Nursing question practice case

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Nursing question practice case

  1. 1. Nursing Board Practice Test CompilationContentsNURSING PRACTICE I: FOUNDATION OF NURSINGPRACTICE..........................................................................4NURSING PRACTICE II.....................................................15NURSING PRACTICE III....................................................26NURSING PRACTICE IV....................................................36NURSING PRACTICE V.....................................................46TEST I - Foundation of Professional Nursing Practice ....56Answers and Rationale – Foundation of ProfessionalNursing Practice.........................................................66TEST II - Community Health Nursing and Care of theMother and Child...........................................................74Answers and Rationale – Community Health Nursingand Care of the Mother and Child .............................84TEST III - Care of Clients with Physiologic andPsychosocial Alterations ................................................91Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................102TEST IV - Care of Clients with Physiologic andPsychosocial Alterations ..............................................111Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................122TEST V - Care of Clients with Physiologic and PsychosocialAlterations....................................................................133Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................144PART III PRACTICE TEST I FOUNDATION OF NURSING.153ANSWERS AND RATIONALE – FOUNDATION OFNURSING ..................................................................158PRACTICE TEST II Maternal and Child Health...............162ANSWERS AND RATIONALE – MATERNAL AND CHILDHEALTH.....................................................................167MEDICAL SURGICAL NURSING .....................................173ANSWERS AND RATIONALE – MEDICAL SURGICALNURSING ..................................................................178PSYCHIATRIC NURSING ................................................180ANSWERS AND RATIONALE – PSYCHIATRIC NURSING.................................................................................185FOUNDATION OF PROFESSIONAL NURSING PRACTICE188ANSWER KEY - FOUNDATION OF PROFESSIONALNURSING PRACTICE..................................................199COMMUNITY HEALTH NURSING AND CARE OF THEMOTHER AND CHILD....................................................200ANSWER KEY: COMMUNITY HEALTH NURSING ANDCARE OF THE MOTHER AND CHILD..........................211Comprehensive Exam 1................................................213CARE OF CLIENTS WITH PHYSIOLOGIC ANDPSYCHOSOCIAL ALTERATIONS......................................222ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGICAND PSYCHOSOCIAL ALTERATIONS .........................234Nursing Practice Test V ................................................235Nursing Practice Test V ................................................245TEST I - Foundation of Professional Nursing Practice..255Answers and Rationale – Foundation of ProfessionalNursing Practice.......................................................265TEST II - Community Health Nursing and Care of theMother and Child.........................................................273Answers and Rationale – Community Health Nursingand Care of the Mother and Child ...........................283TEST III - Care of Clients with Physiologic andPsychosocial Alterations ..............................................290Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................301TEST IV - Care of Clients with Physiologic andPsychosocial Alterations ..............................................310Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................321TEST V - Care of Clients with Physiologic and PsychosocialAlterations....................................................................332Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................343PART III.........................................................................352PRACTICE TEST I FOUNDATION OF NURSING ..............352ANSWERS AND RATIONALE – FOUNDATION OFNURSING ..................................................................357PRACTICE TEST II Maternal and Child Health...............361
  2. 2. 2ANSWERS AND RATIONALE – MATERNAL AND CHILDHEALTH.....................................................................366MEDICAL SURGICAL NURSING .....................................372ANSWERS AND RATIONALE – MEDICAL SURGICALNURSING ..................................................................377PSYCHIATRIC NURSING ................................................379ANSWERS AND RATIONALE – PSYCHIATRIC NURSING.................................................................................384FUNDAMENTALS OF NURSING PART 1 ........................387FUNDAMENTALS OF NURSING PART 2 ........................392ANSWERS and RATIONALES for FUNDAMENTALS OFNURSING PART 2......................................................397FUNDAMENTALS OF NURSING PART 3 ........................401ANSWERS and RATIONALES for FUNDAMENTALS OFNURSING PART 3......................................................405MATERNITY NURSING Part 1........................................409ANSWERS and RATIONALES for MATERNITY NURSINGPart 1........................................................................418MATERNITY NURSING Part 2........................................428Answer for maternity part 2 ....................................433PEDIATRIC NURSING ....................................................434ANSWERS and RATIONALES for PEDIATRIC NURSING.................................................................................439COMMUNITY HEALTH NURSING Part 1........................444COMMUNITY HEALTH NURSING Part 2........................454MEDICAL SURGICAL NURSING Part 1...........................475ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 1........................................................479MEDICAL SURGICAL NURSING Part 2...........................481MEDICAL SURGICAL NURSING Part 2.......................485ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 2........................................................489MEDICAL SURGICAL NURSING Part 3...........................491ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 3........................................................495PSYCHIATRIC NURSING Part 1......................................497ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 1........................................................................502PSYCHIATRIC NURSING Part 2......................................504ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 2........................................................................509PSYCHIATRIC NURSING Part 3......................................512ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 3........................................................................516PROFESSIONAL ADJUSTMENT......................................519LEADERSHIP and MANAGEMENT.................................522NURSING RESEARCH Part 1..........................................532NURSING RESEARCH Part 2..........................................542Nursing Research Suggested Answer Key................546
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  4. 4. 4NURSING PRACTICE I: FOUNDATION OF NURSINGPRACTICESITUATION: Nursing is a profession. The nurse shouldhave a background on the theories and foundation ofnursing as it influenced what is nursing today.1. Nursing is the protection, promotion andoptimization of health and abilities, preventionof illness and injury, alleviation of sufferingthrough the diagnosis and treatment of humanresponse and advocacy in the care of theindividuals, families, communities and thepopulation. This is the most accepted definitionof nursing as defined by the:a. PNAb. ANAc. Nightingaled. Henderson2. Advancement in Nursing leads to thedevelopment of the Expanded Career Roles.Which of the following is NOT an expandedcareer role for nurses?a. Nurse practitionerb. Nurse Researcherc. Clinical nurse specialistd. Nurse anaesthesiologist3. The Board of Nursing regulated the Nursingprofession in the Philippines and is responsiblefor the maintenance of the quality of nursing inthe country. Powers and duties of the board ofnursing are the following, EXCEPT:a. Issue, suspend, revoke certificates ofregistrationb. Issue subpoena duces tecum, adtestificandumc. Open and close colleges of nursingd. Supervise and regulate the practice ofnursing4. A nursing student or a beginning staff nurse whohas not yet experienced enough real situationsto make judgments about them is in what stageof Nursing Expertise?a. Noviceb. Newbiec. Advanced Beginnerd. Competent5. Benner’s “Proficient” nurse level is differentfrom the other levels in nursing expertise in thecontext of having:a. the ability to organize and plan activitiesb. having attained an advanced level ofeducationc. a holistic understanding and perceptionof the clientd. intuitive and analytic ability in newsituationsSITUATION: The nurse has been asked to administer aninjection via Z TRACK technique. Questions 6 to 10 referto this.6. The nurse prepares an IM injection for an adultclient using the Z track technique. 4 ml ofmedication is to be administered to the client.Which of the following site will you choose?a. Deltoidb. Rectus femorisc. Ventrogluteald. Vastus lateralis7. In infants 1 year old and below, which of thefollowing is the site of choice for intramuscularInjection?a. Deltoidb. Rectus femorisc. Ventrogluteald. Vastus lateralis8. In order to decrease discomfort in Z trackadministration, which of the following isapplicable?a. Pierce the skin quickly and smoothly ata 90 degree angleb. Inject the medication steadily at around10 minutes per millilitrec. Pull back the plunger and aspirate for 1minute to make sure that the needle didnot hit a blood vesseld. Pierce the skin slowly and carefully at a90 degree angle9. After injection using the Z track technique, thenurse should know that she needs to wait for afew seconds before withdrawing the needle andthis is to allow the medication to disperse intothe muscle tissue, thus decreasing the client’sdiscomfort. How many seconds should the nursewait before withdrawing the needle?a. 2 seconds
  5. 5. 5b. 5 secondsc. 10 secondsd. 15 seconds10. The rationale in using the Z track technique in anintramuscular injection is:a. It decreases the leakage of discolouringand irritating medication into thesubcutaneous tissuesb. It will allow a faster absorption of themedicationc. The Z track technique prevent irritationof the muscled. It is much more convenient for the nurseSITUATION: A Client was rushed to the emergency roomand you are his attending nurse. You are performing avital sign assessment.11. All of the following are correct methods inassessment of the blood pressure EXCEPT:a. Take the blood pressure reading on botharms for comparisonb. Listen to and identify the phases ofKorotkoff’s soundc. Pump the cuff to around 50 mmHgabove the point where the pulse isobliteratedd. Observe procedures for infection control12. You attached a pulse oximeter to the client. Youknow that the purpose is to:a. Determine if the client’s hemoglobinlevel is low and if he needs bloodtransfusionb. Check level of client’s tissue perfusionc. Measure the efficacy of the client’s anti-hypertensive medicationsd. Detect oxygen saturation of arterialblood before symptoms of hypoxemiadevelops13. After a few hours in the Emergency Room, Theclient is admitted to the ward with an order ofhourly monitoring of blood pressure. The nursefinds that the cuff is too narrow and this willcause the blood pressure reading to be:a. inconsistentb. low systolic and high diastolicc. higher than what the reading should bed. lower than what the reading should be14. Through the client’s health history, you gatherthat the patient smokes and drinks coffee. Whentaking the blood pressure of a client whorecently smoked or drank coffee, how longshould the nurse wait before taking the client’sblood pressure for accurate reading?a. 15 minutesb. 30 minutesc. 1 hourd. 5 minutes15. While the client has pulse oximeter on hisfingertip, you notice that the sunlight is shiningon the area where the oximeter is. Your actionwill be to:a. Set and turn on the alarm of theoximeterb. Do nothing since there is no identifiedproblemc. Cover the fingertip sensor with a towelor bedsheetd. Change the location of the sensor everyfour hours16. The nurse finds it necessary to recheck the bloodpressure reading. In case of such re assessment,the nurse should wait for a period of:a. 15 secondsb. 1 to 2 minutesc. 30 minutesd. 15 minutes17. If the arm is said to be elevated when taking theblood pressure, it will create a:a. False high readingb. False low readingc. True false readingd. Indeterminate18. You are to assessed the temperature of theclient the next morning and found out that heate ice cream. How many minutes should youwait before assessing the client’s oraltemperature?a. 10 minutesb. 20 minutesc. 30 minutesd. 15 minutes19. When auscultating the client’s blood pressurethe nurse hears the following: From 150 mmHgto 130 mmHg: Silence, Then: a thumping soundcontinuing down to 100 mmHg; muffled soundcontinuing down to 80 mmHg and then silence.
