NURSING PRACTICE 1 Foundation of PROFESSIONAL Nursing Practice

1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive ano!in. What
shou"d Nurse Suzie do when one o# the c"ients does N$T have a reada%"e identi#ication %and&
A. 's( the c"ient i# she is Mrs. Santos
. As! t"e c#ient "is na$e
C. 's( the room mate i# the c"ient is Mrs. Santos
%. )ompare the *+ %and with the %ed %ag
,ationa"e: wear -our *+ %and #or sa#et-. .our wrist%and *+ wi"" %e chec(ed man- times during -our sta-. .ou
ma- a"so %e as(ed -our name and another identi#ier/ such as -our %irthda-/ repeated"-.
2. izette/ a head nurse in surgica" unit/ hears one o# the sta## nurses sa- that she does not touch an- c"ient
assigned to her un"ess she per#orms nursing procedures or conducts ph-sica" assessment. To guide the sta##
nurse in the use o# touch/ which o# the #o""owing wou"d %e the 01ST response o# izette&
A. 23se touch when the situation ca""s #or it4
. &Touc" ser'es as a connection (et)een t"e nurse and t"e *atient+
C. 23se touch with discretion4
%. 2Touch is used in ph-sica" assessment4
Touc" and 'isua#isation to faci#itate a t"era*eutic re#ations"i* in an intensi'e care unit,,a *ersona# e-*erience.
T"is *a*er descri(es "o) t"e nature of touc" )as e-*#ored and uti#ised in nursing *ractice to *ro$ote a t"era*eutic re#ations"i* (et)een nurse
and c#ient in an intensi'e care setting. It e-*#ains "o) t"is. and ot"er co$*#e$entar/ t"era*ies suc" as 'isua#isation and re#a-ation tec"ni0ues.
)ere used to faci#itate a counse##ing situation. and a#so to effect t"e reso#ution of acute an-iet/ as an a#ternati'e to t"e traditiona# a##o*at"ic
a**roac".
5. .ou are as(ed to teach the c"ient/ Mr. apuz/ who has rig"t sided )ea!ness the use o# a cane. Which
o%servation wi"" indicate that Mr. apuz is using the cane correct"-&
A. The cane and one #oot or %oth #eet are on the #"oor at a"" times
. 6e advances the cane #o""owed %- the "e#t "eg
C. C#ient !ee*s t"e cane on t"e rig"t side a#ong t"e )ea! #eg
%. )"ient "eans to the "e#t side which stronger
)ane $pposite '##ected eg
4. 7eorge/ a 45 -ear o"d e!ecutive/ is schedu"ed #or cardiac %-pass surger-. Whi"e %eing prepared #or surger-/
he sa-s to the nurse 2* am not going to have the surger-. * ma- die %ecause o# the ris(4. Which response %-
the nurse is most appropriate&
A. 2Without the surger- -ou wi"" most "i(e"- die sooner4
. 2There are a"wa-s ris(s invo"ved with surger-.4
C. 2There is a c"ient in the other room who had success#u" surger- and -ou can ta"( to him4
%. &T"is $ust (e 'er/ frig"tening for /ou. Te## $e "o) /ou fee# a(out t"e surger/+
8. ' c"ient is ordered to ta(e asi!/ a diuretic/ to %e ta(en ora""- dai"-. Which o# the #o""owing is an
appropriate instruction %- the nurse&
A. Re*ort to t"e *"/sician t"e effects of t"e $edication or urination
. Ta(e the medicine ear"- in the morning
C. Ta(e a #u"" g"ass o# water with the medicine
%. Measure #re9uenc- o# urination in 24 hours
,ationa"e: asi! wi"" ma(e -ou urinate more o#ten and -ou ma- get deh-drated easi"-. :o""ow -our doctor;s instructions a%out using potassium
supp"ements or getting enough sa"t and potassium in -our diet.
<. Nurse 7"enda gets a ca"" #rom a neigh%or who te""s her that his 5 -ears o"d daughter has %een vomiting and
has #ever and as(s #or advice. Which o# the #o""owing is the most appropriate action o# the nurse&
A. $%serve the chi"d #or an hour. *# the chi"d does not improve/ re#er to the ph-sician in the
neigh%orhood
. ,ecommend to %ring the chi"d immediate"- to the hospita"
C. 'ssess the chi"d/ recommend o%servation and administer acetaminophen. *# s-mptoms continue/
%ring to the hospita"
%. Te## t"e neig"(or to o(ser'e t"e c"i#d and gi'e *#ent/ of f#uids. If t"e c"i#d does not i$*ro'e.
ring t"e c"i#d to t"e "os*ita#
=. Wi"#red/ 50 -ears o"d ma"e/ was %rought to the hospita" due to in>uries sustained #rom a vehicu"ar accident.
Whi"e %eing transported to the ?@ra- department/ the straps accidenta""- %ro(e and the c"ient to the #"oor
hitting his head. *n this situation/ the nurse is:
A. Not responsi%"e %ecause o# the doctrine o# respondent superior
. :ree #rom an- neg"igence that caused harm to the patient
C. Lia(#e a#ong )it" t"e e$*#o/er for t"e use of a defecti'e e0ui*$ent t"at "ar$s t"e c#ient
%. Tota""- responsi%"e #or the neg"igence
A. Whi"e going on evening round/ Nurse 1dna saw Mrs. Pascua" meditating and a#terwards started singing
pra-er#u" h-mns. What is the 01ST response o# 1dna&
A. *gnore the incidence
. ,eport the incidence to the head nurse
C. Res*ect t"e c#ient1s actions as t"is *ro'ides structure and su**ort to t"e c#ient
%. )a"" her attention so she can go to s"eep
B. ' c"ient as(s #or advice on "ow cho"estero" #ood. .ou advise the c"ient to eat the #o""owing:
A. )hic(en "iver/ cow "iver/ eggs
. Lean (eef and *or!. egg )"ite. fis"
C. 0a"ut/ sa"ted eggs/ duc( and chic(en egg
%. Por( "iempo/ cow %rain/ "ungs and (idne-
10. The code o# ethics #or nurses has an interpretative statement that provides:
A. )ontinuit- o# care #or the improvement o# the c"ient
. Guide for carr/ing out nursing res*onsi(i#ities t"at t"e *ro'ide 0ua#it/ care and for t"e
et"ica# o(#igation of t"e *rofession
C. Standards o# care in carr-ing out nursing responsi%i"ities
%. *dentica" care to a"" c"ients in an- setting
11. Which o# the #o""owing situations wou"d possi%"- cause a nurse to %e sued due to neg"igence&
A. Nurse ga'e a c#ient )rong $edication and an "our #ater. c#ient co$*#ained of d/s*nea
. Whi"e preparing a medication/ the nurse notices that instead o# 1 ta%"et/ she put two ta%"ets into the
c"ientCs medicine cup
C. 's the nurse was a%out to administer education/ the c"ient 9uestioned wh- the medication is sti""
given when in #act the ph-sician discontinued it
%. Nurse administered 2 ta%"ets o# ana"gesic instead o# 1 ta%"et as prescri%ed. Patient noticed the error
and comp"ained
,ationa"e: When a nurse has %een named in a "awsuit #or in>uring a patient

whi"e he or she was on dut-/ such a "awsuit is #or Dneg"igence.D

Man-
times/ it is a"so re#erred to as nursing ma"practice %ecause

the nurse/ in his or her ro"e as a nurse/ is accused o# doing

something that in#"icted in>ur- to a
patient.
12. .our nurse supervisor as(s -ou who among the #o""owing c"ients is most suscepti%"e to getting in#ection i#
admitted to the hospita".
A. +ia%etic c"ient t-pe 2
. )"ient with chronic o%structive pu"monar- disease E)$P+FG
C. C#ient )it" second degree (urns
%. )"ient with psoriasis
,ationa"e: S(in is the #irst "ine o# de#ense against pathogenic microorganisms. 0ecause it inter#aces with the
environment/ s(in p"a-s a ver- important ro"e in protecting Ethe %od-F against pathogens. *ts other #unctions are
insu"ation/ temperature regu"ation/ sensation/ s-nthesis o# vitamin +/ and the protection o# vitamin 0 #o"ates.
15. Mr. )hris Martinez has %een con#ined #or three da-s. 6is wi#e he"ped ta(e care o# him and he has o%served
her to %e 2too invo"ved4 in his care. 6e comp"ained to the head nurse a%out this. Which o# the #o""owing
wou"d %e the 01ST response o# the nurse&
A. 2+onCt worr-. * wi"" ca"" the attention o# -our wi#e4
. 2.our wi#e is >ust tr-ing to he"p %ecause she is worried a%out -ou4
C. &2"at are /our t"oug"ts a(out /our )ife1s in'o#'e$ent in /our care+3
%. 2.our wi#e can assist -ou we"" in -our care and recover-:
14. The nurse is in the hospita" canteen and hears who sta## nurses ta"(ing a%out the c"ient con#ined in ,oom
<12. The- mentioned his name and discussed detai"s o# his condition. Which o# the #o""owing actions
shou"d the nurse ta(e&
A. A**roac" t"e t)o nurses and te## t"e$ t"eir actions are ina**ro*riate es*ecia##/ in a *u(#ic
*#ace
. Wait ti"" nurses #inish the discussion ad report the situation to the supervisor
C. Sa- nothing to avoid em%arrassing the sta## nurses
%. ,emain 9uiet and ignore the discussion
18. The son o# Mr. ,osario/ a =< -ear o"d man/ reports to the nursing the communit- hea"th center that his
#ather has %een getting out o# %ed at night and wa"(s around the house in the ear"- hours o# the morning
causing him to #a"" and in>ure himse"#. Which instruction wi"" -ou give&
'. 'pp"- restrains during the night hours on"-
0. 'dvise hospita"ization to prevent #uture accidents
). Heep a radio or TI #or compan- and to orient the c"ient
+. 4a'e so$eone c"ec! on t"e c#ient fre0uent#/ at nig"t
SITUATIONAL
Situation 1 J Preparation and administration o# the medications is a nursing #unction that cannot %e de"egated. *t is
important that the nurse has a deep understanding o# this responsi%i"it- that is meant to save patientCs "ives.
