Subject: Fundamentals of Nursing Number of Hours: 2 Hours Number of Items: 100 Items Passing1.Score: 75 1.
a.
5.
What stress response can you expect from a patient with blood sugar of 50 mg/dl?
a.
Body will try to decrease the glucose level
Which of the following statement describes d escribes a
b.
There will be a halt in the release of sex hormone
violation of the right to confidentiality?
c.
Client will appear restless
Telling the mother of the 18 year old about the
d.
Blood pressure will increase
result of the ELISA test. b.
³Patient Kris Aquino¶s room number is 15 on the
6. All of the following are purpose of inflammation
third floor.´ As a response by Nurse to Kris¶s relative who asked about the patient¶s room
except: a.
number. c.
The nurse failed to give the medication on time
phagocytosis b.
resulting to patient¶s cardiac arrest. d.
2.
Localized tissue injury by increasing capillary permeability
³ROOM 1A. PATIENT: SKIPPY PEANUT BUTTER.
c.
Protect the tissue from injury by producing pain
DOCTOR: DR. ENSURE NUTRITION.´
d.
Prepare for tissue repair
The last expected process in the stage of
7.
Which of these statements least describes
inflammation is characterized by: a.
There will be sudden redness of the affected part.
b.
Heat will increase on the affected part.
c.
The affected part will lose its normal no rmal function.
d.
Exudates will flow from the injured site.
Nursing? a.
It is an art and science of caring for the health of the individual, family, or community in any setting.
b.
It is a health-oriented profession which requires formal training committed to the ideals of service.
c. 3.
Increase heat, thereby produce abatement of
It mainly deals with the treatment of health
What kind of exudates is expected where there is
conditions affecting an individual, community or
an antibody-antigen reaction as a result of
family.
microorganism infection?
d.
It is basically premised on the greatest human
a.
Serous
b.
Serosanguinous
c.
Purulent
8.
When should the nurse start giving Ind eral?
d.
Sanguinous
a.
When anxiety reaches +1
b.
When the client starts to have narrow perceptual
4.
principle of ³love thy neighbor´.
Which of the following is incorrect following the
field and selective inattentiveness
maintenance of a Foley Catheter?
c.
When problem solving is not possible
a.
d.
When the client is immobilized and di sorganized
9.
Nurse Aida has seen her patient, Roger, for the
Keep urine catheter below the neutral pH of 7.0
b.
c.
d.
The use of sterile technique is a prerequisite for the attachment of a Foley Catheter
very first time. She establishes a contract about
Discourage client from drinking cranberry or
the frequency of their meetings and introduced
fruit juice to avoid urine acidification.
Roger about the expected termination. She started
Wash genital area twice daily or as often as
taking baseline assessment and set interventions
needed
and outcomes. On what phase of NPR do Nurse Aida and Roger belong?
a.
Pre-orientation
She then files a lawsuit against the suspect. In this
b.
Orientation
scenario, Imelda would be:
c.
Working
a.
Defendant
d.
Termination
b.
Plaintiff
c.
Principal
d.
Felon
10. The client is placed on NPO in preparation for a blood test. Adreno-cortical response is activated and which of the following is an expected
14. During the lawsuit, Imelda learned that the
response?
suspect, Sage, was paid to assassinate her. In this
a.
Low BP
case, which pairing would best fit for this
b.
Decreased Urine Output
scenario?
c.
Warm, flushed, dry skin
a.
Sage ± Accessory
d.
Low serum Sodium levels
b.
Crime ± Consummated
c.
Crime ± Frustrated
d.
Crime ± Attempted
11. The client is in stress because he was told by the physician that he needs to undergo surgery for the removal of the tumor in his bladder. Which of the following are expected physiologic responses
15. Imelda is in the recovery stage after the incident.
to this event? i.
Constipation
ii.
Urinary frequency
iii.
Hyperglycemia
iv.
Increased BP a.
iii, iv
b.
i, iii, iv
c.
i, ii, iv
d.
i, iv
As a nurse, you know that the diet that will be prescribed to Imelda is: a.