  6. 6. 6What is the client’s blood pressure?a. 130/80b. 150/100c. 100/80d. 150/10020. In a client with a previous blood pressure of130/80 4 hours ago, how long will it take torelease the blood pressure cuff to obtain anaccurate reading?a. 10-20 secondsb. 30-45 secondsc. 1-1.5 minutesd. 3-3.5 minutesSituation: Oral care is an important part of hygienicpractices and promoting client comfort.21. An elderly client, 84 years old, is unconscious.Assessment of the mouth reveals excessivedryness and presence of sores. Which of thefollowing is BEST to use for oral care?a. lemon glycerineb. Mineral oilc. hydrogen peroxided. Normal saline solution22. When performing oral care to an unconsciousclient, which of the following is a specialconsideration to prevent aspiration of fluids intothe lungs?a. Put the client on a sidelying positionwith head of bed loweredb. Keep the client dry by placing towelunder the chinc. Wash hands and observes appropriateinfection controld. Clean mouth with oral swabs in a carefuland an orderly progression23. The advantages of oral care for a client includeall of the following, EXCEPT:a. decreases bacteria in the mouth andteethb. reduces need to use commercialmouthwash which irritate the buccalmucosac. improves client’s appearance and self-confidenced. improves appetite and taste of food24. A possible problem while providing oral care tounconscious clients is the risk of fluid aspirationto lungs. This can be avoided by:a. Cleaning teeth and mouth with cottonswabs soaked with mouthwash to avoidrinsing the buccal cavityb. swabbing the inside of the cheeks andlips, tongue and gums with dry cottonswabsc. use fingers wrapped with wet cottonwashcloth to rub inside the cheeks,tongue, lips and umsd. suctioning as needed while cleaning thebuccal cavity25. Your client has difficulty of breathing and ismouth breathing most of the time. This causesdryness of the mouth with unpleasant odor. Oralhygiene is recommended for the client and inaddition, you will keep the mouth moistened byusing:a. salt solutionb. petroleum jellyc. waterd. mentholated ointmentSituation – Ensuring safety before, during and after adiagnostic procedure is an important responsibility ofthe nurse.26. To help Fernan better tolerate thebronchoscopy, you should instruct him topractice which of the following prior to theprocedure?a. Clenching his fist every 2 minutesb. Breathing in and out through the nosewith his mouth openc. Tensing the shoulder muscles while lyingon his backd. Holding his breath periodically for 30seconds27. Following a bronchoscopy, which of thefollowing complains to Fernan should be notedas a possible complication:a. Nausea and vomitingb. Shortness of breath and laryngealstridorc. Blood tinged sputum and coughingd. Sore throat and hoarseness28. Immediately after bronchoscopy, you instructedFernan to:a. Exercise the neck musclesb. Refrain from coughing and talking
  7. 7. 7c. Breathe deeplyd. Clear his throat29. Thoracentesis may be performed for cytologicstudy of pleural fluid. As a nurse your mostimportant function during the procedure is to:a. Keep the sterile equipment fromcontaminationb. Assist the physicianc. Open and close the three-way stopcockd. Observe the patient’s vital signs30. Right after thoracentesis, which of the followingis most appropriate intervention?a. Instruct the patient not to cough or deepbreathe for two hoursb. Observe for symptoms of tightness ofchest or bleedingc. Place an ice pack to the puncture sited. Remove the dressing to check forbleedingSituation: Knowledge of the acid-base disturbance andthe functions of the electrolytes is necessary todetermine appropriate intervention and nursing actions.31. A client with diabetes milletus has a bloodglucose level of 644 mg/dL. The nurse interpretsthat this client is at most risk for thedevelopment of which type of acid-baseimbalance?a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis32. In a client in the health care clinic, arterial bloodgas 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 whichacid base disturbance?a. Respiratory acidosisb. Metabolic acidosisc. Respiratory alkalosisd. Metabolic alkalosis33. A client has an order for ABG analysis on radialartery specimens. The nurse ensures that whichof the following has been performed or testedbefore the ABG specimens are drawn?a. Guthrie testb. Romberg’s testc. Allen’s testd. Weber’s test34. A nurse is reviewing the arterial blood gas valuesof a client and notes that the ph is 7.31, Pco2 is50 mmHg, and the bicarbonate is 27 mEq/L. Thenurse concludes that which acid basedisturbance is present in this client?a. Respiratory acidosisb. Metabolic acidosisc. Respiratory alkalosisd. Metabolic alkalosis35. Allen’s test checks the patency of the:a. Ulnar arteryb. Carotid arteryc. Radial arteryd. Brachial arterySituation 6: Eileen, 45 years old is admitted to thehospital with a diagnosis of renal calculi. She isexperiencing severe flank pain, nauseated and with atemperature of 39 0C.36. Given the above assessment data, the mostimmediate goal of the nurse would be which ofthe following?a. Prevent urinary complicationb. maintains fluid and electrolytesc. Alleviate paind. Alleviating nausea37. After IVP a renal stone was confirmed, a leftnephrectomy was done. Her post-operativeorder includes “daily urine specimen to be sentto the laboratory”. Eileen has a foley catheterattached to a urinary drainage system. How willyou collect the urine specimen?a. remove urine from drainage tube withsterile needle and syringe and emptyurine from the syringe into thespecimen containerb. empty a sample urine from thecollecting bag into the specimencontainerc. Disconnect the drainage tube from theindwelling catheter and allow urine toflow from catheter into the specimencontainer.d. Disconnect the drainage from thecollecting bag and allow the urine toflow from the catheter into thespecimen container.
  8. 8. 838. Where would the nurse tape Eileen’s indwellingcatheter in order to reduce urethral irritation?a. to the patient’s inner thighb. to the patient’ buttocksc. to the patient’s lower thighd. to the patient lower abdomen39. Which of the following menu is appropriate forone with low sodium diet?a. instant noodles, fresh fruits and ice teab. ham and cheese sandwich, fresh fruitsand vegetablesc. white chicken sandwich, vegetablesalad and tead. canned soup, potato salad, and diet soda40. How will you prevent ascending infection toEileen who has an indwelling catheter?a. see to it that the drainage tubingtouches the level of the urineb. change he catheter every eight hoursc. see to it that the drainage tubing doesnot touch the level of the urined. clean catheter may be used sinceurethral meatus is not a sterile areaSituation: Hormones are secreted by the various glandsin the body. Basic knowledge of the endocrine system isnecessary.41. Somatocrinin or the Growth hormone releasinghormone is secreted by the:a. Hypothalamusb. Posterior pituitary glandc. Anterior pituitary glandd. Thyroid gland42. All of the following are secreted by the anteriorpituitary gland except:a. Somatotropin/Growth hormoneb. Thyroid stimulating hormonec. Follicle stimulating hormoned. Gonadotropin hormone releasinghormone43. All of the following hormones are hormonessecreted by the Posterior pituitary gland except:a. Vasopressinb. Anti-diuretic hormonec. Oxytocind. Growth hormone44. Calcitonin, a hormone necessary for calciumregulation is secreted in the:a. Thyroid glandb. Parathyroid glandc. Hypothalamusd. Anterior pituitary gland45. While Parathormone, a hormone that negatesthe effect of calcitonin is secreted by the:a. Thyroid glandb. Parathyroid glandc. Hypothalamusd. Anterior pituitary glandSituation: The staff nurse supervisor requests all the staffnurses to “brainstorm” and learn ways to instructdiabetic clients on self-administration of insulin. Shewants to ensure that there are nurses available daily todo health education classes.46. The plan of the nurse supervisor is an example ofa. in service education processb. efficient management of humanresourcesc. increasing human resourcesd. primary prevention47. When Mrs. Guevarra, a nurse, delegates aspectsof the clients care to the nurse-aide who is anunlicensed staff, Mrs. Guevarraa. makes the assignment to teach the staffmemberb. is assigning the responsibility to theaide but not the accountability forthose tasksc. does not have to supervise or evaluatethe aided. most know how to perform taskdelegated48. Connie, the new nurse, appears tired andsluggish and lacks the enthusiasm she had sixweeks ago when she started the job. The nursesupervisor shoulda. empathize with the nurse and listen toherb. tell her to take the day offc. discuss how she is adjusting to her newjobd. ask about her family life49. Process of formal negotiations of workingconditions between a group of registered nursesand employer is
  9. 9. 9a. grievanceb. arbitrationc. collective bargainingd. strike50. You are attending a certification oncardiopulmonary resuscitation (CPR) offered andrequired by the hospital employing you. This isa. professional course towards creditsb. in-service educationc. advance trainingd. continuing educationSituation: As a nurse, you are aware that properdocumentation in the patient chart is your responsibility.51. Which of the following is not a legally bindingdocument but nevertheless very important inthe care of all patients in any health caresetting?a. Bill of rights as provided in the Philippineconstitutionb. Scope of nursing practice as defined byRA 9173c. Board of nursing resolution adopting thecode of ethicsd. Patient’s bill of rights52. A nurse gives a wrong medication to the client.Another nurse employed by the same hospital asa risk manager will expect to receive which ofthe following communication?a. Incident reportb. Nursing kardexc. Oral reportd. Complain report53. Performing a procedure on a client in theabsence of an informed consent can lead towhich of the following charges?a. Fraudb. Harassmentc. Assault and batteryd. Breach of confidentiality54. Which of the following is the essence ofinformed consent?a. It should have a durable power ofattorneyb. It should have coverage from aninsurance companyc. It should respect the client’s freedomfrom coerciond. It should disclose previous diagnosis,prognosis and alternative treatmentsavailable for the client55. Delegation is the process of assigning tasks thatcan be performed by a subordinate. The RNshould always be accountable and should notlose his accountability. Which of the following isa role included in delegation?a. The RN must supervise all delegatedtasksb. After a task has been delegated, it is nolonger a responsibility of the RNc. The RN is responsible and accountablefor the delegated task in adjunct withthe delegated. Follow up with a delegated task isnecessary only if the assistive personnelis not trustworthySituation: When creating your lesson plan forcerebrovascular disease or STROKE. It is important toinclude the risk factors of stroke.56. The most important risk factor is:a. Cigarette smokingb. binge drinkingc. Hypertensiond. heredity57. Part of your lesson plan is to talk about etiologyor cause of stroke. The types of stroke based oncause are the following EXCEPT:a. Embolic strokeb. diabetic strokec. Hemorrhagic stroked. thrombotic stroke58. Hemmorhagic stroke occurs suddenly usuallywhen the person is active. All are causes ofhemorrhage, EXCEPT:a. phlebitisb. damage to blood vesselc. traumad. aneurysm59. The nurse emphasizes that intravenous drugabuse carries a high risk of stroke. Which drug isclosely linked to this?a. Amphetaminesb. shabuc. Cocained. Demerol