1<. .ou are to administer an intramuscu"ar in>ection to +u"ce/ 1 K -ear o"d gir". The most appropriate site to
administer the drug is:
A. +orso g"utea" region C. 5astus #atera#is
. Ientra" #orearm +. 7"utea" region
1=. 'n in#ant is ordered to receive 800 m" o# +8NSS #or 24 hours. The *ntravenous drip is running at <0
dropsLminute. 6ow man- drops per minute shou"d #"ow rate %e&
A. <0 drops per minute ). 50 drops per minute
. 21 drops per minute +. 18 drops per minute
1A. :o""owing surger-/ 6enr- is to receive 20 m19 Emi""ie9uiva"entF o# potassium ch"oride to %e added to 1000
m" o# +8W to run #or A hours. The intravenous in#usion set is ca"i%rated at 20 drops per mi""i"iter. 6ow
man- drops per minute shou"d the rate %e to in#use 1 "iter o# +8W #or A hours&
A. 42 drops ). <0 drops
. 20 drops +. 52 drops
1B. Mr. argo is to receive 1 "iter o# +8, to run #or 12 hours. The drop #actor o# the *I in#usion set is 10
drops per minute. 'ppro!imate"- how man- drops per minute shou"d the *I %e regu"ated&
A. 15@14 drops ). 10@12 drops
. 1=@1A drops +. 18@1< drops
20. The ph-sician ordered Nem%uta" Na gr ??. The %ott"e contains 100 mgLcapsu"e. 6ow man- capsu"es wi""
%e administered to the c"ient&
A. 1 capsu"e ). 2 capsu"e
. 1 K capsu"e +. K capsu"e
Situation 2 J The nurse supervisor is o%serving the sta## nurses in her hospita" to see how 9ua"it- o# care provided
to c"ients can %e improved
21. The nurse supervisor is not satis#ied with the %ed %ath that is provided %- Nurse 'rthur. To improve the
care provided to the patients in the unit %- Nurse 'rthur/ the nurse supervisor shou"d:
A. Te"" the nurse how to give %ed %aths correct"-
. 's( another sta## nurse to do the %ed %aths instead
C. Provide a manua" to %e read on giving %ed %aths
%. ring t"e staff nurse to a c#ient1s roo$ and de$onstrate a c#eansing (at"
22. The sta## nurse discusses with the novice nurse the t-pe o# wound dressing that is %est to use #or a c"ient.
Together/ the- o%serve how we"" the dressings a%sor% the drainage. *n what step o# the decision ma(ing
process are the-&
A. Testing option ). +e#ining the pro%"em
. Considering effects on resu#t +. Ma(ing #ina" decisions
25. To chec( i# the nurses under her supervision use critica" thin(ing/ Mrs. +avid o%serves i# the nurses act
responsi%"- when at wor(. Which o# the #o""owing actions o# a nurse demonstrates the attitude o#
responsi%i"it-&
A. Thin(ing o# a"ternative methods o# nursing care
. Sharing ideas regarding patient care
C. Fo##o)ing standards of *ractice
%. P"anning other approaches #or patient care
24. The nurse who ma(es c"inica" >udgment can %e depended upon to improve the 9ua"it- o# care c"ients. Nurse
Mu"ie uses such good c"inica" >udgment when she gives priorit- care to this c"ient:
A. ,oman/ a c"ient who is am%u"ator- and #or surger- tomorrow
. A *ost,o*erati'e c#ient. Re/. )"o "as a (#ood *ressure of 67897 $$4g
C. Mr. '%ad/ a c"ient who needs instructions #or home medications
%. :red/ a c"ient who received pain medication 8 minutes ago
28. ' good nursing care p"an is dependent on a correct"- written nursing diagnosis. *t de#ines c"ientCs pro%"em
and its possi%"e cause. The #o""owing is an e!amp"e o# a we"" written nursing diagnosis:
A. 'cute pain re"ated to a"tered s(in integrit- secondar- to h-sterectom-
. 1"ectro"-te im%a"ance re"ated to h-poca"cemia
C. A#tered nutrition re#ated to "ig" fat inta!e secondar/ to o(esit/
%. Hnow"edge de#icit re"ated to proctosigmoidoscop-
Situation 5 J .ou are ta(ing care o# Mrs. e-%a/ << -ears o"d/ who is termina""- i"" with ovarian cancer stage *I
2<. When caring #or a d-ing c"ient -ou wi"" per#orm which o# the #o""owing activities&
A. 1ncourage the c"ient to reach optima" hea"th
. 'ssist c"ient per#orm activities o# dai"- "iving
C. Assist t"e c#ient to)ards a *eacefu# deat"
%. Motivate c"ient to gain independence
2=. The c"ient prepares #or her eventua" death and discusses with the nurse and her #ami"- how she wou"d "i(e
her #unera" to "oo( "i(e and what dress she wi"" use. This c"ient is in the stage o#:
A. Acce*tance ). +enia"
. ,eso"ution +. 0argaining
2A. The nurse is to administer +emero" 80 mg and Iistari" 80 mg. *M to Mrs. e-%a. +emero" is avai"a%"e in a
$u#tidose 'ia# "a%e""ed 100mgLm" whi"e Iistari" comes in an ampu"e "a%e""ed 80mgLm". -ou are to give the
%oth medications in one in>ection. .ou wi"":
A. 2it"dra) t"e $edication fro$ t"e 'ia# first t"en fro$ t"e a$*u#e
. *n>ect air into the via"/ then into the ampu"e
C. *n>ect air into the ampu"e/ aspirate desired dose/ then into the via"
%. Withdraw medication #rom the ampu"e then #rom the via"
2B. When giving +emero" 80 mg #rom the mu"tidose via" "a%e""ed 100 mgLm" and Iistari" 80 mgLm" #rom an
ampu"e "a%e""ed 80 mgLm"/ what is the tota" vo"ume that wi"" in>ect to the c"ient&
A. 2 m" C. 1.9 $#
. 1 m" +. 1.=8 m"
50. Mrs. e-%a is emaciated and is at ris( #or deve"oping which pro%"em in s(in integrit-&
A. 0"isters C. Pressure sores
. ,eddening o# the s(in +. Pustu"es
Situation 4 J .ou are assigned to wor( in an orthopedic ward where c"ients are e!pected to have pro%"ems in
mo%i"it- and immo%i"it-:
51. ,ami"Cs right "eg is in>ured and Nurse Haren has to move him #rom the %ed to a whee" chair. Which o# the
#o""owing is the appropriate nursing action o# Nurse Haren&
A. Put the c"ient on the edge o# the %ed and p"ace the whee"chair at her %ac(
. :ace the c"ient and p"ace the whee"chair on her "e#t side
C. Put the c"ient on the %ed and p"ace the whee"chair on the other side o# the %ed
%. Put t"e c#ient on t"e edge of t"e (ed and *#ace t"e )"ee#c"air on t"e c#ient1s #eft side
52. )ar"o has to %e maintained on a dorsa" recum%ent position. Which o# the #o""owing shou"d %e prevented&
A. 'dduction o# the shou"der
. atera" #"e!ion o# the sternoc"eidosmatoid musc"e
C. 6-pere!tension o# the (nees
%. Anterior f#e-ion of #u$(ar cur'ature
55. Moseph pre#ers to %e in high #ow"erCs position most o# the time. The nurse shou"d prevent which o# the
#o""owing&
A. Posterior f#e-ion of t"e #u$(ar cur'ature
. *nterna" rotation o# the shou"der
C. 1!terna" rotation o# the hip
%. 'dduction o# the shou"der
54. 'nthon- as(s to %e assisted to move up the %ed. Which o# the #o""owing shou"d Nurse +iana do #irst&
A. Move the patient to the edge o# the %ed near the nurse
. 'd>ust the %ed to the #"at position
C. Loc! t"e )"ee#s of t"e (ed
%. ,aise the %ed rai"s opposite the nurse
58. Which o# the #o""owing supportive devices can %e used most e##ective"- %- Nurse 'rno"d to prevent
e!terna" rotation o# the right "eg&
A. Sand(ags ). Pi""ow
. :irm mattress +. 6igh #oot %oard
Situation 8 J 's -ou %egin wor( in the hospita" where -ou are on pro%ation/ -ou are tas(ed to ta(e care o# a #ew
patients. The c"ients have varied needs and -ou are e!pected to provide care #or them.
5<. 'n am%u"ator- c"ient/ Mr. Nosimo/ is %eing prepared #or %ed. Which o# the #o""owing nursing actions
promote sa#et- #or the c"ient&
A. Turning o## the "ights to promote s"eep and rest
. *nstructing the c"ient a%out the use o# the ca"" s-stem
C. Raising t"e side rai#s
%. P"acing the %ed in high position
5=. Mi((a/ a 28 -ear o"d #ema"e c"ient/ is admitted with right "ower 9uadrant a%domina" pain. The ph-sician
diagnosed the c"ient with acute appendicitis and an emergenc- appendectom- was per#ormed. Twe"ve hours
#o""owing surger-/ the patient comp"ained o# pain. Which o# the #o""owing is the most appropriate nursing
diagnosis&
A. *mpaired mo%i"it- re"ated to pain secondar- to an a%domina" incision
. *mpaired movements re"ated to pain due to surger-
C. *mpaired mo%i"it- re"ated to surger-
%. Se'ere *ain re#ated to surger/
5A. .ou are preparing a p"an o# care #or a c"ient who is e!periencing pain re"ated to incisiona" swe""ing
#o""owing "aminectom-. Which o# the #o""owing shou"d %e inc"uded in the nursing care p"an&
A. 1ncourage the c"ient to "og ro"" when turning
. 1ncourage the c"ient to do se"#@care
C. Instruct t"e c#ient to do dee* (reat"ing e-ercises
%. 'm%u"ate the c"ient in the ward premises ever- twent- minutes
5B. Mr. ozano/ 80 -ear o"d e!ecutive/ is recovering #rom severe m-ocardia" in#arction. :or the past 5 da-s/
Mr. ozanoCs h-giene and grooming needs have %een met %- the nursing sta##. Which o# the #o""owing
activities shou"d %e imp"emented to achieve the goa" o# independence #or Mr. ozano&
A. *nvo"ving #ami"- in meeting c"ientCs persona" needs
. Meeting his needs ti"" he is read- to per#orm se"#@care
C. Preparing a da- to da- activit- "ist to %e #o""owed %- c"ient
%. In'o#'ing :r. Lo;ano in "is care
40. Mr. 1rnest opez is termina""- i"" and he chose to %e at home with his #ami"-. What nursing actions are %est
initiated to prepare the #ami"- o# Mr. opez&
A. Ta"( with the #ami"- mem%ers a%out the advantage o# sta-ing in the hospita" #or proper care
. Pro'ide su**ort to t"e fa$i#/ $e$(ers (/ teac"ing )a/s to care for t"eir #o'ed one
C. )onvince the c"ient to sta- in the hospita" #or pro#essiona" care
%. Te"" the c"ient to %e with his #ami"-
Situation < J M-rna/ a researcher/ proposes a stud- on the re"ationship %etween hea"th va"ues and the hea"th
promotion activities o# sta## nurses in a se"ected co""ege o# nursing.
