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68627164 comprehensive-nursing-board-exam-review-500-page-test-111213225254-phpapp02

  1. 1. Nursing Board Practice Test Compilation FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188 Contents NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE .......................................................................... 4 NURSING PRACTICE II ..................................................... 15 NURSING PRACTICE III .................................................... 26 NURSING PRACTICE IV.................................................... 36 NURSING PRACTICE V..................................................... 46 TEST I - Foundation of Professional Nursing Practice .... 56 Answers and Rationale – Foundation of Professional Nursing Practice ......................................................... 66 TEST II - Community Health Nursing and Care of the Mother and Child ........................................................... 74 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ............................. 84 ANSWER KEY - FOUNDATION OF PROFESSIONAL NURSING PRACTICE.................................................. 199 COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .................................................... 200 ANSWER KEY: COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .......................... 211 Comprehensive Exam 1................................................ 213 CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS...................................... 222 ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS ......................... 234 Nursing Practice Test V ................................................ 235 Nursing Practice Test V ................................................ 245 TEST I - Foundation of Professional Nursing Practice .. 255 TEST III - Care of Clients with Physiologic and Psychosocial Alterations ................................................ 91 Answers and Rationale – Foundation of Professional Nursing Practice ....................................................... 265 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 102 TEST II - Community Health Nursing and Care of the Mother and Child ......................................................... 273 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 111 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ........................... 283 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 122 TEST III - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 290 TEST V - Care of Clients with Physiologic and Psychosocial Alterations.................................................................... 133 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 301 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 144 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 310 PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 321 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 158 PRACTICE TEST II Maternal and Child Health ............... 162 ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH..................................................................... 167 MEDICAL SURGICAL NURSING ..................................... 173 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 178 PSYCHIATRIC NURSING ................................................ 180 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 185 TEST V - Care of Clients with Physiologic and Psychosocial Alterations.................................................................... 332 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 343 PART III ......................................................................... 352 PRACTICE TEST I FOUNDATION OF NURSING .............. 352 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 357 PRACTICE TEST II Maternal and Child Health ............... 361
  2. 2. ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH..................................................................... 366 MEDICAL SURGICAL NURSING ..................................... 372 MEDICAL SURGICAL NURSING Part 1 ........................... 475 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 1 ........................................................ 479 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 377 MEDICAL SURGICAL NURSING Part 2 ........................... 481 PSYCHIATRIC NURSING ................................................ 379 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 2 ........................................................ 489 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 384 FUNDAMENTALS OF NURSING PART 1 ........................ 387 FUNDAMENTALS OF NURSING PART 2 ........................ 392 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 2 ...................................................... 397 FUNDAMENTALS OF NURSING PART 3 ........................ 401 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 3 ...................................................... 405 MATERNITY NURSING Part 1 ........................................ 409 ANSWERS and RATIONALES for MATERNITY NURSING Part 1 ........................................................................ 418 MEDICAL SURGICAL NURSING Part 2 ....................... 485 MEDICAL SURGICAL NURSING Part 3 ........................... 491 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 3 ........................................................ 495 PSYCHIATRIC NURSING Part 1 ...................................... 497 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 1 ........................................................................ 502 PSYCHIATRIC NURSING Part 2 ...................................... 504 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 2 ........................................................................ 509 PSYCHIATRIC NURSING Part 3 ...................................... 512 MATERNITY NURSING Part 2 ........................................ 428 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 3 ........................................................................ 516 Answer for maternity part 2 .................................... 433 PROFESSIONAL ADJUSTMENT ...................................... 519 PEDIATRIC NURSING .................................................... 434 LEADERSHIP and MANAGEMENT ................................. 522 ANSWERS and RATIONALES for PEDIATRIC NURSING ................................................................................. 439 NURSING RESEARCH Part 1 .......................................... 532 COMMUNITY HEALTH NURSING Part 1........................ 444 Nursing Research Suggested Answer Key ................ 546 COMMUNITY HEALTH NURSING Part 2........................ 454 2 NURSING RESEARCH Part 2 .......................................... 542
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  4. 4. 5. NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE SITUATION: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today. 1. 2. 3. 4. 4 Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and the population. This is the most accepted definition of nursing as defined by the: a. PNA b. ANA c. Nightingale d. Henderson Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT an expanded career role for nurses? a. Nurse practitioner b. Nurse Researcher c. Clinical nurse specialist d. Nurse anaesthesiologist The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following, EXCEPT: a. Issue, suspend, revoke certificates of registration b. Issue subpoena duces tecum, ad testificandum c. Open and close colleges of nursing d. Supervise and regulate the practice of nursing A nursing student or a beginning staff nurse who has not yet experienced enough real situations to make judgments about them is in what stage of Nursing Expertise? a. Novice b. Newbie c. Advanced Beginner d. Competent Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having: a. the ability to organize and plan activities b. having attained an advanced level of education c. a holistic understanding and perception of the client d. intuitive and analytic ability in new situations SITUATION: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer to this. 6. The nurse prepares an IM injection for an adult client using the Z track technique. 4 ml of medication is to be administered to the client. Which of the following site will you choose? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 7. In infants 1 year old and below, which of the following is the site of choice for intramuscular Injection? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 8. In order to decrease discomfort in Z track administration, which of the following is applicable? a. Pierce the skin quickly and smoothly at a 90 degree angle b. Inject the medication steadily at around 10 minutes per millilitre c. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel d. Pierce the skin slowly and carefully at a 90 degree angle 9. After injection using the Z track technique, the nurse should know that she needs to wait for a few seconds before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue, thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle? a. 2 seconds
  5. 5. 5 b. 5 seconds c. 10 seconds d. 15 seconds 10. The rationale in using the Z track technique in an intramuscular injection is: a. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissues b. It will allow a faster absorption of the medication c. The Z track technique prevent irritation of the muscle d. It is much more convenient for the nurse that the patient 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 15. 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 16. The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the nurse should wait for a period of: a. 15 seconds b. 1 to 2 minutes c. 30 minutes d. 15 minutes 17. If the arm is said to be elevated when taking the blood pressure, it will create a: a. False high reading b. False low reading c. True false reading d. Indeterminate 18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature? a. 10 minutes b. 20 minutes c. 30 minutes d. 15 minutes 19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80 mmHg and then silence. SITUATION: A Client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment. 11. 12. 13. 14. All of the following are correct methods in assessment of the blood pressure 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 You attached a pulse oximeter to the client. You know that the purpose is 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 antihypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops After a few hours in the Emergency Room, The client 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 Through the client’s health history, you gather
  6. 6. What is the client’s blood pressure? a. 130/80 b. 150/100 c. 100/80 d. 150/100 20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? a. 10-20 seconds b. 30-45 seconds c. 1-1.5 minutes d. 3-3.5 minutes to lungs. This can be avoided by: a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity b. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs c. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums d. suctioning as needed while cleaning the buccal cavity 25. Situation: Oral care is an important part of hygienic practices and promoting client comfort. 21. 22. 23. 24. 6 An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? a. lemon glycerine b. Mineral oil c. hydrogen peroxide d. Normal saline solution When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? a. Put the client on a sidelying position with head of bed lowered b. Keep the client dry by placing towel under the chin c. Wash hands and observes appropriate infection control d. Clean mouth with oral swabs in a careful and an orderly progression The advantages of oral care for a client include all of the following, EXCEPT: a. decreases bacteria in the mouth and teeth b. reduces need to use commercial mouthwash which irritate the buccal mucosa c. improves client’s appearance and selfconfidence d. improves appetite and taste of food A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: a. salt solution b. petroleum jelly c. water d. mentholated ointment Situation – Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. 26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? a. Clenching his fist every 2 minutes b. Breathing in and out through the nose with his mouth open c. Tensing the shoulder muscles while lying on his back d. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: a. Nausea and vomiting b. Shortness of breath and laryngeal stridor c. Blood tinged sputum and coughing d. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instructed Fernan to: a. Exercise the neck muscles b. Refrain from coughing and talking
  7. 7. 7 c. Breathe deeply d. Clear his throat d. Weber’s test 34. 29. 30. Right after thoracentesis, which of the following is most appropriate intervention? a. Instruct the patient not to cough or deep breathe for two hours b. Observe for symptoms of tightness of chest or bleeding c. Place an ice pack to the puncture site d. Remove the dressing to check for bleeding A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, Pco2 is 50 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 35. Allen’s test checks the patency of the: a. Ulnar artery b. Carotid artery c. Radial artery d. Brachial artery Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: a. Keep the sterile equipment from contamination b. Assist the physician c. Open and close the three-way stopcock d. Observe the patient’s vital signs Situation: Knowledge of the acid-base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the development of which type of acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimens are drawn? a. Guthrie test b. Romberg’s test c. Allen’s test Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 36. Given the above assessment data, the most immediate goal of the nurse would be which of the following? a. Prevent urinary complication b. maintains fluid and electrolytes c. Alleviate pain d. Alleviating nausea 37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post-operative order includes “daily urine specimen to be sent to the laboratory”. Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? a. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container b. empty a sample urine from the collecting bag into the specimen container c. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container.
