability of the study. Advocate 10. indications and special instructions. subjected to statistical treatment B. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to: A. perceive her participation in an experience !4. ―Hmm. Ask her what time she would like to watch the informative video about the medication.

‖ D. 18.” 15. Tolerating all behavior in the client. It solves my problem of insomnia. This is a demonstration of the nurse‘s role as: A.A. observation B. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that states: A. communication skills 17. I wish I can take it for life. congruence of behavior? A. D.‖ C. 16. communicating a message or a need. The mentally ill person responds positively to the nurse who is warm and caring. C. B. Responding in a punitive manner to the client. theoretical knowledge B. One way to increase objectivity in dealing with one‘s fears and anxieties is through the process of: A. mother surrogate C. B. Which is the MOST direct violation of the concept. therapist . intervention C. verbally agreeing with the nurse D. ―I have to take this medicine judiciously‖ B. Human beings are systems of interdependent and interrelated parts. All of the following responses are non therapeutic. All behavior is meaningful. counselor B. Regina commits to herself that she understood and will observe all the medicine precautions by: A. Communicating ambivalent messages to the client. validation D. Rejecting the client as a unique human being C. collaboration 19. 20. ―I will inform you and the doctor any untoward reactions I have. personality make up C. D. affixing her signature to the teaching plan that she has understood the nurse B. committing what she learned to her memory C. ―I know I will stop taking the medicine when there is advice from the doctor for me to discontinue. The nurse‘s most unique tool in working with the emotionally ill client is his/her A. “I like taking this sleeping pill. emotional reactions D. relying on her husband to remember the precautions Situation 4 – The nurse-patient relationship is a modality through which the nurse meets the client‘s needs. There is a basic similarity among all human beings. Each individual has the potential for growth and change in the direction of positive mental health.

loyalty C. towards the end of the relationship D.‖ D. “I am sorry. Ask the client what is the purpose of contacting his relatives. extrovert C.” 25.‖ 23. at the start of the relationship 22. ―I want to tell you something but can you promise that you will keep this a secret?‖ A therapeutic response of the nurse is: A. ―The best time to talk is during the nurse-client interaction time. She became neglectful of her personal hygiene. The client asks to visit the nurse after his discharge. schizoid B. She was observed to be talking irrelevantly and incoherently. Assist the client to bring his concern to the attention of the social worker. ―Yes. The client says. I am committed to have this time available for us while you are at the hospital and ends after your discharge. 26. ambivert . B. If you keep it confidential. when the client asks how long the relationship would be B. was reported to be gradually withdrawing and isolating herself from friends and family members. She was diagnosed as schizophrenia disorder. professionalism 24. C. Rapport has been established in the nurse-client relationship. trustworthiness B. though I would want to.‖ C. integrity D.” B. The client has not been visited by relatives for months. this is part of privileged communication. ―Here (gives her mobile phone). Promise!‖ C. you have the right to invoke confidentiality of our interaction. The best time to inform the client about terminating the nurse-patient relationship is: A. When the nurse respects the client‘s self-disclosure. ―Yes. ―Of course yes. The appropriate response of the nurse would be: A.D. Situation 6 – Camila. D. 25 years old.‖ B. 21.‖ D. it is my principle to uphold my client‘s rights. “Yes. Inform the attending physician about the request of the client. this is a gauge for the nurse‘s: A. socializing agent Situation 5 – The nurse engages the client in a nurse-patient interaction. The past history of Camila would most probably reveal that her premorbid personality is: A. this is just between you and me. An appropriate action of the nurse would be: A. You may call this number now‖. ―I am committed for your care. during the working phase C. He gives a telephone number and requests the nurse to call. our interaction is confidential provided the information you tell me is not detrimental to your safety. it is against hospital policy. ―Yes.

