SURIGAO EDUCATION CENTER

Km. 2, 8400 Surigao City, Philippines

College of Allied Medical Sciences
Bachelor of Science in Nursing
NUPC 19- Com App 1
Prelim Exam
Name: _______________________________ Date: ___________ Score: __________
Multiple Choice: Read carefully the statement. Write the letter of your best answer
Below after the last number of your exam.
Situation: Your nursing unit plans to conduct a study on the use of structured
preoperative preparation in lessening the demand for post-operative pain
medications.
1) Which of the following research activities should you initially do?
a) Find out from interview how many patients are willing to participate
b) Get the permission from the hospital director
c) Review literature on the topic
d) Prepare the tool for collecting data
2) Which of the following statements do NOT contribute to the researchability of your
proposed problem?
a) Potential use of findings c) Well-defined problem statement
b) Readability of finding d) Measurability of variables
3) A study /research table should NOT contain which of the following?
a) Categories of data collected c) Specific title of table
b) Relevant rows and columns d) Names and sample of the selected
4) Which of the following actions will facilitate analysis of research data?
a) Consult a physician c) Consult a complete expert
b) Consult an adviser d) Categorize data collected
5) The research methodology that is appropriate for the above problem would be:
a) Descriptive b) elow c) Experimental d) Quasi
experimental
6) Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to
receive Lanoxin. What should Nurse Suzie does when one of the clients does NOT
have a readable identification band?
a) Ask the client if she is Mrs. Santos
b) Ask the client his name
c) Ask the room mate if the client is Mrs. Santos
d) Compare the ID band with the bed tag
7) Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she
does not touch any client assigned to her unless she performs nursing procedures or
conducts physical assessment. To guide staff nurse in the use of touch, which of the
following would be the BEST response of Lizette?
a) "Use touch when the situation calls for it".
b) “Touch serves as a connection between the nurse and the patient."
c) "Use touch with discretion."
d) “Touch is used in physical assessment."
8) You are asked to teach the client, Mr. Lapuz who has right sided weakness the use
of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly?
a) The cane and one foot or both feet are on the floor at all times
b) He advances the cane followed by the left leg
c) Client keeps the cane on the right side along the weak leg
d) Client leans to the left side which is stronger
9) George, a 43 year old executive, is scheduled for cardiac bypass surgery. While
being prepared for surgery, he says to the nurse "I am not going to have the surgery.
I may die because of the risk". Which response by the nurse is most appropriate?
a) "Without the surgery you will most likely die sooner."
b) “There are always risks involved with surgery."
c) “There is a client in the other room who had successful surgery and you can talk
to him".
d) "This must be very frightening for you. Tell me how you feel about the surgery."
2
10)A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the
following is an appropriate instruction by the nurse?
a) Report to the physician the effects of the medication on urination
b) Take the medicine early in the morning
c) Take a full glass of water with the medicine
d) Measure frequency of urination in 24 hours
Situation: Joint Commission on Accreditation of Hospital Organization (JCAHO)
patient safety goals and requirements include the care and efficient use of
technology in the OR and elsewhere in the healthcare facility.
11)As the head nurse in the OR, how can you improve the effectiveness of clinical
alarm systems?
a) Limit suppliers to a few so that quality is maintained
b) Implement a regular inventory of supplies and equipment
c) Adherence to manufacturer’s recommendation
d) Implement a regular maintenance and testing of alarm systems
12)Overdosage of medication or anesthetic can happen even with the aid of technology
like infusion pumps, sphygmomanometer and similar devices/machines. As a staff,
how can you improve the safety of using infusion pumps?
a) Check the functionality of the pump before use
b) Select your brand of infusion pump like you do with your cellphone
c) Allow the technician to set the infusion pump before use
d) Verify the flow rate against your computation
13)JCAHOs universal protocol for surgical and invasive procedures to prevent wrong
site, wrong person, and wrong procedure/surgery includes the following, EXCEPT:
a) Mark the operative site if possible
b) Conduct pre-procedure verification process
c) Take a video of the entire intra-operative procedure
d) Conduct “time out” immediately before starting the procedure
14)You identified a potential risk of pre-and postoperative clients. To reduce the risk of
patient harm resulting from fall, you can implement the following, EXCEPT:
a) Assess potential risk of fall associated with the patient’s medication regimen
b) Take action to address any identified risks through Incident Report (IR)
c) Allow client to walk with relative to the OR
d) Assess and periodically reassess individual client’s risk for falling
15)As a nurse, you know you can improve on accuracy of patient’s identification by 2
patient identifiers, EXCEPT:
a) Identify the client by his/her wrist tag and verify with family members
b) Identify client by his/her wrist tag and call his/her by name
c) Call the client by his/her case and bed number
d) Call the patient by his/her name and bed number
16)Nurse Glenda gets a call from a neighbor who tells her that his 3 years old daughter
has been vomiting and has fever and asks for advice. Which of the following is the
most appropriate action of the nurse?
a) Observe the child for an hour if the child does not improve, refer to the physician
in the neighborhood
b) Recommend to bring the child immediately to the hospital
c) Assess the child, recommend observation and administer acetaminophen. If
symptoms continue, bring to the hospital
d) Tell the neighbor to observe the child and give plenty of fluids. If the child does
not improve, bring the child to the hospital
17)Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from
a vehicular accident. While being transported to the X-ray department, the straps
accidentally broke and the client fell to the floor hitting his head. In this situation, the
nurse is:
Not responsible because of the doctrine of respondent superior
i) Free from any negligence that caused harm to the patient
ii) Liable along with the employer for the use of a detective equipment that
harms the client
iii) Totally responsible for the negligence
18)While going on evening round, Nurse Edna saw Mrs. Pascual meditating and
afterwards started singing prayerful hymns. What is the BEST response of Edna?
i) Ignore the incidence
ii) Report the incidence to the head nurse
iii) Respect the client's actions as this provides structure and support to the client
iv) Call her attention so she can go to sleep
3
19)A client asks for advice on low cholesterol food. You advise the client to eat the
following:
a) Chicken liver, cow liver, eggs
b) Lean beef and pork, egg white, fish
c) Balut, salted eggs, duck and chicken egg
d) Pork liempo, cow brain, lungs and kidney
20)The code of ethics for nurses has an interpretive statement that provides:
a) Continuity of care for the improvement of the client
b) Guide for carrying out nursing responsibilities that provide quality care and for the
ethical obligation of the profession
c) Standards of care in carrying out nursing responsibilities
d) Identical care to all clients in any setting
Situation: Management of nurse practitioners is done by qualified nursing leaders
who had clinical experience and management experience.
21)An example of a management function of a nurse is:
a) Teaching patient do breathing and coughing exercises
b) Preparing for a surprise party for a client
c) Performing nursing procedures for clients
d) Directing and evaluating the staff nurses
22)Your head nurse in the unit believes that the staff nurses are not capable of decision
making so she makes the decisions for everyone without consulting anybody. This
type of leadership is:
a) Laissez-faire leadership c) Autocratic leadership
b) Democratic leadership d) Bureaucratic leadership
23)When the head nurse in your ward plots and approves your work schedules and
directs your work, she is demonstrating:
a) Responsibility b) Delegation c) Accountability
d) Authority
24)The following tasks can be safely delegated by a nurse to a non-nurse health worker
EXCEPT:
a) Transfer a client from bed to chair c) Irrigation of a nasogastric tube
b) Change IV infusions d) Take vital signs
25)You made a mistake in giving the medicine to the wrong client. You notify the client’s
doctor and write an incident report. You are demonstrating:
a) Responsibility b) Accountability c) Authority d) Autocracy
26.Which of the following situations would possibly cause a nurse to be sued due to
negligence?
A. Nurse gave a client wrong medication and an hour later, client complained of
dyspnea
B. While preparing a medication, the nurse notices that instead of 1 tablet, she
put two tablets into the client's medicine cup
C. As the nurse was about to administer medication, the client questioned why
the medication is still given when in fact the physician discontinued it
D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed.
Patient noticed the error and complained.