41. *n %oth 9uantitative 9ua"itative research/ the used o# a #rame o# re#erences is re9uired. Which o# the
#o""owing items serves as the purpose o# a #ramewor(&
A. *ncorporates theories into nursingCs %od- o# (now"edge
. $rganizes the deve"opment o# stud- and "in(s the #indings to the nursingCs %od- o# (now"edge
C. Pro'ides #ogica# structure of t"e researc" findings
%. *denti#ies concepts and re"ationships %etween concepts
42. M-rna needs to review re"evant "iterature and studies. The #o""owing processes are underta(en in reviewing
"iterature 1?)1PT:
A. ocating and identi#-ing resources ). )"ari#-ing a research topic
. ,eading and recording notes %. Using t"e #i(rar/
45. The primar- purpose #or reviewing "iterature is to:
A. $rganize materia"s re"ated to the pro%"em o# interest
. Generate (road (ac!ground and understanding of infor$ation re#ated to t"e researc"
*ro(#e$ of interest
C. Se"ect topics re"ated to the pro%"em o# interest
%. 7ather current (now"edge o# the pro%"em o# interest
44. *n #ormu"ating the research h-pothesis/ researcher M-rna shou"d state the research 9uestion as
A. What is the response o# the sta## nurses to the hea"th va"ues&
. 6ow is varia%"e 2hea"th va"ue4 perceived in a popu"ation&
C. Is t"ere a significant re#ations"i* (et)een "ea#t" 'a#ues and "ea#t" *ro$otion acti'ities of t"e
staff nurses3
%. 6ow do hea"th va"ues a##ect hea"th promotion activities o# the sta## nurses&
48. The proposed stud- shows the re"ationship %etween the varia%"es. Which o# the #o""owing is the
independent varia%"es&
A. Sta## nurses in a se"ected co""ege o# nursing
. 4ea#t" 'a#ues
C. 6ea"th promotion activities
%. ,e"ationship %etween hea"th va"ues and hea"th promotion activities
Situation = J Whi"e wor(ing in a tertiar- hospita"/ -ou are assigned to he medica" ward
4<. .our c"ient/ Mr. +iaz/ is concerned that he can not pa- his hospita" %i""s and pro#essiona" #ees. .ou re#er
him to a:
A. Nurse supervisor ). 0oo((eeping department
. Socia# )or!er +. ph-sician
4=. Mr. Magno has "ung cancer and is going through chemotherap-. 6e is re#erred %- the onco"og- nurse to a
se"#@he"p group o# c"ients with cancer to:
A. Recei'e e$otiona# su**ort ). Provide #inancia" assistance
. To %e part o# a research stud- +. 'ssist with chemotherap-
4A. ' dia%etic h-pertensive c"ient/ Mrs. inao/ needs a change in diet to improve her hea"th status. She shou"d
re#erred to a:
A. Nutritionist ). Ph-sician
. %ietitian +. Medica" Patho"ogist
4B. When co""a%orating with other hea"th team mem%ers/ the %est description o# Nurse ,itaCs ro"e is:
A. 1ncourages the c"ientCs invo"vement in his care
. S"ares and i$*#e$ents orders of t"e "ea#t" tea$ to ensure 0ua#it/ care
C. She "istens to the individua" views o# the team mem%ers
%. 6e"ps c"ient set goa"s o# care and discharge
80. Nurse ,ita is success#u" in co""a%orating with hea"th team mem%ers a%out the care o# Mr. inao. This is
%ecause she has #o""owing competencies:
A. Co$$unication. trust. and decision $a!ing
. )on#"ict management/ trust/ negotiation
C. Negotiation/ decision ma(ing
%. Mutua" respect/ negotiation/ trust
Situation A J The practice o# nursing goes with responsi%i"ities and accounta%i"it- whether -ou wor( in a hospita"
or in a communit- setting to -our main o%>ective is to provide sa#e nursing to -our c"ients&
81. To provide sa#e 9ua"it- nursing care to various c"ients in an- setting/ the most important too" o# the nurse is:
A. Critica# t"in!ing to decide a**ro*riate nursing actions
. 3nderstanding o# various nursing diagnoses
C. $%servation s(i""s #or data co""ection
%. Possession o# in scienti#ic (now"edge a%out c"ient needs
82. .ou ensure the appropriateness and sa#et- o# -our nursing interventions whi"e caring #or various c"ient
groups %-:
A. )reating p"ans o# care #or particu"ar c"iente"e
. *denti#-ing the correct nursing diagnoses #or c"ients
C. :a!ing a t"oroug" assess$ents of c#ient needs and *ro(#e$s
%. 3sing standards o# nursing care as -our criteria #or eva"uation
85. The e##ectiveness o# -our nursing care p"an #or -our c"ients is determined %-
A. The num%er o# nursing procedures per#ormed to com#ort the c"ient
. The amount o# medications administered to the c"ient as ordered
C. The num%er o# times the c"ient ca""s the nurse
%. T"e outco$e of nursing inter'entions (ased on *#an of care
84. .ou are assigned to Mrs. 'mado/ age 4B/ who was admitted #or possi%"e surger-. She comp"ained o#
recurrent pain at the right upper 9uadrant o# the a%domen 1@2 hours a#ter ingestion o# #att- #ood. She a"so
had #re9uent %outs o# dizziness/ %"ood pressure o# 1=0L100/ hot #"ashes. Which o# the a%ove s-mptoms
wou"d %e an o%>ective cue&
A. #ood *ressure $easure$ent of 1<78177
. )omp"aint o# hot #"ashes
C. ,eport o# pain a#ter ingestion o# #att- #ood
%. )omp"aint o# #re9uent %outs o# dizziness
88. Whi"e ta"(ing with Mrs. 'mado/ it is most important #or the nurse to:
A. Schedu"e the "a%orator- e!ams ordered #or her
. %o an assess$ent of t"e c#ient to deter$ine *riorit/ needs
C. Te"" the c"ient that -our shi#t ends a#ter eight hours
%. 6ave the c"ient sign an in#ormed consent
Situation B J $ra" care is an important part o# h-gienic practices and promoting c"ient com#ort.
8<. 'n e"der"- c"ient/ A4 -ears o"d/ is unconscious. 'ssessment o# the mouth revea"s e!cessive dr-ness and
presence o# sores. Which o# the #o""owing is 01ST to use #or ora" care&
A. emon g"-cerine ). Minera" oi"
. 6-drogen pero!ide %. Nor$a# sa#ine so#ution
Norma" Sa"ine is common"- used especia""- #or the management o# mouth sores. emon g"-cerine causes #urther
dr-ness. Minera" oi" is contraindicated #or the ris( o# aspiration E"ipid pneumoniaF/ 6-drogen pero!ide irritates ora"
mucosa and a"ter the norma" #"ora o# the mouth.
8=. When per#orming ora" care to an unconscious c"ient/ which o# the #o""owing is a specia" consideration to
prevent aspiration o# #"uids into the "ungs&
A. Put the c"ient on a side"-ing position with head o# %ed "owered
. Heep the c"ient dr- %- p"acing towe" under the chin
C. Wash hands and o%serve appropriate in#ection contro"
%. C#ean $out" )it" ora# s)a(s in a carefu# and an order#/ *rogression
8A. The advantages o# ora" care #or a c"ient inc"ude a"" o# the #o""owing/ 1?)1PT:
A. +ecreases %acteria in the mouth and teeth
. ,educes need to use commercia" mouthwash wLc irritate the %ucca" mucosa
C. I$*ro'es c#ient1s a**earance and se#f,confidence
%. *mproves appetite and taste o# #ood
8B. ' possi%"e pro%"em whi"e providing ora" care to unconscious c"ients is the ris( o# #"uid aspiration to "ungs.
This can %e avoided %-:
A. )"eaning teeth and mouth with cotton swa%s soa(ed with mouth wash to avoid rinsing the %ucca"
cavit-.
. S)a((ing t"e inside of t"e c"ee!s and #i*s. tongue and gu$s )it" dr/ cotton s)a(s.
C. 3se #ingers wrapped with wet cotton washc"oth to ru% inside the chee(s/ tongue/ "ips and gums.
%. Suctioning as needed whi"e c"eaning the %ucca" cavit-.
<0. .our c"ient has di##icu"t- o# %reathing and mouth %reathing most o# the time. This causes dr-ness o# the
mouth with unp"easant odor. $ra" h-giene is recommended #or the c"ient and in addition/ -ou wi"" (eep the
mouth moisten %- using:
'. Sa"t so"ution
. 2ater
). Petro"eum >e""-
+. Mentho"ated ointment
Situation 10 @ 1rrors whi"e providing nursing care to patients must %e avoided and minimized at a"" times. 1##ective
management o# avai"a%"e resources ena%"es the nurse to provide sa#e 9ua"it- patient care.
<1. *n the hospita" where -ou wor(/ increased incidence o# medication error was identi#ied as the num%er one
pro%"em in the unit. +uring the %rainstorming session department/ pro%a%"e causes were identi#ied. Which
o# the #o""owing process re"ated&
'. *nterruptions
0. 3se o# uno##icia" a%%reviations
). ac( o# (now"edge
%. Fai#ure to identif/ c#ient
<2. Miscommunication o# drug orders was identi#ied as a pro%a%"e cause o# medication error. Which o# the
#o""owing is a sa#e medication practice is re"ated to this&
'. Maintain medication in its unit dose pac(age unti" point o# actua" administration
0. Note %oth generic and %rand name o# the medication in the Medication 'dministration ,ecord
C. On#/ officia##/ a**ro'ed a((re'iations $a/(e used in t"e *rescri*tion orders
+. 1ncourage c"ients to as( 9uestion a%out their medications
<5. The hospita" has an ongoing 9ua"it- assurance program. Which o# the #o""owing indicates imp"ementation
o# process standards&
'. The nurses chec( c"ientCs identi#ication %and %e#ore giving medications
0. The nurse reports adverse reaction to drugs
C. A'erage )aiting ti$e for $edication ad$inistration is $easured
+. The unit has we"" venti"ated medication room
<4. Which o# the #o""owing actions indicate that Nurse Merome is per#orming outcome eva"uation 9ua"it- care&
'. *nterviews nurses #or comments regarding sta##ing
0. Measures waiting time #or c"ients per nurseCs ca""
). )hec(s e9uipment #or its ca"i%ration schedu"e
%. %eter$ines )"et"er nurses *erfor$ s!in assess$ent e'er/ s"ift
<8. 'n order #or a c"ient was given and the nurse in charge o# the c"ient reports that she has no e!perience o#
doing the procedure %e#ore. Which o# the #o""owing is the most appropriate action o# the nurse supervisor&
'. 'ssign another nurse to per#orm the procedure
0. 's( the nurse to #ind a wa- to "earn the procedure
). Te"" the nurse to read the procedure manua"
%. %o t"e *rocedure )it" t"e nurse
Situation 11 J Mr. MoseCs chart is the permanent "ega" recording o# a"" in#ormation that re"ates to his hea"th care
management. 's such/ the entries in the chart must have accurate data
<<. Mr. MoseCs chart contains a"" in#ormation a%out his hea"th care. The #unctions o# records inc"ude a""
#o""owing 1?)1PT:
'. Means o# communication that hea"th team mem%ers use to communicate their contri%utions to their
c"ientCs hea"th care
0. The c"ientCs record a"so shows a document o# how much hea"th care agencies wi"" %e reim%ursed #or
their services
). 1ducationa" resource #or student o# nursing and medicine
%. Recording of actions in ad'ance to sa'e ti$e
<=. 'n advantage o# automated or computerized c"ient care s-stem is:
'. The nurse diagnoses #or a c"ientCs data can %e accurate"- determined
0. )ost o# con#inement wi"" %e reduced
). *n#ormation concerning the c"ient can %e easi"- updated
%. T"e nu$(er of *eo*#e to ta!e care of t"e c#ient )i## (e reduced
<A. *n#ormation in the patientCs chart is inadmissi%"e in court as evidence when:
'. ' c"ientCs #ami"- re#uses to have it used
0. The c"ient o%>ects to its use
). The handwriting is not "egi%"e
%. It "as too $an/ a((re'iations t"at are &unofficia#+
<B. Nursing audit aims to:
'. Provide research data to hospita" personne"
0. Stud- c"ientCs i""ness and treatment regimen c"ose"-
C. Co$*are actua# nursing done to esta(#is"ed standards
+. Provide in#ormation to hea"th@care providers
=0. ' te"ephone order is given #or a c"ient in -our ward. What is -our most appropriate action&
'. )op- the order on the chart and sign the ph-sicianCs name as c"ose to his origina" signature as
possi%"e
. Re*eat t"e order (ac! to t"e *"/sician. co*/ onto t"e order s"eet and indicate t"at it is a
te#e*"one order
). Write the order in the c"ientCs chart and have the head nurse co@sign it
+. Te"" the ph-sician that -ou cannot ta(e the order %ut -ou wi"" ca"" the nurse supervisor
Situation 12 J Nurse ,o9ue/ a new"- hired nurse/ is as(ed to ta(e over an a%sent nurse in another unit. She wi""
ta(e care o# c"ients with various conditions.