  10. 10. 1060. A participant in the STROKE class asks what is arisk factor of stroke. Your best response is:a. “More red blood cells thicken bloodand make clots more possible.”b. “Increased RBC count is linked to highcholesterol.”c. “More red blood cell increaseshemoglobin content.”d. “High RBC count increases bloodpressure.”Situation: Recognition of normal values is vital inassessment of clients with various disorders.61. A nurse is reviewing the laboratory test resultsfor a client with a diagnosis of severedehydration. The nurse would expect thehematocrit level for this client to be which of thefollowing?a. 60%b. 47%c. 45%d. 32%62. A nurse is reviewing the electrolyte results of anassigned client and notes that the potassiumlevel is 5.6 mEq/L. Which of the following wouldthe nurse expect to note on the ECG as a resultof this laboratory value?a. ST depressionb. Prominent U wavec. Inverted T waved. Tall peaked T waves63. A nurse is reviewing the electrolyte results of anassigned client and notes that the potassiumlevel is 3.2 mEq/L. Which of the following wouldthe nurse expect to note on the ECG as a resultof this laboratory value?a. U wavesb. Elevated T wavesc. Absent P wavesd. Elevated ST Segment64. Dorothy underwent diagnostic test and theresult of the blood examination are back. Onreviewing the result the nurse notices which ofthe following as abnormal finding?a. Neutrophils 60%b. White blood cells (WBC) 9000/mmc. Erythrocyte sedimentation rate (ESR) is39 mm/hrd. Iron 75 mg/100 ml65. Which of the following laboratory test resultindicate presence of an infectious process?a. Erythrocyte sedimentation rate (ESR) 12mm/hrb. White blood cells (WBC) 18,000/mm3c. Iron 90 g/100mld. Neutrophils 67%Situation: Pleural effusion is the accumulation of fluid inthe pleural space. Questions 66 to 70 refer to this.66. Which of the following is a finding that the nursewill be able to assess in a client with Pleuraleffusion?a. Reduced or absent breath sound at thebase of the lungs, dyspnea, tachpyneaand shortness of breathb. Hypoxemia, hypercapnea andrespiratory acidosisc. Noisy respiration, crackles, stridor andwheezingd. Tracheal deviation towards the affectedside, increased fremitus and loud breathsounds67. Thoracentesis is performed to the client witheffusion. The nurse knows that the removal offluid should be slow. Rapid removal of fluid inthoracentesis might cause:a. Pneumothoraxb. Cardiovascular collapsec. Pleurisy or Pleuritisd. Hypertension68. 3 Days after thoracentesis, the client againexhibited respiratory distress. The nurse willknow that pleural effusion has reoccurred whenshe noticed a sharp stabbing pain duringinspiration. The physician ordered a closed tubethoracotomy for the client. The nurse knowsthat the primary function of the chest tube is to:a. Restore positive intrathoracic pressureb. Restore negative intrathoracic pressurec. To visualize the intrathoracic contentd. As a method of air administration viaventilator69. The chest tube is functioning properly if:a. There is an oscillationb. There is no bubbling in the drainagebottle
  11. 11. 11c. There is a continuous bubbling in thewaterseald. The suction control bottle has acontinuous bubbling70. In a client with pleural effusion, the nurse isinstructing appropriate breathing technique.Which of the following is included in theteaching?a. Breath normallyb. Hold the breath after each inspirationfor 1 full minutec. Practice abdominal breathingd. Inhale slowly and hold the breath for 3to 5 seconds after each inhalationSITUATION: Health care delivery system affects thehealth status of every filipino. As a Nurse, Knowledge ofthis system is expected to ensure quality of life.71. When should rehabilitation commence?a. The day before dischargeb. When the patient desiresc. Upon admissiond. 24 hours after discharge72. What exemplified the preventive and promotiveprograms in the hospital?a. Hospital as a center to prevent andcontrol infectionb. Program for smokersc. Program for alcoholics and drug addictsd. Hospital Wellness Center73. Which makes nursing dynamic?a. Every patient is a unique physical,emotional, social and spiritual beingb. The patient participate in the overallnursing care planc. Nursing practice is expanding in the lightof modern developments that takesplaced. The health status of the patient isconstantly changing and the nurse mustbe cognizant and responsive to thesechanges74. Prevention is an important responsibility of thenurse in:a. Hospitalsb. Communityc. Workplaced. All of the above75. This form of Health Insurance providescomprehensive prepaid health services toenrollees for a fixed periodic payment.a. Health Maintenance Organizationb. Medicarec. Philippine Health Insurance Actd. Hospital Maintenance OrganizationSituation: Nursing ethics is an important part of thenursing profession. As the ethical situation arises, so isthe need to have an accurate and ethical decisionmaking.76. The purpose of having a nurses’ code of ethics is:a. Delineate the scope and areas of nursingpracticeb. identify nursing action recommended forspecific health care situationsc. To help the public understandprofessional conduct expected ofnursesd. To define the roles and functions of thehealth care givers, nurses, clients77. The principles that govern right and properconduct of a person regarding life, biology andthe health professionals is referred to as:a. Moralityb. Religionc. Valuesd. Bioethics78. A subjective feeling about what is right or wrongis said to be:a. Moralityb. Religionc. Valuesd. Bioethics79. Values are said to be the enduring believe abouta worth of a person, ideas and belief. If Valuesare going to be a part of a research, this iscategorized under:a. Qualitativeb. Experimentalc. Quantitatived. Non Experimental80. The most important nursing responsibility whereethical situations emerge in patient care is to:a. Act only when advised that the action isethically sound
  12. 12. 12b. Not takes sides, remain neutral and fairc. Assume that ethical questions are theresponsibility of the health teamd. Be accountable for his or her ownactions81. Why is there an ethical dilemma?a. the choices involved do not appear to beclearly right or wrongb. a client’s legal right co-exist with thenurse’s professional obligationc. decisions has to be made based onsocietal norms.d. decisions has to be mad quickly, oftenunder stressful conditions82. According to the code of ethics, which of thefollowing is the primary responsibility of thenurse?a. Assist towards peaceful deathb. Health is a fundamental rightc. Promotion of health, prevention ofillness, alleviation of suffering andrestoration of healthd. Preservation of health at all cost83. Which of the following is TRUE about the Codeof Ethics of Filipino Nurses, except:a. The Philippine Nurses Association forbeing the accredited professionalorganization was given the privilege toformulate a Code of Ethics for Nurseswhich the Board of Nursingpromulgatedb. Code for Nurses was first formulated in1982 published in the Proceedings of theThird Annual Convention of the PNAHouse of Delegatesc. The present code utilized the Code ofGood Governance for the Professions inthe Philippinesd. Certificates of Registration of registerednurses may be revoked or suspended forviolations of any provisions of the Codeof Ethics.84. Violation of the code of ethics might equate tothe revocation of the nursing license. Whorevokes the license?a. PRCb. PNAc. DOHd. BON85. Based on the Code of Ethics for Filipino Nurses,what is regarded as the hallmark of nursingresponsibility and accountability?a. Human rights of clients, regardless ofcreed and genderb. The privilege of being a registeredprofessional nursec. Health, being a fundamental right ofevery individuald. Accurate documentation of actions andoutcomesSituation: As a profession, nursing is dynamic and itspractice is directed by various theoretical models. Todemonstrate caring behaviour, the nurse applies variousnursing models in providing quality nursing care.86. When you clean the bedside unit and regularlyattend to the personal hygiene of the patient aswell as in washing your hands before and after aprocedure and in between patients, you indentto facilitate the body’s reparative processes.Which of the following nursing theory are youapplying in the above nursing action?a. Hildegard Peplaub. Dorothea Oremc. Virginia Hendersond. Florence Nightingale87. A communication skill is one of the importantcompetencies expected of a nurse. Interpersonalprocess is viewed as human to humanrelationship. This statement is an application ofwhose nursing model?a. Joyce Travelbeeb. Martha Rogersc. Callista Royd. Imogene King88. The statement “the health status of an individualis constantly changing and the nurse must becognizant and responsive to these changes” bestexplains which of the following facts aboutnursing?a. Dynamicb. Client centredc. Holisticd. Art89. Virginia Henderson professes that the goal ofnursing is to work interdependently with otherhealth care working in assisting the patient to
  13. 13. 13gain independence as quickly as possible. Whichof the following nursing actions bestdemonstrates this theory in taking care of a 94year old client with dementia who is totallyimmobile?a. Feeds the patient, brushes his teeth,gives the sponge bathb. Supervise the watcher in renderingpatient his morning carec. Put the patient in semi fowler’s position,set the over bed table so the patient caneat by himself, brush his teeth andsponge himselfd. Assist the patient to turn to his sides andallow him to brush and feed himself onlywhen he feels ready90. In the self-care deficit theory by Dorothea Orem,nursing care becomes necessary when a patientis unable to fulfil his physiological, psychologicaland social needs. A pregnant client needingprenatal check-up is classified as:a. Wholly compensatoryb. Supportive Educativec. Partially compensatoryd. Non compensatorySituation: Documentation and reporting are just asimportant as providing patient care, As such, the nursemust be factual and accurate to ensure qualitydocumentation and reporting.91. Health care reports have different purposes. Theavailability of patients’ record to all health teammembers demonstrates which of the followingpurposes:a. Legal documentationb. Researchc. Educationd. Vehicle for communication92. When a nurse commits medication error, sheshould accurately document client’s responseand her corresponding action. This is veryimportant for which of the following purposes:a. Researchb. Legal documentationc. Nursing Auditd. Vehicle for communication93. POMR has been widely used in many teachinghospitals. One of its unique features is SOAPIEcharting. The P in SOAPIE charting shouldinclude:a. Prescription of the doctor to thepatient’s illnessb. Plan of care for patientc. Patient’s perception of one’s illnessd. Nursing problem and Nursing diagnosis94. The medical records that are organized intoseparate section from doctors or nurses hasmore disadvantages than advantages. This isclassified as what type of recording?a. POMRb. Modified POMRc. SOAPIEd. SOMR95. Which of the following is the advantage of SOMRor Traditional recording?a. Increases efficiency in data gatheringb. Reinforces the use of the nursingprocessc. The caregiver can easily locate propersection for making charting entriesd. Enhances effective communicationamong health care team membersSituation: June is a 24 year old client with symptoms ofdyspnea, absent breath sounds on the right lung andchest x ray revealed pleural effusion. The physician willperform thoracentesis.96. Thoracentesis is useful in treating all of thefollowing pulmonary disorders except:a. Hemothoraxb. Hydrothoraxc. Tuberculosisd. Empyema97. Which of the following psychological preparationis not relevant for him?a. Telling him that the gauge of the needleand anesthesia to be usedb. Telling him to keep still during theprocedure to facilitate the insertion ofthe needle in the correct placec. Allow June to express his feelings andconcernsd. Physician’s explanation on the purposeof the procedure and how it will be done98. Before thoracentesis, the legal consideration youmust check is:a. Consent is signed by the client