27.Your nurse supervisor asks you who among the following clients is most
susceptible to getting infection if admitted to the hospital:
a. Diabetic client type 2
b. Client with chronic obstructive pulmonary disease (COPD)
c. Client with second degree burns
d. Client with psoriasis
28.Mr. Chris Martinez has been confined for three days. His wife helped take care of
him and he has observed her to be too involved in his care. He complained to the
head nurse about this. Which of the following would be the BEST response of the
nurse?
A. "Don’t worry. I will call the attention of your wife."
B. "Your wife is just trying to help because she is worried about you."
C. "What are your thoughts about your wife's involvement in your care?"
D. “Your wife can assist you well in your care and recovery."
4
29.The nurse is in the hospital canteen and hears two staff nurses talking about the
client confined in Room 401 . They mentioned his name and discussed details of
his condition. Which of the following actions should the nurse take?
a. Approach the two nurses and tell them that their actions are inappropriate
especially in a public place
b. Wait till the nurses finish the discussion and report the situation to the
supervisor
c. Say nothing to avoid embarrassing the staff nurses
d. Remain quiet and ignore the discussion
30.The son of Mr. sanches, a 76 year old man, reports to the nurse in the
community health center that his father has been getting out of bed at night and
walks around the house in the early hours of the morning causing him to fail and
injure himself. Which instruction would you give?
a. Apply restraints during the night hours only
b. Advise hospitalization to prevent future accidents
c. Keep a radio or TV for company and to orient the client
d. Have someone check on the client frequently at night
Situation: Nurse Shane is responsible to accurately records and reports patient’s
progress. He is able to communicate to the other member of the team by
documenting the nursing care plan and the appropriate nursing intervention.
31.A main function of the patient’s records is to:
a. Prepare the nurse for the shift worked c) Serve as a vehicle for
communication
b. Serve as a record of financial charges d) Ensure that the
message is received
32.When Nurse Shane writes in the chart and discovers an error has been made,
which is the BEST approach?
a. Erase the erroneous material
b. Carefully ink out the erroneous material
c. Place as asterisk next to the statement, then footnote it
d. Draw a straight line through the error and initial it
33.Which of the following persons cannot have the access to the patient record?
a. Physical therapist b) Lawyer of the family c) The patient
d) Speech therapist
34.POMR charting is different from traditional method because of which of the
following practices?
1. SOAP charting
2. Use of progress notes
3. Narrative charting
4. Use of checklist
5. Use of a database
a)3, 4 and 5 b)1, 2 and 5 c) 1, 2 and 3 d) 2, 3 and 4
35.Which of the following qualities are relevant in documenting patients care?
1. Accuracy and consciousness
2. Thoroughness and currentness
3. Systematic and orderly
4. Legibly, properly dated and signed
5. Use of locally accepted abbreviation
a) All except 4 b) All of the above c) All except 3 d) All except 5
36.You are to administer an intramuscular injection to Dulce, 1 1/2 year old girl. The
most appropriate site to administer the drug is:
a. dorso gluteal region
b. ventrogluteal region
c. vastuslateralis
d. gluteal region
37.An infant is ordered to receive 500 ml of D5NSS for 24 hours. The Intravenous
infusion set is at 60 drops/ml. How many drops per minute should the flow rate
be?
a. 60 drops per minute
b. 21 drops per minute
c. 30 drops per minute
d. 15 drops per minute
5
38.Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium
chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous
infusion set is calibrated at 20 drops per milliliter. How many drops per minute
should the rate be to infuse 1 liter of D5W for 8 hours?
a. 42 drops
b. 20 drops
c. 60 drops
d. 32 drops
39.Mr. Lagrito is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the
IV infusion set is 10 drops per ml. Approximately how many drops per minutes
should the IV be regulated?
a. 13 – 14 drops
b. 17 – 18 drops
c. 10 – 12 drops
d. 15 – 16 drops
40.The Physician ordered Nembutal Na gr. XX. The bottle contains 100 mg/capsule.
How many capsules will be administered to the client?
a. 11 capsule
b. 12 capsules
c. 15 capsule
d. 10 capsule
Situation: As a nurse, Jinnah has specific responsibilities as professional. She
has to demonstrate specific competencies.
41.The essential components of professional nursing practice are all the following
EXCEPT:
a. Culture b) Care c) Cure
d) Coordination
42.Nurse Jinnah is assigned to care for four (4) patients. Which of the following
patients should she give first priority?
a. Misty, who is terminally ill with breast cancer
b. Violet, who was previously lucid but is now unarousable
c. Daisy, who is newly admitted and is scheduled for an executive check-up
d. Rose, who has cholelithiasis and is for operation on call
43.Ms. May, the Nursing Supervisor of the intensive care unit (ICU) is not on duty
when Nurse Jinnah committed a serious medication error. Which statement
accurately reflects the accountability of the nursing supervisor?
a. Ms. May should be informed when she goes back on duty
b. Although Ms. May is not on duty, the nursing supervisor on duty decides
to call her if time permits
c. The nursing supervisor on duty will notify Ms. May at home
d. Ms. May is not on duty therefore it is unnecessary to inform her
44.Which barrier should Nurse Jinnah avoid in order to manage time wisely?
a. Practical planning b) Procrastination c) Setting limits d)
Realistic personal expectation
45.Nurse Jinnah is caring for Naj who has just been transferred to the private room.
He is anxious because he fears he won’t be monitored as closely as he was in
the Coronary Care Unit. How can Nurse Jinnah allay his fear?
a. Move the patient's bed to a room far from the nurse’s station to reduce his
fears
b. Assign the same nurse to him when possible
c. Allow the patient uninterrupted period of time
d. Limit the patient's visitors to coincide with CCU policies
46.The nurse supervisor is not satisfied with the bed bath that is provided by Nurse
Arthur. To improve the care provided to the patients in the unit by Nurse Arthur,
the nurse supervisor should:
a. tell the nurse how to give bed baths correctly
b. ask another staff nurse to do the bed baths instead
c. provide a manual to be read on giving bed baths
d. bring the staff nurse to a client's room and demonstrate a cleansing bath
6
47.The staff nurse discusses with the novice nurse the type of wound dressing that
is best to use for a client. Together, they observe how well the dressings absorb
the drainage. In what-step of the decision- making process are they?
a. Testing options
b. Considering effects on results
c. Defining the problem
d. Making final decisions
48.To check if the nurses under her supervision use critical thinking, Mrs. David
observers if the nurses act responsibly when at work. Which of the following
actions of a nurse demonstrates the attitude of responsibility?
a. Thinking of alternative methods of nursing care
b. Sharing ideas regarding patient care
c. Following standards of practice
d. Planning other approaches for patient care
49.The nurse who makes clinical judgment can be depended upon to improve the
quality of care of clients. Nurse Julie uses such good clinical judgment when she
gives priority care to this client:
a. Roman, a client who is ambulatory and for surgery tomorrow
b. A post-operative client, Rey, who has a blood pressure of 90/50 mmHg
c. Mr. Abad, a client who needs instructions for home medications
d. Fred, a client who received pain medication 5 minutes ago
50.A good nursing care plan is dependent on a correctly written nursing diagnosis. It
defines a client’s problem and its possible cause. The following is an example of
a well written nursing diagnosis:
a. Acute pain related to altered skin integrity secondary to hysterectomy
b. Electrolyte imbalance related to hypocalcemia
c. Altered nutrition related to high fat intake secondary to obesity
d. Knowledge deficit related to proctosigmoidoscopy
Situation: Yamato is now working as a staff nurse in a general hospital. He has to
be prepared to handle situations with ethico-legal and moral implication.
51.Yamato is on a night duty in the surgical ward. One of his patients, Daisuke, is a
prisoner who sustained an abdominal gunshot wound. He is being guarded by
policeman from the local police unit. During his rounds he heard a commotion.
