NURSING PRACTICE I SET A
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NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions.
2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
4. AVOID ERASURES.
5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is
punishable by law. Per RA 8981.
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INSTRUCTIONS:1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set .
2. Write the subject title “Nursing Practice I” on the box provided.
3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.
MULTIPLE CHOICE
1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do 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
2. 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 the staff nurse in the use of touch, which of the following would be 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”.
3. 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
4. George, a 43 year old executive is scheduled for cardiac bypass surgery. While being prepared for the 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. Tel me how you feel about the surgery.”
5. 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
6. Nurse Glenda gets a call from the 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.
7. 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, he straps accidentally broke and the client fell to the floor hitting to his head. In this situation, the nurse is:
A. not responsible because of the doctrine of respondent superior B. free from any negligence that caused harm to the patient
C. liable along with the employer for the use of a defective equipment that harms the client
D. totally responsible for the negligence
8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna?
A. Ignore the incidence
B. Report the incidence to the head nurse
C. Respect the client’s actions as this provides structure and support to the client
D. Call her attention so she can go to sleep
9. 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 ewhite, fish C. Balut, salted eggs, duck and chicken egg D. Pork liempo, cow brain, lungs and kidney
10. The code of ethics for nurses has an interpretative 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
11. 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.
12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital?
A. Diabetic client type2
B. Client with chronic obstructive pulmonary disease (COPD) C. Client with second degree burns
D. Client with psoriasis
13. 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.”
14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612. 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
15. The son of Mr. Rosario, 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 fall and injure himself. Which instruction would you give?
A. Apply restraints during 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
SITUATIONAL
Situation 1 – Preparation and administration of medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save patient’s lives.
16. You are to administer an intramuscular injection to Dulce, 1 ½ year old girl. The most appropriate site to administer the drug is:
A. dorso gluteal region C. vastus lateralis B. ventral forearm D. gluteal region
17. An infant is ordered to receive 500ml of D5NSS for 24 hours. The intravenous drip is running at 60 drops/minute. How many drops per minute should the flow rate be?
A. 60 drops per minute C. 30 drops per minute B. 21 drops per minute D. 15 drops per minute
18. 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 C. 60 drops
19. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drop per minutes should the IV be regulated?
A. 13-14 drops C. 10-12 drops
B. 17-18 drops D. 15-16 drops
20. The physician ordered Nembutal Na gr XX. The bottle contains 100mg/capsule. How many capsule will be administered to the client?
A. 1 capsule C. 2 capsule
B. 1 ½ capsule D. ½ capsule
Situation 2 – The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved.
21. 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 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
22. 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 C. Defining the problem B. Considering effects on results D. Making final decisions
23. To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act responsibly when at work. Which of the following actions of the 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
24. 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 medications 5 minutes ago
25. 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 3– You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV.
26. When caring for a dying client, you will perform which of the following activities? A. Encourage the client to reach optimal health
C. Assist the client towards a peaceful death D. Motivate client to gain independence
27. 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 C. denial
B. resolution D. bargaining
28. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a mutidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 50 mg/ml. You are to give the 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 the desired dose, then into the vial D. withdraw medication from the ampule then from the vial
29. When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml, what is the total volume that you will inject to the client?
A. 2 ml C. 1.5 ml
B. 1 ml D. 1.75 ml
30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity?
A. Blisters C. Pressure sores
B. Reddening of the skin D. Pustules
Situation 4 – You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility.
31. Ramil’s right leg is injured and Nurse Karen has to move him from the bed to w 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
32. 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 sternocleidomastoid muscle C. Hyperextension of the knees
D. Anterior flexion of the lumbar curvature
33. 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
34. 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 flat position
C. Lock the wheels of the bed
35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg?
A. Sandbags C. Pillow
B. Firm mattress D. High foot board
Situation 5 – As you begin to work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them.
36. 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 rest and sleep B. Instructing the client about the use of call system C. Raising the side rails
D. Placing the bed in high position
37. 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
38. 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 ward premises every twenty minutes
39. 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
40. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action 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 6 – Myrna, a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing.
41. In both quantitative and qualitative research, the used 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
42. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT:
A. locating and identifying resources C. clarifying a research topic B. reading and recording notes D. using the library
43. 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
44. 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? 45. 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 7 – While working in a tertiary hospital, you are assigned to the medical ward.