  8. 8. 38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? a. to the patient’s inner thigh b. to the patient’ buttocks c. to the patient’s lower thigh d. to the patient lower abdomen regulation is secreted in the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland 45. 39. 40. Which of the following menu is appropriate for one with low sodium diet? a. instant noodles, fresh fruits and ice tea b. ham and cheese sandwich, fresh fruits and vegetables c. white chicken sandwich, vegetable salad and tea d. canned soup, potato salad, and diet soda How will you prevent ascending infection to Eileen who has an indwelling catheter? a. see to it that the drainage tubing touches the level of the urine b. change he catheter every eight hours c. see to it that the drainage tubing does not touch the level of the urine d. clean catheter may be used since urethral meatus is not a sterile area Situation: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. All of the following are secreted by the anterior pituitary gland except: a. Somatotropin/Growth hormone b. Thyroid stimulating hormone c. Follicle stimulating hormone d. Gonadotropin hormone releasing hormone Situation: The staff nurse supervisor requests all the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 46. The plan of the nurse supervisor is an example of a. in service education process b. efficient management of human resources c. increasing human resources d. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra a. makes the assignment to teach the staff member b. is assigning the responsibility to the aide but not the accountability for those tasks c. does not have to supervise or evaluate the aide d. most know how to perform task delegated 48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should a. empathize with the nurse and listen to her b. tell her to take the day off c. discuss how she is adjusting to her new job d. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is Somatocrinin or the Growth hormone releasing hormone is secreted by the: a. Hypothalamus b. Posterior pituitary gland c. Anterior pituitary gland d. Thyroid gland 42. 43. 44. 8 All of the following hormones are hormones secreted by the Posterior pituitary gland except: a. Vasopressin b. Anti-diuretic hormone c. Oxytocin d. Growth hormone Calcitonin, a hormone necessary for calcium While Parathormone, a hormone that negates the effect of calcitonin is secreted by the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland
  9. 9. 9 a. b. c. d. grievance arbitration collective bargaining strike d. It should disclose previous diagnosis, prognosis and alternative treatments available for the client 55. 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is a. professional course towards credits b. in-service education c. advance training d. continuing education Situation: As a nurse, you are aware that proper documentation in the patient chart is your responsibility. 51. 52. 53. 54. Which of the following is not a legally binding document but nevertheless very important in the care of all patients in any health care setting? a. Bill of rights as provided in the Philippine constitution b. Scope of nursing practice as defined by RA 9173 c. Board of nursing resolution adopting the code of ethics d. Patient’s bill of rights A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication? a. Incident report b. Nursing kardex c. Oral report d. Complain report Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges? a. Fraud b. Harassment c. Assault and battery d. Breach of confidentiality Which of the following is the essence of informed consent? a. It should have a durable power of attorney b. It should have coverage from an insurance company c. It should respect the client’s freedom from coercion Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation? a. The RN must supervise all delegated tasks b. After a task has been delegated, it is no longer a responsibility of the RN c. The RN is responsible and accountable for the delegated task in adjunct with the delegate d. Follow up with a delegated task is necessary only if the assistive personnel is not trustworthy Situation: When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 56. The most important risk factor is: a. Cigarette smoking b. binge drinking c. Hypertension d. heredity 57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: a. Embolic stroke b. diabetic stroke c. Hemorrhagic stroke d. thrombotic stroke 58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: a. phlebitis b. damage to blood vessel c. trauma d. aneurysm 59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? a. Amphetamines b. shabu c. Cocaine d. Demerol
  10. 10. d. Iron 75 mg/100 ml 60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: a. “More red blood cells thicken blood and make clots more possible.” b. “Increased RBC count is linked to high cholesterol.” c. “More red blood cell increases hemoglobin content.” d. “High RBC count increases blood pressure.” Situation: Recognition of normal values is vital in assessment of clients with various disorders. 61. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. ST depression b. Prominent U wave c. Inverted T wave d. Tall peaked T waves 63. 64. 10 A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. U waves b. Elevated T waves c. Absent P waves d. Elevated ST Segment Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? a. Neutrophils 60% b. White blood cells (WBC) 9000/mm c. Erythrocyte sedimentation rate (ESR) is 39 mm/hr Which of the following laboratory test result indicate presence of an infectious process? a. Erythrocyte sedimentation rate (ESR) 12 mm/hr b. White blood cells (WBC) 18,000/mm3 c. Iron 90 g/100ml d. Neutrophils 67% Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this. 66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural effusion? a. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath b. Hypoxemia, hypercapnea and respiratory acidosis c. Noisy respiration, crackles, stridor and wheezing d. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds 67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause: a. Pneumothorax b. Cardiovascular collapse c. Pleurisy or Pleuritis d. Hypertension 68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to: a. Restore positive intrathoracic pressure b. Restore negative intrathoracic pressure c. To visualize the intrathoracic content d. As a method of air administration via ventilator 69. The chest tube is functioning properly if: a. There is an oscillation b. There is no bubbling in the drainage bottle A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following? a. 60% b. 47% c. 45% d. 32% 62. 65.