  14. 14. 14b. Medicine preparation is correctc. Position of the client is correctd. Consent is signed by relative andphysician99. As a nurse, you know that the position for Junebefore thoracentesis is:a. Orthopneicb. Low fowlersc. Knee-chestd. Sidelying position on the affected side100. Which of the following anaesthetics drug is usedfor thoracentesis?a. Procaine 2%b. Demerol 75 mgc. Valium 250 mgd. Phenobartbital 50 mg
  15. 15. 15NURSING PRACTICE IISituation: Mariah is a 31 year old lawyer who has beenmarried for 6 months. She consults you for guidance inrelation with her menstrual cycle and her desire to getpregnant.1. She wants to know the length of her menstrualcycle. Her previous menstrual period is October22 to 26. Her LMB is November 21. Which of thefollowing number of days will be your correctresponse?A. 29B. 28C. 30D. 312. You advised her to observe and record the signsof Ovulation. Which of the following signs willshe likely note down?1. A 1 degree Fahrenheit rise in basal bodytemperature2. Cervical mucus becomes copious andclear3. One pound increase in weight4. MittelschmerzA. 1, 2, 4B. 1, 2, 3C. 2, 3, 4D. 1, 3, 43. You instruct Mariah to keep record of her basaltemperature every day, which of the followinginstructions is incorrect?A. If coitus has occurred; this should bereflected in the chartB. It is best to have coitus on the eveningfollowing a drop in BBT to becomepregnantC. Temperature should be takenimmediately after waking and beforegetting out of bedD. BBT is lowest during the secretoryphase4. She reports an increase in BBT on December 16.Which hormone brings about this change in herBBT?A. EstrogenB. GonadotropineC. ProgesteroneD. Follicle stimulating hormone5. The following month, Mariah suspects she ispregnant. Her urine is positive for Humanchorionic gonadotrophin. Which structureproduces Hcg?A. Pituitary glandB. Trophoblastic cells of the embryoC. Uterine deciduasD. Ovarian folliclesSituation: Mariah came back and she is now pregnant.6. At 5 month gestation, which of the followingfetal development would probably be achieve?A. Fetal movement are felt by MariahB. Vernix caseosa covers the entire bodyC. Viable if delivered within this periodD. Braxton hicks contractions are observed7. The nurse palpates the abdomen of Mariah.Now At 5 month gestation, What level of theabdomen can the fundic height be palpated?A. Symphysis pubisB. Midpoint between the umbilicus and thexiphoid processC. Midpoint between the symphysis pubisand the umbilicusD. Umbilicus8. She worries about her small breasts, thinkingthat she probably will not be able to breastfeedher baby. Which of the following responses ofthe nurse is correct?A. “The size of your breast will not affectyour lactation”B. “You can switch to bottle feeding”C. “You can try to have exercise to increasethe size of your breast”D. “Manual expression of milk is possible”9. She tells the nurse that she does not take milkregularly. She claims that she does not want togain too much weight during her pregnancy.Which of the following nursing diagnosis is apriority?A. Potential self-esteem disturbancerelated to physiologic changes inpregnancyB. Ineffective individual coping related tophysiologic changes in pregnancyC. Fear related to the effects of pregnancyD. Knowledge deficit regarding nutritional
  16. 16. 16requirements of pregnancies related tolack of information sources10. Which of the following interventions will likelyensure compliance of Mariah?A. Incorporate her food preferences thatare adequately nutritious in her mealplanB. Consistently counsel toward optimumnutritional intakeC. Respect her right to reject dietaryinformation if she choosesD. Inform her of the adverse effects ofinadequate nutrition to her fetusSituation: Susan is a patient in the clinic where you work.She is inquiring about pregnancy.11. Susan tells you she is worried because shedevelops breasts later than most of her friends.Breast development is termed as:A. AdrenarcheB. ThelarcheC. MamarcheD. Menarche12. Kevin, Susan’s husband tells you that he isconsidering vasectomy After the birth of theirnew child. Vasectomy involves the incision ofwhich organ?A. The testesB. The epididymisC. The vas deferensD. The scrotum13. On examination, Susan has been found of havinga cystocele. A cystocele is:A. A sebaceous cyst arising from the vulvarfoldB. Protrusion of intestines into the vaginaC. Prolapse of the uterus into the vaginaD. Herniation of the bladder into thevaginal wall14. Susan typically has menstrual cycle of 34 days.She told you she had coitus on days 8, 10, 15 and20 of her menstrual cycle. Which is the day onwhich she is most likely to conceive?A. 8thdayB. Day 15C. 10thdayD. Day 2015. While talking with Susan, 2 new patients arrivedand they are covered with large towels and thenurse noticed that there are many cameramanand news people outside of the OPD. Uponassessment the nurse noticed that both of themare still nude and the male client’s penis is stillinside the female client’s vagina and the maleclient said that “I can’t pull it”. Vaginismus wasyour first impression. You know that Thepsychological cause of Vaginismus is related to:A. The male client inserted the penis toodeeply that it stimulates vaginal closureB. The penis was too large that is why thevagina triggered its defense to attemptto close itC. The vagina does not want to bepenetratedD. It is due to learning patterns of thefemale client where she views sex asbad or sinfulSituation: Overpopulation is one problem in thePhilippines that causes economic drain. Most Filipinosare against in legalizing abortion. As a nurse, Mastery ofcontraception is needed to contribute to the society andeconomic growth.16. Supposed that Dana, 17 years old, tells you shewants to use fertility awareness method ofcontraception. How will she determine herfertile days?A. She will notice that she feels hot, as ifshe has an elevated temperature.B. She should assess whether her cervicalmucus is thin, copious, clear andwatery.C. She should monitor her emotions forsudden anger or cryingD. She should assess whether her breastsfeel sensitive to cool air17. Dana chooses to use COC as her family planningmethod. What is the danger sign of COC youwould ask her to report?A. A stuffy or runny noseB. Slight weight gainC. Arthritis like symptomsD. Migraine headache18. Dana asks about subcutaneous implants and sheasks, how long will these implants be effective.Your best answer is:A. One month
  17. 17. 17B. Five yearsC. Twelve monthsD. 10 years19. Dana asks about female condoms. Which of thefollowing is true with regards to femalecondoms?A. The hormone the condom releasesmight cause mild weight gainB. She should insert the condom beforeany penile penetrationC. She should coat the condom withspermicide before useD. Female condoms, unlike male condoms,are reusable20. Dana has asked about GIFT procedure. Whatmakes her a good candidate for GIFT?A. She has patent fallopian tubes, sofertilized ova can be implanted on themB. She is RH negative, a necessarystipulation to rule out RH incompatibilityC. She has normal uterus, so the sperm canbe injected through the cervix into itD. Her husband is taking sildenafil, so allsperms will be motileSituation: Nurse Lorena is a Family Planning andInfertility Nurse Specialist and currently attends toFAMILY PLANNING CLIENTS AND INFERTILE COUPLES.The following conditions pertain to meeting the nursingneeds of this particular population group.21. Dina, 17 years old, asks you how a tubal ligationprevents pregnancy. Which would be the bestanswer?A. Prostaglandins released from the cutfallopian tubes can kill spermB. Sperm cannot enter the uterus becausethe cervical entrance is blocked.C. Sperm can no longer reach the ova,because the fallopian tubes are blockedD. The ovary no longer releases ova asthere is nowhere for them to go.22. The Dators are a couple undergoing testing forinfertility. Infertility is said to exist when:A. A woman has no uterusB. A woman has no childrenC. A couple has been trying to conceive for1 yearD. A couple has wanted a child for 6months23. Another client named Lilia is diagnosed as havingendometriosis. This condition interferes withfertility because:A. Endometrial implants can block thefallopian tubesB. The uterine cervix becomes inflamedand swollenC. The ovaries stop producing adequateestrogenD. Pressure on the pituitary leads todecreased FSH levels24. Lilia is scheduled to have ahysterosalphingogram. Which of the followinginstructions would you give her regarding thisprocedure?A. She will not be able to conceive for 3months after the procedureB. The sonogram of the uterus will revealany tumors presentC. Many women experience mild bleedingas an after effectD. She may feel some cramping when thedye is inserted25. Lilia’s cousin on the other hand, knowing nurseLorena’s specialization asks what artificialinsemination by donor entails. Which would beyour best answer if you were Nurse Lorena?A. Donor sperm are introduced vaginallyinto the uterus or cervixB. Donor sperm are injected intra-abdominally into each ovaryC. Artificial sperm are injected vaginally totest tubal patencyD. The husband’s sperm is administeredintravenously weeklySituation: You are assigned to take care of a group ofpatients across the lifespan.26. Pain in the elder persons requires carefulassessment because they:A. experienced reduce sensory perceptionB. have increased sensory perceptionC. are expected to experience chronic painD. have a decreased pain threshold27. Administration of analgesics to the older personsrequires careful patient assessment becauseolder people:A. are more sensitive to drugs