He saw the policeman trying to hit Daisuke. He asked the policeman why he was
trying to hit the patient. The policeman denied the matter. Which among the
following activities will Nurse Yamato do first?
a. Write an accident report c) Call your nurse
supervisor and report the incident
b. Call security officer and report the incident d) Call the physician on
duty
52.Yamato is on a morning duty in the medical ward. He has 10 patients assigned to
him. During his endorsement rounds, he found out that one of his patients was
not in bed. The patient next to him informed Nurse Yamato that the patient went
home without notifying the nurses. Which among the following will Nurse Yamato
do first?
a. Make an incident report c) Wait for 2 hours before
reporting
b. Call security to report the incident d) Report the incident to your
supervisor
53.Nurse Yamato is assigned in the medical ward. He was asked to check the
narcotics cabinet. He found out that what is on record does not tally with the
drugs used. Which among the following will Nurse Yamato do first?
a. Write an incident report and refer the matter to the nursing director
b. Keep your findings to yourself
c. Report the matter to your supervisor
d. Find out from the endorsement any patient who might have been given
narcotics
54.Yamato is on duty in the medical ward. The mother of his patient who is also a
nurse, came running to the nurse’s station and informed that her son, Ken, went
into cardiopulmonary arrest. What will Nurse Yamato do?
a. Start basic life support measures
b. Call for the Code
c. Bring the crush cart to the room
d. Go to see Ken and assess for airway patency and breathing problems
7
55.Nurse Yamato is admitting Koshiro to the ward and he found out that the patient
is positive for HIV. Which among the following will he do first?
a. Take note of it and plan to endorse this to next shift c) Write an incident
report
b. Keep this matter to yourself d) Report the matter
to your head nurse
56.When caring for a dying client you will perform which of the following activities?
a. Encourage the client to reach optimal health
b. Assist client perform activities of daily living
c. Assist the client towards a peaceful death
d. Motivate client to gain independence
57.The client prepares for her eventual death and discusses with the nurse and her
family how she would like her funeral to look like and what dress she will use.
This client is in the stage of:
a. acceptance
b. resolution
c. denial
d. bargaining
58.The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM to Mrs. Leyba.
Demerol is available in a mutidose vial labeled 100mg/ml while Vistaril comes in
an ampule labeled 50 mg/ml. You are to give both medications in one injection.
You will:
a. withdraw the medication from the vial first then from the ampule
b. inject air into the vial, then into the ampule
c. Inject air into the ampule, aspirate desired dose, then into the vial
d. withdraw medication from the ampule then from the vial
59.When giving Demerol 50 mg from a multidose vial labeled 100 mg/ml and Vistaril
50 mg from an ampule labeled 50 mg/ml. What is the total volume that you will
inject to the client?
A. 2 ml
B. I ml
C. 1.5 ml
D. 1.75 ml
60.Mrs. Bernas is emaciated and is at risk for developing which problem in skin
integrity?
a. Blisters
b. Reddening of the skin
c. Pressure sores
d. Pustules
Situation:Sora is experiencing left sharp pain and occasional hematuria. She was
advised to undergo IVP by her physician.
61.Sora was so anxious about the procedure and particularly expressed her low
pain threshold. Nursing health instruction will include:
a. Assure the client that the pain is associated with the warm sensation
during the administration of the Hypaque by IV
b. Assure the client that the procedure is painless
c. Assure the client that contrast medium will be given orally
d. Assure the client that x-ray procedure like IVP is only done by experts
62.What will Nurse Taichi monitor and instruct the client and significant others post
IVP?
a. Report signs and symptoms for delayed allergic reaction
b. Observe NPO for 6 hours
c. Increased fluid intake
d. Monitor intake and output
63.Post IVP, Sora should excrete the contrast medium. Nurse Taichi instructed the
family to include more vegetables in the diet and:
a. Increase fluid intake c) Eat sodium and potassium rich
foods
b. Decrease fluid intake d) Avoid sodium and
potassium rich foods
64.The IVP reveals that Sora has small renal calculus that can be passed out
spontaneously. To increase the chance of passing the stones, you instructed her
to force fluids and do which of the following?
a. Balanced diet b) Ambulate more c) Strain all urine d) Bed
rest
8
65.Sora's mother asks Nurse Taichiwhat is that condition wherein there is the
presence of calculi in the urinary tract. The nurse is correct when he answers:
a. Cholelithiasis b) Nephrolithiasis c)Ureterolithiasis d)Urolithiasis
66.Ramil’s right leg is injured and Nurse Karen has to move him from the bed to a
wheel chair. Which of the following is the appropriate nursing action of Nurse
Karen?
a. Put the client on the edge of the bed and place the wheelchair at her back
b. Face the client and place the wheelchair on her left side
c. Put the client on the edge of the bed and place the wheelchair on the
other side of the bed
d. Put the client on the edge of the bed and place the wheelchair on the
client's left side
67.Carlo has to be maintained on a dorsal recumbent position. Which of the
following should be prevented?
a. Adduction of the shoulder
b. Lateral flexion of the sternocleidosmastoid muscle
c. Hyperextension of the knees
d. Anterior flexion of lumbar curvature
68.Joseph prefers to be in high fowler's position most of the time. The nurse should
prevent which of the following?
a. Posterior flexion of the lumbar curvature
b. Internal rotation of the shoulder
c. External rotation of the hip
d. Adduction of the shoulder
69.Anthony asks to be assisted to move up the bed. Which of the following should
Nurse Diana do first?
a. Move the patient to the edge of the bed near the nurse
b. Adjust the bed to a flat position
c. Lock the wheels of the bed
d. Raise the bed rails opposite the nurse
70.Which of the following supportive devices can be used most effectively by Nurse
Arnold to prevent external rotation of the right leg?
a. Sandbags
b. Firm mattress
c. Pillow
d. High foot board
Situation:Takeru, 11 years old, has “kissing tonsils” and is scheduled for
tonsillectomy and adenoidectomy or T & A.
71.Nurse Hikari is taking care of Takeru who will undergo T & A in the morning. His
mother asked the nurse if Takeru will be put to sleep. Nurse Hikari's teaching will
focus on:
a. Spinal anesthesia b) Anesthesiologist’s preference c) Local
anesthesia d) General anesthesia
72.Takeru's mother asks Nurse Hikari what food to prepare and give after surgery.
Nurse Hikari will appropriately say:
a. Balanced diet when fully awake c) Ice cream when fully
awake
b. Hot soup when awake d) Soft diet when fully
awake
73.Yuri, the PACU nurse, will maintain postoperative T and A client in what position?
a. Supine with neck hyperextended and supported with pillow
b. Prone with the head on pillow and turned to the side
c. Semi-fowler’s with neck flexed
d. Reverse trendelenburg with extended neck
74.Nurse Hikari should monitor the client for the most common postoperative
complication of:
a. Hemorrhage c) Oropharyngeal edema
b. Endotracheal tube perforation d) Epiglottis
75.Takeru is to be discharged in the afternoon of the same day after tonsillectomy
and adenoidectomy. Nurse Hikari will make sure that the family knows to:
a. Offer osteorized feeding
b. Offer soft foods for a week to minimize discomfort while swallowing
c. Supplement his diet with Vitamin C rich juices to enhance healing
d. Offer clear liquid for 3 days to prevent irritation
9
76.An ambulatory client, Mr. Zosimo, is being prepared for bed. Which of the
following nursing actions promote safety for the client?
a. Turning off the lights to promote sleep and rest
b. Instructing the client about the use of the call system
c. Raising the side rails
d. Placing the bed in high position
77.Mikka, a 25 year old female client, is admitted with right lower quadrant
abdominal pain. The physician diagnosed the client with acute appendicitis and
an emergency appendectomy was performed. Twelve hours following surgery,
the patient complained of pain. Which of the following is the most appropriate
nursing diagnosis?
a. Impaired mobility related to pain secondary to an abdominal incision
b. Impaired movements related to pain due to surgery
c. Impaired mobility related to surgery
d. Severe pain related to surgery
78.You are preparing a plan of care for a client who is experiencing pain related to
incisional swelling following laminectomy. Which of the following should be
included in the nursing care plan?
a. Encourage the client to log roll when turning
b. Encourage the client to do self-care
c. Instruct the client to do deep breathing exercises
d. Ambulate the client in that ward premises every twenty minutes
79.Mr. Lozano, 50 year old executive, is recovering from severe myocardial
infarction. For the past 3 days, Mr. Lozano's hygiene and grooming needs have
been met by the nursing staff. Which of the following activities should be
implemented to achieve the goal of independence for Mr. Lozano?
a. Involving family members in meeting client's personal needs
b. Meeting his needs till he is ready to perform self-care
c. Preparing a day to day activity list to be followed by client
d. Involving Mr. Lozano in his care
80.Mr. Ernest Lopez is terminally ill and he chose to be at home with his family.