46. 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 C. bookkeeping department
B. Social worker D. physician
47. 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 C. provide financial assistance B. to be a part of a research study D. assist with chemotherapy
48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a:
A. nutritionist C. physician
B. dietitian D. medical pathologist
49. 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
C. she listens to the individual views of the team members D. helps client set goals of care and discharge
50. Nurse Rita is successful in collaborating with health team 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 and trust
Situation 8 – The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to provide safe nursing to your clients?
51. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse 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
52. 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 53. 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
54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. 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
55. While talking with Mrs. Amado, 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 9 – Oral care is an important part of hygienic practices and promoting client comfort.
56. 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 C. Mineral oil
57. 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 58. 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
59. 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 with mouthwash to avoid rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity
60. 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 C. petroleum jelly
B. water D. mentholated ointment
Situation 10 – Errors while providing nursing care to patients must be avoided and minimized at all time. Effective management of available resources enables the nurse to provide safe, quality patient care.
61. 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 C. lack of knowledge
B. use of unofficial abbreviations D. failure to identify client
62. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is 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 Method
C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications.
63. 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
64. 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 client’s per nurse’s call C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment every shift
65. 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 way to learn the procedure C. Tell the nurse to read the procedure manual D. Do the procedure with the nurse
Situation 11 – Mr. Jose’s chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data.
66. Mr. Jose’s chart contains all information about his health care. The functions of records include all 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
67. An advantage of automated or computerized client care system is:
A. The nursing diagnoses for a client’s data can be accurately determined B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated D. The number of people to take care of the client will be reduced 68. 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” 69. 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
70. 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
Situation 12 – Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of clients with various conditions.
71. Which of the following client conditions should be Miss Roque’s priority in the pediatric unit? A. The baby whose fantanelle 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 door D. A baby boy whose circumcision has yellowish exudate
72. 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 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
73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. While Doris is doing spone 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
74. 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
75. 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 13 – Infections are quite commonly the reasons for a client’s hospitalization. Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care.
76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding?
A. Neutrophils 60%
B. White blood cells (WBC) 9000/mm
C. Erythrocyte sedimentation rate (ESR) is 39 mm/hr D. Iron 75 mg/100 ml
77. 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
78. 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
79. Which of the following laboratory test result indicate presence of an infectious process? A. Erythrocyte sedimentation rate (ESR) 12 mm/hr
B. White blood cells (WBC) 18,000/mm3 C. Iron 90 g/100ml
D. Neutrophils 67%
80. Among the clients you are assigned to take care of, who is the most susceptible to infection? A. Diabetic client C. client with pulmonary emphysema B. Client with burns D. client with myocardial infarction Situation 14 – You are a newly hired nurse in a tertiary hospital. You have finished your
orientation program recently and you are beginning to assimilate the culture of the profession.
81. Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an:
A. competent nurse C. proficient nurse B. novice nurse D. advanced beginner
82. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:
A. the ability to organize and plan activities
B. having attained an advanced level of education
C. a holistic understanding and perception of the client D. intuitive and analytic ability in new situations
83. As you become socialized into the nursing “culture” you become a patient advocate. Advocacy is explained by the following EXCEPT:
A. respecting a person’s right to be autonomous B. demonstrating loyalty to the institution’s rights
C. shared respect, trust and collaboration in meeting health needs D. protecting and supporting another person’s rights
84. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a:
A. Clinical nurse specialist C. community health nurse B. Critical care nurse D. staff nurse
85. You join a continuing education program to help you: A. Earn credits for license renewal
B. Get in touch with colleagues in nursing C. Enhance your basic knowledge
Situation 15 – When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke.
86. The most important risk factor is:
A. Cigarette smoking C. binge drinking
B. Hypertension D. heredity
87. 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 C. diabetic stroke B. Hemorrhagic stroke D. thrombotic stroke
88. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT:
A. phlebitis C. damage to blood vessel
B. trauma D. aneurysm
89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this?
A. Amphetamines C. shabu
B. Cocaine D. Demerol
90. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: A. “More red blood cells thicken blood and make clots more possible.”
B. “Increased RBC count is linked to high cholesterol.” C. “More red blood cell increases hemoglobin content.” D. “High RBC count increases blood pressure.”