Low calorie, high protein with Vitamin A and C rich foods
b.
High protein, high calorie with Vitamin A and C rich foods
c.
High calorie, low protein with Vitamin A and C rich foods
d.
High protein, high calories with Vitamin A and E rich foods
12. Imelda was slashed and hacked by an unknown suspect. She suffered from massive tissue loss
16. Side walk vendor Christine was rushed to
and laceration on her arms and elbow in an
Bantayan Doctors Hospital after being attacked by
attempt to evade the criminal. As a nurse, you
a group of muggers. After learning she had no
know that the type of healing that will most likely
money in her, the health staff recommended her to
occur is:
go to Bantayan Public Hospital without providing
a.
First intention
basic treatment. In this case, the health staff:
b.
Second intention
c.
Third intention
d.
Fourth intention
a. Are right because they might get fired for treating a person without money b. Are wrong under RA 8344 c. Are right because they are protected under PD 626
13. After being hospitalized, Imelda learned that the suspect was caught and held in Mandaue City Jail.
d. Are wrong because they violated RA 8355 and are negligent.
17. Which of the following scenarios constitutes
20. With the situation in number 19, Nurse Casera
negligence to Nurse Jackie, an orthopedic nurse?
observes the patient to have moist cough. In this
Nurse Jackie delegates a task to LPN Jamie
case, the next priority action would b e to:
a.
b.
causing a Mercuric thermometer to break and then
a. Auscultate the lung fields
puncturing Theresa¶s armpit.
b.
Nurse Jackie sees a patient on the floor on the
L/min
oncologic wing who fell after being prescribed
c.
Provide Salbutamol through inhaler
with an anxiolytic and whose side rails have not
d.
Perform Chest Percussion to facilitate drainage of
been raised. This resulted into a fracture. c.
secretions
Nurse Jackie accidentally gives Phenylhydramine to a patient. The patient receives no reaction.
d.
Provide oxygen through nasal cannula at 1-2
21. Which of the following scenarios would indicate
Nurse Jackie transports Patient Theresa to the ward through a wheelchair which broke halfway
the need to perform cold compress? a.
through the journey causing erythema on Theresa¶s buttocks.
Upon you assessment, the site is erythematous. b.
Patient¶s IV insertion site is pale.
c.
Patient complains of pain on the IV insertion site.
18. Patient Aricayos was confined in the hospital due to burning sensation during urination and was
Patient complains of pain on the IV insertion site.
Upon you assessment, the site is cold to touch. d.
Patient¶s IV insertion site is swelling and pale.
diagnosed as UTI. Upon looking on her chart, the doctor orders urine specimen to be collected to
22. Which of the following actions of Nurse Inday are
determine appropriate antibiotic to provide. Which of the following actions are in line with the
correct? a.
Doctor¶s order? a. Ask patient to void, discard the first urine
Changing the tubing and dressing of patient Nacky receiving PNSS every 24 hours.
b.
Mixing Patient Jackie¶s TPN solution
collection.
c.
Changing the IV solution every 24 hours.
b.
Instruct patient to fill the sample bottle with urine
d.
Changing the TPN tubing and filter every 72 hours.
c.
Discard first voided urine and collect the second voided until on the same time the following day.
d.
23. Which of the following actions of Nurse Theresa is
Collect 5-10 mL of urine sample
correct for a patient whose BP frequently elevates to around 200/160, is receiving Nitroglycerin, and
19. Patient Nacky was diagnosed with DHF and the
complains of tingling below the tongue?
doctor ordered BT for her. Twenty-five minutes
a. Activate code blue and prepare crash kit
after the induction of the therapy, the patient
b.
Do nothing and tell patient that it¶s just normal
complains of chapped lips. Nurse Casera would
c.
Prepare anti-dysrythmics
be correct if she:
d.
Play soft music on the background or talk to
a.
Stops the infusion
b.
Continues the infusion
c.
Checks the tube
d.