What nursing actions are best initiated to prepare the family of Mr. Lopez?
a. Talk with the family members about the advantage of staying in the
hospital for proper care
b. Provide support to the family members by teaching ways to care for their
loved one
c. Convince the client to stay in the hospital for professional care
d. Tell the client to be with his family
Situation: Concerted work efforts among members of the surgical team is
essential to the success of the surgical procedure.
81.The sterile nurse or sterile personnel touch only sterile supplies and instruments.
When there is a need for sterile supply which is not in the sterile field, who hands
out these items by opening its outer cover?
a. Circulating Nurse b) Anesthesiologist c) Scrub Nurse
d) Nursing Aide
82.The OR team performs distinct roles for one surgical procedure to be
accomplished within a prescribed time frame and deliver a standard patient
outcome. While the surgeon performs the surgical procedure, who monitors the
status of the client like urine output, blood loss?
a. Scrub Nurse b) Surgeon c) Anesthesiologist d)
Circulating Nurse
83.Surgery schedules are communicated to the OR usually a day prior to the
procedure by the nurse of the floor or ward where the patient is confined. For
orthopedic cases, what department is usually informed to be present in the OR?
a. Rehabilitation department c) Maintenance department
b. Laboratory department d) Radiology department
84.While team effort is needed in the OR for efficient and quality patient care
delivery, we should limit the number of people in the room for infection control.
Who comprise this team?
a. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
b. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
10
85.In massive blood loss, prompt replacement of compatible blood is crucial. What
department needs to be alerted to coordinate closely with the patient’s family for
immediate blood component therapy?
a. Security Division b) Chaplaincy c) Social Service Section
d) Pathology department
86.In both quantitative and qualitative research, the use of a frame of reference is
required. Which of the following items serves as the purpose of a framework?
a. Incorporates theories into nursing's body of knowledge
b. Organizes the development of study and links the findings to nursing's
body of knowledge
c. Provides logical structure of the research findings
d. Identifies concepts and relationships between concepts
87.Myrna needs to review relevant literature and studies. The following processes
are undertaken in reviewing literature EXCEPT:
a. Locating and identifying resources
b. Reading and recording notes
c. Clarifying a research topic
d. Using the library
88.The primary purpose for reviewing literature is to :
a. organize materials related to the problem of interest
b. generate broad background and understanding of information related to
the research problem of interest
c. select topics related to the problem of interest
d. gather current knowledge of the problem of interest
89.In formulating the research hypotheses, researcher Myrna should state the
research question as:
a. What is the response of the staff nurses to the health values?
b. How is variable “health value" perceived in a population?
c. Is there a significant relationship between health values and health
promotion activities of the staff nurses?
d. How do health values affect health promotion activities of the staff nurses?
90.The proposed study shows the relationship between the variables. Which of the
following is the independent variable?
a. Staff nurses in a selected college of nursing
b. Health values
c. Health promotion activities
d. Relationship between health values and health promotion activities
Situation: Mimi, 45 years old, is waiting for her doctor’s appointment at the clinic
where Nurse Joe works.
91.Nurse Joe is to interview the client as an initial nursing action so that he can:
a. Document important data in her client records for health team to read
b. Gather data about her lifestyle, health needs and problems to develop
plan of care
c. Provide solutions to her immediate health concern
d. Identify the most appropriate nurse diagnosis for her heath problem
92.During the interview, Mimi experiences a sharp abdominal pain on the right side
of her abdomen. She further tells Nurse Joe that an hour ago, she ate fatty food
and this had happened many times before. The nurse will record this as:
a. Client complains of intermittent abdominal pain an hour after eating fatty
foods
b. After eating fatty food the client experienced severe abdominal pain
c. Client claims to have sharp abdominal pains after eating fatty food
unrelieved by pain medication
d. Client reported sharp abdominal pain on the right upper quadrant of
abdomen an hour after ingestion of fatty foods
93.Mimi tells the nurse that she has been on a high protein, high fat, and low
carbohydrate diet order to lose weight and that she has successfully lost 8 lbs
during the past two weeks. In planning a healthy balanced diet for her, Nurse Joe
will:
a. Encourage her to eat well-balanced diet with a variety of food from the
major food groups and take plenty of fluids
b. Ask her to shift to a macrobiotic diet rich in complex carbohydrates
c. Encourage her to cleanse her body toxins by changing a vegetarian diet
with regular exercise
d. Encourage her to eat a high carbohydrate, low protein diet and low fat diet
11
94.Nurse Joe learns that Mimi drinks 5-8 cups of coffee a day plus cola drinks.
Because she is in her pre-menopausal years, the nurse instructs her to decrease
consumption of coffee and cola preparation because:
a. These products increase calcium loss from the bones
b. These products have stimulant effect n the body
c. These products encourage increase in sugar consumption
d. These products are addicting
95.Health education plan for Mimi stresses prevention of NCD or Noncommunicable
diseases that are influenced by lifestyle. These include the
following EXCEPT:
a. Cancer b) Diabetes Mellitus c)
Osteoporosis d) Cardiovascular diseases
96.Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and
professional fees. You refer him to a:
a. nurse supervisor
b. social worker
c. bookkeeping department
d. physician
97.Mr. Magno has lung cancer and is going through chemotherapy. He is referred
by the oncology nurse to a self-help group of clients with cancer to:
a. receive emotional support
b. to be part of a research study
c. provide financial assistance
d. assist with chemotherapy
98.A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her
health status. She should be referred to a:
a. nutritionist
b. dietitian
c. physician
d. medical pathologist
99.When collaborating with other health team members, the best description of
Nurse Rita's role is:
a. encourages the client's involvement in his care
b. shares and implements orders of the health team to ensure quality care
c. she listens to the individual views of the team members
d. helps client set goals of care and discharge
100. Nurse Rita is successful in collaborating with health learn members about
the care of Mr. Linao. This is because she has the following competencies:
a. Communication, trust, and decision making
b. Conflict management, trust, negotiation
c. Negotiation, decision making
d. Mutual respect, negotiation, trust
Situation: Nurse Anthony is a staff nurse in the medical-surgical ward of a tertiary
hospital. He should be knowledgeable regarding perioperative nursing care of
various patients with elimination problem.
101. A lithotripsy to break up renal calculi is unsuccessful, and nephrolithotomy
is performed on Mr. Petrelli. A postoperative observation that Nurse Anthony
should report to the physician would be:
a. Passage of pink-tinged urine c) Pink drainage on the
dressing
b. Intake of 1750 ml in 24 hours d) Urine output of 20 to 30
ml per hour
102. Mr. Langdon, 42 years old, has a heminephrectomy and returns from the
postanesthesia care unit (PACU) with a nephrostomy tube and an indwelling
catheter. The client's urinary output is 50 ml/hr. Nurse Anthony should:
a. Record the findings c) Irrigate the nephrostomy tube
b. Encourage oral fluids d) Notify the physician
immediately
103. On the third postoperative day of Mr. Langdon following a
heminephrectomy, Nurse Anthony notices a large amount of bright red blood
staining the dressing. Nurse Anthony should immediately:
a. Change the dressing c) Milk the nephrostomy
tube
b. Apply direct pressure d) Note the amount and
chart it
12
104. Mr. McCain, 30 years old, has been diagnosed as having bladder cancer,
and a cystectomy and an ileal conduit are scheduled. Preoperatively, Nurse
Anthony plans to:
a. Limit fluid intake for 24 hours c) Teach the procedure for
irrigation of the stoma
b. Teach muscle-tightening exercises d) Provide cleansing
enemas and laxatives as ordered
105. After a nephrectomy, Mr. Soto, 50 years old, arrives from the
postanesthesia care unit with a plastic airway in place. When observing the client
for signs of hemorrhage, Nurse Anthony must be certain to:
a. Turn the client to observe the dressings
b. Keep the client's nail beds in view at all times
c. Observe the client for hemoptysis when suctioning
d. Report any increase in the client's blood pressure immediately
106. To provide safe quality nursing care to various clients in any setting, the
most important tool of the nurse so is:
a. critical thinking to decide appropriate nursing actions
b. understanding of various nursing diagnoses
c. observation skills for data collection
d. possession of in scientific knowledge about client needs
107. You ensure the appropriateness and safety of your nursing interventions
while caring for various client groups by:
a. Creating plans of care for particular clientele
b. Identifying the correct nursing diagnoses for clients
c. Making a thorough assessment of client needs and problems
d. Using standards of nursing care as your criteria for evaluation
108. The effectiveness of your nursing care plan for your clients is determined
by:
a. The number of nursing procedures performed to comfort the client
b. The amount of-medications administered to the client as ordered
c. The number of times the client calls the nurse
d. The outcome of nursing interventions based on plan of care
109. You are assigned to Mrs. Amado, age 49, who was admitted for possible
surgery. She complained of recurrent pain at the right upper quadrant of the
abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of
dizziness, blood pressure of 170/100 hot flashes. Which of the above symptoms
would be an objective cue?