  18. 18. 18B. have increased hepatic, renal andgastrointestinal functionC. have increased sensory perceptionD. mobilize drugs more rapidly28. The elderly patient is at higher risk for urinaryincontinence because of:A. increased glomerular filtrationB. decreased bladder capacityC. diuretic useD. dilated urethra29. Which of the following is the MOST COMMONsign of infection among the elderly?A. decreased breath sounds with cracklesB. painC. feverD. change in mental status30. Priorities when caring for the elderly traumapatient:A. circulation, airway, breathingB. airway, breathing, disability (neurologic)C. disability (neurologic), airway, breathingD. airway, breathing, circulation31. Preschoolers are able to see things from whichof the following perspectives?A. Their peersB. Their own and their mother’sC. Their own and their caregivers’D. Only their own32. In conflict management, the win-win approachoccurs when:A. There are two conflicts and the partiesagree to each oneB. Each party gives in on 50% of thedisagreements making up the conflictC. Both parties involved are committed tosolving the conflictD. The conflict is settled out of court so thelegal system and the parties win33. According to the social-interactional perspectiveof child abuse and neglect, four factors place thefamily members at risk for abuse. These riskfactors are the family members at risk for abuse.These risk factors are the family itself, thecaregiver, the child, andA. The presence of a family crisisB. The national emphasis on sexC. GeneticsD. Chronic poverty34. Which of the following signs and symptomswould you most likely find when assessing andinfant with Arnold-Chiari malformation?A. Weakness of the leg muscles, loss ofsensation in the legs, and restlessnessB. Difficulty swallowing, diminished orabsent gag reflex, and respiratorydistressC. Difficulty sleeping, hypervigilant, and anarching of the backD. Paradoxical irritability, diarrhea, andvomiting.35. A parent calls you and frantically reports that herchild has gotten into her famous ferrous sulfatepills and ingested a number of these pills. Herchild is now vomiting, has bloody diarrhea, and iscomplaining of abdominal pain. You will tell themother to:A. Call emergency medical services (EMS)and get the child to the emergency roomB. Relax because these symptoms will passand the child will be fineC. Administer syrup of ipecacD. Call the poison control center36. A client says she heard from a friend that youstop having periods once you are on the “pill”.The most appropriate response would be:A. “The pill prevents the uterus frommaking such endometrial lining, that iswhy periods may often be scant orskipped occasionally.”B. “If your friend has missed her period,she should stop taking the pills and get apregnancy test as soon as possible.”C. “The pill should cause a normalmenstrual period every month. Itsounds like your friend has not beentaking the pills properly.”D. “Missed period can be very dangerousand may lead to the formation ofprecancerous cells.”37. The nurse assessing newborn babies and infantsduring their hospital stay after birth will noticewhich of the following symptoms as a primarymanifestation of Hirschsprung’s disease?A. A fine rash over the trunkB. Failure to pass meconium during thefirst 24 to 48 hours after birth
  19. 19. 19C. The skin turns yellow and then brownover the first 48 hours of lifeD. High-grade fever38. A client is 7 months pregnant and has just beendiagnosed as having a partial placenta previa.She is stable and has minimal spotting and isbeing sent home. Which of these instructions tothe client may indicate a need for furtherteaching?A. Maintain bed rest with bathroomprivilegesB. Avoid intercourse for three days.C. Call if contractions occur.D. Stay on left side as much as possiblewhen lying down.39. A woman has been rushed to the hospital withruptured membrane. Which of the followingshould the nurse check first?A. Check for the presence of infectionB. Assess for Prolapse of the umbilicalcordC. Check the maternal heart rateD. Assess the color of the amniotic fluid40. The nurse notes that the infant is wearing aplastic-coated diaper. If a topical medicationwere to be prescribed and it were to go on thestomachs or buttocks, the nurse would teach thecaregivers to:A. avoid covering the area of the topicalmedication with the diaperB. avoid the use of clothing on top of thediaperC. put the diaper on as usualD. apply an icepack for 5 minutes to theoutside of the diaper41. Which of the following factors is most importantin determining the success of relationships usedin delivering nursing care?A. Type of illness of the clientB. Transference and counter transferenceC. Effective communicationD. Personality of the participants42. Grace sustained a laceration on her leg fromautomobile accident. Why are lacerations oflower extremities potentially more seriousamong pregnant women than other?A. lacerations can provoke allergicresponses due to gonadotropic hormonereleaseB. a woman is less able to keep thelaceration clean because of her fatigueC. healing is limited during pregnancy sothese will not heal until after birthD. increased bleeding can occur fromuterine pressure on leg veins43. In working with the caregivers of a client with anacute or chronic illness, the nurse would:A. Teach care daily and let the caregiversdo a return demonstration just beforedischargeB. Difficulty swallowing, diminished orabsent gag reflex, and respiratorydistress.C. Difficulty sleeping, hypervigilant, and anarching of the backD. Paradoxical irritability, diarrhea, andvomiting44. Which of the following roles BEST exemplifiesthe expanded role of the nurse?A. Circulating nurse in surgeryB. Medication nurseC. Obstetrical nurseD. Pediatric nurse practitioner45. According to DeRosa and Kochura’s (2006)article entitled “Implement Culturally CompetentHealth Care in your work place,” cultures havedifferent patterns of verbal and nonverbalcommunication. Which difference does?A. NOT necessarily belong?B. Personal behaviorC. Subject matterD. Eye contactE. Conversational style46. You are the nurse assigned to work with a childwith acute glomerulonephritis. By following theprescribed treatment regimen, the childexperiences a remission. You are now checkingto make sure the child does not have a relapse.Which finding would most lead you to theconclusion that a relapse is happening?A. Elevated temperature, cough, sorethroat, changing complete blood count(CBC) with diiferentialB. A urine dipstick measurement of 2+proteinuria or more for 3 days, or thechild found to have 3-4+ proteinutriaplus edema.
  20. 20. 20C. The urine dipstick showing glucose in theurine for 3 days, extreme thirst, increasein urine output, and a moon face.D. A temperature of 37.8 degrees (100degrees F), flank pain, burningfrequency, urgency on voiding, andcloudy urine.47. The nurse is working with an adolescent whocomplains of being lonely and having a lack offulfillment in her life. This adolescent shies awayfrom intimate relationships at times yet at othertimes she appears promiscuous. The nurse willlikely work with this adolescent in which of thefollowing areas?A. IsolationB. Lack of fulfillmentC. LonelinessD. Identity48. The use of interpersonal decision making,psychomotor skills, and application ofknowledge expected in the role of a licensedhealth care professional in the context of publichealth welfare and safety is an example of:A. DelegationB. ResponsibilityC. SupervisionD. Competence49. The painful phenomenon known as “back labor”occurs in a client whose fetus in what position?A. Brow positionB. Breech positionC. Right Occipito-Anterior PositionD. Left Occipito-Posterior Position50. FOCUS methodology stands for:A. Focus, Organize, Clarify, Understandand SolutionB. Focus, Opportunity, Continuous, Utilize,SubstantiateC. Focus, Organize, Clarify, Understand,SubstantiateD. Focus, Opportunity, Continuous(process), Understand, SolutionSITUATION: The infant and child mortality rate in the lowto middle income countries is ten times higher thanindustrialized countries. In response to this, the WHOand UNICEF launched the protocol IntegratedManagement of Childhood Illnesses to reduce themorbidity and mortality against childhood illnesses.51. If a child with diarrhea registers two signs in theyellow row in the IMCI chart, we can classify thepatient as:A. Moderate dehydrationB. Severe dehydrationC. Some dehydrationD. No dehydration52. Celeste has had diarrhea for 8 days. There is noblood in the stool, he is irritable, his eyes aresunken, the nurse offers fluid to Celeste and hedrinks eagerly. When the nurse pinched theabdomen it goes back slowly. How will youclassify Celeste’s illness?A. Moderate dehydrationB. Severe dehydrationC. Some dehydrationD. No dehydration53. A child who is 7 weeks has had diarrhea for 14days but has no sign of dehydration is classifiedas:A. Persistent diarrheaB. DysenteryC. Severe dysenteryD. Severe persistent diarrhea54. The child with no dehydration needs hometreatment. Which of the following is notincluded in the rules for home treatment in thiscase?A. Forced fluidsB. When to returnC. Give vitamin A supplementD. Feeding more55. Fever as used in IMCI includes:A. Axillary temperature of 37.5 or higherB. Rectal temperature of 38 or higherC. Feeling hot to touchD. All of the aboveE. A and C onlySituation: Prevention of Dengue is an important nursingresponsibility and controlling it’s spread is a priority onceoutbreak has been observed.56. An important role of the community healthnurse in the prevention and control of DengueH-fever includes:A. Advising the elimination of vectors bykeeping water containers covered
  21. 21. 21B. Conducting strong health educationdrives/campaign directed towardsproper garbage disposalC. Explaining to the individuals, families,groups and community the nature ofthe disease and its causationD. Practicing residual spraying withinsecticides57. Community health nurses should be alert inobserving a Dengue suspect. The following isNOT an indicator for hospitalization of H-feversuspects?A. Marked anorexia, abdominal pain andvomitingB. Increasing hematocrit countC. Cough of 30 daysD. Persistent headache58. The community health nurses’ primary concernin the immediate control of hemorrhage amongpatients with dengue is:A. Advising low fiber and non-fat dietB. Providing warmth through light weightcoversC. Observing closely the patient for vitalsigns leading to shockD. Keeping the patient at rest59. Which of these signs may NOT be REGARDED asa truly positive signs indicative of Dengue H-fever?A. Prolonged bleeding timeB. Appearance of at least 20 petechiaewithin 1cm squareC. Steadily increasing hematocrit countD. Fall in the platelet count60. Which of the following is the most importanttreatment of patients with Dengue H-fever?A. Give aspirin for feverB. Replacement of body fluidsC. Avoid unnecessary movement of patientD. Ice cap over the abdomen in case ofmelenaSituation: Health education and Health promotion is animportant part of nursing responsibility in thecommunity. Immunization is a form of health promotionthat aims at preventing the common childhood illnesses.61. In correcting misconceptions and myths aboutcertain diseases and their management, thehealth worker should first:A. Identify the myths and misconceptionsprevailing in the communityB. Identify the source of these myths andmisconceptionsC. Explain how and why these myths cameaboutD. Select the appropriate IEC strategies tocorrect them62. How many percent of measles are prevented byimmunization at 9 months of age?A. 80%B. 99%C. 90%D. 95%63. After TT3 vaccination a mother is said to beprotected to tetanus by around:A. 80%B. 99%C. 85%D. 90%64. If ever convulsions occur after administeringDPT, what should the nurse best suggest to themother?A. Do not continue DPT vaccinationanymoreB. Advise mother to comeback after 1 weekC. Give DT instead of DPTD. Give pertussis of the DPT and remove DT65. These vaccines are given 3 doses at one monthintervals:A. DPT, BCG, TTB. OPV, HEP. B, DPTC. DPT, TT, OPVD. Measles, OPV, DPTSituation – With the increasing documented cases ofCANCER the best alternative to treatment still remains tobe PREVENTION. The following conditions apply.66. Which among the following is the primary focusof prevention of cancer?A. Elimination of conditions causing cancerB. Diagnosis and treatmentC. Treatment at early stageD. Early detection67. In the prevention and control of cancer, which ofthe following activities is the most important