=1. Which o# the #o""owing c"ient conditions shou"d miss ,o9ueCs priorit- in the pediatric unit&
A. T"e (a(/ )"ose fontane##e is (u#ging and fir$ )"i#e as#ee*
. The in#ant who is %rought in #or upper respirator- tract in#ection whose temperature is s"ight"- e"evated
C. ' %a%- who is waiting a#ter %eing awa(ened %- the %anging o# the door
%. ' %a%- %o- whose circumcision has -e""owish e!udates
=2. When suctioning the endoctrachea" tu%e/ the nurse shou"d:
'. 1!p"ain procedure to patient/ insert catheter gent"- app"-ing suction/ withdrawn using twisting
motion
. Insert cat"eter unti# resistance is $et. t"en )it"dra) s#ig"t#/. a**#/ing suction inter$ittent#/
as cat"eter is )it"dra)n
). 6-pero!-genate c"ient then insert catheter using %ac( and #orth motion
+. *nsert suction catheter #our inches into the tu%e/ suction 50 seconds using twir"ing motion as
catheter is withdrawn
=5. Nurse ,o9ue is giving instructions to +oris/ the daughter o# a comatose patient/ to give a sponge %ath.
Whi"e +oris is doing the sponge %ath/ what action o# +oris needs correction&
A. Ans)ering t"e *"one )"i#e )earing g#o'es used for s*onge (at"
0. ,o""ing the patient "i(e a dog to %ac( ru%
). ining the ru%%er mat with %ed sheet as incontinence pad #or the patient
+. Turning the patient on the "e#t side with s"ight"- e"evated
=4. +ina sustained a #racture on the u"na and a cast wi"" %e app"ied. What nursing action %e#ore cast
app"ication is most important #or Nurse ,o9ue to do&
'. 3se %a%- powder to reduce irritation under the cast
0. 'ssess sensation o# each arm
). 1va"uate s(in temperature in the area
%. C"ec! radia# *u#ses (i#atera##/ and co$*are
=8. To o%tain specimen #or sputum cu"ture and sensitivit-/ which o# the #o""owing instruction is %est&
A. U*on )a!ing u*. coug" dee*#/ and e-*ectorate into container
0. )ough a#ter pursed "ip %reathing
). Save sputum #or two da-s in covered container
+. '#ter respirator- treatment/ e!pectorate into a container
Situation 15 J in#ections are 9uite common"- the reasons #or a c"ientCs hospita"ization. 'ppropriate interpretation o#
diagnostic tests and measures #or in#ection contro" are he"p#u" in the management o# patient care.
=<. +oroth- underwent diagnostic test and the resu"t o# the %"ood e!amination are %ac(. $n reviewing the
resu"t the nurse notices which o# the #o""owing as a%norma" #inding&
'. Neutrophi"s <0O
0. White %"ood ce""s EW0)F B000Lmm
). 1r-throc-te sedimentation E1S,F is 5BmmLhr.
+. *ron =8mgL100m"
==. Surgica" sepsis is o%served when:
'. *nserting an intravenous catheter
0. +isposing o# s-ringes and need"es in puncture proo# containers
C. 2as"ing "ands (efore c"anging )ound dressing
+. P"acing dirt- soi"ed "inen in moisture resistant %ags
=A. ' c"ient with vira" in#ection wi"" most "i(e"- mani#est which o# the #o""owing during the i""ness stage o# the
in#ection&
'. )"ient was e!posed to the in#ection 2 da-s ago %ut without an- s-mptoms
. Ora# te$*erature s"o)s fe'er
). 'cute s-mptoms are no "onger visi%"e
+. )"ient 2#ee"s sic(4 %ut can do norma" activities
=B. Which o# the #o""owing "a%orator- test resu"ts indicate presence o# an in#ectious process&
'. 1r-throc-te sedimentation rate E1S,F 12mmLhr
0. White %"ood ce""s EW0)F 1A/000Lmm5
). *ron B0gL100m"
+. Neutrophi"s <=O
A0. 'mong the c"ients -ou are assigned to ta(e care o#/ who is most suscepti%"e to in#ection&
'. +ia%etic c"ient
. C#ient )it" (urns
). )"ient with pu"monar- emph-sema
+. )"ient with m-ocardia" in#arction
Situation 14 J .ou are a new"- hired nurse in a tertiar- hospita". .ou have #inished -our orientation program
recent"- and -ou are %eginning to assimi"ate the cu"ture o# the pro#ession.
A1. 3sing 0ennerCs stages o# nursing e!pertise/ -ou are the %eginning nurse practitioner. .ou wi"" ran( -our
se"# as aLan:
'. )ompetent nurse
. No'ice nurse
). Pro#icient nurse
+. 'dvanced %eginner
Fi'e Le'e#s or Stages of enner1s :ode#=
1. Novice
2. 'dvance 0eginner
5. )ompetent
4. Pro#icient
8. 1!pert Nurses
A2. 0ennerCs 2pro#icient4 nurse "eve" is di##erent #rom the other "eve"s in nursing e!pertise in the conte!t o#
having:
'. The a%i"it- to organize and p"an activities
0. 6aving attained an advanced "eve" o# education
C. A "o#istic understanding and *erce*tion of t"e c#ient
+. *ntuitive and ana"-tic a%i"it- in new situations
Novice Nurses
@ who are tas( oriented
Advance Beginners
@ who are a"e to demonstrate margina""- accepta%"e per#ormance.
Competent Nurses
@ per#orming the same ro"e #or two or three -ears who have deve"oped the a%i"it- to view their actions as part
o# the "ong@range goa"s set #or their patients.
@ Their conscious and de"i%erative p"anning s(i""s promote and organization.
Proficient Nurses
@ oo( at situations as who"es rather than a series o# tas(s.
@ 6ave "earned #rom their e!periences the need to deve"op a p"an o# care #or a patent to %e guided #rom a point
' to point 0 and that in t-pica" situations/ a patient is e!pected to mani#est speci#ic %ehaviors to achieve
speci#ic goa"s. $nce those %ehaviors are not e!hi%ited within a certain period o# time or time #rame/ it
imp"ies that changes shou"d %e done in the care p"an.
Expert Nurses
@ 1!pertise is so em%edded in their practice as the- intuitive"- (now what is happening with their patients.
@ Strive #or pro#essiona" advancement who eventua""- %ecome c"inica" specia"ists.
A5. 's -ou %ecome socia"ized into the nursing 2cu"ture4 -ou %ecome a patient advocate. 'dvocac- is e!p"ained
%- the #o""owing 1?)1PT:
'. ,especting a personCs right to %e autonomous
. %e$onstrating #o/a#t/ to t"e institution1s rig"ts
). Shared respect/ trust and co""a%oration in meeting hea"th needs
+. Protecting and supporting another personCs rights
A4. Modern da- nursing has "ed to deve"opment o# the e!panded ro"e o# the nurse as seen in the #unction o# a:
'. C#inica# nurse s*ecia#ist ). )ommunit- hea"th nurse
0. )ritica" care nurse +. Sta## nurse
A8. .ou >oin a continuing education program to he"p -ou:
'. 1arn credits #or "icense renewa"
0. 7et in touch with co""eagues in nursing
). 1nhance -our %asic (now"edge
%. U*date /our !no)#edge and s!i##s re#ated to fie#d of interest
Situation 18 J When creating -our "esson p"an #or cere%rosvascu"ar disease or ST,$H1/
it is important to inc"ude the ris( #actors o# stro(e
A<. The most important ris( #actor is:
'. )igarette smo(ing ). 0inge drin(ing
0. 4/*ertension +. 6eredit-
A=. Part o# -our "esson p"an is to ta"( a%out etio"og- or cause o# stro(e. The t-pes o# stro(e %ased on cause
are the #o""owing 1?)1PT:
A. 1m%o"ic stro(e C. %ia(etic stro!e
. 6emorrhagic stro(e +. Throm%otic stro(e
AA. 6emorrhagic stro(e occurs sudden"- usua""- when the person is active. '"" are causes o# hemorrhage/
1?)1PT:
'. P"#e(itis ). +amage to %"ood vesse"
0. Trauma +. 'neur-sm
AB. The nurse emphasizes that intravenous drug a%use carries a high ris( o# stro(e. Which drug is c"ose"-
"in(ed to this&
A. 'mphetamines ). Sha%u
. )ocaine +. %e$ero#
B0. ' Participant in the ST,$H1 c"ass as(s what is the ris( #actor o# stro(e. .our %est response is:
'. 2More red %"ood ce""s thic(en %"ood and ma(e c"ots more possi%"e4
0. 2*ncreased ,0) count is "in(ed to high cho"estero"4
). 2More red %"ood ce""s increases hemog"o%in content4
%. &4ig" RC increases (#ood *ressure+
Situation 1< J 'ccurate computation prior to drug administration is a %asic s(i"" a"" nurses must have.
B1. ,udo"# is a diagnosed with amoe%iasis and is to receive Metronidazo"e E:"ag-"F ta%"ets 1.8 gm dai"- in 5
divided doses #or = consecutive da-s. Which o# the #o""owing is the correct dose o# the drug that c"ient wi""
received per ora" administration&
'. 1/000 mg tid ). 1/800 mg tid
0. 800 mg tid +. 280 mg tid
B2. ,hona/ a 2 -ear o"d #ema"e was prescri%ed to receive <2.8 mg suspension three times a da-. The avai"a%"e
dose is 128 mgLm". Which o# the #o""owing shou"d Nurse Pau"o prepare #or each ora" dose&
'. 8 m" ). 2.8 m"
0. 1.28 m" +. 10 m"
B5. The ph-sician ordered Potassium )h"oride EH)F in +8W 1 "iter to %e in#used in 24 hours #or Mrs. 7omez.
Since Potassium )h"oride is high ris( drug/ Nurse ,o%ert used an intravenous pump. Which o# the #o""owing
shou"d Nurse ,o%ert do to sa#e"- administer this drug&
'. )hec( the pump setting ever- 2 hours
0. Teach the c"ient how the in#usion pump operates
). 6ave another nurse chec( the in#usion pump setting
%. Set t"e a#ar$ of t"e *u$* #oad enoug" to (e "eard
B4. 0a%- iza/ 5 months o"d/ with a congenita" heart de#ormit-/ has an order #rom her ph-sician: 2give 5.00 cc
o# ano!in toda- #or 1 da- on"-4. Which o# the #o""owing is the most appropriate action %- the nurse&
A. C#arif/ order )it" t"e attending *"/sician
0. +iscuss the order with the pediatric heart specia"ist in the unit
). 'dminister ano!in intravenous"- as it is the usua" route o# administration
+. ,e#er to the medication administration record #or previous administration o# ano!in
Infants ages 1 month to 2 years: 3 to !" mcg#$g P%& over 2' hrs I t(o or more divided doses ) ! to * hrs&
+aintenance dose is 2, to 3, of tota- digita-i.ing dose&
B8. When Nurse Norma was a%out to administer the medications o# c"ient ennie/ the re"ative o# ennie to"d
the nurse that the- %u- her medicines and showed the container o# medications o# the c"ient. Which o# the
#o""owing is the most appropriate action %- the nurse&
'. 6o"d the administration o# the c"ientCs medication and re#er to the head nurse
0. Put aside the medications she prepared and instead administer the c"ientCs medications
C. Te## t"e c#ient t"at s"e )i## infor$ t"e *"/sician a(out t"is
+. 0ring the medications o# the c"ient to the nurseCs station and prepare according"-
Situation 1= J .ou are ta(ing care o# Mrs. Santi""an/ 4A -ear o"d woman who is unconscious a#ter a
cere%rovascu"ar accident. .ou are aware that there are man- ph-sica" comp"ications due to immo%i"it-.
