1

Rhonchi (gurgles) are continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. A nurse understands that
the cause of this adventitious breath sounds is:
Choose one answer.
a. Rubbing together of inflamed pleural surfaces.

b. Air passing through a constricted bronchus as a result of secretions,

swelling, and tumors.

c. Air passing through fluid or mucus in any air passage.

d. Air passing through narrowed air passages as a result of secretions,

swelling, and tumors.

Question2
Because nursing research usually focuses on humans, a major nursing responsibility is to be aware of and to advocate on behalf of client's rights.
Which of the following statements best describe the right to self-determination in research?
Choose one answer.
a. provision of complete information about the research/study

b. assurance of the anonymity of a study participant

c. freedom from constraints, or any undue influences to participate in a

study

d. avoidance of any exposure to the possibility of injury beyond everyday

situations

Question3
The research design is the overall plan for obtaining answers to the questions being studied and for handling some of the difficulties encountered
during the research process. The purpose of the design is to maximize control over factors that can interfere in the validity of the findings. What type
of research design is used wherein there is total control of the study?
Choose one answer.
a. pretest-posttest design

b. nonexperimental design

c. experimental design

d. quasi-experimental design

Question4
When using an instrument or tool in quantitative research, it is important to ensure its reliability and validity. Reliabilityis the consistency with which it
measures the target attribute, while validity refers to the degree to which an instrument measures what it is supposed to measure. Harry, a nurse
researcher, has found an instrument to measure the level of self-esteem of school-age children. He wants to test its validity so he consults a panel of
experts to evaluate the validity of the instrument. This is called:
Choose one answer.
a. Both content and face validity

b. content validity

c. face validity

d. None of the above

Question5
Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. This phase includes
establishing client goals and objectives. Which of the following objectives for the nursing diagnosis of Ineffective Airway Clearance related to poor
cough effort is NOT properly stated?
Choose one answer.
a. The client will not experience aspiration.
 b. The client will show no signs of pallor or cyanosis by 12 hours post-surgery.

c. The client will have lungs clear upon auscultation during entire postoperative
period.

d. The client will demonstrate effective coughing and increased air exchange
within 24 hours after surgery.

6
Preoperative teaching is a vital part of nursing care to reduce clients' anxiety and postoperative complications and increases their satisfaction with
the surgical experience. Which of the following statements by the client indicates that preoperative teaching regarding gallbladder surgery has been
effective?
Choose one answer.
a. "After surgery, I can immediately resume the diet I had before I
was operated."

b. "I cannot eat or drink anything at least 8 hours before my surgery."

c. "I will only do deep breathing exercises when I am experiencing

pain."

d. "I am not going to cough after surgery because if I do, my wound

will tear apart."

Question7
Assessment is a continuous process carried out during all phases of the nursing process. Which of these is NOT part of the assessment phase?
Choose one answer.
a. Distinguishing relevant from irrelevant data

b. Validating data

c. Comparing patterns with norms

d. Organizing data

Question8
Nursing informatics is the specialty that integrates nursing science, computer science, and information science to manage and communicate data,
information and knowledge in nursing practice to support patients, nurses, and other providers in their decision-making in all roles and settings (ANA,
2001). The two most common types of computer systems used by nurses are management information systems (MIS) and hospital information
systems (HIS). Which of these is the main difference between MIS and HIS?
Choose one answer.
a. MIS focuses on the types of data needed to manage client care
activities and health care organizations. HIS is designed to facilitate the
organization and application of data used to manage an organization or
management.

b. HIS is more general as MIS is more specific in managing data.

c. MIS is designed to facilitate the organization and application of data

used to manage an organization or management. HIS focuses on the
types of data needed to manage client care activities and health care
organizations.

d. MIS and HIS do not have any differences.

Question9
Liver biopsy is the removal of a small amount of liver tissue, usually needle aspiration. During the procedure, you instruct the client to inhale and
exhale deeply several times and to hold his breath after the final exhalation for up to 10 seconds as the needle is inserted. What is the main purpose
why the client needs to holds his breath during needle insertion?
Choose one answer.
a. Holding the breath minimizes the pain experienced by the client
as the needle is inserted.