Situation 16 – Accurate computation prior to drug administration is a basic skill all nurses must have.
91. Rudolf is diagnosed with amoebiasis and is to received 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 received per oral administration?
A. 1,000 mg tid C. 1,500 mg tid
B. 500 mg tid D. 50 mg tid
92. Rhona, 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 Paolo prepare for each oral dose?
A. 0.5 ml C. 2.5 ml
B. 1.5 ml D. 10 ml
93. 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
94. 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
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin 95. 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 nurse?
A. Hold the nurse 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 Situation 17 – You are taking care of Mrs. Santillan a 48 year old woman who is unconscious
after a cerebrovascular accident. You are aware that there are many physical complications due to immobility.
96. You should be alert for the following complications she may experience EXCEPT:
A. Impaired mobility C. hypostatic pneumonia
B. Contractures and muscle atrophy D. pressure sores
97. 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 musculo-skeletal system D. Facilitates rest and sleep
98. 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
99. You are going to move Mrs. Santillan, a 150 lbs unconscious woman. Some principls to use when moving the client include the following EXCEPT:
A. prepare to move client by taking 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 or bending at the waist
100. 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 extremeties C. Apply restraints
D. Raise bed rails
SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR
WATCHERS. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A
GROUND FOR CANCELLATION OF YOUR EXAMINATION.
NURSING PRACTICE II SET A
_________________________________________________________________
NURSING PRACTICE II – Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS:6. This test booklet contains 100 test questions.
7. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
8. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
9. AVOID ERASURES.
10. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is
punishable by law. Per RA 8981.
_________________________________________________________________
INSTRUCTIONS:4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set .
5. Write the subject title “Nursing Practice II” on the box provided.
6. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.
MULTIPLE CHOICE
1. Registered nurses can be identified as a:
A. Organization C. group
B. Culture D. subculture
2. Among children candidates for organ transplant, when all selected children have appropriate tissue matches for the same donated organ, the basis for the decision as to which child gets the organ is given to the child who:
A. will receive the most benefit from the new organ B. is most likely to die without the transplant
C. is selected by the lottery system for available organs D. is at the top of the list and has waited the longest time
3. The nurse uses what equipment to check for fluid between the parietal and visceral layers of the tunica vaginalis, the outermost covering of the testes?
A. 30 cc syringe C. Fluid meter
B. transilluminator D. Manometer
4. Which of the following examples best defines the term role reversal? A. a lazy person becomes very productive in the family
B. the good child takes on a bad child role
C. a person who has been a good provider quits his or her job D. the child assumes a caregiver role toward the caregiver
5. When a nurse breaches the duty of confidentiality, he or she can be disciplined by both the employer and the Board of Nursing. In addition to this discipline, he or she can:
A. be held responsible for any damages that result B. be fined by the federal government
C. be sentenced for up to 1 year in jail
D. immediately lose his or her nursing license
A. normative-reactive C. providing information
B. training D. power coercive
7. The nurse knows that the occurrence of shoulder dystocia during labor is: A. polyhydramnios C. preterm birth
B. maternal age D. macrosomia
8. The nurse instructs the mother that when overstimulated the infant will: A. show increased alertness and eye contact
B. respond with coordinated, synchronous body movement C. look away to reduce the intensity of the interaction D. drift off to deep sleep to shut out the interaction
9. Some strategies to maintain professional health are listed below. Which is NOT necessarily correct?
A. Networking with others in the health care field B. Join a professional organization
C. Goal setting
D. Read fiction and non-fiction materials
10. The nurse is assessing an 8 month-old infant for head lag, pulling the infant by the hands from a supine to a sitting position. The head does not stay in line with the body when being pulled forward. Which of the following statements best represents the significance of this finding?
A. Head lag should not be tested until the child is over 1 year of age.
B. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations.
C. The nurse has not conducted the test correctly and must do it again using proper technique.
D. This is a normal finding, as the infant’s head will not stay in line until after 8 months of age.
11. Which statement is correct regarding the use of the cervical cap? A. It may affect Pap smear results.
B. It does not need to be fitted by the physician. C. It does not require the use of spermicide. D. It must be removed within 24 hours.