B<. .ou shou"d %e a"ert #or the #o""owing comp"ications she ma- e!perience 1?)1PT:
'. I$*aired $o(i#it/ ). 6-postatic pneumonia
0. )ontractures and musc"e atroph- +. Pressure sores
B=. Proper positioning o# an immo%i"ized unconsciousness c"ient is important to the #o""owing reasons
1?)1PT:
'. Maintain s(in integrit-
0. Promotes optima" "ung e!pansion
). Prevent in>uries and de#ormities o# the muscu"o@s(e"eta" s-stem
%. Faci#itates rest and s#ee*
BA. When positioning -our c"ient/ -ou shou"d o%serve good %od- mechanics #or -our se"# and the c"ient. This
means that the nurse:
'. 3ses %ac( musc"es
. Assu$es correct (od/ a#ign$ent and efficient use of $usc#es to a'oid in>ur/
). $%serve rh-thmic movements when moving a%out
+. 3ses "arge musc"es on"-
BB. .ou are going to move Mrs. Santi""an/ a 180"%s. unconscious woman. Some princip"es to use when moving
the c"ient inc"ude the #o""owing 1?1PT:
'. Prepare to move the c"ient %- ta(ing a deep %reath and tightening a%domina" and g"utea" musc"es.
0. Maintain wide %ase o# support with #eet and (nees #"e!ed
C. Pus" or *u## using ar$s and #egs instead of #ifting
+. Move c"ose to the o%>ect to %e moved "eaning or %ending at the waist
100. '#ter moving Mrs. Santi""an to the desired position/ which action wi"" -ou avoid&
'. 'void #riction %etween %on- prominences
0. P"ace pi""ow to c"ient position c"ientCs e!tremities
C. A**#/ restraints
+. ,aise %ed rai"s
PPP 1N+ PPP
NURSING PRACTICE II Co$$unit/ 4ea#t" Nursing and Care of t"e :ot"er and C"i#d
1. ,egistered nurses can %e identi#ied as a:
'. Organi;ation ). 7roup
0. )u"ture +. Su%cu"ture
2. 'mong chi"dren candidates #or organ transp"ant/ when a"" se"ected chi"dren have appropriate tissue matches
#or the same donated organ/ the %asis #or the decision as to which chi"d gets organ is that the organ is given
to the chi"d who:
'. Wi"" receive the most %ene#it #rom new organ
. Is $ost #i!e#/ to die )it"out t"e trans*#ant
). *s se"ected %- the "otter- s-stem #or avai"a%"e organs
+. *s at the top o# the "ist and has waited the "ongest tome
App-ying the princip-e of /eneficence0 and cu-ture&
5. The nurse uses what e9uipment to chec( #or #"uid %etween the parieta" and viscera" "a-ers o# the tunica
vagina"is/ the outermost covering o# the testes&
'. 50 cc s-ringe ). :"uid meter
0. Transi##u$inator +. Manometer
4. Which o# the #o""owing e!amp"es %est de#ines the term ro"e reversa"&
'. ' "az- person %ecomes ver- productive in the #ami"-
0. The good chi"d ta(es on a %ad chi"d ro"e
). ' person who has %een a good provider 9uits his or her >o%
%. T"e c"i#d assu$es a caregi'er ro#e to)ard t"e caregi'er
1ationa-e: In psychodrama0 role reversal is a techni)ue (here the protagonist is as$ed0 /y the psychodrama
director0 to exchange ro-es (ith another person 2an auxi-iary ego3 on the psychodrama stage& 4he former assumes
as many of the ro-es of the other as possi/-e and vice versa& In that (ay one is a/-e not on-y to experience a
different perspective of the situation 2to (a-$ into someone5s e-se5s shoes3 /ut a-so to (itness one5s o(n /ehaviour
from the other side& 4here/y0 the ro-e reversa- can /ring significant menta- catharsis0 insight0 and transformation&
8. When a nurse %reaches the dut- o# con#identia""-/ he she can %e discip"ined %- %oth the emp"o-er and
0oard o# Nursing. *n addition to this discip"ine/ he or she can:
A. e "e#d res*onsi(#e for an/ da$ages t"at resu#t
0. 0e #ined %- the #edera" government
). 0e sentenced #or up to 1 -ear in >ai"
+. *mmediate"- "ose his or her nursing "icense
<. ' strateg- #or change that #ocuses on teaching wor(ers new techno"og- is:
'. Nor$ati'e,reeducati'e ). Providing in#ormation
0. Training +. Power coercive
=. The nurse (nows that the occurrence o# the shou"der d-stocia during "a%or is most "i(e"- re"ated to:
A. Po"-h-dramnios ). Preterm %irth
. Materna" 'ge %. :acroso$ia
A. The nurse instructs the mother that when overstimu"ated the in#ant wi"":
'. Show increased a"ertness and e-e contact
0. ,espond with coordinated/ s-nchronous %od- movement
C. Loo! a)a/ to reduce t"e intensit/ of t"e interaction
+. +ri#t o## to deep s"eep to shut out the interaction
B. Some strategies to maintain pro#essiona" hea"th are "isted %e"ow. Which is N$T necessari"- correct&
'. Networ(ing with others in the hea"th care #ie"d
0. Moin a pro#essiona" organization
). 7oa" setting
%. Read fiction and nonfiction $ateria#s
10. The nurse is assessing an A@month@o"d in#ant #or head "ag/ pu""ing the in#ant %- the hands #rom a supine to a
sitting position. The head does not sta- in "ine with the %od- when %eing pu""ed #orward. Which o# the
#o""owing statements %est represents the signi#icance o# this #inding&
'. 6ead "ag shou"d not %e tested unti" the chi"d is over 1 -ear o# age
. Significant "ead #ag after t"e age of ? $ont"s $a/ indicate (rain in>ur/ and needs furt"er
in'estigations
). The nurse has not conducted the test correct"- and must do it again using proper techni9ue
+. This is a norma" #inding/ as the in#antCs head wi"" sta-
11. Which statement is correct regarding the use o# cervica" cap&
'. *t ma- a##ect Pap smear resu"ts
0. *t does not need to %e #itted %- a ph-sician
C. It does not re0uire t"e use of a s*er$icide
+. *t must %e removed within 24 hours
12. The ma>or components o# communication process are:
'. Ier%a"/ written/ and nonver%a"
0. Spea(er/ "istener and rep"-
). :acia" e!pression/ tone o# voice/ and gestures
%. :essage. sender. c"anne#. recei'er. and feed(ac!
15. The e!tent o# %urns in chi"dren are norma""- assessed and e!pressed in terms o#:
'. The amount o# %od- sur#ace that is un%urned
. Percentages of tota# (od/ surface area @TSAA
). 6ow deep the deepest %urns are
+. The severit- o# the %urns on a 1 to 8 sca"e
14. The schoo" nurse notices a chi"d who is wearing o"d/ dirt-/ poor@#itting c"othesQ is a"wa-s hungr-Q has no
"unch mone-Q and is a"wa-s tired. When the nurse as(s the %o- his tiredness/ he ta"(s o# p"a-ing outside
unti" midnight. The nurse wi"" suspect that this chi"d is:
'. 0eing raised %- a parent o# "ow inte""igence 9uotient E*RF
0. 'n orphan
C. A 'icti$ of c"i#d neg#ect
+. ' victim o# povert-
18. Which o# the #o""owing indicates the t-peEsF o# acute rena" #ai"ure&
'. :our t-pes: hemorrhagic with or without c"otting/ and nonhemorrhagic with or with c"otting
0. $ne t-pe: acute
C. T"ree t/*es= *rerena#. intrarena# and *ostrena#
+. Two t-pes: acute and su%acute
1<. ' means o# #aci"itating pro#essiona" sta## deve"opment is %- %ui"ding upon s(i""s/ a%i"ities/ and e!perience
o# each practitioner is ca""ed:
'. The novice to e!pert mode"
0. Situationa" "eadership mode"
C. Career en"ance$ent
+. )"inica" "adder
1=. Which o# the #o""owing 9uestions %- the nurse wou"d %est #it the phi"osoph- o# the nursing mutua"
participation o# care ENMPM)F&
'. 2have -ou %rushed -our chi"dCs teeth toda-4&G
0. 2how does -our chi"d "oo( to -ou toda-4&
). 2where have -ou %een a"" morning4&
%. &do /ou t"in! /our c"i#d1s co#or is )orse+3
1A. There are numerous de#initions o# the word 2hea"th4. Which de#inition %e"ow is #rom :"orence
Nightinga"e&
'. ' state or a process o# %eing and %ecoming an integrated and who"e person
0. The state o# %eing #ree #rom i""ness or in>ur-
C. eing )e## and using e'er/ *o)er t"e indi'idua# *ossesses to t"e fu##est e-tent
+. ' state o# comp"ete and ph-sica"/ socia"/ and menta" we""@%eing and not mere"- the a%sence o#
disease and in#irmit-
' @ & Q 0 J traditiona" de#inition Q + J #rom W6$.
1B. *n#orma" communication ta(es p"ace when an individua"s ta"( and is %est descri%ed %- sa-ing the
participants:
'. 're invo"ve in a pree!isting in#orma" re"ationships
0. Ta"( with s"ang words
C. 4a'e no *articu#ar agenda or *rotoco#
+. 're re"a!ed
20. Tertiar- care %- home hea"th nurse is directed towards chi"dren with:
A. Pro(#e$s in $o(i#it/
0. Short@term needs
). Minor pro%"ems
+. )"inica""- apparent disease
21. The endometrium thic(ness during which phase o# the menstrua" c-c"e&
'. Secretor- phase
0. Menstrua" phase
C. Pro#iferati'e *"ase
+. *schemic phase
22. ' measurement too" to articu"ate the nursing wor("oad #or a speci#ic patient or groups o# patients over a
speci#ic period o# time is ca""ed:
A. Staffing *attern
0. S(i"" mi!
). 0enchmar(ing
+. Patient c"assi#ication
25. The mother o# a B@month@o"d in#ant is concerned that the head circum#erence o# her %a%- is greater than the
chest circum#erence. The 01ST response o# the nurse is:
'. 2these circum#erence norma""- are the same/ %ut in some %a%ies this >ust di##ers4
0. 2perhaps -our %a%- was sma"" #or gestationa" age or premature4
C. &t"is is nor$a# unti# t"e age of 1 /ear. )"en t"e c"est )i## (e greater+
+. 2"et me as( -ou a #ew 9uestions/ and perhaps we can #igure out the cause o# this di##erence4
1ationa-e: A ne(/orn5s head is usua--y a/out 2 centimeters -arger than the chest si.e& Bet(een ! months and 2
years0 /oth measurements are a/out e)ua-& After 2 years0 the chest si.e /ecomes -arger than the head&
A series of measurements over time that sho( an increased rate of head gro(th often can provide more va-ua/-e
information than a sing-e measurement that is -arger than expected&
24. Which o# the #o""owing approaches wou"d wor( %est when the nurse is communicating with an in#ant&
A. Use an adu#t 'oice >ust /ou )ou#d for an/one.
0. )ommunicate through the caregivers
). '""ow the chi"d time to warm up to the nurse
+. ,espond on"- a#ter the chi"d cries #or a "itt"e whi"e
28. 1vidence@%ased care started in medicine as a wa- to:
'. Promote techno"ogica" advances in medicine
0. *ncorporate co""a%oration within a"" hea"th care discip"ines
C. Integrate indi'idua# e-*erience )it" c#inica# researc"
+. Teach medica" students the art and science o# medicine
2<. The nurse assessing new%orn %a%ies and in#ants during their hospita" sta- a#ter %irth wi"" notice which o#
the #o""owing s-mptoms as primar- mani#estation o# 6irschsprungQs disease&
'. ' #ine rash over the trun(
. Fai#ure to *ass $econiu$ during t"e first BC to CD "ours after (irt"
). The s(in turns -e""ow and then %rown over the #irst 4A hours o# "i#e
+. 6igh@grade #ever
,ationa"e: 4irsc"s*rungEs disease/ or congenita# agang#ionic $egaco#on/ invo"ves an en"argement o# the co"on/
caused %- %owe" o%struction resu"ting #rom an agang"ionic section o# %owe" Ethe norma" enteric nerves are a%sentF
that starts at the anus and progresses upwards. The "ength o# %owe" that is a##ected varies %ut se"dom stretches #or
more than a #oot or so.