  11. 11. 11 c. There is a continuous bubbling in the waterseal d. The suction control bottle has a continuous bubbling 70. In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the following is included in the teaching? a. Breath normally b. Hold the breath after each inspiration for 1 full minute c. Practice abdominal breathing d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation 75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic payment. a. Health Maintenance Organization b. Medicare c. Philippine Health Insurance Act d. Hospital Maintenance Organization Situation: Nursing ethics is an important part of the nursing profession. As the ethical situation arises, so is the need to have an accurate and ethical decision making. 76. 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 77. 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 78. A subjective feeling about what is right or wrong is said to be: a. Morality b. Religion c. Values d. Bioethics 79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If Values are going to be a part of a research, this is categorized under: a. Qualitative b. Experimental c. Quantitative d. Non Experimental 80. 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 SITUATION: Health care delivery system affects the health status of every filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life. 71. When should rehabilitation commence? a. The day before discharge b. When the patient desires c. Upon admission d. 24 hours after discharge 72. What exemplified the preventive and promotive programs in the hospital? a. Hospital as a center to prevent and control infection b. Program for smokers c. Program for alcoholics and drug addicts d. Hospital Wellness Center 73. Which makes nursing dynamic? a. Every patient is a unique physical, emotional, social and spiritual being b. The patient participate in the overall nursing care plan c. Nursing practice is expanding in the light of modern developments that takes place d. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes 74. Prevention is an important responsibility of the nurse in: a. Hospitals b. Community c. Workplace d. All of the above
  12. 12. 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 81. 82. 83. 84. 12 Why is there an ethical dilemma? a. the choices involved do not appear to be clearly right or wrong b. a client’s legal right co-exist with the nurse’s professional obligation c. decisions has to be made based on societal norms. d. decisions has to be mad quickly, often under stressful conditions According to the code of ethics, which of the following is the primary responsibility of the nurse? a. Assist towards peaceful death b. Health is a fundamental right c. Promotion of health, prevention of illness, alleviation of suffering and restoration of health d. Preservation of health at all cost Which of the following is TRUE about the Code of Ethics of Filipino Nurses, except: a. 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. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates c. The present code utilized the Code of Good Governance for the Professions in the Philippines d. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the license? a. PRC b. PNA c. DOH d. BON 85. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability? a. Human rights of clients, regardless of creed and gender b. The privilege of being a registered professional nurse c. Health, being a fundamental right of every individual d. Accurate documentation of actions and outcomes Situation: As a profession, nursing is dynamic and its practice is directed by various theoretical models. To demonstrate caring behaviour, the nurse applies various nursing models in providing quality nursing care. 86. When you clean the bedside unit and regularly attend to the personal hygiene of the patient as well as in washing your hands before and after a procedure and in between patients, you indent to facilitate the body’s reparative processes. Which of the following nursing theory are you applying in the above nursing action? a. Hildegard Peplau b. Dorothea Orem c. Virginia Henderson d. Florence Nightingale 87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is viewed as human to human relationship. This statement is an application of whose nursing model? a. Joyce Travelbee b. Martha Rogers c. Callista Roy d. Imogene King 88. The statement “the health status of an individual is constantly changing and the nurse must be cognizant and responsive to these changes” best explains which of the following facts about nursing? a. Dynamic b. Client centred c. Holistic d. Art 89. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care working in assisting the patient to
  13. 13. 13 gain independence as quickly as possible. Which of the following nursing actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally immobile? a. Feeds the patient, brushes his teeth, gives the sponge bath b. Supervise the watcher in rendering patient his morning care c. Put the patient in semi fowler’s position, set the over bed table so the patient can eat by himself, brush his teeth and sponge himself d. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready include: a. Prescription of the doctor to the patient’s illness b. Plan of care for patient c. Patient’s perception of one’s illness d. Nursing problem and Nursing diagnosis The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording? a. POMR b. Modified POMR c. SOAPIE d. SOMR 95. 90. 94. Which of the following is the advantage of SOMR or Traditional recording? a. Increases efficiency in data gathering b. Reinforces the use of the nursing process c. The caregiver can easily locate proper section for making charting entries d. Enhances effective communication among health care team members In the self-care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to fulfil his physiological, psychological and social needs. A pregnant client needing prenatal check-up is classified as: a. Wholly compensatory b. Supportive Educative c. Partially compensatory d. Non compensatory Situation: Documentation and reporting are just as important as providing patient care, As such, the nurse must be factual and accurate to ensure quality documentation and reporting. Situation: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest x ray revealed pleural effusion. The physician will perform thoracentesis. 96. 91. Health care reports have different purposes. The availability of patients’ record to all health team members demonstrates which of the following purposes: a. Legal documentation b. Research c. Education d. Vehicle for communication 92. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should 97. Which of the following psychological preparation is not relevant for him? a. Telling him that the gauge of the needle and anesthesia to be used b. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place c. Allow June to express his feelings and concerns d. Physician’s explanation on the purpose of the procedure and how it will be done 98. Before thoracentesis, the legal consideration you must check is: a. Consent is signed by the client When a nurse commits medication error, she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes: a. Research b. Legal documentation c. Nursing Audit d. Vehicle for communication 93. Thoracentesis is useful in treating all of the following pulmonary disorders except: a. Hemothorax b. Hydrothorax c. Tuberculosis d. Empyema
  14. 14. b. Medicine preparation is correct c. Position of the client is correct d. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: a. Orthopneic b. Low fowlers c. Knee-chest d. Sidelying position on the affected side 100. Which of the following anaesthetics drug is used for thoracentesis? a. Procaine 2% b. Demerol 75 mg c. Valium 250 mg d. Phenobartbital 50 mg 14
  15. 15. 15 D. Follicle stimulating hormone NURSING PRACTICE II Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She consults you for guidance in relation with her menstrual cycle and her desire to get pregnant. 1. She wants to know the length of her menstrual cycle. Her previous menstrual period is October 22 to 26. Her LMB is November 21. Which of the following number of days will be your correct response? A. 29 B. 28 C. 30 D. 31 2. You advised her to observe and record the signs of Ovulation. Which of the following signs will she likely note down? 1. A 1 degree Fahrenheit rise in basal body temperature 2. Cervical mucus becomes copious and clear 3. One pound increase in weight 4. Mittelschmerz A. 1, 2, 4 B. 1, 2, 3 C. 2, 3, 4 D. 1, 3, 4 3. You instruct Mariah to keep record of her basal temperature every day, which of the following instructions is incorrect? A. If coitus has occurred; this should be reflected in the chart B. It is best to have coitus on the evening following a drop in BBT to become pregnant C. Temperature should be taken immediately after waking and before getting out of bed D. BBT is lowest during the secretory phase 4. She reports an increase in BBT on December 16. Which hormone brings about this change in her BBT? A. Estrogen B. Gonadotropine C. Progesterone 5. The following month, Mariah suspects she is pregnant. Her urine is positive for Human chorionic gonadotrophin. Which structure produces Hcg? A. Pituitary gland B. Trophoblastic cells of the embryo C. Uterine deciduas D. Ovarian follicles Situation: Mariah came back and she is now pregnant. 6. At 5 month gestation, which of the following fetal development would probably be achieve? A. Fetal movement are felt by Mariah B. Vernix caseosa covers the entire body C. Viable if delivered within this period D. Braxton hicks contractions are observed 7. The nurse palpates the abdomen of Mariah. Now At 5 month gestation, What level of the abdomen can the fundic height be palpated? A. Symphysis pubis B. Midpoint between the umbilicus and the xiphoid process C. Midpoint between the symphysis pubis and the umbilicus D. Umbilicus 8. She worries about her small breasts, thinking that she probably will not be able to breastfeed her baby. Which of the following responses of the nurse is correct? A. “The size of your breast will not affect your lactation” B. “You can switch to bottle feeding” C. “You can try to have exercise to increase the size of your breast” D. “Manual expression of milk is possible” 9. She tells the nurse that she does not take milk regularly. She claims that she does not want to gain too much weight during her pregnancy. Which of the following nursing diagnosis is a priority? A. Potential self-esteem disturbance related to physiologic changes in pregnancy B. Ineffective individual coping related to physiologic changes in pregnancy C. Fear related to the effects of pregnancy D. Knowledge deficit regarding nutritional