  22. 22. 22function of the community health nurse?A. Conduct community assemblies.B. Referral to cancer specialist those clientswith symptoms of cancer.C. Use the nine warning signs of cancer asparameters in our process of detection,control and treatment modalities.D. Teach woman about proper/correctnutrition.68. Who among the following are recipients of thesecondary level of care for cancer cases?A. Those under early case detectionB. Those under post case treatmentC. Those scheduled for surgeryD. Those undergoing treatment69. Who among the following are recipients of thetertiary level of care for cancer cases?A. Those under early treatmentB. Those under early detectionC. Those under supportive careD. Those scheduled for surgery70. In Community Health Nursing, despite theavailability and use of many equipment anddevices to facilitate the job of the communityhealth nurse, the best tool any nurse should bewel be prepared to apply is a scientific approach.This approach ensures quality of care even at thecommunity setting. This is nursing parlance isnothing less than the:A. nursing diagnosisB. nursing researchC. nursing protocolD. nursing processSituation – Two children were brought to you. One withchest indrawing and the other had diarrhea. Thefollowing questions apply:71. Using Integrated Management and ChildhoodIllness (IMCI) approach, how would you classifythe 1st child?A. BronchopneumoniaB. Severe pneumoniaC. No pneumonia : cough or coldD. Pneumonia72. The 1st child who is 13 months has fastbreathing using IMCI parameters he has:A. 40 breaths per minute or moreB. 50 breaths per minuteC. 30 breaths per minute or moreD. 60 breaths per minute73. 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 offeredfluids and and the child drinks eagerly. Howwould you classify Nina’s illness?A. Some dehydrationB. Severe dehydrationC. DysenteryD. No dehydration74. Nina’s treatment should include the followingEXCEPT:A. reassess the child and classify him fordehydrationB. for infants under 6 months old who arenot breastfed, give 100-200 ml cleanwater as well during this periodC. Give in the health center therecommended amount of ORS for 4hours.D. Do not give any other foods to the childfor home treatment75. While on treatment, Nina 18 months oldweighed 18 kgs. and her temperature registeredat 37 degrees C. Her mother says she developedcough 3 days ago. Nina has no general dangersigns. She has 45 breaths/minute, no chest in-drawing, no stridor. How would you classifyNina’s manifestation?A. No pneumoniaB. PneumoniaC. Severe pneumoniaD. Bronchopneumonia76. Carol is 15 months old and weighs 5.5 kgs and itis her initial visit. Her mother says that Carol isnot eating well and unable to breastfeed, he hasno vomiting, has no convulsion and notabnormally sleepy or difficult to awaken. Hertemperature is 38.9 deg C. Using the integratedmanagement of childhood illness or IMCIstrategy, if you were the nurse in charge ofCarol, how will you classify her illness?A. a child at a general danger signB. severe pneumoniaC. very severe febrile diseaseD. severe malnutrition77. Why are small for gestational age newborns at
  23. 23. 23risk for difficulty maintaining body temperature?A. their skin is more susceptible toconduction of coldB. they are preterm so are born relativelysmall in sizeC. they do not have as many fat stored asother infantsD. they are more active than usual so theythrow off comes78. Oxytocin is administered to Rita to augmentlabor. What are the first symptoms of waterintoxication to observe for during thisprocedure?A. headache and vomitingB. a high choking voiceC. a swollen tender tongueD. abdominal bleeding and pain79. Which of the following treatment should NOT beconsidered if the child has severe denguehemorrhagic fever?A. use plan C if there is bleeding from thenose or gumsB. give ORS if there is skin Petechiae,persistent vomiting, and positivetourniquet testC. give aspirinD. prevent low blood sugar80. In assessing the patient’s condition using theIntegrated Management of Childhood Illnessapproach strategy, the first thing that a nurseshould do is to:A. ask what are the child’s problemB. check for the four main symptomsC. check the patient’s level ofconsciousnessD. check for the general danger signs81. A child with diarrhea is observed for thefollowing EXCEPT:A. how long the child has diarrheaB. presence of blood in the stoolC. skin PetechiaeD. signs of dehydration82. The child with no dehydration needs hometreatment. Which of the following is NOTincluded in the care for home management atthis case?A. give drugs every 4 hoursB. give the child more fluidsC. continue feeding the childD. inform when to return to the healthcenter83. Ms. Jordan, RN, believes that a patient should betreated as individual. This ethical principle thatthe patient referred to:A. beneficenceB. respect for personC. nonmaleficenceD. autonomy84. When patients cannot make decisions forthemselves, the nurse advocate relies on theethical principle of:A. justice and beneficenceB. beneficence and nonmaleficenceC. fidelity and nonmaleficenceD. fidelity and justice85. Being a community health nurse, you have theresponsibility of participating in protecting thehealth of people. Consider this situation:Vendors selling bread with their bare hands.They receive money with these hands. You donot see them washing their hands. What shouldyou say/do?A. “Miss, may I get the bread myselfbecause you have not washed yourhands”B. All of theseC. “Miss, it is better to use a pick upforceps/ bread tong”D. “Miss, your hands are dirty. Wash yourhands first before getting the bread”Situation: The following questions refer to commonclinical encounters experienced by an entry level nurse.86. A female client asks the nurse about the use of acervical cap. Which statement is correctregarding the use of the cervical cap?A. It may affect Pap smear results.B. It does not need to be fitted by thephysician.C. It does not require the use ofspermicide.D. It must be removed within 24 hours.87. The major components of the communicationprocess are:A. Verbal, written and nonverbal
  24. 24. 24B. Speaker, listener and replyC. Facial expression, tone of voice andgesturesD. Message, sender, channel, receiver andfeedback88. The extent of burns in children are normallyassessed and expressed in terms of:A. The amount of body surface that isunburnedB. Percentages of total body surface area(TBSA)C. How deep the deepest burns areD. The severity of the burns on a 1 to 5burn scale.89. The school nurse notices a child who is wearingold, dirty, poor-fitting clothes; is always hungry;has no lunch money; and is always tired. Whenthe nurse asks the boy his tiredness, he talks ofplaying outside until midnight. The nurse willsuspect that this child is:A. Being raised by a parent of lowintelligence quotient (IQ)B. An orphanC. A victim of child neglectD. The victim of poverty90. Which of the following indicates the type(s) ofacute renal failure?A. Four types: hemorrhagic with andwithout clotting, and nonhemorrhagicwith and without clottingsB. One type: acuteC. Three types: prerenal, intrarenal andpostrenalD. Two types: acute and subacuteSituation: 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 tocontract AIDS?A. Syringe and needlesB. Sexual contactC. Body fluidsD. Transfusion92. Causative organism in AIDS is one of thefollowing;A. FungusB. retrovirusC. BacteriaD. Parasites93. You are assigned in a private room of Mike.Which procedure should be of outmostimportance;A. Alcohol washB. Washing IsolationC. Universal precautionD. Gloving technique94. What primary health teaching would you give tomike;A. Daily exerciseB. reverse isolationC. Prevent infectionD. Proper nutrition95. Exercise precaution must be taken to protecthealth worker dealing with the AIDS patients .which among these must be done as priority:A. Boil used syringe and needlesB. Use gloves when handling specimenC. Label personal belongingD. Avoid accidental woundSituation: Michelle is a 6 year old preschooler. She wasreported by her sister to have measles but she is athome because of fever, upper respiratory problem andwhite sports in her mouth.96. Rubeola is an Arabic term meaning Red, the rashappears on the skin in invasive stage prior toeruption behind the ears. As a nurse, yourphysical examination must determinecomplication especially:A. Otitis mediaB. Inflammatory conjunctivaC. Bronchial pneumoniaD. Membranous laryngitis97. To render comfort measure is one of thepriorities, Which includes care of the skin, eyes,ears, mouth and nose. To clean the mouth, yourantiseptic solution is in some form of which onebelow?A. WaterB. AlkalineC. SulfurD. Salt98. As a public health nurse, you teach mother andfamily members the prevention of complicationof measles. Which of the following should be
  25. 25. 25closely watched?A. Temperature fails to dropB. Inflammation of the nasophraynxC. Inflammation of the conjunctivaD. Ulcerative stomatitis99. Source of infection of measles is secretion ofnose and throat of infection person. Filterablevirus of measles is transmitted by:A. Water supplyB. Food ingestionC. DropletD. Sexual contact100. Method of prevention is to avoidexposure to an infection person. Nursingresponsibility for rehabilitation of patientincludes the provision of:A. Terminal disinfectionB. ImmunizationC. Injection of gamma globulinD. Comfort measures
  26. 26. 26NURSING PRACTICE IIISituation: Leo lives in the squatter area. He goes tonearby school. He helps his mother gather molassesafter school. One day, he was absent because of fever,malaise, anorexia and abdominal discomfort.1. Upon assessment, Leo was diagnosed to havehepatitis A. Which mode of transmission has theinfection agent taken?a. Fecal-oralb. Dropletc. Airborned. Sexual contact2. Which of the following is concurrent disinfectionin the case of Leo?a. Investigation of contactb. Sanitary disposal of faeces, urine andbloodc. Quarantine of the sick individuald. removing all detachable objects in theroom, cleaning lighting and air ductsurfaces in the ceiling, and cleaningeverything downward to the floor3. Which of the following must be emphasizedduring mother’s class to Leo’s mother?a. Administration of Immunoglobulin tofamiliesb. Thorough hand washing before andafter eating and toiletingc. Use of attenuated vaccinesd. Boiling of food especially meat4. Disaster control should be undertaken whenthere are 3 or more hepatitis A cases. Which ofthese measures is a priority?a. Eliminate faecal contamination fromfoodsb. Mass vaccination of uninfectedindividualsc. Health promotion and education tofamilies and communities about thedisease it’s cause and transmissiond. Mass administration of Immunoglobulin5. What is the average incubation period ofHepatitis A?a. 30 daysb. 60 daysc. 50 daysd. 14 daysSituation: As a nurse researcher you must have a verygood understanding of the common terms of conceptused in research.6. The information that an investigator collectsfrom the subjects or participants in a researchstudy is usually called;a. Hypothesisb. Variablec. Datad. Concept7. Which of the following usually refers to theindependent variables in doing researcha. Resultb. outputc. Caused. Effect8. The recipients of experimental treatment is anexperimental design or the individuals to beobserved in a non experimental design arecalled;a. Settingb. Treatmentc. Subjectsd. Sample9. The device or techniques an investigatoremploys to collect data is called;a. Sampleb. hypothesisc. Instrumentd. Concept10. The use of another person’s ideas or wordingswithout giving appropriate credit results frominaccurate or incomplete attribution of materialsto its sources. Which of the following is referredto when another person’s idea is inappropriatecredited as one’s own;a. Plagiarismb. assumptionc. Quotationd. ParaphraseSituation – Mrs. Pichay is admitted to your ward. TheMD ordered “Prepare for thoracentesis this pm toremove excess air from the pleural cavity.”