2=. ' c"ient is = months pregnant and has >ust %een diagnosed as having a partia" p"acenta previa. She is sta%"e
has minima" spotting and is %eing sent home. Which o# these instruction to the c"ient ma- indicate a need
#urther teaching&
'. Maintain %ed rest with %athroom privi"eges
. A'oid intercourse for t"ree da/s
). )a"" i# contractions occur
+. Sta- on "e#t side as much as possi%"e when "-ing down
2A. Which o# the #o""owing groups o# peop"e in the wor"d disproportionate"- represents the home"ess
popu"ation&
A. 6ispanics C. African A$ericans
. 'sians +. )aucasians
2B. The nurse assessing a chi"d or ado"escent with a diagnosis o# d-sr-thmic disorder wou"d #ind which o# the
#o""owing s-mptoms&
A. A'oid co'ering t"e area of t"e to*ica# $edication )it" t"e dia*er
0. 'void the use o# c"othing on top o# the diaper
). Put the diaper on as usua"
+. 'pp"- an icepac( #or 8 minutes to the outside o# the diaper
50. The nurse assessing a chi"d or ado"escent with a diagnosis o# d-sr-thmic disorder wou"d #ind which o# the
#o""owing s-mptoms&
'. a%i"e mood and h-peractive th-roid with an increase in circu"ating th-roid hormones and
associated s-mptoms
0. Severe sha(ing o# the hands when tr-ing to ho"d a g"ass o# water or other o%>ect
). ' depression that is deeper/ more acute/ and more "i(e"- to "ead to suicide than ma>or depressive
disorder
%. A de*ressed or irrita(#e $ood for $ost of t"e da/. on $ost da/s. for B or $ore /ears and #o)
energ/ fatigue
+-sth-mic +isorder is a chronic condition characterized %- depressive s-mptoms that occur #or most o# the da-/
more da-s than not/ #or at "east 2 -ears. *n chi"dren/ the mood ma- %e irrita%"e rather than depressed/ and the
re9uired minimum duration is on"- 1 -ear.
51. .ou were the nurse assigned to wor( with a chi"d who has had who"e %rain radiation. .ou have assessed the
chi"d to %e s"eeping up to 20 hours a da- and is having some nausea/ parents in wLc o# the #o""owing areas&
'. 'ccepting a reoccurrence o# the tumor
. %ea#ing )it" t"e side effects of t"e radiation t"era*/
). )aring #or the d-ing chi"d
+. 'ccepting the imminent death o# their chi"d
52. The nurse is p"anning interventions #or a chi"d who has in#"ammator- %owe" disease E*0+F with a nursing
diagnosis 2Nutrition: ess than %od- re9uirements.4 Which o# the #o""owing interventions wi"" %e the most
he"p#u" in reso"ving this nursing pro%"em&
A. Two "arge mea"s a da- instead o# severa" minimea"s and snac(s
. Specia" *0+ diet Ediet that has %een proven e##ective #or treating *0+F
C. Sa#t,free diet "ig" in *otassiu$. 'ita$ins. and $inera#s
%. +iet as to"erated with "actose h-dro"-zed mi"( instead o# mi"( products/ and omission o# high"-
seasoned #oods/ and reduction o# #i%er
55. 1motiona" inte""igence consists o# a num%er o# competencies. Some o# these are "isted %e"ow. Which is
N$T a characteristic o# emotiona" inte""igence&
A. Se"#@esteem ). 1mpath-
. Se"#@awareness %. Se#f,regu#ation
54. +ata co""ection #or driving and restraining #orces/ inc"uding costs/ desira%i"it-/ and #easi%i"it-/ is a:
A. Peop"e issue C. Po#itica# issue
. Structura" issue +. Techno"og- issue
58. $ne o# #our #actors descri%ing the e!perience o# se!ua""- a%used chi"dren and e##ect it has on their growth
and deve"opment is stigmatization that occurs when:
'. ' chi"d %"ames him@or herse"# #or the se!ua" a%use and %egins to withdraw and iso"ate
0. Newspapers and the media donCt (eep se!ua" a%use private and accidenta""- or on purpose revea"
the name o# the victim
). The chi"d has %een %"amed %- the a%user #or his or her se!ua" %ehaviors/ sa-ing that the chi"d as(ed
to %e touched or did not ma(e the a%user stop
%. T"e c"i#d is s"ared (/ ot"er $e$(ers of t"e fa$i#/ or friends )"en se-ua# a(use (eco$es
*u(#ic !no)#edge
5<. The pain#u" phenomenon (nown as 2%"ac( "a%or4 occurs in a c"ient whose #etus in what position&
A. 0row position ). 0reech position
. ,ight occipito@anterior position %. Left occi*ito,*osterior *osition
5=. :$)3S methodo"og- stand #or
'. :ocus/ $rganize/ )"ari#-/ 3nderstand/ So"ution
0. :ocus/ $pportunit-/ )ontinuous/ 3ti"ize/ Su%stantiate
). :ocus/ $rganize/ )"ari#-/ 3nderstand/ Su%stantiate
+. :ocus/ $pportunit-/ )ontinuous EprocessF/ 3nderstand/ So"ution
5A. Whi"e communit- hea"th nurses #ocus on the individua" or the #ami"-/ which o# the #o""owing do the- have
as their #ina" o%>ective&
'. The we""@%eing o# the chronica""- i""
0. The #inancia" we""@%eing o# the #ami"-
). The we""@%eing o# the e!tended #ami"-
%. T"e )e##,(eing of t"e co$$unit/
5B. Which o# the #o""owing is the %est e!amp"e o# the ethica" princip"e o# #ide"it-&
'. +oing whatever the c"ient or the c"ientCs ph-sician as(s o# -ou
. Fee*ing a *ro$ise to return to t"e c#ient1s roo$ at a gi'en ti$e
). 0eing good #riend to the c"ient %- sharing secrets
+. Saving the c"ient time and mone- - not wasting supp"ies
40. Which o# the #o""owing #actors is most important in determining the success o# the re"ationships used in
de"ivering nursing care&
'. T-pe o# i""ness o# the c"ient
0. Trans#erence and countertrans#erence
C. Effecti'e co$$unication
+. Persona"it- o# the participants
41. Which o# the #o""owing statements %est descri%es the term g"ove t-pe %urs&
'. The parent was wearing heav- g"oves or stoc(ings on his or her hands whi"e immersing the chi"d in
hot sca"ding water
0. The parents have dipped the chi"d into the hot "i9uid whi"e he or she was as"eep
). The chi"d was wearing a g"ove when immersed in hot "i9uid
%. T"e (urn "as t"e #oo! of a g#o'e i$$ersed in "ot sca#ding )ater
42. The schoo" nurse (eeps a "ist o# enro""ed students who have medica" or re"igious o%>ections to
immunizations and those who are "i(e"- to have decreased immunit-. The nurse "i(e"- (eeps this "ist to:
A. Pro'ide statistics for t"e de*art$ent of "ea#t"
0. ,eassure the #ami"- that the nurse wi"" respect the #ami"-Cs wishes at a"" times
). Meet nationa" government re9uirements
+. :aci"itate e!c"usion in case o# an out%rea( o# high"- communica%"e disease in the schoo"
45. Preschoo"ers are a%"e to see things #rom which o# the #o""owing perspectives&
'. Their peersC
. T"eir o)n and t"eir caregi'ers1
). Their own and their motherCs
+. $n"- their own
44. *n con#"ict management/ the win@win approach occurs when:
'. There are con#"icts and the parties agree toe each win one
. Eac" *art/ gi'es in on 97G of t"e disagree$ents $a!ing u* t"e conf#ict
). 0oth parties invo"ved are committed to so"ving the con#"ict
+. The con#"ict is sett"ed out o# court so the "ega" s-stem and the parties win
48. 'ccording to the socia"@interactiona" s-stematic perspective o# chi"d a%use and neg"ect/ #our #actors p"ace
the #ami"- mem%ers at ris( #or a%use. These ris( #actors are thee #ami"- itse"#/ the caregiver/ the chi"d and:
A. The presence o# a #ami"- crisis ). the nationa" emphasis on se!
. 7enetics %. C"ronic *o'ert/
4<. When a person is discussing the strong in#"uences that chi"d@rearing methods have on the deve"opment o#
the chi"d/ this person is most pro%a%"- coming #rom which o# the #o""owing viewpoints or theories&
'. Natura"istic ). Neoc"assic
0. Nature +. Nurture
4=. *n wor(ing with the caregivers o# a chi"d with an acute or chronic i""ness/ the nurse wou"d:
A. Teac" care dai#/ and #et t"e caregi'ers do a return de$onstration >ust (efore disc"arge
0. +e"egate care o# the chi"d to a nurseCs aide and ma(e certain he or she understands the care
de"egated and comp"etes it
). Teach care ear"- and a""ow caregivers to provide dai"- care #or as man- aspects o# the chi"dCs care as
possi%"e
+. Ta(e responsi%i"it- #or the chi"dCs care unti" the da- %e#ore discharge/ and then give caregivers
instructions
4A. Which o# the #o""owing signs and s-mptoms wou"d -ou most "i(e"- #ind when assessing an in#ant with
'rno"d@)hiari ma"#ormation&
'. Wea(ness o# the "eg musc"es/ "oss o# sensation in the "egs and rest"essness
. %ifficu#t/ s)a##o)ing. di$inis"ed or a(sent gag ref#e-. and res*irator/ distress
). +i##icu"t- s"eeping/ h-pervigi"ant and an arching o# the %ac(
+. Parado!ica" irrita%i"it-/ diarrhea/ and vomiting
Arnold-Chiari malformation0 sometimes referred to as Chiari I malformation or ACM0 is a ma-formation of the
/rain& It consists of a do(n(ard disp-acement of the cere/e--ar tonsi-s and the medu-a through the foramen
magnum0 sometimes causing hydrocepha-us as a resu-t of o/struction of C67 outf-o(&
4he incidence of Arno-d8Chiari +a-formation 2Chiari I ma-formation3 defined as tonsi-ar hernations of 3 to mm
or greater is approximate-y 1 in 102""& 4he incidence of symptomatic Chiari is -ess /ut un$no(n& 4he average age
at diagnosis is a/out 2' and it is more common in (omen& It occurs in many chi-dren /orn (ith /oth spina /ifida
and hydrocepha-us& 4he Austrian patho-ogist 9ans Chiari in the -ate 1*""s descri/ed seeming-y re-ated anoma-ies
of the hind/rain0 the so ca--ed Chiari ma-formations I0 II and III& :ater0 other investigators added a fourth 2Chiari
I;3 ma-formation& 4he sca-e of severity is rated I 8 I;0 (ith I; /eing the most severe&
4he /rainstem0 crania- nerves0 and the -o(er portion of the cere/e--um may /e stretched or compressed& 4herefore0
any of the functions contro--ed /y these areas may /e affected& 4he /-oc$age of Cere/ro86pina- 7-uid 2C673 f-o(
may a-so cause a syrinx to form0 eventua--y -eading to syringomye-ia& Chiari is often associated (ith ma<or
headaches0 sometimes mista$en as migraines& Chiari headaches usua--y inc-ude intense thro//ing in the /ac$ of
the head& Chiari a-so inc-udes extreme musc-e soreness and -o( energy -eve-s& It a-so can cause a hoarseness in
the voice&
In infants, the most common symptoms are stridor and swallowing difficulties. In o-der chi-dren0 upper 2and
-o(er as age marches on3 -im/ (ea$ness and /reathing difficu-ties may occur& Patients may experience no
symptoms or remain asymptomatic unti- ear-y adu-thood0 at (hich point they may experience )uic$ onset severe
headaches and nec$ pain& 7atigue0 di..iness0 vertigo0 neuropathic pain0 pain at the point of tethering0 visua-
distur/ances0 difficu-ty s(a--o(ing0 tinnitus0 s-eep apnoea0 impaired fine motor s$i--s0 musc-e (ea$ness0
pa-pitations and excessive c-earing of the throat (ith no o/structions are other common symptoms& Because of the
comp-ex com/ination of symptoms0 and the -ac$ of experience (ith the ma-formation /y many neuro-ogists and
neurosurgeons0 patients are fre)uent-y misdiagnosed& Common misdiagnoses inc-ude c-inica- depression0
fi/romya-gia0 chronic fatigue syndrome0 and mu-tip-e sc-erosis&
6ome patients may go an entire -ifetime (ithout having noticea/-e symptoms& %r0 symptoms can /e minima-0 then
turn severe sudden-y due to head trauma (hich a-ters the condition of the spine0 /rain0 or cere/e--ar tonsi-s and
/egins to cause more difficu-ties&
Presentation in infancy
Inspiratory stridor
=ysphagia or nasa- regurgitation
Aspiration from /i-atera- a/ductor voca- cord para-ysis or centra- neura- dysfunction or /oth
1espiratory distress
Episodes of apnea
>ea$ cry
6co-iosis
?uadriparesis
%pisthotonic posture
4B. ' parent ca""s -ou #rantica""- reports that her chi"d has gotten into her #errous su"#ate pi""s and ingested a
num%er o# these pi""s. 6er chi"d is now vomiting/ has %"ood- diarrhea/ and is comp"aining o# a%domina"
pain. .ou wi"" te"" her mother to:
A. Ca## e$ergenc/ $edica# ser'ices @E:SA and get t"e c"i#d to t"e e$ergenc/ roo$
0. ,e"a! %ecause these s-mptoms wi"" pass the chi"d wi"" %e #ine
). 'dminister s-rup o# ipecac
+. )a"" the poison contro" center
80. SSSSSSSSSSSSSS.. -ou are on 2the pi""4. The most appropriate response wou"d %e:
'. 2The pi"" prevents the uterus #rom ma(ing such endometria" "ining/ that is wh- periods ma- o#ten %e
scant or s(ipped occasiona""-4
0. 2*# -our #riend has missed her period/ she shou"d stop ta(ing the pi""s and get a pregnanc- test as
soon as possi%"e4
). 2The pi"" shou"d cause a norma" menstrua" period ever- month. *t sounds "i(e -our #riend has not
%een ta(ing the pi""s proper"-4
+. 2Missed periods can %e ver- dangerous and ma- "ead to the #ormation o# precancerous ce""s4
81. .ou are the nurse assigned to wor( with a chi"d with acute g"omeru"onephritis. 0- #o""owing the prescri%ed
regimen/ the chi"d e!periences a remission. .ou are now chec(ing to ma(e sure the chi"d does not have a
re"apse. Which #inding wou"d most "ead -ou to the conc"usion that a re"apse is happening&
'. 1"evated temperature/ cough/ sore throat/ changing comp"ete %"ood countE)0)F with di##erentia"
. A urine di*stic! $easure$ent of BH *roteinuria or $ore for I da/s. or t"e c"i#d found to "a'e
I,CH *roteinuria *#us ede$a
). The urine dipstic( showing g"ucose in the urine #or 5 da-s/ e!treme thirst/ increase in urine output/
and a moon #ace
+. ' temperature o# 5=.A degrees )E100degrees :F/ #"an( pain/ %urning/ #re9uenc-/ urgenc- on voiding.
'nd c"oud- urine.
82. The nurse is wor(ing with an ado"escent who comp"ains o# %eing "one"- and having a "ac( o# #u"#i""ment in
her "i#e. This ado"escent shies awa- #rom intimate re"ationships at times/ -et at other times she appears
promiscuous. The nurse wi"" "i(e"- wor( with this ado"escent in which o# the #o""owing area&
'. *so"ation
0. one"iness
). ac( o# #u"#i""ment
%. Identit/
85. The use o# interpersona" decision ma(ing/ ps-chomotor s(i""s/ and app"ication o# (now"edge e!pected in
the ro"e o# a "icensed hea"th care pro#essiona" in the conte!t o# pu%"ic hea"th we"#are and sa#et- is an
e!amp"e o#.
'. +e"egation
0. Supervision
). ,esponsi%i"it-
%. Co$*etence
84. ' chi"d su##ers a head in>ur- in a tum%"ing accident in g-m c"ass. The nurseCs %est course o# action is to:
'. 7et the chi"d up wa"(ing and ma(e sure he or she sta-s awa(e
0. eave the chi"d and go get he"p
). eave the chi"d in the care o# an o"der chi"d and go get he"p
%. Sta/ )it" t"e c"i#d. !ee* assessing. and "a'e so$eone ca## t"e care gi'ers
88. The 'merican academ- o# pediatrics suggests that caregivers do which o# the #o""owing things in regard to
ph-sica" activities #or preschoo"ers&
'. Push the chi"d to practice sports activities whi"e the- are more #"e!i%"e
. Encourage a 'ariet/ of *"/sica# acti'ities in a nonco$*etiti'e en'iron$ent
). 6ave the chi"d engage in competitive sports to see where the- e!ce"
+. Heep ph-sica" activities to a minimum unti" the chi"d is in grade schoo"
8<. Which o# the #o""owing arrangements is genera""- considered to %e the %est or the parents o# a hospita"ized
in#ant or -oung chi"d&
A. Roo$ing,in
0. Separate caregiver s"eeping room to the unit
). +a- visits and s"eeping at home
+. Sta-ing at a near%- hote" or mote"
8=. When one person a""ows the con#"ict to %e reso"ves at his or her own e!pense/ this is re#erred to in con#"ict
management as:
'. osing ). The win@"ose approach
0. Winning whi"e "osing +. The "ose@win approach
8A. Which o# the #o""owing statements %est descri%es ac9uaintance rape&
'. Se!ua" intercourse when one person engaging in the activit- is unsure a%out wanting to do so
0. When two peop"e donCt "ove each other and engage in se!ua" activities
). When someone on a date tric(s the other person into having se!ua" intercourse
%. Se-ua# intercourse co$$itted )it" force or t"e t"reat of force )it"out *erson1s consent
8B. The schoo" nurse is teaching a hea"th education and h-giene course to a group o# high schoo"s ma"es/ which
inc"udes a num%er o# -oung men who are competitive sports team. Which o# the #o""owing hea"th practices
wou"d the nurse most stress in preventing the transmission o# human immunode#icienc- virus E6*IF virus
in case an- team mem%er has 6*I or ac9uired immunode#icienc- s-ndrome E'*+SF
'. No sharing o# underarm deodorant or shower soap
. No s"aring or ra;ors or toot"(rus"es
). Ma(ing certain towe"s have %een washed in %oi"ing water
+. 'voiding ph-sica" contact such as sports hug or swats
<0. 't 1= wee(sC gestation/ a t-pe 1 dia%etic undergoes an u"trasound e!amination. What in#ormation a%out the
#etus at this time in pregnanc- wou"d resu"ts o# this e!amination provide&
'. P"acenta" maturit- ). 7estationa" age
0. Esti$ated feta# )eig"t +. :eta" "ung maturit-
<1. Which o# the #o""owing %est descri%es a di##erence in communicating with schoo"@age chi"dren versus
todd"ers&
A. Todd#ers re0uire $ore e$*at"/ and $ore touc"ing and "o#ding
0. :or todd"ers/ preparation #or procedures is >ust %e#ore the procedure and much ear"ier #or schoo"@
aged chi"dren
). )aregivers need "ess in#ormation when care invo"ves a schoo"@aged chi"d
+. The num%er o# words is more when communicating with a todd"er than it is with a schoo"@aged
chi"dren
<2. 7enetic testing shou"d %e per#ormed on a chi"d on"- i#:
A. T"e *arents (ot" )ant it *erfor$ed
0. *t is in %est interest o# the chi"d
). *t is necessar- #or the chi"d to survive
+. No one o%>ects
<5. *n#ant head contro" is >udged %- the:
A. A(i#it/ to "o#d "ead )8o su**ort
0. Presence or a%sence o# head "ag
). ,igidit- o# the nec( and head
+. 'mount o# %ec( wrin("ing
<4. Which o the #o""owing ro"es 01ST e!emp"i#ies the e!panded ro"e o# the nurse&
'. )ircu"ating nurse in surger-
0. Medication nurse
). $%stetrica" nurse
%. Pediatric nurse *ractitioner
<8. The tone and pitch o# the voice/ vo"ume/ in#"ection/ speed/ grunts and other voca"izations are re#erred to %-
which o# the #o""owing terms&
'. Paraver%e" c"ues ). Third e"ement
0. Anci##ar/ s*eec" +. 1nhancements
<<. The p"an@do@stud- c-c"e %egins with
A. :our stages C. T"ree 0uestions
. :ive agendas +. Two concepts
4he p-an8do8study cyc-e is a mode- for improvement&
>hen considering changing a process0 there are three )uestions (e have to as$ ourse-ves:
>hat are (e trying to achieve@
>hat changes can (e ma$e that (i-- resu-t in an improvement@
9o( (i-- (e $no( if the change is /eneficia-@
<=. +uring -our shi#t/ -ou noted one o# -our pregnant c"ients considered as 2waiting case4 mani#est morning
sic(ness and which "ater progresses. Which assessment #inding ma- indicate a possi%"e deve"oping
comp"ication&
A. Materna" pu"se B0 ). :6T 188
. Trace g"ucose in the urine %. 1H !etones in t"e urine
<A. The nurse is wor(ing with a chi"d who is going to have a %one marrow aspiration. The ph-sician orders
T') Etetracaine/ adrena"ine/ and cocaineF. Which o# the #o""owing is the route o# administration&
'. 'pp"ication to the s(in/ covered with a dressing prior to the procedure
0. Su%cutaneous
C. I5 using a 'er/ s#o) dri* o'er a**ro-i$ate#/ C "ours *rior to *rocedure
+. Nasa" inha"ation
<B. 'ccording to +e,osa and HochuraCs E200<F artic"e entit"ed 2*mp"ement )u"tura""- )ompetent 6ea"th )are
in -ou Wor(p"ace/4 cu"tures have di##erent patterns o# ver%a" and nonver%a" communication. Which
di##erences does N$T necessari"- %e"ong&
A. Persona" %ehavior C. Su(>ect $atter
. 1-e contact +. )onversationa" st-"e
=0. The nurse instructs the caregivers o# a new%orn to notch the diapers or #o"d them in such a wa- to e!pose
the cord. The ma>or purpose o# e!posing the cord is to:
'. ,emind the caregivers to do cord care
0. Heep the diaper #rom ru%%ing the cord
C. Pro'ide air circu#ation for t"e cord
+. '""ow visua"ization at a"" times
=1. The "eve" o# hea"th o# an individua"/ #ami"-/ group/ popu"ation/ or communit- is ca""ed:
'. 6ea"th assets ). Rua"it- o# "i#e
0. 4ea#t" status +. hea"th needs
=2. The nurse is teaching a group o# e!pectant mothers a%out the prevention o# diaper dermatitis. The nurse
e!p"ains that one preventive measures *s the use o#:
A. '%sor%ent disposa%"e diapers ). P"astic panties over diapers
. 0a%- powder or cornstarch %. C#ot" dia*er
=5. The )ode o# Nurses
A. de#ineates a## o(#igation and res*onsi(i#ities of t"e nurse
0. is a %inding oath/ which te""s nurses how to ma(e ethica" decisions
). assists the nurse in #ormu"ating a persona" %e"ie# s-stem
+. supports the concepts o# respect
=4. The o%"igation to correct"- per#orm oneCs assigned duties is:
A. +e"egation ). ,esponsi%i"it-
. 'ssignment %. Accounta(i#it/
=8. +uring a routine postpartum assessment #o""owing a norma" vagina" de"iver-/ the nurse notes the #undus to
%e s"ight"- %ogg-. Which action shou"d the nurse ta(e to decrease the ris( o# uterine inversion during
uterine massage&
'. Massage on"- unti" cramping %egins
0. P"ace one hand on the a%domen a%ove the s-mph-sis pu%is
). 's( the c"ient to am%u"ate to the %athroom to empt- her %"adder
%. Position t"e c#ient in a s#ig"t Trende#en(urg *osition
Situation 1 J Nurse isa manages her own reproductive )hi"drenCs Nursing )"inic in Sorsogon and necessari"- she
attends to hea"th conditions o# mothers and chi"dren. The #o""owing conditions pertain to the 7,$W*N7 :1T3S.