  16. 16. requirements of pregnancies related to lack of information sources 10. Which of the following interventions will likely ensure compliance of Mariah? A. Incorporate her food preferences that are adequately nutritious in her meal plan B. Consistently counsel toward optimum nutritional intake C. Respect her right to reject dietary information if she chooses D. Inform her of the adverse effects of inadequate nutrition to her fetus Situation: Susan is a patient in the clinic where you work. She is inquiring about pregnancy. 11. Susan tells you she is worried because she develops breasts later than most of her friends. Breast development is termed as: A. Adrenarche B. Thelarche C. Mamarche D. Menarche 12. Kevin, Susan’s husband tells you that he is considering vasectomy After the birth of their new child. Vasectomy involves the incision of which organ? A. The testes B. The epididymis C. The vas deferens D. The scrotum 13. On examination, Susan has been found of having a cystocele. A cystocele is: A. A sebaceous cyst arising from the vulvar fold B. Protrusion of intestines into the vagina C. Prolapse of the uterus into the vagina D. Herniation of the bladder into the vaginal wall 14. Susan typically has menstrual cycle of 34 days. She told you she had coitus on days 8, 10, 15 and 20 of her menstrual cycle. Which is the day on which she is most likely to conceive? A. 8th day B. Day 15 C. 10th day D. Day 20 16 15. While talking with Susan, 2 new patients arrived and they are covered with large towels and the nurse noticed that there are many cameraman and news people outside of the OPD. Upon assessment the nurse noticed that both of them are still nude and the male client’s penis is still inside the female client’s vagina and the male client said that “I can’t pull it”. Vaginismus was your first impression. You know that The psychological cause of Vaginismus is related to: A. The male client inserted the penis too deeply that it stimulates vaginal closure B. The penis was too large that is why the vagina triggered its defense to attempt to close it C. The vagina does not want to be penetrated D. It is due to learning patterns of the female client where she views sex as bad or sinful Situation: Overpopulation is one problem in the Philippines that causes economic drain. Most Filipinos are against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and economic growth. 16. Supposed that Dana, 17 years old, tells you she wants to use fertility awareness method of contraception. How will she determine her fertile days? A. She will notice that she feels hot, as if she has an elevated temperature. B. She should assess whether her cervical mucus is thin, copious, clear and watery. C. She should monitor her emotions for sudden anger or crying D. She should assess whether her breasts feel sensitive to cool air 17. Dana chooses to use COC as her family planning method. What is the danger sign of COC you would ask her to report? A. A stuffy or runny nose B. Slight weight gain C. Arthritis like symptoms D. Migraine headache 18. Dana asks about subcutaneous implants and she asks, how long will these implants be effective. Your best answer is: A. One month
  17. 17. 17 B. Five years C. Twelve months D. 10 years 19. Dana asks about female condoms. Which of the following is true with regards to female condoms? A. The hormone the condom releases might cause mild weight gain B. She should insert the condom before any penile penetration C. She should coat the condom with spermicide before use D. Female condoms, unlike male condoms, are reusable 20. Dana has asked about GIFT procedure. What makes her a good candidate for GIFT? A. She has patent fallopian tubes, so fertilized ova can be implanted on them B. She is RH negative, a necessary stipulation to rule out RH incompatibility C. She has normal uterus, so the sperm can be injected through the cervix into it D. Her husband is taking sildenafil, so all sperms will be motile Situation: Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. 21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer? A. Prostaglandins released from the cut fallopian tubes can kill sperm B. Sperm cannot enter the uterus because the cervical entrance is blocked. C. Sperm can no longer reach the ova, because the fallopian tubes are blocked D. The ovary no longer releases ova as there is nowhere for them to go. 22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when: A. A woman has no uterus B. A woman has no children C. A couple has been trying to conceive for 1 year D. A couple has wanted a child for 6 months 23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because: A. Endometrial implants can block the fallopian tubes B. The uterine cervix becomes inflamed and swollen C. The ovaries stop producing adequate estrogen D. Pressure on the pituitary leads to decreased FSH levels 24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure? A. She will not be able to conceive for 3 months after the procedure B. The sonogram of the uterus will reveal any tumors present C. Many women experience mild bleeding as an after effect D. She may feel some cramping when the dye is inserted 25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. Donor sperm are introduced vaginally into the uterus or cervix B. Donor sperm are injected intraabdominally into each ovary C. Artificial sperm are injected vaginally to test tubal patency D. The husband’s sperm is administered intravenously weekly Situation: You are assigned to take care of a group of patients across the lifespan. 26. Pain in the elder persons requires careful assessment because they: A. experienced reduce sensory perception B. have increased sensory perception C. are expected to experience chronic pain D. have a decreased pain threshold 27. Administration of analgesics to the older persons requires careful patient assessment because older people: A. are more sensitive to drugs
  18. 18. B. have increased hepatic, renal and gastrointestinal function C. have increased sensory perception D. mobilize drugs more rapidly 28. The elderly patient is at higher risk for urinary incontinence because of: A. increased glomerular filtration B. decreased bladder capacity C. diuretic use D. dilated urethra 29. Which of the following is the MOST COMMON sign of infection among the elderly? A. decreased breath sounds with crackles B. pain C. fever D. change in mental status 30. Priorities when caring for the elderly trauma patient: A. circulation, airway, breathing B. airway, breathing, disability (neurologic) C. disability (neurologic), airway, breathing D. airway, breathing, circulation 31. Preschoolers are able to see things from which of the following perspectives? A. Their peers B. Their own and their mother’s C. Their own and their caregivers’ D. Only their own 32. In conflict management, the win-win approach occurs when: A. There are two conflicts and the parties agree to each one B. Each party gives in on 50% of the disagreements making up the conflict C. Both parties involved are committed to solving the conflict D. The conflict is settled out of court so the legal system and the parties win 33. According to the social-interactional perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and A. The presence of a family crisis B. The national emphasis on sex C. Genetics 18 D. Chronic poverty 34. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting. 35. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to: A. Call emergency medical services (EMS) and get the child to the emergency room B. Relax because these symptoms will pass and the child will be fine C. Administer syrup of ipecac D. Call the poison control center 36. A client says she heard from a friend that you stop having periods once you are on the “pill”. The most appropriate response would be: A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or skipped occasionally.” B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible.” C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly.” D. “Missed period can be very dangerous and may lead to the formation of precancerous cells.” 37. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Hirschsprung’s disease? A. A fine rash over the trunk B. Failure to pass meconium during the first 24 to 48 hours after birth
  19. 19. 19 C. The skin turns yellow and then brown over the first 48 hours of life D. High-grade fever 38. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching? A. Maintain bed rest with bathroom privileges B. Avoid intercourse for three days. C. Call if contractions occur. D. Stay on left side as much as possible when lying down. 39. A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first? A. Check for the presence of infection B. Assess for Prolapse of the umbilical cord C. Check the maternal heart rate D. Assess the color of the amniotic fluid 40. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to: A. avoid covering the area of the topical medication with the diaper B. avoid the use of clothing on top of the diaper C. put the diaper on as usual D. apply an icepack for 5 minutes to the outside of the diaper 41. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. Type of illness of the client B. Transference and counter transference C. Effective communication D. Personality of the participants 42. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other? A. lacerations can provoke allergic responses due to gonadotropic hormone release B. a woman is less able to keep the laceration clean because of her fatigue C. healing is limited during pregnancy so these will not heal until after birth D. increased bleeding can occur from uterine pressure on leg veins 43. In working with the caregivers of a client with an acute or chronic illness, the nurse would: A. Teach care daily and let the caregivers do a return demonstration just before discharge B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress. C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting 44. Which of the following roles BEST exemplifies the expanded role of the nurse? A. Circulating nurse in surgery B. Medication nurse C. Obstetrical nurse D. Pediatric nurse practitioner 45. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your work place,” cultures have different patterns of verbal and nonverbal communication. Which difference does? A. NOT necessarily belong? B. Personal behavior C. Subject matter D. Eye contact E. Conversational style 46. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening? A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinutria plus edema.