12. The major components of the communication process are: A. verbal, written and nonverbal
B. speaker, listener and reply
C. facial expression, tone of voice and gestures
D. message, sender, channel, receiver and feedback
13. The extent of burns in children are normally assessed and expressed in terms of: A. the amount of body surface that is unburned
B. percentages of total body surface area (TBSA) C. how deep the deepest burns are
D. the severity of the burns on a 1 to 5 burn scale.
14. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is:
A. being raised by a parent of low intelligence quotient (IQ) B. an orphan
C. a victim of child neglect D. the victim of poverty
15. Which of the following indicates the type(s) of acute renal failure?
A. Four types: hemorrhagic with and without clotting, and nonhemorrhagic with and without clottings
B. One type: acute
C. Three types: prerenal, intrarenal and postrenal D. Two types: acute and subacute
16. A means of facilitating professional staff development is by building upon skills, abilities, and of experience of each practitioner is called:
A. the novice to expert model C. career enhancement B. situational leadership model D. clinical ladder
17. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual participation model of care (NMPMC)?
A. “Have you brushed your child’s teeth today?” B. “How does your child look to you today?”
C. “Where have you been all morning?” D. “Do you think your child’s color is worse”?
18. There are numerous definitions of the word “health”. Which definition below is from Florence Nightingale?
A. A state or a process of being and becoming an integrated and whole person B. The state of being free from illness or injury
C. Being well and using every power the individual possesses to the fullest extent D. A state of complete physical, social, and mental well-being and not merely the absence
of disease or infirmity
19. Informal communication takes place when individuals talk and is best described by saying the participants:
A. are involved in a preexisting informal relationship B. talk with slang words
C. have no particular agenda or protocol D. are relaxed
20. Tertiary care by the home health nurse is directed toward children with: A. problems in mobility C. minor problems
B. short-term needs D. clinically apparent disease 21. The endometrium thickens during which phase of the menstrual cycle?
A. Secretory phase C. Proliferative phase
B. Menstrual phase D. Ischemic phase
22. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over a specific period of time is called:
A. staffing pattern C. benchmarking
B. skill mix D. patient classification
23. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. The BEST response by the nurse is:
A. “These circumference normally are the same, but in some babies this just differs.” B. “Perhaps your baby was small for gestational age or premature.”
D. “Let me ask you a few questions, and perhaps we can figure out the cause of this difference.”
24. Which of the following approaches would work best when the nurse is communicating with an infant?
A. Use an adult voice just as you would for anyone. B. Communicate through the caregivers.
C. Allow the child time to warm up to the nurse. D. Respond only after the child cries for a while.
25. Evidence-based care started in medicine as a way to: A. promote technological advances in medicine
B. incorporate collaboration within all health care disciplines C. integrate individual experience with clinical research D. teach medical students the art and science of medicine
26. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Hirschsprung’s disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the first 24 to 48 hours after birth C. The skin turns yellow and then brown over the first 48 hours of life D. High-grade fever
27. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching?
A. Maintain bed rest with bathroom privileges B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible when lying down.
28. Which of the following groups of people in the world disproportionately represents the homeless population?
A. Hispanics C. African Americans
B. Asians D. Caucasians
29. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to:
A. avoid covering the area of the topical medication with the diaper B. avoid the use of clothing on top of the diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the outside of the diaper
30. The nurse assessing a child or adolescent with a diagnosis of dysrhytmic disorder would find which of the following symptoms?
A. Labile mood and hyperactive thyroid with an increase in circulating thyroid hormones and associated symptoms
B. Severe shaking of the hands when trying to hold a glass of water or other object C. A depression that is deeper, more acute, and more likely to lead to suicide than major
depressive disorder
D. A depressed or irritable mood for most of the day, on most days, for 2 or more years and low energy or fatigue.
31. You were the nurse assigned to work with a child who has had whole brain radiation. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea, malaise, fever and dysphasia. Based on this assessment, you are to work with the patients in which of the following areas.
A. Accepting a reoccurrence of the tumor
B. Dealing with the side effects of radiation therapy C. Caring for the dying child
D. Accepting the imminent death of their child
32. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis of “Nutrition: Less than body requirements.” Which of the following
interventions will be most helpful in resolving this nursing problem? A. Two large meals a day instead of several minimeals and snacks B. Special IBD diet (diet that has been proven effective for treating IBD) C. Salt-free diet high in potassium, vitamins and minerals
D. Diet as tolerated with lactose hydrolyzed milk instead of milk products, and omission of highly seasoned foods, and reduction of fiber
33. Emotional intelligence consists of a number of competencies. Some of these are listed below. Which is NOT a characteristic of emotional intelligence?