  27. 27. 2711. Which of the following nursing responsibilities isessential in Mrs. Pichay who will undergothoracentesis?a. Support and reassure client during theprocedureb. Ensure that informed consent has beensignedc. Determine if client has allergic reactionto local anesthesiad. Ascertain if chest x-rays and other testshave been prescribed and completed12. Mrs. Pichay who is for thoracentesis is assignedby the nurse to which of the following positions?a. Trendelenburg positionb. Supine positionc. Dorsal Recumbent positiond. Orthopneic position13. During thoracentesis, which of the followingnursing intervention will be most crucial?a. Place patient in a quiet and cool roomb. Maintain strict aseptic techniquec. Advice patient to sit perfectly stillduring needle insertion until it has beenwithdrawn from the chestd. Apply pressure over the puncture site assoon as the needle is withdrawn14. To prevent leakage of fluid in the thoracic cavity,how will you position the client afterthoracentesis?a. Place flat in bedb. Turn on the unaffected sidec. Turn on the affected sided. On bed rest15. Chest x-ray was ordered after thoracentesis.When your client asks what is the reason foranother chest x-ray, you will explain:a. To rule out pneumothoraxb. To rule out any possible perforationc. To decongestd. To rule out any foreign bodySituation: A computer analyst, Mr. Ricardo J. Santos, 25was brought to the hospital for diagnostic workup afterhe had experienced seizure in his office.16. Just as the nurse was entering the room, thepatient who was sitting on his chair begins tohave a seizure. Which of the following must thenurse do first?a. Ease the patient to the floorb. Lift the patient and put him on the bedc. Insert a padded tongue depressorbetween his jawsd. Restraint patient’s body movement17. Mr Santos is scheduled for CT SCAN for the nextday, noon time. Which of the following is thecorrect preparation as instructed by the nurse?a. Shampoo hair thoroughly to remove oiland dirtb. No special preparation is needed.Instruct the patient to keep his headstill and steadc. Give a cleansing enema and give fluidsuntil 8 AMd. Shave scalp and securely attachelectrodes to it18. Mr Santos is placed on seizure precaution.Which of the following would becontraindicated?a. Obtain his oral temperatureb. Encourage to perform his own personalhygienec. Allow him to wear his own clothingd. Encourage him to be out of bed19. Usually, how does the patient behave after hisseizure has subsided?a. Most comfortable walking and movingaboutb. Becomes restless and agitatedc. Sleeps for a period of timed. Say he is thirsty and hungry20. Before, during and after seizure. The nurseknows that the patient is ALWAYS placed in whatposition?a. Low fowler’sb. Side lyingc. Modified trendelenburgd. SupineSituation: Mrs. Damian an immediate post opcholecystectomy and choledocholithotomy patient,complained of severe pain at the wound site.21. Choledocholithotomy is:a. The removal of the gallbladderb. The removal of the stones in thegallbladderc. The removal of the stones in the
  28. 28. 28common bile ductd. The removal of the stones in the kidney22. The simplest pain relieving technique is:a. Distractionb. Deep breathing exercisec. Taking aspirind. Positioning23. Which of the following statement on pain isTRUE?a. Culture and pain are not associatedb. Pain accompanies acute illnessc. Patient’s reaction to pain Variesd. Pain produces the same reaction such asgroaning and moaning24. In pain assessment, which of the followingcondition is a more reliable indicator?a. Pain rating scale of 1 to 10b. Facial expression and gesturesc. Physiological responsesd. Patients description of the painsensation25. When a client complains of pain, your initialresponse is:a. Record the description of painb. Verbally acknowledge the painc. Refer the complaint to the doctord. Change to a more comfortable positionSituation: You are assigned at the surgical ward andclients have been complaining of post pain at varyingdegrees. Pain as you know, is very subjective.26. A one-day postoperative abdominal surgeryclient has been complaining of severe throbbingabdominal pain described as 9 in a 1-10 painrating. Your assessment reveals bowel sounds onall quadrants and the dressing is dry and intact.What nursing intervention would you take?a. Medicate client as prescribedb. Encourage client to do imageryc. Encourage deep breathing and turningd. Call surgeon stat27. Pentoxidone 5 mg IV every 8 hours wasprescribed for post abdominal pain. Which willbe your priority nursing action?a. Check abdominal dressing for possibleswellingb. Explain the proper use of PCA toalleviate anxietyc. Avoid overdosing to preventdependence/toleranced. Monitor VS, more importantly RR28. The client complained of abdominal distentionand pain. Your nursing intervention that canalleviate pain is:a. Instruct client to go to sleep and relaxb. Advice the client to close the lips andavoid deep breathing and talkingc. Offer hot and clear soupd. Turn to sides frequently and avoid toomuch talking29. Surgical pain might be minimized by whichnursing action in the O.R.a. Skill of surgical team and lessermanipulationb. Appropriate preparation for thescheduled procedurec. Use of modern technology in closing thewoundd. Proper positioning and draping of clients30. Inadequate anesthesia is said to be one of thecommon cause of pain both in intra and post oppatients. If General anesthesia is desired, it willinvolve loss of consciousness. Which of thefollowing are the 2 general types of GA?a. Epidural and Spinalb. Subarachnoid block and Intravenousc. Inhalation and Regionald. Intravenous and InhalationSituation: Nurse’s attitudes toward the pain influencethe way they perceive and interact with clients in pain.31. Nurses should be aware that older adults are atrisk of underrated pain. Nursing assessment andmanagement of pain should address thefollowing beliefs EXCEPT:a. Older patients seldom tend to reportpain than the younger onesb. Pain is a sign of weaknessc. Older patients do not believe inanalgesics, they are tolerantd. Complaining of pain will lead to beinglabeled a ‘bad’ patient32. Nurses should understand that when a clientresponds favorably to a placebo, it is known asthe ‘placebo effect’. Placebos do not indicate
  29. 29. 29whether or not a client has:a. Conscienceb. Diseasec. Real paind. Drug tolerance33. You are the nurse in the pain clinic where youhave client who has difficulty specifying thelocation of pain. How can you assist such client?a. The pain is vagueb. By charting-it hurts all overc. Identify the absence and presence ofpaind. As the client to point to the painful areby just one finger34. What symptom, more distressing than pain,should the nurse monitor when giving opioidsespecially among elderly clients who are in pain?a. Forgetfulnessb. Drowsinessc. Constipationd. Allergic reactions like pruritis35. Physical dependence occurs in anyone whotakes opiods over a period of time. What do youtell a mother of a ‘dependent’ when asked foradvice?a. Start another drug and slowly lessen theopioid dosageb. Indulge in recreational outdoor activitiesc. Isolate opioid dependent to a restfulresortd. Instruct slow tapering of the drugdosage and alleviate physicalwithdrawal symptomsSituation: The nurse is performing health educationactivities for Janevi Segovia, a 30 year old Dentist withInsulin dependent diabetes Miletus.36. Janevi is preparing a mixed dose of insulin. Thenurse is satisfied with her performance whenshe:a. Draw insulin from the vial of clearinsulin firstb. Draw insulin from the vial of theintermediate acting insulin firstc. Fill both syringes with the prescribedinsulin dosage then shake the bottlevigorouslyd. Withdraw the intermediate actinginsulin first before withdrawing the shortacting insulin first37. Janevi complains of nausea, vomiting,diaphoresis and headache. Which of thefollowing nursing intervention are you going tocarry out first?a. Withhold the client’s next insulininjectionb. Test the client’s blood glucose levelc. Administer Tylenol as orderedd. Offer fruit juice, gelatine and chickenbouillon38. Janevi administered regular insulin at 7 A.M andthe nurse should instruct Jane to avoidexercising at around:a. 9 to 11 A.Mb. Between 8 A.M to 9 A.Mc. After 8 hoursd. In the afternoon, after taking lunch39. Janevi was brought at the emergency room afterfour month because she fainted in her clinic. Thenurse should monitor which of the following testto evaluate the overall therapeutic complianceof a diabetic patient?a. Glycosylated hemoglobinb. Ketone levelsc. Fasting blood glucosed. Urine glucose level40. Upon the assessment of Hba1c of Mrs. Segovia,The nurse has been informed of a 9% Hba1cresult. In this case, she will teach the patient to:a. Avoid infectionb. Prevent and recognize hyperglycaemiac. Take adequate food and nutritiond. Prevent and recognize hypoglycaemia41. The nurse is teaching plan of care for Jane withregards to proper foot care. Which of thefollowing should be included in the plan?a. Soak feet in hot waterb. Avoid using mild soap on the feetc. Apply a moisturizing lotion to dry feetbut not between the toesd. Always have a podiatrist to cut your toenails; never cut them yourself42. Another patient was brought to the emergencyroom in an unresponsive state and a diagnosis ofhyperglycaemic hyperosmolar nonketoticsyndrome is made. The nurse immediately
  30. 30. 30prepares to initiate which of the followinganticipated physician’s order?a. Endotracheal intubationb. 100 unites of NPH insulinc. Intravenous infusion of normal salined. Intravenous infusion of sodiumbicarbonate43. Jane eventually developed DKA and is beingtreated in the emergency room. Which findingwould the nurse expect to note as confirmingthis diagnosis?a. Comatose stateb. Decreased urine outputc. Increased respiration and an increase inpHd. Elevated blood glucose level and lowplasma bicarbonate level44. The nurse teaches Jane to know the differencebetween hypoglycaemia and ketoacidosis. Janedemonstrates understanding of the teaching bystating that glucose will be taken if which of thefollowing symptoms develops?a. Polyuriab. Shakinessc. Blurred Visiond. Fruity breath odour45. Jane has been scheduled to have a FBS taken inthe morning. The nurse tells Jane not to eat ordrink after midnight. Prior to taking the bloodspecimen, the nurse noticed that Jane is holdinga bottle of distilled water. The nurse asked Janeif she drink any, and she said “yes.” Which of thefollowing is the best nursing action?a. Administer syrup of ipecac to removethe distilled water from the stomachb. Suction the stomach content using NGTprior to specimen collectionc. Advice to physician to reschedule todiagnostic examination next dayd. Continue as usual and have the FBSanalysis performed and specimen betakenSituation: Elderly clients usually produce unusual signswhen it comes to different diseases. The ageing processis a complicated process and the nurse shouldunderstand that it is an inevitable fact and she must beprepared to care for the growing elderly population.46. Hypoxia may occur in the older patients becauseof which of the following physiologic changesassociated with aging.a. Ineffective airway clearanceb. Decreased alveolar surfaced areac. Decreased anterior-posterior chestdiameterd. Hyperventilation47. The older patient is at higher risk forincontinence because of:a. Dilated urethrab. Increased glomerular filtration ratec. Diuretic used. Decreased bladder capacity48. Merle, age 86, is complaining of dizziness whenshe stands up. This may indicate:a. Dementiab. Functional declinec. A visual problemd. Drug toxicity49. Cardiac ischemia in an older patient usuallyproduces:a. ST-T wave changesb. Chest pain radiating to the left armc. Very high creatinine kinase leveld. Acute confusion50. The most dependable sign of infection in theolder patient is:a. Change in mental statusb. Feverc. Paind. Decreased breath sounds with cracklesSituation – In the OR, there are safety protocols thatshould be followed. The OR nurse should be well versedwith all these to safeguard the safety and quality ofpatient delivery outcome.51. Which of the following should be given highestpriority when receiving patient in the OR?a. Assess level of consciousnessb. Verify patient identification andinformed consentc. Assess vital signsd. Check for jewelry, gown, manicure, anddentures52. Surgeries like I and D (incision and drainage) anddebridement are relatively short procedures butconsidered ‘dirty cases’. When are these