  20. 20. C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face. D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine. 47. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following areas? A. Isolation B. Lack of fulfillment C. Loneliness D. Identity 48. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of: A. Delegation B. Responsibility C. Supervision D. Competence 49. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position? A. Brow position B. Breech position C. Right Occipito-Anterior Position D. Left Occipito-Posterior Position 50. FOCUS methodology stands for: A. Focus, Organize, Clarify, Understand and Solution B. Focus, Opportunity, Continuous, Utilize, Substantiate C. Focus, Organize, Clarify, Understand, Substantiate D. Focus, Opportunity, Continuous (process), Understand, Solution SITUATION: The infant and child mortality rate in the low to middle income countries is ten times higher than industrialized countries. In response to this, the WHO and UNICEF launched the protocol Integrated Management of Childhood Illnesses to reduce the morbidity and mortality against childhood illnesses. 20 51. If a child with diarrhea registers two signs in the yellow row in the IMCI chart, we can classify the patient as: A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 52. Celeste has had diarrhea for 8 days. There is no blood in the stool, he is irritable, his eyes are sunken, the nurse offers fluid to Celeste and he drinks eagerly. When the nurse pinched the abdomen it goes back slowly. How will you classify Celeste’s illness? A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 53. A child who is 7 weeks has had diarrhea for 14 days but has no sign of dehydration is classified as: A. Persistent diarrhea B. Dysentery C. Severe dysentery D. Severe persistent diarrhea 54. The child with no dehydration needs home treatment. Which of the following is not included in the rules for home treatment in this case? A. Forced fluids B. When to return C. Give vitamin A supplement D. Feeding more 55. Fever as used in IMCI includes: A. Axillary temperature of 37.5 or higher B. Rectal temperature of 38 or higher C. Feeling hot to touch D. All of the above E. A and C only Situation: Prevention of Dengue is an important nursing responsibility and controlling it’s spread is a priority once outbreak has been observed. 56. An important role of the community health nurse in the prevention and control of Dengue H-fever includes: A. Advising the elimination of vectors by keeping water containers covered
  21. 21. 21 B. Conducting strong health education drives/campaign directed towards proper garbage disposal C. Explaining to the individuals, families, groups and community the nature of the disease and its causation D. Practicing residual spraying with insecticides 57. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for hospitalization of H-fever suspects? A. Marked anorexia, abdominal pain and vomiting B. Increasing hematocrit count C. Cough of 30 days D. Persistent headache 58. The community health nurses’ primary concern in the immediate control of hemorrhage among patients with dengue is: A. Advising low fiber and non-fat diet B. Providing warmth through light weight covers C. Observing closely the patient for vital signs leading to shock D. Keeping the patient at rest 59. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue Hfever? A. Prolonged bleeding time B. Appearance of at least 20 petechiae within 1cm square C. Steadily increasing hematocrit count D. Fall in the platelet count 60. Which of the following is the most important treatment of patients with Dengue H-fever? A. Give aspirin for fever B. Replacement of body fluids C. Avoid unnecessary movement of patient D. Ice cap over the abdomen in case of melena Situation: Health education and Health promotion is an important part of nursing responsibility in the community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses. 61. In correcting misconceptions and myths about certain diseases and their management, the health worker should first: A. Identify the myths and misconceptions prevailing in the community B. Identify the source of these myths and misconceptions C. Explain how and why these myths came about D. Select the appropriate IEC strategies to correct them 62. How many percent of measles are prevented by immunization at 9 months of age? A. 80% B. 99% C. 90% D. 95% 63. After TT3 vaccination a mother is said to be protected to tetanus by around: A. 80% B. 99% C. 85% D. 90% 64. If ever convulsions occur after administering DPT, what should the nurse best suggest to the mother? A. Do not continue DPT vaccination anymore B. Advise mother to comeback after 1 week C. Give DT instead of DPT D. Give pertussis of the DPT and remove DT 65. These vaccines are given 3 doses at one month intervals: A. DPT, BCG, TT B. OPV, HEP. B, DPT C. DPT, TT, OPV D. Measles, OPV, DPT Situation – With the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. The following conditions apply. 66. Which among the following is the primary focus of prevention of cancer? A. Elimination of conditions causing cancer B. Diagnosis and treatment C. Treatment at early stage D. Early detection 67. In the prevention and control of cancer, which of the following activities is the most important
  22. 22. function of the community health nurse? A. Conduct community assemblies. B. Referral to cancer specialist those clients with symptoms of cancer. C. Use the nine warning signs of cancer as parameters in our process of detection, control and treatment modalities. D. Teach woman about proper/correct nutrition. 68. Who among the following are recipients of the secondary level of care for cancer cases? A. Those under early case detection B. Those under post case treatment C. Those scheduled for surgery D. Those undergoing treatment 69. Who among the following are recipients of the tertiary level of care for cancer cases? A. Those under early treatment B. Those under early detection C. Those under supportive care D. Those scheduled for surgery 70. In Community Health Nursing, despite the availability and use of many equipment and devices to facilitate the job of the community health nurse, the best tool any nurse should be wel be prepared to apply is a scientific approach. This approach ensures quality of care even at the community setting. This is nursing parlance is nothing less than the: A. nursing diagnosis B. nursing research C. nursing protocol D. nursing process Situation – Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: 71. Using Integrated Management and Childhood Illness (IMCI) approach, how would you classify the 1st child? A. Bronchopneumonia B. Severe pneumonia C. No pneumonia : cough or cold D. Pneumonia 72. The 1st child who is 13 months has fast breathing using IMCI parameters he has: A. 40 breaths per minute or more B. 50 breaths per minute 22 C. 30 breaths per minute or more D. 60 breaths per minute 73. Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is irritable, and her eyes are sunken. The nurse offered fluids and and the child drinks eagerly. How would you classify Nina’s illness? A. Some dehydration B. Severe dehydration C. Dysentery D. No dehydration 74. Nina’s treatment should include the following EXCEPT: A. reassess the child and classify him for dehydration B. for infants under 6 months old who are not breastfed, give 100-200 ml clean water as well during this period C. Give in the health center the recommended amount of ORS for 4 hours. D. Do not give any other foods to the child for home treatment 75. While on treatment, Nina 18 months old weighed 18 kgs. and her temperature registered at 37 degrees C. Her mother says she developed cough 3 days ago. Nina has no general danger signs. She has 45 breaths/minute, no chest indrawing, no stridor. How would you classify Nina’s manifestation? A. No pneumonia B. Pneumonia C. Severe pneumonia D. Bronchopneumonia 76. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness? A. a child at a general danger sign B. severe pneumonia C. very severe febrile disease D. severe malnutrition 77. Why are small for gestational age newborns at