Calls the physician who ordered the procedure
patient to calm him/her
24. Ava is a ward nurse in the Sang Carlows hospital. During her shift, a patient verbalized ³I couldn¶t sleep well because of the noises made by cars outside´. Nurse Ava would be correct if she would first:
a. Assess and investigate the cause of the sleep
client with on-going IV fluid infusion should the
deprivation
nurse evaluate further?
b.
Provide anxiolytics to patient as ordered
a.
Gastric distention
c.
Tell patient that the problem lies in her mind
b.
Frequent urination
d.
Provide patient with a glass of milk prior to sleep
c.
Dyspnea
d.
Slight pain at the IV insertion site when client
Situation: To validate the applicability of Nursing intervention
moves.
with the rapidly changing technology-based care of client, the nurse should engage in the continuous search for scientific
29. The Doctor prescribes Spironolactone to a client
knowledge to improve the knowledge base of the nursing
for the treatment of hypertension. Which dietary
profession. When doing a culture-related research, the nurse
choice of the client reflects a need for further
should be aware of the cultural beliefs and practices.
instruction from the nurse? a. Apples
25. Nursing research as a process in based on the:
b.
Yogurt
a.
Trial and error method
c.
Wheat Bread
b.
Step-by-Step process
d.
Fresh Oranges
c.
Scientific method
d.
Nursing process
30. Phantom limb pain is considered as: a.
Superficial pain
b.
Intractable pain
hallmark of scientific research?
c.
Somatic pain
a.
Pre-selected samples
d.
Neuropathic pain
b.
Statistical treatment of data
c.
The experiment
d.
Interpretation of results
26. Which of the following is considered as the
31. The management principle ³span of control´ is best illustrated in which of the following situations?
27. Which of the following behavior of Nurse Inday
a.
reflects her sensitivity to the client¶s cultural beliefs? a.
b.
leader. b.
Providing immediate post-mortem care to the body of Abdullah.
c.
Identifying the appropriate number of persons who directly report to the manager. m anager.
d.
motor vehicular accident. c.
Identifying the number of patient for nursing management.
Discussing the possibility of organ donation with the family of a Jehovah¶s Witness who dies from a
Instructing the staff to report only to the team
Directing the subordinates to report to all team leaders.
Joining the family of a Baptist client in singing hymn to the dying client.
32. Which principle does the nurse consider in
d. Accepting the anger of the Catholic client¶s family as a part of the grieving process.
supporting the client¶s right to self-determination? a.
Physician¶s order
b.
Consent
28. The nurse is monitoring the client¶s IV fluid
c.
Client¶s reaction
infusion. Which assessment finding, if noted in a
d.
Diagnosis
33. Immediately after surgery, the client has two IV
d.
Palpate bladder area every hour - 3 hours before
lines, a drainage tube, a foley catheter and an
termination to observe blockage or urethral
order for pain medication. Which of the following
stenosis
is the highest priority for the nurse? 38. Which of the following solutions used in enema in
a.
Nutrition
b.
Safety
c.
Input and Output
a.
Kayexalate
d.
Bladder Elimination
b.
Neomycin
c.
Normal Saline
d.
Hypertonic
34. Which of the following clients would qualify for
indicated for patients with hyperkalemia?
hospice care? a. A 25-year-old client with leukemia undergoing chemotherapy
39. The Wong-Baker rating scale is used to determine: a.
Degree of proliferation of Cancer cells
b. A 75-year-old with terminal metastatic cancer
b.
Intensity and severity of pain
c. A 30-year-old client undergoing rehabilitation for
c. Amount of radiation received during a radiation
heroin addiction d. A 45-year-old client with post-partum depression
therapy d.
The number of bacterial colony present in a microbial sensitivity test
35. Which of the following tasks should not be delegated by a nurse manager to a staff nurse? a.
40. Patient Ava was confined in a hospital due to
Evaluation of a new piece of equipment to be used
severe abdominal pain. In her chart, the following
by the staff in the unit
were listed: 25 mg Meperedine IVTT OD and 500
b.
Selection of a new nursing care delivery system
mg Mefenamic Acid TID. Upon administering the
c.
Preparation of vacation schedule
medications to the patient, patient verbalized ³I
d.