b. For comfort purposes only

c. This immobilizes the chest wall and liver and keeps the
diaphragm in its highest position, avoiding injury to the lung and
liver.
 d. Holding the breath contracts the abdominal muscles so that the
contour of the liver will be well-defined for easier insertion of the
needle.
Question10
Nursing care oriented to health promotion, wellness, and illness prevention can be understood in terms of health activities on the different levels of
preventive care. A client is a known hypertensive for 5 years. She has been taught at the health center about the possible complications of the
disease if it is not managed properly and this includes stroke. She has modified her lifestyle since then by quitting smoking, exercising regularly and
by eating a balanced diet. These activities demonstrate:
Choose one answer.
a. Secondary prevention

b. Primary prevention

c. Tertiary prevention

d. None of the choices

11
R.A. 9173 (The Philippine Nursing Act of 2002)defines the scope of nursing practice in the Philippines.Which of the following statements is NOT
included in the scope of nursing?
Choose one answer.
a. A community health nurse teaching a group of hypertensive clients
about regular monitoring of blood pressure.

b. A nurse providing oral hygiene to a bed-ridden patient.

c. A nurse administering an IV antibiotic after being ordered by the

physician.

d. A nurse performing internal examination of a woman during labor

who experienced minimal vaginal bleeding during the second trimester.

Question12
Positioning a client in good body alignment and changing the position regularly (every 2 hours) and systematically are essential aspects of nursing
practice. Your client is experiencing difficulty of breathing, therefore you place him in a semi-Fowler's position. A possible problem of this position is
the posterior flexion of the lumbar curvature which may be brought about by the unsupported portion of the upper part of the body elevated at 30-45
degrees commencing at the hips. How will you make sure this problem is prevented?
Choose one answer.
a. Place a pillow under lower legs.

b. Place a pillow to support the head, neck and upper back.

c. Place a pillow at the lower back.

d. Place a pillow under the forearms to eliminate pull on

shoulder.

Question13
Vital signs, which should be looked at in total, are checked to monitor the functions of the body. A client with end-stage renal disease is undergoing
hemodialysis. He has an AV fistula on his right arm and the client's chart reads "save both arms" for a possible creation of another fistula on his left
arm. When taking his blood pressure, you know that the only possible way is to take it on his thighs. Where should you place the BP cuff?
Choose one answer.
a. Around the upper portion of his mid-thigh with the bladder
over the posterior aspect the thigh and the bottom edge in line
with the knee.

b. Around his mid-thigh with the bladder over the posterior

aspect of the thigh and the bottom edge around the knee

c. Around his lower thigh with the bladder over the posterior
aspect of the thigh and the upper edge around the knee

d. Around the knee of the client

Question14
Nurses document evidence of the nursing process in a variety of forms throughout the clinical record. You are a nurse in the medical ward and you
are assigned to a new patient for the shift. You want to know about the case of the patient and the kind of nursing care and therapeutic management
already done to help her in her condition throughout her stay at the hospital. You therefore read the:
Choose one answer.
 a. Nursing discharge summary

b. Kardex

c. Flow sheet

d. Progress notes

Question15
Clients who have been immobilized for even a few days may require assistance with ambulation. You are assisting your client while she tries to
ambulate after her surgery 2 days ago. Suddenly, she feels weak and seems to be fainting, however, there is no nearby chair or wheelchair wherein
you can lower the patient. You can assist the client to a horizontal position on the floor before fainting occurs. You can do the following, EXCEPT:
Choose one answer.
a. All of the above.

b. Assume a broad stance with both feet parallel to each other.

c. Allow the client to slide down your leg, and lower the person gently to
the floor.

d. Bring the client backward so that your body supports the person.

16
Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the
benefits and risks of treatment, alternatives to the treatment, and prognosis if not treated by a health care provider. An informed consent needs to be
acquired for the performance of endoscopy for a 17-year-old male adolescent, however, there are no other significant others present during that
time. A nurse should remember that the patient:
Choose one answer.
a. Does not have the legal capacity to give consent

b. Is not able to make an acceptable or intelligent choice

c. Is able to give voluntary consent when his parents are not

available

d. Will most likely be unable to choose between alternatives when

asked to consent

Question17
Nursing practice is governed by many legal concepts and it is important for nurses to know the basics of legal concepts, because nurses are
accountable for their professional judgments and actions. You inserted a Foley catheter to a patient with urinary retention even though the patient
refused to. You informed the patient that this will benefit her. Even if you have a good intention, you are liable for:
Choose one answer.
a. invasion of privacy

b. unintentional tort

c. assault

d. battery

Question18
Thoracentesis is used to remove the excess fluid or air to ease breathing. Your client is to undergo thoracentesis and you assist him to assume a
position that is indicated for the procedure. Which of these can be his position during the procedure?
1 Sitting position with the arms above the head
2 Sitting position with the arm elevated and stretched forward
3 Sitting position in which the client leans over a pillow or overbed table
4 Sitting position with both arms crossed in front of the chest
Choose one answer.
a. All of the above
 b. 2, 3 and 4