a. Blood pressure measurement of 170/100
b. Complaint of hot flashes
c. Report of pain after ingestion of fatty food
d. Complaint of frequent bouts of dizziness
110. While talking with Mr. Alfredo, it is most important for the nurse to:
a. Schedule the laboratory exams ordered for her
b. Do an assessment of the client to determine priority needs
c. Tell the client that your shift ends after eight hours
d. Have the client sign an informed consent
Situation: Eden, 45 years old, is admitted to the hospital with complains of
respiratory infection, fatigue, loss of appetite, nausea and vomiting, and
increased bronze pigmentation of the skin. The physician's diagnosis is
Addison's disease.
111. Eden complains of respiratory infection. When her vital signs are
assessed, her blood pressure is 90/40 mm Hg. Nurse Charlie should notify the
physician immediately because:
a. Blood gases need to be drawn c) Shock may be
developing
b. Seizure activity is imminent d) The reading is atypical
112. Hypotension associated with Addison's disease involves a disturbance in
the production of:
a. Estrogens b) Androgens c) Glucocorticoids d)
Mineralocorticoids
13
113. The treatment of Eden includes a high-protein, high-calorie diet with extra
salt. As a means of encouraging Eden to eat, Nurse Charlie explains that:
a. Increased amounts of potassium are needed to replace renal losses
b. Increased protein is needed to heal the adrenal tissue and thus cure the
disease
c. Increased vitamins are needed to supply energy to assist in regaining the
lost weight
d. Extra salt is needed to replace the amount being lost due to lack of
sufficient aldosterone to conserve sodium
114. Eden is receiving teaching about her disease from Nurse Charlie. Which
statement the client makes indicates to the nurse that she understands the
teaching?
a. “I should avoid strenuous exercise during hot weather.”
b. “I should not eat salty foods.”
c. “I need to take medication only when I am having symptoms.”
d. “I should eat foods such as bananas and oranges several times daily.”
115. Nurse Charlie is teaching Eden about drug therapy for her condition. In
evaluating the effectiveness of teaching regarding drug therapy, Nurse Charlie
should expect her to be able to verbalize the need:
a. To avoid antibiotics c) To taper the steroid dose
116. An elderly client, 84 years old, is unconscious. Assessment of the mouth
reveals excessive dryness and presence of sores. Which of the following is
BEST to use for oral care?
a. Lemon glycerine
b. Hydrogen peroxide
c. Mineral oil
d. Normal saline solution
117. When performing oral care to an unconscious client, which of the following
is a special consideration to prevent aspiration of fluids into the lungs?
a. Put the client on a sidelying position with head of bed lowered
b. Keep the client dry by placing towel under the chin
c. Wash hands and observe appropriate infection control
d. Clean mouth with oral swabs in a careful and an orderly progression
118. The advantages of oral care for a client include all of the following,
EXCEPT:
a. decreases bacteria in the mouth and teeth
b. reduces need to use commercial mouthwash which irritate the buccal mucosa
c. improves client's appearance and self-confidence
d. improves appetite and taste of food
119. A possible problem while providing oral care to unconscious clients is the
risk of fluid aspiration to lungs. This can be avoided by:
a. Cleaning teeth and mouth with cotton swabs soaked withmouth wash to
avoid rinsing the buccal cavity
b. Swabbing the inside of the cheeks and lips, tongue and gums with dry
cotton swabs
c. Use fingers wrapped with wet cotton washcloth to rub inside the
cheeks,tongue, lips and gums
d. Suctioning as needed while cleaning the buccal cavity
120. Your client has difficulty of breathing and is mouth breathing most of the
time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is
recommended for the client and in addition, you will keep the mouth moistened
by using:
a. salt solution
b. water
c. petroleum jelly
d. mentholated ointment
Situation: Jessica, a 35-year-old patient, complains of weight gain, facial hair,
absent menstruation, frequent bruising, increase blood pressure and acne. The
doctor's diagnosis is Cushing's syndrome.
121. Jessica may manifest signs of diabetes mellitus because:
a. The cortical hormones stimulate rapid weight loss
b. Excessive ACTH secretion damages pancreatic tissue
c. Tissue catabolism results in a negative nitrogen balance
d. Glucocorticoids accelerate the process of gluconeogenesis
14
122. Nurse Tracy understands that the cause of Cushing's syndrome is most
commonly:
a. Pituitary hypoplasia c) Hyperplasia of the adrenal
cortex
b. Insufficient ACTH production d) Deprivation of
adrenocortical hormones
123. Jessica is placed on a low-sodium, high-potassium diet because:
a. The use of salt probably contributed to the disease
b. Excess weight will be gained if sodium is not limited
c. The loss of excess salt in the urine requires less renal stimulation
d. Excessive secretions of aldosterone and cortisone cause renal retention of
sodium and loss of potassium
124. Jessica will undergo a transsphenoidalhypophysectomy to remove the
pituitary tumor. Preoperatively, Nurse Tracy should assess the patient for
potential complications by:
a. Testing for ketones in the patient's urine
b. Testing the patient's urine specific gravity
c. Checking the patient's temperature every 4 hours
d. Performing capillary glucose testing every 4 hours
125. In the immediate postoperative period following
transsphenoidalhypophysectomy, Nurse Tracy should carefully assess Jessica
for:
Hypocortisolism b) Hypoglycemia c) Hyperglycemia d)Hypercalcemia
126. In the hospital where you work, increased incidence of medication error
was identified as the number one problem in the unit. During the brainstorming
session of the nursing service department, probable causes were identified.
Which of the following is process related?
a. Interruptions
b. Use of unofficial abbreviations
c. Lack of knowledge
d. Failure to identify client
127. Miscommunication of drug orders was identified as a probable cause of
medication error. Which of the following is a safe medication practice related to
this?
a. Maintain medication in its unit dose package until point of actual
administration
b. Note both generic and brand name of the medication in the Medication
Administration Record
c. Only officially approved abbreviations maybe used in the prescription
orders
d. Encourage clients to ask question about their medications
128. The hospital has an ongoing quality assurance program. Which of the
following indicates implementation of process standards?
a. The nurses check client's identification band before giving medications
b. The nurse reports adverse reaction to drugs
c. Average waiting time for medication administration is measured
d. The unit has well ventilated medication room
129. Which of the following actions indicate that Nurse Jerome is performing
outcome evaluation of quality care?
a. Interviews nurses for comments regarding staffing
b. Measures waiting time for clients per nurse's call
c. Checks equipment for its calibration schedule
d. Determines how many clients post- surgery have experienced infection
130. An order for a client was given and the nurse in charge of the client
reports that she has no experience of doing the procedure before.Which of the
following is the most appropriate action of the nurse supervisor?
a. Assign another nurse to perform the procedure
b. Ask the nurse to find a way to learn the procedure
c. Tell the nurse to read the procedure manual
d. Do the procedure with the nurse
15
Situation: Chandra Suresh, age 68, is admitted with a tentative diagnosis of
hyperosmolar hyperglycemic nonketotic syndrome (HHNS). His medical history
reveals that he has type II diabetes mellitus that is being controlled with the oral
antidiabetic drug tolazamide.