  23. 23. 23 risk for difficulty maintaining body temperature? A. their skin is more susceptible to conduction of cold B. they are preterm so are born relatively small in size C. they do not have as many fat stored as other infants D. they are more active than usual so they throw off comes 78. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure? A. headache and vomiting B. a high choking voice C. a swollen tender tongue D. abdominal bleeding and pain 79. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever? A. use plan C if there is bleeding from the nose or gums B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test C. give aspirin D. prevent low blood sugar 80. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to: A. ask what are the child’s problem B. check for the four main symptoms C. check the patient’s level of consciousness D. check for the general danger signs 81. A child with diarrhea is observed for the following EXCEPT: A. how long the child has diarrhea B. presence of blood in the stool C. skin Petechiae D. signs of dehydration 82. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for home management at this case? A. give drugs every 4 hours B. give the child more fluids C. continue feeding the child D. inform when to return to the health center 83. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to: A. beneficence B. respect for person C. nonmaleficence D. autonomy 84. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of: A. justice and beneficence B. beneficence and nonmaleficence C. fidelity and nonmaleficence D. fidelity and justice 85. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do? A. “Miss, may I get the bread myself because you have not washed your hands” B. All of these C. “Miss, it is better to use a pick up forceps/ bread tong” D. “Miss, your hands are dirty. Wash your hands first before getting the bread” Situation: The following questions refer to common clinical encounters experienced by an entry level nurse. 86. A female client asks the nurse about the use of a cervical cap. Which statement is correct regarding the use of the cervical cap? A. It may affect Pap smear results. B. It does not need to be fitted by the physician. C. It does not require the use of spermicide. D. It must be removed within 24 hours. 87. The major components of the communication process are: A. Verbal, written and nonverbal
  24. 24. B. Speaker, listener and reply C. Facial expression, tone of voice and gestures D. Message, sender, channel, receiver and feedback 88. The extent of burns in children are normally assessed and expressed in terms of: A. The amount of body surface that is unburned B. Percentages of total body surface area (TBSA) C. How deep the deepest burns are D. The severity of the burns on a 1 to 5 burn scale. 89. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is: A. Being raised by a parent of low intelligence quotient (IQ) B. An orphan C. A victim of child neglect D. The victim of poverty 90. Which of the following indicates the type(s) of acute renal failure? A. Four types: hemorrhagic with and without clotting, and nonhemorrhagic with and without clottings B. One type: acute C. Three types: prerenal, intrarenal and postrenal D. Two types: acute and subacute Situation: Mike 16 y/o has been diagnosed to have AIDS; he worked as entertainer in a cruise ship; 91. Which method of transmission is common to contract AIDS? A. Syringe and needles B. Sexual contact C. Body fluids D. Transfusion 92. Causative organism in AIDS is one of the following; A. Fungus B. retrovirus C. Bacteria 24 D. Parasites 93. You are assigned in a private room of Mike. Which procedure should be of outmost importance; A. Alcohol wash B. Washing Isolation C. Universal precaution D. Gloving technique 94. What primary health teaching would you give to mike; A. Daily exercise B. reverse isolation C. Prevent infection D. Proper nutrition 95. Exercise precaution must be taken to protect health worker dealing with the AIDS patients . which among these must be done as priority: A. Boil used syringe and needles B. Use gloves when handling specimen C. Label personal belonging D. Avoid accidental wound Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth. 96. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to eruption behind the ears. As a nurse, your physical examination must determine complication especially: A. Otitis media B. Inflammatory conjunctiva C. Bronchial pneumonia D. Membranous laryngitis 97. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below? A. Water B. Alkaline C. Sulfur D. Salt 98. As a public health nurse, you teach mother and family members the prevention of complication of measles. Which of the following should be
  25. 25. 25 closely watched? A. Temperature fails to drop B. Inflammation of the nasophraynx C. Inflammation of the conjunctiva D. Ulcerative stomatitis 99. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is transmitted by: A. Water supply B. Food ingestion C. Droplet D. Sexual contact 100. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of patient includes the provision of: A. Terminal disinfection B. Immunization C. Injection of gamma globulin D. Comfort measures
  26. 26. c. 50 days d. 14 days NURSING PRACTICE III Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort. 1. 2. 3. 4. 5. 26 Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken? a. Fecal-oral b. Droplet c. Airborne d. Sexual contact Which of the following is concurrent disinfection in the case of Leo? a. Investigation of contact b. Sanitary disposal of faeces, urine and blood c. Quarantine of the sick individual d. removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor Which of the following must be emphasized during mother’s class to Leo’s mother? a. Administration of Immunoglobulin to families b. Thorough hand washing before and after eating and toileting c. Use of attenuated vaccines d. Boiling of food especially meat Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority? a. Eliminate faecal contamination from foods b. Mass vaccination of uninfected individuals c. Health promotion and education to families and communities about the disease it’s cause and transmission d. Mass administration of Immunoglobulin What is the average incubation period of Hepatitis A? a. 30 days b. 60 days Situation: As a nurse researcher you must have a very good understanding of the common terms of concept used in research. 6. The information that an investigator collects from the subjects or participants in a research study is usually called; a. Hypothesis b. Variable c. Data d. Concept 7. Which of the following usually refers to the independent variables in doing research a. Result b. output c. Cause d. Effect 8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called; a. Setting b. Treatment c. Subjects d. Sample 9. The device or techniques an investigator employs to collect data is called; a. Sample b. hypothesis c. Instrument d. Concept 10. The use of another person’s ideas or wordings without giving appropriate credit results from inaccurate or incomplete attribution of materials to its sources. Which of the following is referred to when another person’s idea is inappropriate credited as one’s own; a. Plagiarism b. assumption c. Quotation d. Paraphrase Situation – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”
  27. 27. 27 11. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis? a. Support and reassure client during the procedure b. Ensure that informed consent has been signed c. Determine if client has allergic reaction to local anesthesia d. Ascertain if chest x-rays and other tests have been prescribed and completed a. Ease the patient to the floor b. Lift the patient and put him on the bed c. Insert a padded tongue depressor between his jaws d. Restraint patient’s body movement Mr Santos is placed on seizure precaution. Which of the following would be contraindicated? a. Obtain his oral temperature b. Encourage to perform his own personal hygiene c. Allow him to wear his own clothing d. Encourage him to be out of bed Usually, how does the patient behave after his seizure has subsided? a. Most comfortable walking and moving about b. Becomes restless and agitated c. Sleeps for a period of time d. Say he is thirsty and hungry 20. During thoracentesis, which of the following nursing intervention will be most crucial? a. Place patient in a quiet and cool room b. Maintain strict aseptic technique c. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest d. Apply pressure over the puncture site as soon as the needle is withdrawn 18. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position? a. Low fowler’s b. Side lying c. Modified trendelenburg d. Supine Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions? a. Trendelenburg position b. Supine position c. Dorsal Recumbent position d. Orthopneic position 13. Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse? a. Shampoo hair thoroughly to remove oil and dirt b. No special preparation is needed. Instruct the patient to keep his head still and stead c. Give a cleansing enema and give fluids until 8 AM d. Shave scalp and securely attach electrodes to it 19. 12. 17. 14. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis? a. Place flat in bed b. Turn on the unaffected side c. Turn on the affected side d. On bed rest 15. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain: a. To rule out pneumothorax b. To rule out any possible perforation c. To decongest d. To rule out any foreign body Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office. Situation: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site. 21. 16. Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first? Choledocholithotomy is: a. The removal of the gallbladder b. The removal of the stones in the gallbladder c. The removal of the stones in the