=<. $%stetrica" c"ient Marichu as(s how much "onger Nurse isa wi"" re#er to the %a%- inside her as an em%r-o.
What wou"d -our %est e!p"anation&
'. 6er %a%- wi"" %e a #etus as soon as p"acenta #orms
. Fro$ t"e ti$e of i$*#antation unti# 9 to D )ee!s. t"e (a(/ is in e$(r/o
). '#ter the 20
th
wee( o# pregnanc-/ the %a%- is ca""ed a z-gote
+. This term is used during the time %e#ore #erti"ization
==. Marichu is worried that her %a%- wi"" %e %orn with a congenita" heart disease. What assessment o# a #etus at
%irth is important to he"p detect congenita" heart de#ect&
'. +etermining that the co"or o# the um%i"ica" cord is not green
. Assessing )"et"er t"e u$(i#ica# cord "as t)o arteries and one 'ein
). 'ssessing whether the WhartonCs >e""- o# the cord has a p6 higher than =.2
+. Measuring the "ength o# the cord to %e certain that it is "onger than 5 #eet
=A. 'dditiona""-/ Nurse isa wou"d gather more in#ormation a%out MarichuCs worr- a%out what ma- threaten
the hea"th o# her %a%-. What wou"d Nurse isa hope to #ind&
'. 6as Marichu %een over"- an!ious a%out something
0. 6as Marichu su##ered #rom an- communica%"eLcontagious disease at the time o# her ear"- stage o#
pregnanc-
). 6as Marichu engaged in se!ua" activit- during the #eta" deve"opment state o# her chi"d
%. 4as :aric"u engaged in an/ detri$enta# acti'ities during t"e feta# de'e#o*$ent stage e.g.
s$o!ing. drin!ing. ta!ing. drugs. a (ad fa##. or atte$*ts to ter$inate *regnanc/
=B. Marichu is schedu"ed to have an u"trasound e!amination. What instruction wou"d -ou give %e#ore here
e!amination&
'. .ou can have medicines #or pain #or an- contractions caused %- the test
0. +rin( at "east 5 g"asses o# #"uid %e#ore the procedure
). The intravenous #"uid in#used to di"ate -our uterus does not hurt the #etus
%. 5oid i$$ediate#/ (efore t"e *rocedure to reduce /our (#adder si;e
A0. Marichu is schedu"ed to have an amniocentesis to test #or #eta" maturit-. What instruction wou"d -ou give
her %e#ore this procedure&
'. The ?@ra- used to revea" -our #etusC position has no "onger term e##ects
0. The intravenous #"uid in#used to di"ate -our uterus does not hurt the #etus
). No more amniotic #"uid #orms a#terward/ which is wh- on"- a sma"" amount is removed
%. 5oid i$$ediate#/ (efore t"e *rocedure to reduce /our (#adder si;e
Situation 2@ hea"th instruction s are essentia""- given to pregnant mothers
A1. ' pu%"ic hea"th nurse wou"d instruct a pregnant woman to noti#- the ph-sician immediate"- i# which o# the
#o""owing s-mptoms occur during pregnanc-&
'. Presence o# dar( co"or in the nec(
. Increased 'agina# disc"arge
). Swe""ing o# #ace
+. 0reast tenderness
A2. ' woman who is B wee(s pregnant comes to the hea"th center with moderate %right red vagina" %"eeding.
$n ph-sica" e!amination/ the ph-sician #inds the c"ientCs cervi! 2 cm di"ated. Which term %est descri%es the
c"ientCs condition&
'. Missed a%ortion inevita%"e a%ortion
0. *ncomp"ete a%ortion
C. Ine'ita(#e a(ortion
+. Threatened a%ortion
A5. *n a %ig government hospita" Nurse Pura is ta(ing care o# a woman with a diagnosis o# a%ruption p"acenta.
What comp"ication o# this condition is o# most concern to Nurse Pura&
'. 3rinar- tract in#ection
0. Pu"monar- em%o"ism
). 6-poca"caemia
%. %isse$inated intra'ascu#ar coagu#ation
A4. Which o# the #o""owing #indings on a new"- de"ivered womanCs chart wou"d indicate she is at ris( #or
deve"oping postpartum hemorrhage&
'. Post@term de"iver-
0. 1pidura" anesthesia
C. Grand $u#ti*art/
+. Premature rupture o# mem%rane
A8. Mrs. 6acienda 7arcia 58 -.o. postpartum c"ient is at ris( o# throm%oph"e%itis. Which o# the #o""owing
nursing interventions decreases her chance o# deve"oping postpartum throm%ophe"e%itis
'. 0reast#eeding the new %orn
. Ear#/ a$(u#ation
). 'dministration o# anticoagu"ant postpartum
+. *mmo%i"ization and e"evation o# the "ower e!tremities
Situation 5@ with the increasing documented cases o# )'N)1, the %est a"ternative to treatment sti"" remains to %e
P,1I1NT*$N. The #o""owing conditions app"-.
A<. Which among the #o""owing is the primar- #ocus o# prevention o# cancer&
A. E#i$ination of conditions causing cancer
0. +iagnosis and treatment
). Treatment at ear"- stage
+. 1ar"- detection
A=. *n the prevention and contro" o# cancer which o# the #o""owing activities is the most important #unction o#
the communit- hea"th nurse&
'. )onduct o# communit- assem%"ies
0. ,e#erra" to cancer specia"ist those c"ients with s-mptoms o# cancer
C. Use t"e nine )arning signs of cancer as *ara$eters in our *rocess of detection. contro#. and
treat$ent $oda#ities
+. Teach women a%out correctLproper nutrition
AA. Who among the #o""owing are recipients o# the secondar- "eve" o# care #or cancer cases&
A. T"ose under ear#/ case detection
0. Those under post care treatment
). Those schedu"ed #or surger-
+. Those undergoing treatment
AB. Who among the #o""owing are recipients o# the tertiar- "eve" o# care #or cancer cases&
'. Those under ear"- treatment
. T"ose under su**orti'e care
). Those under ear"- detection
+. Those schedu"ed #or surger-
B0. *n communit- 6ea"th Nursing/ despite the avai"a%i"it- and use o# man- e9uipment and devices to #aci"itate
the >o% o# the communit- hea"th nurse/ the %est too" an- nurse shou"d we"" %e prepared to app"- is a
scienti#ic approach. This approach ensures 9ua"it- o# care even at the communit- setting. This in nursing
par"ance is nothing "ess than the:
'. Nursing diagnosis
0. Nursing protoco"
). Nursing research
%. Nursing *rocess
Situation 4 J +engue hemorrhagic #ever is common hea"th concern in Phi"ippine societ-. *t does not on"- pose a
threat to hea"th %ut more so to the "ives o# %oth -oung and o"d/ and we"" rich and margina"ized o# societ-. The
#o""owing conditions app"-.
B1. 'n important ro"e o# the communit- hea"th nurse in the prevention and contro" +engue 6@#ever inc"udes:
'. 'dvising the e"imination o# vectors %- (eeping water containers covered
0. )onducting strong hea"th education drivesLcampaign directed towards proper gar%age disposa"
C. E-*#aining to t"e indi'idua#s. fa$i#ies. grou*s and co$$unit/ t"e nature of t"e disease and its
causation
+. Practicing residua" spra-ing with insecticides
B2. )ommunit- hea"th nurses shou"d %e a"ert in o%serving a +engue suspect. The #o""owing is N$T an
indicator #or hospita"ization o# 6@#ever suspects.
'. Mar(ed anore!ia/ a%domina" pain and vomiting
0. *ncreasing hematorit count
). :ever #or more than 2 da-s
%. Persistent "eadac"e
B5. The communit- hea"th nursesC primar- concern in the immediate contro" o# hemorrhage among patients
with dengue is:
'. 'dvising "ow #i%er and non@#at diet
0. Providing warmth through "ight weight covers
). $%serving c"ose"- the patient #or vita" signs "eading to shoc(
+. Heeping the patient at rest
B4. Which o# these signs mat N$T %e ,17',+1+ as a tru"- positive signs indicative o# +engue 6@:ever&
'. Pro"onged %"eeding time
. A**earance of at #east 9 *etec"iae
). Steadi"- increasing hematocrit count
+. :a"" in p"ate"et count
B8. Which o# the #o""owing is the most important treatment o# patients with +engue 6@:ever&
'. 7ive aspirin #or #ever
. Re*#ace$ent of (od/ f#uids
). 'void unnecessar- movement o# patient
+. *ce cap over the a%domen in case o# me"ena
Situation 8 J Two chi"dren were %roughtto -ou. $ne with chest in@drawing and the other had diarrhea. The
#o""owing 9uestions app"-.
B<. 3sing the *ntegrated Management T )hi"dhood *""ness E*M)*F approach/ how wou"d -ou c"assi#- the 1
st
chi"d&
A. 0ronchopneumonia C. Se'ere *neu$onia
. No pneumonia: cough or co"d +. Pneumonia
B=. The 1
st
chi"d who s 15 month has #ast %reathing using *M)* parameters he has:
A. C7 (reat"s *er $inute or $ore
0. 80 %reaths per minute
). 50 %reaths per minute or more
+. <0 %reaths per minute
BA. Nina/ the 2
nd
chi"d has diarrhea #or 8 da-s. There is no %"ood in the stoo". She is irrita%"e/ and her e-es are
sun(en. The nurse o##ered #"uids and the chi"d drin(s eager"-. 6ow wou"d -ou c"assi#- NinaCs i""ness&
A. So$e de"/dration
0. +-senter-
). Severe deh-dration
+. No deh-dration
BB. NinaCs treatment shou"d inc"ude the #o""owing 1?)1PT:
'. ,eassess the chi"d and c"assi#- him #or deh-dration
0. :or in#ants under < months o"d who are not %reast#eed/ give 100@200 m" c"ean water as we"" during
this period
). 7ive in the hea"th center the recommended amount o# $,S #or 4 hours
%. %o not gi'e an/ ot"er foods to t"e c"i#d for "o$e treat$ent
100. Whi"e on treatment/ Nina/ 1A months o"d weighed 2A (i"ograms and her temperature registered at 5= ). her
mother sa-s she deve"oped cough 5 da-s ago. Nina has no genera" danger signs. She has 48 %reathsLminute/ no
chest in@drawing/ no stridor. 6ow wou"d -ou c"assi#- NinaCs mani#estation&
'. No pneumonia
0. Severe pneumonia
C. Pneu$onia
+. 0ronchopneumonia
PPP 1N+ PPP