Inventory of equipment and supplies in the
usually get only one pill.´ Nurse Lenie is correct
nursing unit
when she:
36. When determining the priority needs of a client,
a.
Questions the doctor¶s order
b.
Informs the patient that the doctor ordered and it
which of the following should the nurse consider
is her responsibility as a nurse to carry out the
as the highest priority?
orders.
a.
Providing a safe environment
b.
Preservation of life
c.
Ensuring growth and development
d.
Minimizing environmental stimulation
c.
Leave the medications on the bedside and inform patient to take them when she is ready.
d.
Give the medications to the patient and tell her not to ask any questions.
37. Which of the following activities of Nurse Theresa
41. Patient Aricayos, suspected with having Urinary
is correct after receiving orders to terminate
Tract Infection was ordered to have a sample of
Urinary Catheter of Patient Skippy?
her urine sent to the laboratory for analysis. As a
a.
Observe patient for anxiety
student, you were instructed to observe the
b.
Intermittent clamping of catheter for 2-4 hours
procedure in obtaining samples through the
c. Allow patient to verbalize feelings of termination
indwelling catheter. You noted that the nurse
of catheterization
obtained 3-mL sample through a special port in
the tube. With your knowledge in this procedure,
45. When performing a neurologic assessment on a
you knew that the sample will be used to:
client, the nurse finds that the client¶s pupils are
a.
Determine the presence of protein in the urine
fixed and dilated. What does this assessment
b.
Identify the specific type of antibiotic to be used
indicate?
c.
Confirm the diagnosis of Renal Failure
a.
The client is paralyzed.
d.
Quantification of puss cells, if present, in the urine
b.
The client is going to be blind as a result of an
sample
42. Patient Skippy has just undergone Ishihara¶s test.
injury. c.
The client may have meningitis.
d.
The client has received a significant brain i njury.
According to his SO present during the test, the patient ³failed to read the numbers correctly´. You
46. Which of the following is not true about a
would interpret the statement as: a.
b.
hypothesis?
Client has a problem with visual acuity; probably
a.
It is testable
nearsighted or farsighted
b.
It is proven
The air conduction is less than the bone
c.
It is stated in form that it can be accepted or
conduction c.
The patient can¶t properly disseminate colors
d.
The patient has tunnel vision
rejected. d.
It states a relationship between variables.
47. A client refuses to take his/her medication. The 43. You are a nurse assigned to work in the
nurse tells the client that if he/she does not take
Emergency Department of USC hospital. During
the medication, he/she will be placed pl aced in a restraint.
your shift, a male patient was rushed in due to a
The nurse¶s statement can be used as a basis for
vehicular accident. In your assessment, patient
which violation?
was mumbling incomprehensible words and after
a.
Negligence
a minute you noted that patient¶s left eye no
b.
Malpractice
longer responds to light. You would question the
c.
Battery
doctor if he/she orders which of the following?
d. Assault
a.
Mannitol
b.
IV D5 0.9% NaCl at 30 gtts/min
c.
EEG determination
d.
Drainage of CSF
48. Which of the following is the recommended temperature for a sitz bath: a.
90 °F
b.
110 °F
44. Which would the nurse not list as a purpose of the
c.
120 °F
nursing code of ethics when discussing it with a
d.
125 °F
group of new employees? a.
Reminding nurses of the special responsibility
49. Which of the following combination of needles
they assume when caring for the si ck
and routes of medication administration is
b.
Guiding the profession in self-regulation
incorrect?
c.
Providing solutions for specific ethical situations
a.
25 G, 5/8´ long for insulin in sulin administration
d.
Outlining the major ethical considerations of the
b.
26 G, small bone for intradermal injection
nursing profession
c.
20 G, for injection for oil-based medications
d.
23 G, angio-catheter for blood administration in an
b.
adult client.
50. Which of the following characteristics of the vein
Includes foods that are liquid at room and body temperature
c.
Contains most nutrients
d.
Examples include popsicles, gelatins, and broths
should the nurse consider when initiating an IV infusion in the elderly?