c. 1, 2 and 3

d. 3 and 4

Question19
Cardiopulmonary resuscitation (CPR) is a combination of oral resuscitation (mouth-to-mouth breathing), which supplies oxygen to the lungs, and
external cardiac massage (chest compressions), which is intended to reestablish cardiac function and blood circulation. Based on the latest
guidelines in CPR, what is the compression-to-ventilation ratio for all clients except that of newborns?
Choose one answer.
a. 30 compressions:2 breaths

b. 10 compressions:2 breaths

c. 5 compressions:1 breath

d. 15 compressions:2 breaths

Question20
Arterial blood gases (ABGs) are performed to evaluate the client's acid-base balance and oxygenation. Your client is experiencing a prolonged,
severe, asthma attack. Which of the following ABG results would you anticipate?
Choose one answer.
a. Decreased PaCO2, increased PaO2, and decreased pH.

b. Increased PaCO2, increased PaO2, and increased pH.

c. Decreased PaCO2, decreased PaO2, and increased pH.

d. Increased PaCO2, decreased PaO2, and decreased pH.

21
Total parenteral nutrition (TPN) affords the provision of energy and nutrients intravenously and it is an important responsibility of the nurse to monitor
the patient regularly for possible complications related to this therapeutic management. You are regularly assessing your client who is receiving TPN
for signs of hyperglycemia. You will note which of the following if your client is already hyperglycemic?
Choose one answer.
a. Thirst, increased urine output and warm flushed skin

b. Cold clammy skin, sweating and weakness

c. Nausea, vomiting and chills

d. Fever, nausea, vomiting

Question22
Nurses should deliver holistic care to all clients across the lifespan. In doing this, you are putting into practice the theory of:
Choose one answer.
a. Martha Rogers

b. Imogene King

c. Dorothea Orem

d. Florence Nightingale

Question23
Peplau's theory involves the use of a therapeutic relationship between the nurse and the client. When the client assumes the dependent client role,
the nurse and client are on which phase of the therapeutic relationship?
Choose one answer.
 a. Orientation

b. Identification

c. Resolution

d. Exploitation

Question24
It is important that nurses make nursing diagnoses with a high level of accuracy. Which of these guidelines should be followed when writing a
nursing diagnostic statement?
Choose one answer.
a. Use medical terminology rather than nursing terminology to
describe the probable cause of the client's response

b. Word the diagnosis as generally as possible

c. Use statements based on nurse's perception of the client's

response

d. Word the statement so that it is legally advisable

Question25
Leadership is commonly defined as a process of influence in which the leader influences others toward goal achievement. Three leadership styles
are still widely recognized today: the autocratic, democratic, and laissez-faireleadership. A laissez-faire leader is differentiated from other types of
leadership through which of the following?
Choose one answer.
a. There is less control applied in terms of handling the subordinates.

b. The leader acts primarily as a facilitator and a resource person.

c. The leader decides for the whole unit by himself.

d. The leader leaves the decision-making up to the group.

26
The Nurses' Code of Ethics is a formal statement of a group's ideals and values. It is a set of ethical principles that is shared by members of the
group, reflects their moral judgments over time, and serves as a standard for their professional actions. Which of the following is NOT included in the
nurses' code of ethics?
Choose one answer.
a. Personal information acquired in the process of giving nursing care
shall be held in strict confidence.

b. The hallmark of accurate documentation of actions and outcomes of

delivered care is a nursing responsibility.

c. Values, customs, and spiritual beliefs held by individuals are to be

respected.

d. Nurses are the advocates of the client.

Question27
In health care delivery, basic ethical principles assist the health professionals to determine the right or wrong in regard to value issues involving the
pursuit of health, alleviation of suffering, and assisting patients toward peaceful death. Explanation by the attending physician of the important
findings, management, prognosis and evaluations to a newly-diagnosed breast cancer patient is an application of:
Choose one answer.
a. beneficence

b. non-maleficence

c. autonomy
 d. veracity

Question28
Nursing practice involves all aspects of the health-illness continuum. You are a nurse in the community taking care of residents with hypertension.
When you refer to other health professionals those who have severe hypertension that are already at high-risk for stroke, you are doing which area
of nursing practice?
Choose one answer.
a. Promoting health and wellness

b. Preventing illness

c. Restoring health

d. Caring for the dying

Question29
The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Which
of the following describes GERONTICS?
Choose one answer.
a. It is the branch of medicine that deals with the physiological and
psychological aspects of aging and with diagnosis and treatment of
diseases affecting older adults.