  31. 31. 31procedures best scheduled?a. Last caseb. In between casesc. According to availability ofanaesthesiologistd. According to the surgeon’s preference53. OR nurses should be aware that maintaining theclient’s safety is the overall goal of nursing careduring the intraoperative phase. As thecirculating nurse, you make certain thatthroughout the procedure…a. the surgeon greets his client beforeinduction of anesthesiab. the surgeon and anesthesiologist are intandemc. strap made of strong non-abrasivematerials are fastened securely aroundthe joints of the knees and ankles andaround the 2 hands around an armboard.d. Client is monitored throughout thesurgery by the assistant anesthesiologist54. Another nursing check that should not be missedbefore the induction of general anesthesia is:a. check for presence underwearb. check for presence denturesc. check patient’s IDd. check baseline vital signs55. Some lifetime habits and hobbies affectpostoperative respiratory function. If your clientsmokes 3 packs of cigarettes a day for the past10 years, you will anticipate increased risk for:a. perioperative anxiety and stressb. delayed coagulation timec. delayed wound healingd. postoperative respiratory infectionSituation: Sterilization is the process of removing ALLliving microorganism. To be free of ALL livingmicroorganism is sterility.56. There are 3 general types of sterilization use inthe hospital, which one is not included?a. Steam sterilizationb. Physical sterilizationc. Chemical sterilizationd. Sterilization by boiling57. Autoclave or steam under pressure is the mostcommon method of sterilization in the hospital.The nurse knows that the temperature and timeis set to the optimum level to destroy not onlythe microorganism, but also the spores. Whichof the following is the ideal setting of theautoclave machine?a. 10,000 degree Celsius for 1 hourb. 5,000 degree Celsius for 30 minutesc. 37 degree Celsius for 15 minutesd. 121 degree Celsius for 15 minutes58. It is important that before a nurse prepares thematerial to be sterilized, a chemical indicatorstrip should be placed above the package,preferably, Muslin sheet. What is the color ofthe striped produced after autoclaving?a. Blackb. Bluec. Grayd. Purple59. Chemical indicators communicate that:a. The items are sterileb. That the items had undergonesterilization process but not necessarilysterilec. The items are disinfectedd. That the items had undergonedisinfection process but not necessarilydisinfected60. If a nurse will sterilize a heat and moisture labileinstruments, It is according to AORNrecommendation to use which of the followingmethod of sterilization?a. Ethylene oxide gasb. Autoclavingc. Flash sterilizerd. Alcohol immersionSituation 5 – Nurses hold a variety of roles whenproviding care to a perioperative patient.61. Which of the following role would be theresponsibility of the scrub nurse?a. Assess the readiness of the client priorto surgeryb. Ensure that the airway is adequatec. Account for the number of sponges,needles, supplies, used during thesurgical procedure.d. Evaluate the type of anesthesiaappropriate for the surgical client
  32. 32. 3262. As a perioperative nurse, how can you best meetthe safety need of the client after administeringpreoperative narcotic?a. Put side rails up and ask the client notto get out of bedb. Send the client to OR with the familyc. Allow client to get up to go to thecomfort roomd. Obtain consent form63. It is the responsibility of the pre-op nurse to doskin prep for patients undergoing surgery. If hairat the operative site is not shaved, what shouldbe done to make suturing easy and lessenchance of incision infection?a. Drapedb. Pulledc. Clippedd. Shampooed64. It is also the nurse’s function to determine wheninfection is developing in the surgical incision.The perioperative nurse should observe for whatsigns of impending infection?a. Localized heat and rednessb. Serosanguinous exudates and skinblanchingc. Separation of the incisiond. Blood clots and scar tissue are visible65. Which of the following nursing interventions isdone when examining the incision wound andchanging the dressing?a. Observe the dressing and type and odorof drainage if anyb. Get patient’s consentc. Wash handsd. Request the client to expose the incisionwoundSituation – The preoperative nurse collaborates with theclient significant others, and healthcare providers.66. To control environmental hazards in the OR, thenurse collaborates with the followingdepartments EXCEPT:a. Biomedical divisionb. Infection control committeec. Chaplaincy servicesd. Pathology department67. An air crash occurred near the hospital leadingto a surge of trauma patient. One of the lastpatients will need surgical amputation but thereare no sterile surgical equipments. In this case,which of the following will the nurse expect?a. Equipments needed for surgery need notbe sterilized if this is an emergencynecessitating life saving measuresb. Forwarding the trauma client to thenearest hospital that has available sterileequipments is appropriatec. The nurse will need to sterilize the itembefore using it to the client using theregular sterilization setting at 121degree Celsius in 15 minutesd. In such cases, flash sterlizer will be useat 132 degree Celsius in 3 minutes68. Tess, the PACU nurse, discovered that Malou,who weighs 110 lbs prior to surgery, is in severepain 3 hrs after cholecystectomy. Upon checkingthe chart, Malou found out that she has an orderof Demerol 100 mg I.M. prn for pain. Tess shouldverify the order with:a. Nurse Supervisorb. Surgeonc. Anesthesiologistd. Intern on duty69. Rosie, 57, who is diabetic is for debridement ifincision wound. When the circulating nursechecked the present IV fluid, she found out thatthere is no insulin incorporated as ordered.What should the circulating nurse do?a. Double check the doctor’s order andcall the attending MDb. Communicate with the ward nurse toverify if insulin was incorporated or notc. Communicate with the client to verify ifinsulin was incorporatedd. Incorporate insulin as ordered.70. The documentation of all nursing activitiesperformed is legally and professionally vital.Which of the following should NOT be includedin the patient’s chart?a. Presence of prosthetoid devices such asdentures, artificial limbs hearing aid, etc.b. Baseline physical, emotional, andpsychosocial datac. Arguments between nurses andresidents regarding treatmentsd. Observed untoward signs and symptomsand interventions including contaminantintervening factors
  33. 33. 33Situation – Team efforts is best demonstrated in the OR.71. If you are the nurse in charge for schedulingsurgical cases, what important information doyou need to ask the surgeon?a. Who is your internistb. Who is your assistant andanaesthesiologist, and what is yourpreferred time and type of surgery?c. Who are your anaesthesiologist,internist, and assistantd. Who is your anaesthesiologist72. In the OR, the nursing tandem for every surgeryis:a. Instrument technician and circulatingnurseb. Nurse anaesthetist, nurse assistant, andinstrument technicianc. Scrub nurse and nurse anaesthetistd. Scrub and circulating nurses73. While team effort is needed in the OR forefficient and quality patient care delivery, weshould limit the number of people in the roomfor infection control. Who comprise this team?a. Surgeon, anaesthesiologist, scrub nurse,radiologist, orderlyb. Surgeon, assistants, scrub nurse,circulating nurse, anaesthesiologistc. Surgeon, assistant surgeon,anaesthesiologist, scrub nurse,pathologistd. Surgeon, assistant surgeon,anaesthesiologist, intern, scrub nurse74. Who usually act as an important part of the ORpersonnel by getting the wheelchair or stretcher,and pushing/pulling them towards the operatingroom?a. Orderly/clerkb. Nurse Supervisorc. Circulating Nursed. Anaesthesiologist75. The breakdown in teamwork is often times afailure in:a. Electricityb. Inadequate supplyc. Leg workd. CommunicationSituation: Basic knowledge on Intravenous solutions isnecessary for care of clients with problems with fluidsand electrolytes.76. A client involved in a motor vehicle crashpresents to the emergency department withsevere internal bleeding. The client is severelyhypotensive and unresponsive. The nurseanticipates which of the following intravenoussolutions will most likely be prescribed toincrease intravascular volume, replaceimmediate blood loss and increase bloodpressure?a. 0.45% sodium chlorideb. 0.33% sodium chloridec. Normal saline solutiond. Lactated ringer’s solution77. The physician orders the nurse to prepare anisotonic solution. Which of the following IVsolution would the nurse expect the intern toprescribe?a. 5% dextrose in waterb. 0.45% sodium chloridec. 10% dextrose in waterd. 5% dextrose in 0.9% sodium chloride78. The nurse is making initial rounds on the nursingunit 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 followingcomplications has been experienced by theclient?a. Infectionb. Phlebitisc. Infiltrationd. Thrombophelibitis79. A nurse reviews the client’s electrolytelaboratory report and notes that the potassiumlevel is 3.2 mEq/L. Which of the following wouldthe nurse note on the electrocardiogram as aresult of the laboratory value?a. U wavesb. Absend P wavesc. Elevated T wavesd. Elevated ST segment80. One patient had a ‘runaway’ IV of 50% dextrose.To prevent temporary excess of insulin ortransient hyperinsulin reaction what solutionyou prepare in anticipation of the doctor’s

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