  28. 28. common bile duct d. The removal of the stones in the kidney 22. 23. The simplest pain relieving technique is: a. Distraction b. Deep breathing exercise c. Taking aspirin d. Positioning Which of the following statement on pain is TRUE? a. Culture and pain are not associated b. Pain accompanies acute illness c. Patient’s reaction to pain Varies d. Pain produces the same reaction such as groaning and moaning 24. When a client complains of pain, your initial response is: a. Record the description of pain b. Verbally acknowledge the pain c. Refer the complaint to the doctor d. Change to a more comfortable position 28. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is: a. Instruct client to go to sleep and relax b. Advice the client to close the lips and avoid deep breathing and talking c. Offer hot and clear soup d. Turn to sides frequently and avoid too much talking 29. Surgical pain might be minimized by which nursing action in the O.R. a. Skill of surgical team and lesser manipulation b. Appropriate preparation for the scheduled procedure c. Use of modern technology in closing the wound d. Proper positioning and draping of clients 30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post op patients. If General anesthesia is desired, it will involve loss of consciousness. Which of the following are the 2 general types of GA? a. Epidural and Spinal b. Subarachnoid block and Intravenous c. Inhalation and Regional d. Intravenous and Inhalation In pain assessment, which of the following condition is a more reliable indicator? a. Pain rating scale of 1 to 10 b. Facial expression and gestures c. Physiological responses d. Patients description of the pain sensation 25. alleviate anxiety c. Avoid overdosing to prevent dependence/tolerance d. Monitor VS, more importantly RR Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know, is very subjective. 26. 27. 28 A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take? a. Medicate client as prescribed b. Encourage client to do imagery c. Encourage deep breathing and turning d. Call surgeon stat Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will be your priority nursing action? a. Check abdominal dressing for possible swelling b. Explain the proper use of PCA to Situation: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain. 31. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following beliefs EXCEPT: a. Older patients seldom tend to report pain than the younger ones b. Pain is a sign of weakness c. Older patients do not believe in analgesics, they are tolerant d. Complaining of pain will lead to being labeled a ‘bad’ patient 32. Nurses should understand that when a client responds favorably to a placebo, it is known as the ‘placebo effect’. Placebos do not indicate
  29. 29. 29 whether or not a client has: a. Conscience b. Disease c. Real pain d. Drug tolerance 33. 34. 35. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain. How can you assist such client? a. The pain is vague b. By charting-it hurts all over c. Identify the absence and presence of pain d. As the client to point to the painful are by just one finger What symptom, more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain? a. Forgetfulness b. Drowsiness c. Constipation d. Allergic reactions like pruritis Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice? a. Start another drug and slowly lessen the opioid dosage b. Indulge in recreational outdoor activities c. Isolate opioid dependent to a restful resort d. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms Situation: The nurse is performing health education activities for Janevi Segovia, a 30 year old Dentist with Insulin dependent diabetes Miletus. 36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she: a. Draw insulin from the vial of clear insulin first b. Draw insulin from the vial of the intermediate acting insulin first c. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously d. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first 37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry out first? a. Withhold the client’s next insulin injection b. Test the client’s blood glucose level c. Administer Tylenol as ordered d. Offer fruit juice, gelatine and chicken bouillon 38. Janevi administered regular insulin at 7 A.M and the nurse should instruct Jane to avoid exercising at around: a. 9 to 11 A.M b. Between 8 A.M to 9 A.M c. After 8 hours d. In the afternoon, after taking lunch 39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient? a. Glycosylated hemoglobin b. Ketone levels c. Fasting blood glucose d. Urine glucose level 40. Upon the assessment of Hba1c of Mrs. Segovia, The nurse has been informed of a 9% Hba1c result. In this case, she will teach the patient to: a. Avoid infection b. Prevent and recognize hyperglycaemia c. Take adequate food and nutrition d. Prevent and recognize hypoglycaemia 41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan? a. Soak feet in hot water b. Avoid using mild soap on the feet c. Apply a moisturizing lotion to dry feet but not between the toes d. Always have a podiatrist to cut your toe nails; never cut them yourself 42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately
  30. 30. prepares to initiate which of the following anticipated physician’s order? a. Endotracheal intubation b. 100 unites of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate 43. 44. 45. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis? a. Comatose state b. Decreased urine output c. Increased respiration and an increase in pH d. Elevated blood glucose level and low plasma bicarbonate level The nurse teaches Jane to know the difference between hypoglycaemia and ketoacidosis. Jane demonstrates understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops? a. Polyuria b. Shakiness c. Blurred Vision d. Fruity breath odour Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane not to eat or drink after midnight. Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said “yes.” Which of the following is the best nursing action? a. Administer syrup of ipecac to remove the distilled water from the stomach b. Suction the stomach content using NGT prior to specimen collection c. Advice to physician to reschedule to diagnostic examination next day d. Continue as usual and have the FBS analysis performed and specimen be taken Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population. 46. 30 Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging. a. Ineffective airway clearance b. Decreased alveolar surfaced area c. Decreased anterior-posterior chest diameter d. Hyperventilation 47. The older patient is at higher risk for incontinence because of: a. Dilated urethra b. Increased glomerular filtration rate c. Diuretic use d. Decreased bladder capacity 48. Merle, age 86, is complaining of dizziness when she stands up. This may indicate: a. Dementia b. Functional decline c. A visual problem d. Drug toxicity 49. Cardiac ischemia in an older patient usually produces: a. ST-T wave changes b. Chest pain radiating to the left arm c. Very high creatinine kinase level d. Acute confusion 50. The most dependable sign of infection in the older patient is: a. Change in mental status b. Fever c. Pain d. Decreased breath sounds with crackles Situation – In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. 51. Which of the following should be given highest priority when receiving patient in the OR? a. Assess level of consciousness b. Verify patient identification and informed consent c. Assess vital signs d. Check for jewelry, gown, manicure, and dentures 52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these