demanding and speaking louder than usual. psychosis D. overcompensation for hearing loss D. anxiety disorder B. She would prefer to be alone and take her meals by herself. neurosis C. anticipates rejection D. 31. adjust to the loss of sensory and perceptual function B. has been observed to be irritable. Guilt feelings B. Ambivalence C. cognitive impairment D. Narcissistic behavior D. Camila‘s indifference toward the environment is a compensatory behavior to overcome: A. personality disorder Situation 7 – Salome. is irritable B. 80 year old widow. behavior indicative of unresolved repressed conflict of the past 32. participate in conversation and other social situations . Camila refuses to relate with to others because she: A. Lack of participation in peer groups B. social isolation C. cycloid 27. minimize receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of hearing. Solo parenting 29. The nurse will assist Salome and her daughter to plan a goal which is for Salome to: A. She was brought by her daughter to the Geriatric clinic for assessment and treatment. Insecurity feelings 30. The nurse counsels Salome‘s daughter that Salome‘s becoming very loud and tendency to become aggressive is a/an: A. sensory deprivation B. Schizophrenia is a/an: A.D. Faulty family atmosphere and interaction C. ego despair 33. is depressed 28. beginning indifference to the world around her B. attempt to maintain authoritative role C. Extreme rebellion towards authority figures D. feels superior of others C. Which of the following disturbances in interpersonal relationships MOST often predispose to the development of schizophrenia? A. A nursing diagnosis for Salome is: A.

xenophobia 37. the following ways to assist Salome meet her needs and avoiding which of the following: A. Salome was fitted a hearing aid. perception 39. comfortable level C. help find meaning in her behavior C. acrophobia B. 36. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. prescribed level D. Speaking distinctly and slowly C. increase her self-esteem to maintain her authoritative role 34. organic B. She understood the proper use and wear of this device when she says that the battery should be functional. Speaking at eye level and having the client‘s attention D. Allowing her to take her meals alone 35. assist her in recognizing irrational beliefs and thoughts B. audible level Situation 8 – For more than a month now. which of these behaviors indicate a positive result of being able to . claustrophobia C. psychotic D. Using short simple sentences B. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her: A. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her. Which of the following should the nurse implement? A. Cecilia is demonstrating: A. Cecilia‘s problem is that she always sees and thinks negative things hence she is always fearful. psychosomatic C. After discharge. neurotic 38. Cecilia is persistently feeling restless.C. The daughter understood. observation D. Phobia is a symptom described as: A. the device is turned on and adjusted to a: A. worried and feeling as if something dreadful is going to happen. Administer anxiolytic drug 40. provide positive reinforcement for acceptable behavior D. cognition C. agoraphobia D. therapeutic level B. communication B. accept the steady loss of hearing that occurs with aging D.

Has periods of crying. Identification of patient‘s responses to medical diagnoses and treatment C. Anxiety due to unknown D. Relate patient‘s feelings to physician. Least restrictive environment D. initiate and encourage her to verbalize her fears. In an extreme situation and when no other resident or intern is available. Civil liberty 42. continue to make necessary explanations regarding diagnostic tests. Patient’s responses to health and illness as a total person in interaction with the environment D. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. Confidentiality C. the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient‘s records from loss or destruction or from people not authorized to read it.‖ 45. She drives alone along the long expressway. 12 hours 44. Parents or legal guardian D.overcome her phobia? A. 36 hours C. It is unethical to tell one‘s friends and family members data about patients because doing so is a violation of patients‘ rights to: A. 48 hours D. should a nurse receive telephone orders. The nurse must see to it that the written consent of mentally ill patients must be taken from: A. During the orientation. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the: A. 24 hours B. What is the objective data? A. the order has to be correctly written and signed by the physician within: A. Informed consent B. Doctor B. Step by step procedures for the management of common problems . 41. Law enforcement authorities 43. B. She watches television with the family in the recreation room D. She reads a book in the public library B. She joins an art therapy group Situation 9 – It is the first day of clinical experience of nursing students at the Psychiatry Ward. frequently verbalizes fear of what diagnostic tests will reveal C. ―I‘m so worried about what else they‘ll find wrong with me. give emotional support by spending more time with patient. Summary of chronological notations made by individual health team members B. Social worker C. C.