A. Self-esteem C. Empathy
B. Self-awareness D. Self-regulation
34. Data collection for driving and restraining forces, including costs, desirability and feasibility, is a:
A. people issue C. political issue
B. structural issue D. technology issue
35. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization that occurs when:
A. a child blames him or herself for the sexual abuse and begins to withdraw and isolate B. newspapers and the media don’t keep sexual abuse private and accidentally or on
purpose reveal the name of the victim
C. the child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop
D. the child’s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge
36. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position?
A. Brow position C. Breech position
B. Right Occipito-Anterior Position D. Left Occipito-Posterior Position
37. FOCUS methodology stands for:
A. Focus, Organize, Clarify, Understand and Solution B. Focus, Opportunity, Continuous, Utilize, Substantiate C. Focus, Organize, Clarify, Understand, Substantiate
D. Focus, Opportunity, Continuous (process), Understand, Solution
38. While community health nurses focus on the individual or the family, which of the following do they also have as their final objective?
A. The well-being of the chronically ill B. The financial well-being of the family C. The well-being of the extended family
D. The well-being of the community
39. Which of the following is the best example of the ethical principle of fidelity? A. Doing whatever the client or the client’s physician asks of you. B. Keeping a promise to return to the client’s room at a given time C. Being a good friend to the client by sharing secrets
D. Saving the client time and money by not wasting supplies
40. Which of the following factors is most important in determining the success of relationships used in delivering nursing care?
A. Type of illness of the client
B. Transference and counter transference C. Effective communication
D. Personality of the participants
41. Which of the following statements best describes the term glove type burn?
A. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot scalding water
B. The parents have dipped the child into hot liquid while he or she was asleep C. The child was wearing a glove when immersed in hot liquid
D. The burn has the look of a glove immersed in hot scalding water.
42. The school nurse keeps a list of enrolled students who have medical or religious objections to immunizations and those who are likely to have decreased immunity. The nurse likely keeps this list to:
A. provide statistics for the Department of Health
B. reassure the family that the nurse will respect the family’s wishes at all times C. meet national government requirements
D. facilitate exclusion in case of an outbreak of a highly communicable disease in the school.
43. Preschoolers are able to see things from which of the following perspectives? A. Their peers
B. Their own and their caregivers’ C. Their own and their mother’s D. Only their own
44. In conflict management, the win-win approach occurs when: A. there are two conflicts and the parties agree to each one
B. each party gives in on 50% of the disagreements making up the conflict C. both parties involved are committed to solving the conflict
D. the conflict is settled out of court so the legal system and the parties win
45. According to the social-interactional perspective of child abuse and neglect, four factors place the family members at risk for abuse. these risk factors are the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and
A. the presence of a family crisis C. the national emphasis on sex B. genetics D. chronic poverty
46. When a person is discussing the strong influences that childrearing methods have on the development of the child, this person is most probably coming from which of the following viewpoints or theories?
A. Naturalistic C. Neoclassic
47. In working with the caregivers of a client with an acute or chronic illness, the nurse would: A. Teach care daily and let the caregivers do a return demonstration just before
discharge
B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress. C. Difficulty sleeping, hypervigilant, and an arching of the back
D. Paradoxical irritability, diarrhea, and vomiting
48. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress C. Difficulty sleeping, hypervigilant, and an arching of the back
D. Paradoxical irritability, diarrhea, and vomiting.
49. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to:
A. call emergency medical services (EMS) and get the child to the emergency room B. relax because these symptoms will pass and the child will be fine
C. administer syrup of ipecac D. call the poison control center
50. A client says she heard from a friend that you stop having periods once you are on the “pill”. The most appropriate response would be:
A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or skipped occasionally.”
B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible.”
C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly.”
D. “Missed period can be very dangerous and may lead to the formation of precancerous cells.”
51. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening?
A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinutria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine.
52. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following areas?