55. Nurse Skippy listens attentively to the fears and
a.
Smaller size
concerns of her patient Ensure. Which of the
b.
Presence of pathological condition
following roles does Nurse Skippy portray?
c.
Fragility
a.
Caregiver
d.
Prominence
b.
Teacher
c. Advocate 51. The doctor orders an enteric coated medication
d.
Counselor
for a client on gastrostomy tube. What should the nurse do? a.
56. Community Health Nurse Jackie is the sole health
Crush the medication and administer through the
care worker in Barangay Alumnos. On the
tube by mixing with the food preparation.
morning, she visits the homes of the members of
b.
Dissolve it with water before giving the medication
the community to check their vital signs and
c.
Call the pharmacy immediately to request for a
dresses the wounds of some client. In this
change in form
scenario, Nurse Jackie portrays which role of a
d. Administer it orally
nurse? a.
Community Organizer
52. The hospital on which Nurse Jackie is working is
b.
Caregiver
on fire. In this situation, the first thing that Nurse
c.
Teacher
Jackie has to do is to:
d.
Client Advocate
a.
Confine the fire
b.
Try to extinguish the fire
c.
Call the fire department and report the fire
diagnosis and treatment of human responses to
d.
Rescue as many people as possible.
actual or potential health problems:
57. Defined nursing as the involvement in the
a. ANA 53. Which of the following considerations in teaching
b.
WHO
will you provide for an Older Adult patient?
c.
Dorothea Orem
a.
Learns best when benefit is gained
d.
Florence Nightingale
b.
Offer info and encourage participation and
58. Which of the following statement describes the
independent learning c.
d.
Intuitive Period of Nursing?
Teach on the afternoon around 1-3 PM to provide
a.
Early Christian
time for self-care
b.
On-The-Job Training
Present info in small amounts and at a slow pace
c.
Opening of the Florence Nightingale School of Nursing
54. All of the following statements are true when
d.
Social Changes
referring to Clear-Liquid diet except: a.
Prevents dehydration
59. Nurse Inday is caring for a client suffering from ESRD and has signed a DNR form. One day,
patient¶s vital signs crashed. In this case, Nurse
patient¶s chart to ³reinforce dressing PRN.´ Which
Inday¶s action will be governed by which Ethical
of the following procedures done would require a
Principle?
relearning in the basics of Nursing procedures?
a.
Dysthanasia
b.
Orthothanasia
a.
moistening some gauzes to be used in wound
c. Active Euthanasia d.
Passive Euthanasia
Nurse Harry Potter uses only normal saline in
care. b.
Nurse Harry Potter packs the wound carefully and meticulously and ensured the all spaces are
Situation: Mary, 18-years-old found out that she was pregnant. She told Rose, a friend, about her condition. Rose offered to
carefully filled up. c.
Nurse Harry Potter ensures that the gauzes used
assist her to solve her problem by referring to Grace, an
in the procedure are sealed and have not been
abortionist. After the abortion was performed, Nina, the helper
opened prior to its use.
of Grace, burned the linens and equipment used in the abortion.
d.
Nurse Harry Potter adds new dressing without removing the old one.
60. Which statement best describes Rose? a. A Principal
64. Which of the following correctly identifies a
b. Accomplice
leader?
c. Accessory
a.
Productivity
d.
b.
Stability
c.
Vision
d.
Smooth Operations
Plaintiff
61. Who would be the accomplice if lawsuits were filed by the state against them? a.
Rose
65. A plane crashes in a community where Nurse
b.
Nina
Jamie is working. During the initial response of
c.
Grace
the incident, which type of leadership is best
d.
None of the above
suited? a. Authoritarian
62. After an arduous legal battle, Judge Nacky has
b.
Democratic
decided that the evidence against Grace was
c.
Laissez-faire
strong and decided Grace guilty on the suit
d.
Multi-critic
against her. Months later, Grace petitioned the Court of Appeals to reconsider the decision.
66. Mrs. Pascual, RN, MAN, MSN is a US trained
Which of the following describes the position of
psychiatric nurse. As a dean, she derives her
the state?
authority over the faculty from which of the
a.