131. Nurse Mohinder anticipates that the most important laboratory test for
confirming a diagnosis of hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) is:
a. Serum potassium level c) Arterial blood gas (ABG)
values
b. Serum sodium level d) Serum osmolarity
132. When Mr. Suresh is first admitted with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS), Nurse Mohinder's priority is to provide:
a. Oxygen b) Carbohydrates c) Fluid replacement
d) Dietary instruction
133. Mr. Suresh requires fluid resuscitation. Which statement about fluid
resuscitation is true for the client with hyperosmolar hyperglycemic nonketotic
syndrome?
a. Administer 2 to 3 L of IV fluid rapidly
b. Administer 6 l of IV fluid over the first 24 hours
c. Administer a dextrose solution containing normal saline solution
d. Administer IV fluid slowly to prevent circulatory overload and collapse
134. Mr. Suresh's condition is stabilized, and he's prepared for discharge.
Nurse Mohinder develops a teaching plan to prepare the patient for discharge
and home management. Which statement indicates that the patient understands
his condition and the preventive measures to control it?
a. “I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual.”
b. “If I experience trembling, weakness, and headache, I should drink a glass
of soda that contains sugar.”
c. “I'll have to monitor my blood glucose level closely and notify the doctor if
it's constantly elevated.”
d. “If I begin to feel especially hunger and thirsty, I'll eat a snack high in
carbohydrates.”
135. Mr. Suresh is taking regular and NPH insulin. He asks why he must mix
the two insulins. Nurse Mohinder explains that regular and NPH insulins are
mixed to ensure:
a. Immediate onset of the regular insulin c) A peak action of the
NPH insulin at 2 hours
b. Onset of the regular insulin within 2 hours d) A total duration of action
of 24 hours
136. Mr. Jose's chart contains all information about his health care. The
functions of records include all following EXCEPT:
a. Means of communication that health team members use to communicate
their contributions to the client's health care
b. The client's record also shows a document of how much health care
agencies will be reimbursed for their services
c. Educational resource for student of nursing and medicine
d. Recording of actions in advance to save time
137. An advantage of automated or computerized client care system is:
a. the nursing diagnosis for a client's data can be accurately determined
b. cost of confinement will be reduced
c. information concerning the client can be easily updated
d. the number of people to take care of the client will be reduced
138. Information in the patient's chart is inadmissible in court as evidence
when:
a. the client's family refuses to have it used
b. the client objects to its use
c. the handwriting is not legible
d. it has too many abbreviations that are "unofficial”
139. Nursing audit aims to:
a. provide research data to hospital personnel
b. study client's illness and treatment regimen closely
c. compare actual nursing done to established standards
d. provide information to health-care providers
16
Situation: Nathan, 8 years old, is admitted to the hospital by his mother Angela
with complains of excessive thirst and hunger, underweight, thin, and excessive
urination. Nathan's admitting diagnosis is type I diabetes mellitus.
140. Angela needs to understand that the type of diabetes that her son has:
a. Is associated with the destruction of beta cells
b. Usually causes complete fat metabolism
c. Is associated with the destruction of alpha cells
d. Often occurs in obese individual
141. An evening snack is planned for Nathan who is receiving Humulin N
insulin. Nurse Peter understands that this will provide:
a. Added calories to help the child gain weight
b. Encouragement for the child to stay on a diet
c. High-carbohydrate nourishment for immediate utilization
d. Nourishment with a latent effect to counteract late insulin activity
142. One nutritional principle to be followed in children with type I diabetes is to
provide for compensatory changes. Nurse Peter should review with the child how
compensation for increased physical activity can be achieved and instruct the
child to:
a. Take the oral hypoglycemic medication on days of heavy exercise
b. Increase dietary intake when there is a plan to exercise more than usual
c. Lower the insulin dose in the morning when extra exercise is anticipated
d. Eat simple sugars that are more rapidly absorbed to compensate for extra
exercise
143. Nurse Peter is teaching Nathan and his mother Angela about
ketoacidosis. He explains that the primary cause of the development of
ketoacidosis is:
a. A GI disturbance b) An insulin overdosage c) Omitted meals d) Not
taking insulin regularly
144. Diabetic coma results from an excess accumulation in the blood of:
a. Sodium bicarbonate, causing alkalosis
b. Ketones from rapid fat breakdown, causing acidosis
c. Nitrogen from protein catabolism, causing ammonia intoxication
d. Glucose from rapid carbohydrate metabolism, causing drowsiness
145. A telephone order is given for a client in your ward. What is your most
appropriate action?
a. Copy the order on to the chart and sign the physician's name as close to
his original signature as possible
b. Repeat the order back to the physician, copy onto the order sheet and
indicate that it is a telephone order
c. Write the order in the client's chart and have the head nurse co-sign it
d. Tell the physician that you can not take the order but you will call the
nurse supervisor
146. Which of the following client conditions should be Miss Roque's priority in
the pediatric unit?
a. The baby whose fontanel is bulging and firm while asleep
b. The infant who is brought in for upper respiratory tract infection whose
temperature is slightly elevated
c. A baby who is wailing after being awakened by the banging of the door
d. A baby boy whose circumcision has yellowish exudate
147. When suctioning the endotracheal tube, the nurse should:
a. explain procedure to patient, insert catheter gently applying suction,
withdrawn using twisting motion
b. insert catheter until resistance is met then withdraw slightly, applying
suction intermittently as catheter is withdrawn
c. Hyperoxygenate client then insert catheter using back and forth motion
d. Insert suction catheter four inches into the tube, suction 30 seconds using
twirling motion as catheter is withdrawn
148. Nurse Roque is giving instructions to Doris, the daughter of a comatose
patient, to give a sponge bath. While Doris is doing the sponge bath, what action
of Doris needs correction?
a. Answering the phone while wearing gloves used for sponge bath
b. Rolling the patient like a log to do back rub
c. Lining the rubber mat with bed sheet as incontinence pad for the patient
d. Turning the patient on the left side with head slightly elevated
17
149. Dina sustained a fracture of the ulna and a cast will be applied. What
nursing action before cast application is most important for Nurse Roque to do?
a. Use baby powder to reduce irritation under the cast
b. Assess sensation of each arm
c. Evaluate skin temperature in the area
d. Check radial pulses bilaterally and compare
150. To obtain specimen for sputum culture and sensitivity, which of the
following instruction is best?
a. Upon waking up, cough deeply and expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered container
d. After respiratory treatment, expectorate into a container
Situation: Elle Bishop, 20 years old, is admitted to the medical floor with
complains of fatigue, feeling of breathlessness, weight loss, productive cough
and dyspnea. Diagnostic testing confirmed her of having Emphysema.
151. When the alveoli lose their normal elasticity as a result of emphysema,
Nurse Bob teaches Elle exercises that lead to effective use of the diaphragm
because:
a. Inspiration has been markedly prolonged and difficult
b. The residual capacity of the lungs has been increased
c. The client has an increase in the vital capacity of the lungs
d. Abdominal breathing is an effective compensatory mechanism that is
spontaneously initiated
152. Nurse Bob administers oxygen at 2 L/minute via nasal cannula to Elle.
The nurse should observe the client closely for:
a. Cyanosis and lethargy c) Hyperemia and
increased respirations
b. Anxiety and tachycardia d) Drowsiness and
decreased respirations
153. Elle experiences a sudden episode of shortness of breath. The physician
diagnoses a spontaneous pneumothorax. Nurse Bob is aware that the probable
cause of the spontaneous pneumothorax is a:
a. Pleural friction rub c) Rupture of a subpleural bleb
b. Tracheoesophageal fistula d) Puncture wound of the chest
wall
154. When a spontaneous pneumothorax is suspected in a client with a history
of emphysema, the nurse should call the physician and:
a. Administer 60% oxygen via venturi mask c) Give oxygen 2 L per
minute via nasal cannula
b. Place the client on the unaffected side d) Prepare for IV
administration of electrolytes
155. When teaching Elle about a spontaneous pneumothorax, Nurse Bob
bases the explanation on the understanding that:
a. The heart and great vessels shift to the affected side
b. The other lung will collapse if not treated immediately
c. There is greater negative pressure within the chest cavity
d. Inspired air will move from the lung into the pleural space
156. Dorothy underwent diagnostic test and the result of the blood examination
are back. On reviewing the result the nurse notices which of the following as
abnormal finding?