A. Isolation C. Lack of fulfillment B. Loneliness D. Identity
53. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of:
B. supervision D. competence
54. A child suffers a head injury in a tumbling accident in gym class. The nurse’s best course of action is to:
A. get the child up walking and make sure he or she stays awake B. leave the child and go get help
C. leave the child in the care of an older child and go get help
D. stay with the child, keep assessing, and have someone call the caregivers 55. The American Academy of Pediatrics suggests that caregivers do which of the following things
in regard to physical activities for preschoolers?
A. Push the child to practice sports activities while they are more flexible
B. Encourage a variety of physical activities in a noncompetitive environment C. Have the child engage in competitive sports to see where they excel
D. Keep physical activities to a minimum until the child is in grade school.
56. Which of the following arrangements is generally considered to be best for the parents of hospitalized infant or young child?
A. Rooming-in
B. Separate caregiver sleeping room on the unit C. Day visits and sleeping at home
D. Staying at a nearby hotel or motel
57. When one person allows the conflict to be resolved at his or her own expense, this is referred to in conflict management as:
A. losing C. the win-lose approach B. winning while losing D. the lose-win approach
58. Which of the following statements best describes acquaintance rape?
A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so
B. When two people don’t love each other and engage in sexual activities
C. When someone on a date tricks the other person into having sexual intercourse D. Sexual intercourse committed with force or the threat of force without a person’s
consent.
59. The school nurse is teaching a health education and hygiene course to a group of high school males, which includes a number of young men who are on competitive sports teams. Which of the following health practices would the nurse most stress in preventing the transmission of human immunodeficiency virus (HIV) virus in case any team member has HIV or acquired immunodeficiency syndrome (AIDS)?
A. No sharing of underarm deodorant or shower soap B. No sharing of razors or toothbrushes
C. Making certain towels have been washed in boiling water D. Avoiding physical contact such as sports hugs or swats
60. At 17 weeks’ gestation, a type 1 diabetic undergoes an ultrasound examination. What information about the fetus at this time in pregnancy would be the results of this examination provide?
A. Placental maturity C. Gestational age B. Estimated fetal weight D. Fetal lung maturity
61. Which of the following best describes a difference in communicating with school age children versus toddlers?
B. For toddlers, preparation for procedures is just before the procedure and much earlier for school-aged children.
C. Caregivers need less information when care involves a school aged child
D. The number of words is more when communicating with a toddler than it is with a school aged children
62. Genetic testing should be performed on a child only if A. the parents both want it performed
B. it is in the best interests of the child C. it i9s necessary for the child to survive D. no one objects
63. Infant head control is judged by the:
A. ability to hold the head without support B. presence or absence of head lag
C. rigidity of the neck and head D. amount of neck wrinkling
64. Which of the following roles BEST exemplifies the expanded role of the nurse? A. Circulating nurse in surgery
B. Medication nurse C. Obstetrical nurse
D. Pediatric nurse practitioner
65. The tone and pitch of the voice, volume, infection, speed, grunts and other vocalizations are referred to by which of the following terms?
A. Paraverbal clues C. Third element
B. Ancillary speech D. Enhancements
66. The plan-do-study-act cycle begins with:
A. four stages C. three questions
B. five agendas D. two concepts
67. During your shift, you noted one of your pregnant clients considered as “waiting case” manifest morning sickness and which later progressed. Which assessment finding may indicate
possible developing complication?
A. Maternal pulse 90 C. FHT 155
B. Trace glucose in the urine D. 1+ ketones in the urine 68. The nurse is working with a child who is going to have a bone marrow aspiration. The
physician orders TAC (tetracaine, adrenaline and cocaine). Which of the following is the route of administration?
A. application to the skin, covered with a dressing prior to the procedure B. subcutaneous
C. IV using a very slow drip over approximately 4 hours prior to procedure D. Nasal inhalation
69. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your workplace,” cultures have different patterns of verbal and nonverbal communication. Which difference does NOT necessarily belong?