Respondent
following types of power?
b.
Principal
a.
Legitimate
c.
Plaintiff
b.
Expert
d.
Defendant
c.
Referent
d.
Information
63. Nurse Harry Potter is assigned to take care of a post-op patient who undergone an appendectomy. You have received an order, written on the
67. The research entitled ³Nurses and Unions:
from accessing your record, and that includes
Evolution of Filipino Nurses¶ Perception Towards
you.´
Unionism´ is of what type of qualitative research? research? a.
Phenomenological
71. Which of the following statements in the Physical
b.
Ethnographic
Assessment records would indicate a need to
c.
Historical
relearn the basics of charting?
d.
Grounded Theory
68. The research entitled ³Most Commonly Used Herbal Remedies in Brgy. Talamban´ can be
a.
Patient¶s lip is cyanotic
b.
Patient is hallucinating
c.
Trachea is midline
d.
CRT > 2 sec.
classified as: a.
Methodological Study
72. Nurse Jackie rushes to Room 3 to respond to a
b.
Case Study
patient who is experiencing a grand mal seizure.
c.
Survey Study
Which of the following interventions would Nurse
d.
Correlation Study
Jackie likely perform in response to the event? a. Administer Phenobarbitals STAT
69. Which of the following entries in the chart would
b.
Put patient in side lying
warrant Nurse Terai a relearning in the basics of
c.
Remove pillows and other objects that would
charting?
suffocate client
a.
The client has a Respiratory Rate of 19 CPM.
b.
The client says, ³I¶m beginning to hear the voices
c.
d.
d.
Raise side rails to prevent client from falling over
again.´
Situation: A 61-year-old man, Mr. Mendoza, is admitted to the
The client has fever when oral temperature was
private ward for observation after complaints of severe chest
taken at 7:00 AM
pain. You are assigned to take care of the client.
BP ± 130/100 73. When doing an initial assessment, the best way
70. During her routine visit to a client in Room 3,
for you to identify the client¶s priority problem is
patient asked Nurse Casera if she could read her chart and bring it home. The best response to this
to: a.
situation would be: a.
symptoms
³I¶m sorry ma¶am but I need to consult the Medical
b.
Director about this because the hospital is the
Talk to the relatives to gather data about history of illness
keeper of the medical records, and thus is
c.
Do auscultation to check for chest congestion
responsible for it.´
d.
Do a physical examination while asking the client
b.
³Yes, you are allowed to see it and bring it home.´
c.
³Yes you can actually read it! But unfortunately, you can only photocopy the chart.´
d.
Interview the client for chief complaints and other
relevant questions
74. Upon establishing Mr. Mendoza¶s nursing needs,
³I¶m sorry, that request cannot be granted. It has always been a policy of this institution to protect the
client¶s
record
against
breaches
the next nursing approach would be to: a.
in
confidentiality. This could be achieved by prohibiting anybody outside the medical team
Introduce the client to the ward staff to put the client and family at ease
b.
Give client and relatives brief tour of the physical set-up of the unit
c.
Take his vital signs for a baseline assessment
d.
Establish
priority
needs
and
implement
78. Considering her level of anxiety, the nurse can
appropriate interventions
75. Mr. Mendoza says he has ³trouble going to sleep´.
best assist Nancy by: a.
Giving her activities to divert her attention
b.
Giving detailed explanations about the treatments
In order to plan your nursing intervention, you will: a.
c.
Observe his sleeping patterns in the next few days
b. Ask him what he meant by this statement c.
she will undergo Preparing her and her family in case surgery is not successful d.
Check his physical environment to decrease noise
Giving her clear but brief information at the level of her understanding
level d.
Take his blood pressure before sleeping and upon
79. The nurse visit Nancy and prods her to eat her
waking up
food. Nancy replies, ³What¶s the use? My time is running out.´ The nurse¶s best response would
76. Mr. Mendoza¶s lower extremities are swollen and shiny. He has pitting pedal edema. When taking
be: a.
care of the client, which of the following interventions would be the most appropriate
will be strong for surgery.´ b.
immediate nursing approach? a.