  31. 31. 31 procedures best scheduled? a. Last case b. In between cases c. According to availability of anaesthesiologist d. According to the surgeon’s preference 53. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure… a. the surgeon greets his client before induction of anesthesia b. the surgeon and anesthesiologist are in tandem c. 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. d. Client is monitored throughout the surgery by the assistant anesthesiologist The nurse knows that the temperature and time is set to the optimum level to destroy not only the microorganism, but also the spores. Which of the following is the ideal setting of the autoclave machine? a. 10,000 degree Celsius for 1 hour b. 5,000 degree Celsius for 30 minutes c. 37 degree Celsius for 15 minutes d. 121 degree Celsius for 15 minutes 59. Chemical indicators communicate that: a. The items are sterile b. That the items had undergone sterilization process but not necessarily sterile c. The items are disinfected d. That the items had undergone disinfection process but not necessarily disinfected If a nurse will sterilize a heat and moisture labile instruments, It is according to AORN recommendation to use which of the following method of sterilization? a. Ethylene oxide gas b. Autoclaving c. Flash sterilizer d. Alcohol immersion Another nursing check that should not be missed before the induction of general anesthesia is: a. check for presence underwear b. check for presence dentures c. check patient’s ID d. check baseline vital signs 55. It is important that before a nurse prepares the material to be sterilized, a chemical indicator strip should be placed above the package, preferably, Muslin sheet. What is the color of the striped produced after autoclaving? a. Black b. Blue c. Gray d. Purple 60. 54. 58. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for: a. perioperative anxiety and stress b. delayed coagulation time c. delayed wound healing d. postoperative respiratory infection Situation: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility. 56. There are 3 general types of sterilization use in the hospital, which one is not included? a. Steam sterilization b. Physical sterilization c. Chemical sterilization d. Sterilization by boiling 57. Autoclave or steam under pressure is the most common method of sterilization in the hospital. Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. 61. Which of the following role would be the responsibility of the scrub nurse? a. Assess the readiness of the client prior to surgery b. Ensure that the airway is adequate c. Account for the number of sponges, needles, supplies, used during the surgical procedure. d. Evaluate the type of anesthesia appropriate for the surgical client
  32. 32. 62. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? a. Put side rails up and ask the client not to get out of bed b. Send the client to OR with the family c. Allow client to get up to go to the comfort room d. Obtain consent form 63. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection? a. Draped b. Pulled c. Clipped d. Shampooed 64. 65. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection? a. Localized heat and redness b. Serosanguinous exudates and skin blanching c. Separation of the incision d. Blood clots and scar tissue are visible 68. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs prior to surgery, is in severe pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with: a. Nurse Supervisor b. Surgeon c. Anesthesiologist d. Intern on duty 69. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do? a. Double check the doctor’s order and call the attending MD b. Communicate with the ward nurse to verify if insulin was incorporated or not c. Communicate with the client to verify if insulin was incorporated d. Incorporate insulin as ordered. 70. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patient’s chart? a. Presence of prosthetoid devices such as dentures, artificial limbs hearing aid, etc. b. Baseline physical, emotional, and psychosocial data c. Arguments between nurses and residents regarding treatments d. Observed untoward signs and symptoms and interventions including contaminant intervening factors Which of the following nursing interventions is done when examining the incision wound and changing the dressing? a. Observe the dressing and type and odor of drainage if any b. Get patient’s consent c. Wash hands d. Request the client to expose the incision wound Situation – The preoperative nurse collaborates with the client significant others, and healthcare providers. 66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT: a. Biomedical division b. Infection control committee c. Chaplaincy services d. Pathology department 67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last 32 patients will need surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the nurse expect? a. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures b. Forwarding the trauma client to the nearest hospital that has available sterile equipments is appropriate c. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes d. In such cases, flash sterlizer will be use at 132 degree Celsius in 3 minutes
  33. 33. 33 Situation – Team efforts is best demonstrated in the OR. 71. 72. 73. 74. 75. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? a. Who is your internist b. Who is your assistant and anaesthesiologist, and what is your preferred time and type of surgery? c. Who are your anaesthesiologist, internist, and assistant d. Who is your anaesthesiologist In the OR, the nursing tandem for every surgery is: a. Instrument technician and circulating nurse b. Nurse anaesthetist, nurse assistant, and instrument technician c. Scrub nurse and nurse anaesthetist d. Scrub and circulating nurses While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team? a. Surgeon, anaesthesiologist, scrub nurse, radiologist, orderly b. Surgeon, assistants, scrub nurse, circulating nurse, anaesthesiologist c. Surgeon, assistant surgeon, anaesthesiologist, scrub nurse, pathologist d. Surgeon, assistant surgeon, anaesthesiologist, intern, scrub nurse Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating room? a. Orderly/clerk b. Nurse Supervisor c. Circulating Nurse d. Anaesthesiologist The breakdown in teamwork is often times a failure in: a. Electricity b. Inadequate supply c. Leg work d. Communication Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. 76. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure? a. 0.45% sodium chloride b. 0.33% sodium chloride c. Normal saline solution d. Lactated ringer’s solution 77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe? a. 5% dextrose in water b. 0.45% sodium chloride c. 10% dextrose in water d. 5% dextrose in 0.9% sodium chloride 78. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that the client’s IV Site is cool, pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client? a. Infection b. Phlebitis c. Infiltration d. Thrombophelibitis 79. A nurse reviews the client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? a. U waves b. Absend P waves c. Elevated T waves d. Elevated ST segment 80. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
  34. 34. order? a. b. c. d. 82. 83. An informed consent is required for: a. closed reduction of a fracture b. irrigation of the external ear canal c. insertion of intravenous catheter d. urethral catheterization Which of the following is not true with regards to the informed consent? a. It should describe different treatment alternatives b. It should contain a thorough and detailed explanation of the procedure to be done c. It should describe the client’s diagnosis d. It should give an explanation of the client’s prognosis You know that the hallmark of nursing accountability is the: a. accurate documentation and reporting b. admitting your mistakes c. filing an incidence report d. reporting a medication error 84. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for deficient fluid volume? a. A client with colostomy b. A client with congestive heart failure c. A client with decreased kidney function d. A client receiving frequent wound irrigation As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection? a. Material compatibility and efficiency b. Odor and availability c. Cost and duration of disinfection process d. Duration of disinfection and efficiency 87. Before you use a disinfected instrument it is essential that you: a. Rinse with tap water followed by alcohol b. Wrap the instrument with sterile water c. Dry the instrument thoroughly d. Rinse with sterile water 88. You have a critical heat labile instrument to sterilize and are considering to use high level disinfectant. What should you do? a. Cover the soaking vessel to contain the vapor b. Double the amount of high level disinfectant c. Test the potency of the high level disinfectant d. Prolong the exposure time according to manufacturer’s direction 89. To achieve sterilization using disinfectants, which of the following is used? a. Low level disinfectants immersion in 24 hours b. Intermediate level disinfectants immersion in 12 hours c. High level disinfectants immersion in 1 hour d. High level disinfectant immersion in 10 hours Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the following? a. Autoclaving at 121 degree Celsius in 15 minutes b. Flash sterilizer at 132 degree Celsius in 3 minutes c. Ethylene Oxide gas aeration for 20 hours d. 2% Glutaraldehyde immersion for 10 hours A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for excess fluid volume? a. The client taking diuretics b. The client with renal failure c. The client with an ileostomy d. The client who requires gastrointestinal suctioning 85. 86. 90. 81. Any IV solution available to KVO Isotonic solution Hypertonic solution Hypotonic solution Situation: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. 34 Situation: The OR is divided into three zones to control traffic flow and contamination