A. Personal behavior C. Subject matter
B. Eye contact D. Conversational style
70. The nurse instructs the caregivers of a newborn to notch the diapers or fold them in such a way as to expose the cord. The major purpose of exposing the cord is to:
A. remind caregivers to do cord care B. keep the diaper from rubbing the cord
C. provide air circulation for the cord D. allow visualizations at all times
71. The level of health of an individual, family, group, population, or community is called: A. health assets C. quality of life
B. health status D. health needs
72. The nurse is teaching a group of expectant mothers about the prevention of diaper dermatitis. The nurse explains that one of the preventive measures is the use of:
A. absorbent disposable diapers C. plastic panties over diapers B. baby powder or cornstarch D. cloth diaper
73. The Code of Nurses
A. delineates all obligations and responsibilities of the nurse
B. is a binding oath, which tells nurses how to make ethical decisions C. assists the nurse in formulating a personal belief system
D. supports the concept of respect for all persons 74. The obligation to correctly perform one’s assigned duties is:
A. Delegation C. responsibility
B. Assignment D. accountability
75. During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus to be slightly boggy. Which action should the nurse take to decrease the risk of uterine inversion during uterine massage?
A. Massage only when cramping begins.
B. Place one hand on the abdomen above the symphysis pubis. C. Ask the client to ambulate to the bathroom to empty her bladder. D. Position the client in a slight Trendelenburg position.
SITUATIONAL
Situation 1 – Nurse Lisa manages her own Reproductive and Children’s Nursing Clinic
in Sorsogon and necessarily she attends to health conditions of mothers and children. The following conditions pertain to the GROWING FETUS.
76. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo. What would be your best explanation?
A. Her baby will be a fetus as soon as the placenta forms
B. From the time of implantation until 5 to 8 weeks, the baby is an embryo C. After the 20th week of pregnancy, the baby is called a zygote
D. This term is used during the time before fertilization
77. Marichu is worried that her baby will be born with a congenital heart disease. What assessment of a fetus at birth is important to help detect congenital heart defect?
A. Determining that the color of the umbilical cord if not green.
B. Assessing whether the umbilical cord has two arteries and one vein. C. Assessing whether the Wharton’s jelly of the cord has a pH higher than 7.2. D. Measuring the length of the cord to be certain that it is longer than 3 feet.
78. Additionally, Nurse Lisa would gather more information about Marichu’s worry about what may threaten the health of her baby. What would Nurse Lisa hope to find?
A. Has Marichu been overly anxious about something.
B. Has MArichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy.
C. Has MArichu engaged in sexual activity during the fetal development state of her child. D. Has MArichu engaged in any detrimental activities during the fetal development
stage e.g. smoking, drinking, taking drugs, a bad fall, or attempts to terminate pregnancy.
79. Marichu is scheduled to have an ultrasound examination. What instruction would you give her before her examination?
A. You can have medicine for pain for any contractions caused by the test. B. Drink at least 3 glasses of fluid before the procedure.
C. The intravenous fluid infused to dilate your uterus does not hurt the fetus. D. Void immediately before the procedure to reduce your bladder size.
80. Marichu is scheduled to have an amniocentesis to test for fetal maturity. What instruction would you give her before this procedure?
A. The X-ray used to reveal your fetus’ position has no long term effects. B. The intravenous fluid infused to dilate your uterus does not hurt the fetus.
C. No more amniotic fluid forms afterward, which is why only a small amount is removed. D. Void immediately before the procedure to reduce your bladder size.
Situation 2 – Health instructions are essentially given to pregnant mothers.
81. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy?
A. Presence of dark color in the neck B. Increased vaginal discharge C. Swelling of the face
D. Breast tenderness
82. A woman who is 9 weeks pregnant comes to the Health Center with moderate bright red vaginal bleeding. On physical examination, the physician finds the client’s cervix 2 cm dilated. Which term best describes the client’s condition?
A. Missed abortion C. Inevitable abortion B. Incomplete abortion D. Threatened abortion
83. In a big government hospital, Nurse Pura is taking care of a woman with a diagnosis of abruption placenta. What complication of this condition is of most concern to Nurse Pura?
A. Urinary tract infection B. Pulmonary embolism C. Hypocalcemia
D. Disseminated intravascular coagulation
84. Which of the following findings on a newly delivered woman’s chart would indicate she is at risk for developing postpartum hemorrhage?
A. Post-term delivery C. Grand multiparity B. Epidural anesthesia D. Premature rupture of membrane
85. Mrs. Hacienda Gracia, 35 year old postpartum client is at risk of thrombophlebitis. Which of the following nursing interventions decreases her chance of developing postpartum
thrombophlebitis?
A. breastfeeding the newborn B. early ambulation
C. administration of anticoagulant postpartum