a. Neutrophils 60%
b. White blood cells (WBC) 90007mm
c. Erythrocyte sedimentation (ESR) is 39 mm/hr
d. Iron 75 mg/100 ml
157. Surgical sepsis is observed when:
a. inserting an intravenous catheter
b. disposing of syringes and needles in puncture proof containers
c. washing hands before changing wound dressing
d. placing dirty soiled linen in moisture resistant bags
158. A client with viral infection will most likely manifest which of the following
during the illness stage of the infection?
a. Client was exposed to the infection 2 days ago but without any symptoms
b. Oral temperature shows fever
c. Acute symptoms are no longer visible
d. Client "feels sick" but can do normal activities
18
159. Which of the following laboratory test results indicate presence of an
infectious process?
a. Erythrocyte sedimentation rate (ESR) 12 mm/hr
b. White blood cells (WBC) 18.000/mm3
c. Iron 90g/100ml
d. Neutrophils 67%
160. Among the clients you are assigned to take care of, who is most
susceptible to infection?
a. Diabetic client
b. Client with burns
c. Client with pulmonary emphysema
d. Client with myocardial infarction
ation: Micah Sanders, 15 years old, is admitted to the hospital due to wheezing
and labored breathing. He has a long history of asthma that seems to be
exacerbated during hay fever season. Micah has undergone skin testing and is
allergic to many environmental factors such as smoke and pollens. Micah's father
had extrinsic asthma as a child. Micah is taking Albuterol (Proventil) and
cromolyn sodium (Intal).
161. While receiving albuterol (Proventil), a beta-adrenergic agonist, for
asthma, Micah complains of palpitation, chest pain and a throbbing headache. In
view of these symptoms, the most appropriate nursing action would be to:
a. Withhold the drug until additional orders are obtained from the physician
b. Tell the client not to worry; these are expected side effects from the
medicine
c. Ask the client to relax; then give instructions to breathe slowly and deeply
for several minutes
d. Reassure the client that these effects are temporary and will subside as
the body becomes accustomed to the drug
162. Which statement by Micah's mother best indicates her understanding of
the use of cromolyn sodium (Intal)?
a. “I will have Micah take this medication during an asthma attack.”
b. “I will open the capsule and dilute it in juice.”
c. “I will tell Micah to take a puff of medication upon exhalation.”
d. “I will have Micah use this medication to prevent asthma attacks.”
163. Micah is being taught how to use a peak flow meter to monitor how well
the asthma is being controlled. Micah should be instructed to:
a. Perform the procedure once in the morning and once at night
b. Move the trunk from an upright to a bending position while exhaling
c. Inhale completely and then blow out as hard and as fast as possible
through the mouthpiece
d. Place the mouthpiece between the lips and in front of the teeth before
starting the procedure
164. Micah is scheduled for surgery. Preoperative teaching should include the
fact that the client:
a. Will be prone to respiratory tract infections
b. Can control and limit asthmatic attacks if desired
c. Should try to limit coughing, because this causes distention of the chest
d. Can control anxiety and decrease the severity of postoperative asthma
attacks
165. What would be the priority goal established for Micah who is being
discharged from the hospital? The client:
a. Is able to obtain pulse oximeter readingsc) Knows the primary care
provider's office hours
b. Demonstrates use of a metered-dose inhaler d) Can identify foods that
may cause wheezing
166. Which of the following theorists consider and utilize nature and
environment in the healing process?
a. Julia Sotejo
b. Ida Jean Orlando
c. Florence Nightingale
d. Imogene King
19
167. In her theory, Imogene King defined nursing process as a dynamic
interpersonal process between nurse, client and health care system. In this
theory, which of the following nursing skills is most important to help client
establish positive adaptation to environment?
a. Assessment skills
b. Communication skills
c. Environment management skills
d. Technical skills
168. Who among the following theorists has identified twenty one specific client
needs or problems in the area of comfort, hygiene, safety, physiologic balance,
psychologic and social factors and sociological and community factors?
a. Faye Abdellah
b. Dorothy Johnson
c. Sister Callista Roy
d. Virginia Henderson
169. Which of the following nurse theorists has stated that the goals of nursing
is to maintain and promote health, prevent illness and care for and rehabilitate ill
and disabled client through “humanistic science and nursing”.
a. Orem
b. Abdellah
c. Nightingale
d. Rogers
170. “Nursing care becomes necessary when clients is unable to fulfill
biological, physiological development or social needs” explains which of the
following theories:
a. Adaptation theory
b. Self-care deficit theory
c. Theory of the “Unity of Man”
d. Transcultural care theory
Situation:Masi Oka, 25 years old, was admitted to the medical-surgical floor with
complains of sore throat, difficulty swallowing, increasing hoarseness of voice,
enlarged cervical lymph nodes and foul breath. Cancer of the larynx was
confirmed by his physician. He is scheduled for total laryngectomy.
171. Mr. Oka will undergo a total laryngectomy tomorrow. He is concerned
about communicating postoperatively. Nurse Hiro should plan for the client to
communicate by which method in the first 24 to 48 hours after surgery?
a. Using the artificial larynx c) Using esophageal
speech
b. Writing or pointing on a communication board d) Using a voice
button
172. Nurse Hiro is discussing options for verbal communication with Mr. Oka
prior to the operation. Which statement by Mr. Oka indicates his understanding of
the available options for verbal communication?
a. “Because of the arthritis in my hands, I think the voice button method
would be easiest to use.”
b. “By the time I leave the hospital, I will be able to talk.”
c. “If I use the esophageal speech, my voice will be high pitched and soft.”
d. “Using an artificial larynx will make me sound sort of monotone.”
173. Immediate postoperative management for Mr. Oka would include:
a. Instructing the client to whisper c) Removing the outer
tracheostomy tube PRN
b. Placing the client in the orthopneic position d) Suctioning the
tracheostomy tube whenever necessary
174. After undergoing the procedure, Nurse Hiro evaluates that the teaching
about activities and the stoma was understood when Mr. Oka states, “I should
avoid:
a. Strenuous exercises.” c) All types of water
sports.”
b. Sleeping with pillows.” d) High-humidity
environments.”
175. Mr. Oka is ready for discharge after undergoing a total laryngectomy.
Nurse Hiro is discussing safety aspects of his home care. Which statement by
Mr. Oka best indicates that he understands the safety aspects of his care at
home?
a. “It is okay to swim as long as I'm careful.”
20
b. “I should use paper tissues to cover my stoma when I'm coughing.”
c. “I should not wear anything to cover my stoma.”
d. “I will need to use a humidifier in my home.”
176. The most important risk factor is:
a. cigarette smoking
b. hypertension
c. binge drinking
d. heredity
177. Part of your lesson plan is to talk about etiology or cause of stroke. The
types of stroke based on cause are the following EXCEPT:
a. embolic stroke
b. hemorrhagic stroke
c. diabetic stroke
d. thrombotic stroke
178. Hemorrhagic stroke occurs suddenly usually when the person is active.
All are causes of hemorrhage, EXCEPT:
a. phlebitis
b. trauma
c. damage to blood vessel
d. aneurysm
179. The nurse emphasizes that intravenous drug abuse carries a high risk of
stroke. Which drug is closely linked to this?
a. Amphetamines
b. Cocaine
c. Shabu
d. Demerol
180. A participant in the STROKE class asks what is a risk factor of stroke.
Your best response Is:
a. "More red blood cells thicken blood and make clots more possible."
b. "Increased RBC count is linked to high cholesterol."
c. "More red blood cells increase hemoglobin content."
d. "High RBC count increases blood pressure."
Situation: Mr. Gabriel Gray, 40 years old, is admitted to the hospital with
complains of restlessness, weight loss, tremors, increased respiration and
corneal laceration. The physician diagnosed him of having hyperthyroidism. He is
scheduled for thyroidectomy.