B. The next time you bed wet.‖ B. A therapeutic verbal approach that communicates strong disapproval is: A. placebo as a form of treatment 48.” C. keep an eye contact while staring at the client B. EXCEPT one compromise the concepts of behavior therapy program. extinction C. Situation 11 – The nurse is often met with the following situations when clients become angry and hostile. All of the following. During your conference. matter of fact in handling the behavior C. C. the nurse recognizes this . be loving yet firm 49. you will change your bed linen and wash the sheets. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual. sympathize for the child D.g.Situation 10 – Marie is 5½ years old and described by the mother as bedwetting at night. Tokens make her materialistic at an early age.‖ 50. To help Marie who bed wets at night practice acceptable and appropriate behavior. A. abnormal bladder development C. infections D. deep sleep factors B. During the pre-interaction phase of the N-P relationship. the nurse should: A. fold his/her arms across his/her chest D. What does your child want that you can give every time he/she wakes up dry in the morning? D. learning D. I expect you to from now on without fail. keep his/her hands behind his/her back or in one‘s pockets C. keep an “open” posture. I‘ll tell your friends and hang your sheets out the window for them to see. ―You are supposed to get up and go in the toilet when you feel you have to go and did not. Hands by sides but palms turned outwards 52. 51. Promise him/her a long awaited vacation after school is over. I‘d be upset and disappointed. Which of the following is the MOST common physiological cause of night bed wetting? A. give a prize. the parent inquires how to motivate Marie to be dry in the morning. 46. reward and punishment B. e. discipline with a kind attitude B. ―If you bed wet. it is important for the parents to be consistent with the following approaches EXCEPT: A. “You are supposed to get up and go in the toilet when you feel you have to go and did not.‖ D. Give praise and hugs occasionally. Your response which is an immediate intervention would be: A. Give a star each time she wakes up dry and every set of five stars. ―If you don‘t make an effort to control your bedwetting. familial and genetic factors 47.

―Don‘t be silly. Ambivalence Situation 13 – Graciela 1½ year old is admitted to the hospital from the emergency room with a fracture of the left femur due to a fall down a flight of stairs. which of the following approaches is NOT therapeutic? A. made a fist and turned away from the nurse. A. which of these nursing diagnoses should have priority? A. ineffective coping D. Graciela . In planning care for a patient with Parkinson‘s disease. ―How do you usually express anger?‖ D. To call for help from other members of the team D. Loss D. his anger was suppressed‖ 54. ―When asked about his relationship with his father. Display empathy towards the patient C. ―Stop! Put that chair down. ―Stop! The security will be here in a minute. Number of accomplishments B. To stay and fight or run away 53. A patient grabs and about to throw it. ―When do you usually feel angry?‖ C. Ability to avoid interpersonal conflict C.” C. Despair C. To encourage thought. altered nutritional state C.normal INITIAL reaction to an assaultive or potentially assaultive person.‖ B. client clenched his jaw/teeth. A. Physical health throughout life D. altered mood state 57. unhappy and miserable is experiencing: A. The nurse best responds saying. Personality development in his life span 60. “Why do you feel angry?” B. Crisis B. potential for injury B. “When asked about his relationship with his father. An elderly who has lots of regrets.‖ D. What situations provoke you to be angry?‖ 55. ―When asked about his relationship with his father. To remain and cope with the incident B. A healthy adaptation to aging is primarily related to an individual‘s… A. “Calm down. ―When asked about his relationship with his father. Which of the following is an accurate way of reporting and recording an incident? A.” Situation 12 – Nursing care for the elderly 56. client was resistant to respond‖ D. client became anxious.‖ B.‖ C.

Graciela is assessed to have no head injury. Periorbital edema D. D. B. I will use white shoe polish to keep the cast neat. Initiative C. B. Narrowing of the pulse pressure B. The traction weights are hanging 10 inches above the floor. The traction ropes move freely through the pulley. B. C. These drugs act on the brain chemistry. The toes of Graciela‘s left foot blanch when the nurse applies pressure on them. Graciela‘s legs are suspended at a 90 degree angle to her trunk. Autonomy Situation 14 – Jolina is an 18 year old beginning college student. Jolina is put on antidepressant drugs. 64. She will be observed for signs of increased intracranial pressure which include: A. I will place plastic sheeting around the perineal area of the cast. 61. which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction? A. The nurse notes that the fall might also cause a possible head injury. A plaster of Paris hip spica is applied. Part of discharge plan is for the nurse to give instructions about the care of Graciela‘s cast to the mother. Industry D. therefore they would be useful in which type of depression? A. Which of these finding is a concern of immediate attention that must be reported to the physician immediately? A. Graciela is scratching the cast over her abdomen. neurotic depression C. While on Bryant‘s traction. The nurse counsels Graciela‘s mother ways to safeguard safety while providing opportunities for Graciela to develop a sense of: A. Trust B. C. The nurse is unable to insert a finger under the edge of Graciela’s cast on her left foot. C. exogenous depression B. Vomiting C. I will reinforce cracked areas on the cast with adhesive tape. Her mother observed that she is having problems relating with her friends. 62. A positive Kernig’s sign 63. Which of these statements indicate that the mother understood an important aspect of cast care? A. psychotic depression . 66. 65. The Bryant‘s traction is removed. She is undecided about her future. lost interest in anything and complained of constant tiredness. D. Graciela’s buttocks are resting on the bed. endogenous depression D. D. I will use cool water to wash the cast. She has lost insight. Graciela‘s cast is still damp.is placed on Bryant‘s traction.