Moisturize lower extremities to prevent skin
Measure fluid intake and output to decrease
³I understand how you feel but you have to try for your children¶s sake.´
c.
irritation b.
³The doctor ordered full diet for you so that you
³Have you told your doctor on how you feel? Are you changing your mind about the surgery?´
d.
³You sound like you are giving up.´
edema c.
Elevate lower extremities
80. The nurse feels sad about Nancy¶s illness and
d.
Provide the client with a list of foods low in
tells her head nurse during the end of shift
sodium
endorsement that ³it¶s unfair for Nancy to have cancer when she is still young and with two kids´.
77. Mr. Mendoza will be discharged from your unit within the hour. Nursing actions when preparing a
The best response of the head nurse would be: a. Advise the nurse to ³be strong and learn to
client for discharge include all except: a.
Making a final physical assessment before client
control her feelings´. b. Assign the nurse to another client to avoid
leaves the hospital b.
Giving instructions about his medication regimen
c.
Walking the client to the hospital exit to ensure his safety
d.
sympathy for the client c.
goes through all the treatments prescribed for her d. Ask the other nurses what they feel about the
Proper recording of pertinent data
Situation: Nancy, mother of 2 young kids, 36 years old, had a
Reassure the nurse that the client has hope if she
patient to find out if they share the same feelings
81. Which of the following does not govern nursing
mammogram and was told that she has breast cysts and that
practice?
she may need surgery. This increases her anxiety as shown by
a.
R.A. 7164
increased pulse and respiratory rate, sweating and feelings of
b.
R.A. 9173
tension.
c.
BON Res. Code of Ethics
d.
BON Res. Scope of Nursing Practice
d. Always never forget to recap a used needle to avoid accidental puncture
82. A nurse who is maintaining a private clinic in the community renders service on maternal and child
86. Patient Jaja is currently admitted for constipation.
health among the neighborhood for a fee is:
The doctor ordered digital removal of the stool.
a.
Primary care nurse
During the procedure, Nurse Daryl notices that
b.
Independent nurse practitioner
Jaja¶s heart rhythm changed. In response to this,
c.
Nurse-midwife
what should Nurse Daryl do?
d.
Nurse specialist
a.
Continue the procedure because it is a normal vagal response from the stimulation of the
83. A vest or jacket restraint is best used for which of
sphincter and rectal wall.
the following purposes?
b.
Reposition client to reduce stress
I.
To prevent a client from climbing out of
c.
Stop the procedure
bed
d. Ask client to perform deep breathing exercises to
II.
To prevent a client from falling out of a
promote relaxation
stretcher III.
To immobilize an arm
87. Upon reading the doctor¶s order in the chart,
IV.
To prevent inflicting injury to one¶s self
Nurse Nebz cannot comprehend the doctor¶s
and others
handwriting. The best response to this is:
a.
I, III
a. Ask a colleague first to see if he/she can read it
b.
I, IV
b. Approach the head nurse and ask if he/she can
c.
I, V
d.
I, II
decipher the order c. Approach the doctor directly and ask about the order
84. Which of the following activities indicates a need
d.
to reinforce education about Routine Fecalysis to
Go to the nurse manager and ask her to read the order to decrease liability
detect ova? a.
The use of sterile specimen container
b.
Placing sample in the refrigerator to keep sample
88. The major concern associated with Electronic Charting System is:
fresh and prevent microbial outgrowth
a.
Network Delay
c.
Collection of 1 inch of stool
b.
Privacy
d.
Helps in detecting parasites
c. Access to records at the same time d.
Network Collision
85. You are about to administer iron to a patient parenterally. Being a new hired nurse in the Sang
a.
b.
c.
89. Which of the following circumstances affecting
Carlows Hospital, you are expected to:
criminal liability can be applied to a person who
Delegate this task to an LPN while providing
committed a murder and surrenders to the
instruction while the LPN performs the task
authorities?
Ensure that the medication is within the muscle
a.
Justifying
tissues
b.