181. Nurse Sylar, recognizing the need to decrease the size and vascularity of
the thyroid gland prior to a thyroidectomy, would expect the physician to order:
a. Pitressin b) Propylthiouracil c) Potassium iodide d) Potassium
permanganate
182. Immediately after thyroidectomy, Mr. Gray should be monitored for:
a. Decreased blood pressure c) Signs of restlessness
b. Urinary retention d) Signs of respiratory obstruction
183. To evaluate possible laryngeal nerve injury following a thyroidectomy,
Nurse Sylar should do which of the following on an hourly basis?
a. Ask the client to speak c) Have the client hum a
familiar tune
b. Ask the client to swallow d) Swab the client's throat to test
the gag reflex
184. An accidental removal of the parathyroid glands during a thyroidectomy
would cause:
a. Tetany b) Myxedema c) Hypovolemic
shock Adrenocortical stimulation
185. On the first postoperative day following thyroidectomy, Mr. Gray tolerates
a full-fluid diet. This is changed to a soft diet on the second postoperative day.
Mr. Gray complains of a sore throat when swallowing. Nurse Sylar should:
a. Reorder the full-fluid diet c) Administer analgesics as
prescribed before meals
b. Notify the physician immediately d) Provide saline gargles
to moisten the mucous membranes
186. Ronald is diagnosed with amoebiasis and is to receive Metronidazole
(Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of
the following is the correct dose of the drug that the client will receive per oral
administration?
a. 1,000 mg tid
21
b. 500 mg tid
c. 1,500 mg tid
d. 250 mg tid
187. Riza, a 2 year old female was prescribed to receive 62.5 mg suspension
three times a day. The available dose is 125 mg/ml. Which of the following
should Nurse Paulo prepare for each oral dose?
a. 0.5 ml
b. 1.25 ml
c. 2.5 ml
d. 1.0 ml
188. The physician ordered Potassium Chloride (KCl) in D5W 1 liter to be
infused In 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk
drug. Nurse Robert used an intravenous pump. Which of the following should
Nurse Robert do to safely administer this drug?
a. Check the pump setting every 2 hours
b. Teach the client how the infusion pump operates
c. Have another nurse check the infusion pump setting
d. Set the alarm of the pump loud enough to be heard
189. Baby Liza, 3 months old, with a congenital heart deformity, has an order
from her physician; "give 3.00 cc of Lanoxin today for 1 dose only". Which of the
following is the most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of
Lanoxin
190. When Nurse Norma was about to administer the medications of client
Lennie, the relative of Lennie told the nurse that they buy her medicines and
showed the container of medications of the client. Which of the following is the
most appropriate action by the nursed?
a. Hold the administration of the client's medication and refer to the head
nurse
b. Put aside the medications she prepared and instead administer the client's
medications
c. Tell the client that she will inform the physician about this
d. Bring the medications of the client to the nurse's station and prepare
accordingly
191. swallowing. Nurse Sylar should:
a. Reorder the full-fluid diet c) Administer analgesics as
prescribed before meals
b. Notify the physician immediately d) Provide saline gargles
to moisten the mucous membranes
Situation: Nurse Dolor is assigned at the surgical ward and clients have been
complaining of postoperative pain at varying degrees. Pain as the nurse knows,
is very subjective.
192. Claire Bennet, who had abdominal surgery 3 days earlier, complains of
sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10
(worst pain). Which intervention should Nurse Dolor implement first?
a. Obtaining an order for a stronger pain medication because the client's pain
has increased
b. Assessing the client to rule out possible complications secondary to
surgery
c. Checking the client's chart to determine when pain medication was last
administered
d. Explaining to the client that the pain should not be this severe 3 days
postoperatively
193. Which intervention should Nurse Dolor plan for Adam Monroe, 35 years
old with arthritis, who remains in bed too long because it hurts to get started?
a. Telling the client to strictly limit the amount of movement of his inflamed
joints
b. teaching the client's family how to transfer the client into a wheelchair
c. Teaching the client the proper method for massaging inflamed, sore joints
d. Encouraging gentle range-of-motion exercises after administering aspirin
and before rising
22
194. One day after open reduction and internal fixation of the left hip, Ali Larter,
30 years old, is complaining of pain. Which data would cause Nurse Dolor to
refrain from administering the pain medication and to notify the health care
provider instead?
a. Left hip dressing dry and intact
b. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
c. Left leg in functional anatomic position
d. Left foot cold to touch; no palpable pedal pulse
195. Which term would Nurse Dolor use to document pain at one site that is
perceived in another site?
a. Referred pain c. intractable pain
b. Phantom pain d. Aftermath of pain
196. Which statement represents the best rationale for using non-invasive and
non-pharmacologic pain control measures in conjunction with other measures?
a. These measures are more effective than analgesics
b. These measures decrease input to large fibers
c. These measures potentiate the effects of analgesics
d. These measures block transmission of type C fiber impulses
197. You should be alert for the following complications she may experience
EXCEPT:
a. Impaired mobility
b. Contractures and muscle atrophy
c. Hypostatic pneumonia
d. Pressure sores
198. Proper positioning of an immobilized unconsciousness client is important
for the following reasons EXCEPT:
a. Maintain skin integrity
b. Promotes optimal lung expansion
c. Prevent injuries and deformities of the musculoskeletal system
d. Facilitates rest and sleep
199. When positioning your client, you should observe good body mechanics
for yourself and the client. This means that the nurse:
a. Uses back muscles
b. Assumes correct body alignment and efficient use of muscles to avoid
injury
c. Observes rhythmic movements when moving about
d. Uses large muscles only
200. You are going to move Mrs. Santillan, a 150 lbs. unconscious woman.
Some principles to use when moving the client include the following EXCEPT:
a. Prepare to move client by taking a deep breath and tightening abdominal
and gluteal muscles
b. Maintain wide base of support With feet and with knees flexed
c. Push and pull using arms and legs instead of lifting
d. Move close to the object to be moved leaning cm bending at the waist
201. After moving Mrs. Santillan to the desired position, which action will you avoid?
a. Avoid friction between bony prominences
b. Place pillows to position client's extremities
c. Apply restraints

1. C
2. C
3. D
4. B
5. A
6. B
7. B
8. D
9. D
10. B
11. B
12. D
13. C
14. B
15. C
16. C
17. iai
18. iii
19. B
20. B
21. D
22. C
23. B
24. C
25. B
26. B
27. C
28. C
29. A
30. d
31. a
32. b
33. b
34. c
35. c
36. b
37. a
38. b
39. c
40. a
41. b
42. c
43. b
44. c
45. a
46. d
47. a
48. a
49. b
50. c
51. c
52. d
53. c
54. d
55. a
56. c
57. a
58. a
59. d
60. c
61. a
62. a
63. a
64. c
65. d
66. d
67. c
68. a
69. c
70. a
71. d
72. d
73. c
74. c
75. b
76. c
77. a
78. c
79. c
80. b
81. a
82. c
83. d
84. b
85. d
86. b
87. d
88. a
89. d
90. b
91. c
92. d
93. a
94. b
95. c
96. d
97. b
98. a
99. b
100. b
101. a
102. a
103. c
104. a
105. a
106. a
107. a
108. c
109. d
110. b
111. d
112. a
113. b
114. d
115. c
116. d
117. c
118. a
119. b
120. d
121. b
122. c
123. b
124. c
125. b
126. b
127. b
128. c
129. c
130. a
131. a
132. a
133. a
134. b
135. b
136. b
137. c
138. b
139. a
140. c
141. d
142. b
143. a
144. c
145. d
146. d
147. a
148. c
149. d
150. d
151. a
152. d
153. b
154. d
155. a
156. b
157. b
158. d
159. b
160. b
161. c
162. b
163. d
164. c
165. d
166. d
167. d
168. c
169. b
170. a
171. c
172. b
173. c
174. b
175. a
176. b
177. a
178. a
179. a
180. c
181. a
182. c
183. d
184. b
185. d
186. b
187. b
188. b
189. b
190. a
191. d
192. d
193. c
194. a
195. b
196. c
197. c
198. c
199. b
200. b
201. a