Where do you go from here? D. Encourage her to join socialization hour so she will start to relate with others. B. After one week of antidepressant medication. Expected because therapeutic effectiveness takes 2-4 weeks. 69. Which of the following questions illustrates the group role of encourager? A. During the predischarge conference. Socialization D. Encourage her to join group therapy with other patients. Insight B. Venlafaxine (Effexor) B. Sertraline (Zoloft) D. D. Make some decisions about her future C.67. Discusses personal concerns with group members 72. Membership dropout generally occurs in group therapy after a member: A. Jolina still manifests depression. Jolina continues to verbalize feeling sad and hopeless. B. One of the nurse‘s important considerations for Jolina INITIALLY is: A. Ineffective result because perhaps the drug‘s dosage is inadequate. Find a good job. Formulate a structured schedule so she is able to channel her energies externally B. Unexpected because therapeutic effectiveness takes within a few days. Productivity C. Solve her own problems Situation 15 – Group Approach in Nursing 71. Experiences feelings of frustration in the group D. What were you saying? B. Unusual because action of antidepressant drug is immediate. Realistically assess her assets and limitations D. C. Let her alone until she feels like mingling with others. Accomplishes his goal in joining the group B. Intimacy . Flouxetine (Prozac) C. the nurse suggests vocational guidance because it should help Jolina to: A. D. The goal of remotivation therapy is to facilitate: A. 70. Imipramine (Tofranil) 68. The nurse evaluates this as: A. She is not mixing well with other clients. C. Discovers that his feelings are shared by the group members C. This is a tricyclic antidepressant drug: A. Why haven‘t we heard from you? 73. Who wants to respond next? C.

Competition Situation 16 – The mental health – psychiatric nurse functions in a variety of setting with different types of clients. Lorelie upon discharge was referred to a volunteer group where she has learned to read patterns. dance music D. 76. The treatment of the family as a unit is based on the belief that the family: A. In a residential treatment home for adolescent girls. provision of social welfare benefits for the poor C. prevention C. Cohesiveness C. Recreational therapy B. religious music B.74. The working phase in a therapy group is usually characterized by which of the following? A. The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of: A. treatment B. aggressive family planning methods B. Which of these topics would the school nurse consider as priority for their parent‘s class? . social action D. Art therapy C. research 78. relaxation music C. To deescalate possible anger and aggression among the clients it is BEST to play: A. malnutrition and social ills such as street children. homeless and prostitution is a predisposing factor to mental illness. Vocational therapy D. What type of therapy is this? A. rock music 80. the clients were becoming increasingly tense and upset because of shortening of their recreation time. cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future. Poverty as reflected in prevalence of communicable diseases. is ―contaminated‖ by the presence of deviant member and all members need treatment. who has therapy together will tend to remain together D. free clinics and more hospitals 77. is a social system and all the members are interrelated components of that system B. rehabilitation D. Educational therapy 79. Caution B. The parents of special children who are behaviorally disturbed need mental health education. Confusion D. as a unit of society needs the opportunity to change its own destiny C. 75. A community approach to cope with this problem is for the nurse to support: A.

requires long term treatment in a hospital based program C. Being in contact with reality and the environment is a function of the: A. Lysergic acid diethylamide C. Effective parenting D. substance dependence: A. teach skills to recognize and respond to health threatening situations B. Orientation phase B. Substance abuse is different from substance dependence in that. Termination phase . promote homeostasis and minimize the client’s withdrawal symptoms 85.A. Commonly known as ―shabu‖ is: A. Sex education Situation 17 – Nurses in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. caused by multiplicity of factors C. Working phase C. conscience B. Methylenedioxy methamphetamine D. it is a priority for the nurse to: A. a common problem brought about by socioeconomic deprivation B. ego C. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is: A. id D. 86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? A. Drug education B. includes characteristics of tolerance and withdrawal 84. super ego 83. implement behavior modification D. due to biochemical factors 82. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses D. increase the client‘s awareness of unsatisfactory protective behaviors C. includes characteristics of adverse consequences and repeated use B. produces less severe symptoms than that of abuse D. Methamphetamine hydrochloride Situation 18 – It is common that clients ask the nurse personal questions. Pre-interaction phase D. Cannabis Sativa B. Child abuse C. 81. During the detoxification stage.