Mitigating
Instill medication though IVTT
c. Aggravating d.
Exempting
b. 90. A nurse was subpoenaed by the court about a malpractice suit filed against a physician. If asked
a.
Cold blood is indicated for patients with Paroxysmal Nocturnal Tachycardia
c.
BT patients should be in their rooms alone to
by the court about certain aspects of the treatment
promote privacy and reduce the occurrence of
received, the nurse would:
tachycardia due to anxiety
Not divulge any information to the court because
d.
it is part of Privileged Communication
Use of 18 or 19 G angiocatheter during the process
b. Answer the questions because it is a legal process c.
95. Nurse Jackie has just administered Xanax to a
Not go to court and not answer the subpoena
patient. An hour after, Nurse Jackie observes
d. Answer the questions only if the patient provides
client to be talking a lot and have a lot of energy
consent to divulge pertinent data
than usual. Nurse Jackie identifies it as: a.
91. As part of working the night shift, Nurse Lenie is
Hypersensitivity reaction
b. Adverse Effect
currently obtaining the vital signs of patient
c.
Desired Effect
Jamie. Nurse Jade notices Jamie to be grinding
d.
Paradoxical Reaction
and clenching her teeth during sleep. Nurse Jade knows this as:
96. At what level of training should a nurse be able to
a.
Somnambulism
engage in independent nursing practice?
b.
Soliloquy
a.
c.
Bruxism
b. Advanced Practice
d.
Narcolepsy
c.
Newly hired
d.
Licensed
Student
92. The following are purposes of enema except: a.
Reduce body temperature
97. Which among the actions of Nurse Paul indicates
b.
Facilitate administration of medications
lack of knowledge regarding fire safety and
c.
Promote fecal evacuation
response?
d.
Promote water exchange
a.
Remove all clients from the vicinity of a fire first
b.
Nurse Jackie prohibits an ambulatory patient from
93. Nurse Theresa is currently taking care of a patient
moving a wheelchair bound client and asks them
with ileostomy. In taking care of the patient, all of the considerations are true except: a.
to leave scene immediately c.
Moisturize skin around the stoma before applying appliance
b. Appliance can be used up to 2 weeks
Nurse Jackie maintains a client on life support with Ambu-bag
d.
Nurse Jackie informs clients not to use the elevator
c. Avoiding gas-forming foods and nuts d.
Yogurt is recommended to decrease odor of feces
98. Nurse Inday is currently assigned in the PACU. She observes the client to be in a state of Post-
94. Which of the following statements are true
a.
Anesthetic Dementia in which client becomes
regarding Blood Transfusion?
combative, consistently attempts to pull his IV
Length of infusion should not be extended beyond
lines, and shouts incoherent words. The doctor,
2 hours to prevent blood coagulation and spoilage
upon seeing the situation writes the order
³Restraints PRN´. Nurse Inday is right when she immediately: a. Applies the restraints immediately by tying patient¶s hands to the side rails tightly b. Applies
the
restraints
by
tying
patient¶s
extremities while providing space for circulation along the extremity c.
Questions the doctor¶s order
d.
Uses the Mitten Restraint because it is less restrictive and still inhibits client from pulling the tubes
99. Peter Paul, who has Meniere¶s disease, said that her environment is moving. Which of the following is a valid assessment? I.
Peter Paul is giving an objective data
II.
Peter Paul is giving a subjective data
III.
The source of the data is primary
IV.
The source of the data is secondary a.
I, III
b.
II, III
c.
II, IV
d.
I, IV
100. You are a Nurse assigned in the orthopedic ward of the Sang Carlows Hospital. During your shift, SO immediately calls your attention to a patient who just received large amount of Xanax. Upon entering the room, you have noticed that the patient has been electrocuted in an attempt to pull out the plugs. Your IMMEDIATE response would be to: a.
Hold the patient and forcefully pull him away from the plug.
b.
Prepare to inject bolus of Epinephrine
c. Activate code blue d.
Call the electrical unit of the hospital to shut down electricity in the unit.
***END OF EXAM***