87. he is slim and walks sluggishly with a limp. When the client asks about the family of the nurse. Avoid the situation and redirect the client‘s attention B. the MOST appropriate response is: A. C. ―What should I do when Ricky fondles his genitalia?‖ An appropriate response of the nurse is for the mother to: A. If the client asks for the nurse‘s telephone number. She asked. He stands 5‘ ½‖ and weighs 100 lbs. Give a brief and simple response and focus on the client. she should . ―What would you do with my number if I give it to you?‖ C. 90. It is 10 o‘clock on your watch. The client knows no other way to begin a conversation. 91. The client asks. The client is simply curious. ―Why do you ask?‖ D. C. Needs for belonging 92. The mother understood that for her son to learn to cope and be independent.‖ C. Needs for safety and security D. what are your thoughts about it?‖ D. ―It is 10 o‘clock. The classroom teacher consults the school nurse for guidance on how to take care of Ricky while inside of the classroom. “Are you getting bored?” B. When the nurse is asked a personal question. ―What time is it?‖ The nurse‘s appropriate is: A. “Are you asking for an official number of the hospital/clinic for your reference?” 88. Divert Ricky’s attention and engage him in satisfying activities B. Introduce another topic like the client‘s interests 89. Engage him in computer TV games that engage his hands 93. Physiological needs B. Some patients are like children in seeking recognition from the nurse. ―Guess. “Why don’t we talk about your family instead?” D. ―It is confidential I just don‘t give it to anyone. Need for self esteem C. which of these reactions indicates a need for her to introspect? A. Tell Ricky that it is wrong to keep fondling his genitalia C. Ricky‘s mother visited the school nurse. what time is it?‖ Situation 19 – Ricky is a 12 year old boy with Down‘s syndrome. His/Her right to privacy is being intruded. Ignore Ricky‘s behavior because he will outgrow it later D. He attends a school for a special education.‖ B. ―If I say No to your request. X-ray of cervical spine showed ―subluxation of C1 in relation to C2 with cord compression‖. The nurse considers as priority. D. The nurse had one on one health education sessions with Ricky‘s mother. Ricky‘s: A. which of these responses is NOT appropriate? A. B. He wears a neck brace as a support for his neck.

Card and table games 95. select and prepare his own food D. Profit from vocational training with moderate supervision B. Preparing and cooking simple menu D. flight of ideas. LSD C. 96. socialize with people B. Experience of ―blackout‖ D. Live successfully in the community C. family 97. Ricky‘s IQ falls within the range of 50-55. Sudden death from cardiac or respiratory depression B. Competitive sport C. Acquire academic skills of 6th grade level Situation 20 – The abuse of dangerous drugs is a serious public health concern that nurses need to address. distortion of size.constantly provide activities for Ricky to be able to: A. Heroin 99. church D. loss of train of thought. A. Marijuana D. Opiates B. he can be expected to: A. do activities of daily living 94. A. Working with clay B. distance and time. All of the following activities are appropriate for Ricky EXCEPT: A. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain. Psychological dependence after prolonged use 100. school C. Danger of acquiring hepatitis or AIDS C. This drug produces mirthfulness. sublimation 98. projection D. fantasies. law enforcement agencies B. A. and ―bloodshot eyes‖ due to dilated pupils. The nurse evaluates that her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse. repression B. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the: A. Perform simple tasks in closely supervised settings D. eventually go to school alone C. The mother of a drug dependent would never consider referring her son to a drug . rationalization C.

Codependent C. The mother‘s behavior can be described as: A.rehabilitation agency because she fears her son might just become worse while relating with other drug users. Caretaking D. Supportive ***END*** . Unhelpful B.

Sign up to vote on this title
UsefulNot useful