b. It considers the nursing care of older adults to be the art and practice of
nurturing, caring, and comforting rather than merely the treatment of
disease.

c. It is the study of all aspects of aging process and its consequences.

d. It is concerned with the assessment of health and functional status of

older adults; diagnosis, planning and implementing health care and
services, and; evaluating the effectiveness of such care.
Question30
The management theory developed by McGregor is the Theory X and Theory Y. This theory is about the two different ways to motivate or influence
others based on underlying attitudes about human nature. Which of the following describe a Theory X nurse manager's perception of his/her nursing
staff?
Choose one answer.
a. They cannot offer creative solutions to help organizations advance.

b. They like to be supervised and avoid added responsibilities.

c. All of the choices.

d. They do not like the work that they are doing.

31
There is a need for recording of the accomplished nursing interventions and the client's responses for effective communication among the members
of the health care team. Documentation of nursing activities is included in which phase of the nursing process?
Choose one answer.
a. Implementation

b. Assessment

c. Evaluation

d. Diagnosis

Question32
The nurse-manager decides what task should be done, when, where and by whom. This can be done throughdelegation. Which of the following is
NOT a reason for delegating?
Choose one answer.
a. Delegation maximizes the use of talents of staff associates.
 b. Delegation reduces managerial costs.

c. Delegation is an opportunity to transfer one's accountability to a task.

d. Delegation saves time and can help develop others.

Question33
Because of their unique position in the health care system, nurses experience conflicts among their loyalties and obligations to clients, families,
primary care providers, employing institutions, and licensing bodies. The attending physician of your patient placed an order in the chart to
administer a pain medication STAT. However, when you arrived in your patient's room, he seems to not be in pain. What will be your action?
Choose one answer.
a. Withhold the medication, further assess the patient and inform the
attending physician of your findings.

b. Wait until the patient experiences pain again then administer the
medication.

c. Inform the charge nurse of the condition.

d. Administer the medication anyway because you might get

reprimanded by the physician.

Question34
Confidentiality is the protection of the participants in a study such as that individual identities are not linked to information provided and are never
publicly divulged. Which of the following statements best manifest confidentiality?
Choose one answer.
a. The patient is L.C.R., 34, female of 5 Jupiter Street, Makati.

b. The respondents are employees of the only private hospital in the

municipality of San Juan in Batangas.

c. The research study was done in the pediatric wards of a tertiary

hospital in Manila.

d. none of the above

Question35
Electrolytes, charged ions capable of conducting electricity, are present in all body fluids and fluid compartments. When you are assessing your
patient, you noticed the following signs and symptoms: numbness, tingling of the extremities and around the mouth, muscle tremors, cramps and
hyperactive deep tendon reflexes. Which of the following electrolytes is most likely to be imbalanced in your patient?
Choose one answer.
a. Sodium

b. Calcium

c. Magnesium

d. Potassium

36
Republic Act No. 9173, otherwise known as the Philippine Nursing Act of 2002 was implemented to define the scope of nursing practice, licensing
requirements, and standards of nursing care. The features of this Law include the following, EXCEPT:
Choose one answer.
a. A member of the Board of Nursing should have at least ten (10) years
of continuous practice of the nursing profession provided that the last five
(5) years of which shall be in the Philippines.

b. The Certificate of Registration may be revoked or suspended if the

nurse demonstrated unprofessional or unethical conduct.

c. The Board of Nursing shall designate the places and dates of the
Nursing Licensure Examination.

d. A faculty in a college of nursing should have at least one (1) year of

clinical practice in a field of specialization.

Question37
Evidence-based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual
patients. You are a nurse-manager in the pay ward who uses evidence-based practice in planning care for your clients. Which of the following is your
priority in planning for these clients?
Choose one answer.
a. Care plans are based on the nurse's clinical experience and from the
latest research findings.

b. Care plans that are standardized are used on all patients.

c. Care plans are individualized according to the client's needs.

d. Care plans follow the standards of care established by the

institution's nursing service.

Question38
A physician orders Ceftriaxone (Rocephin) 2.5 g given via IV piggyback every 8 hours for a client with severe infection. The pharmacy sends a vial
labeled 5g/10ml. When preparing the medication, the nurse should use:
Choose one answer.
a. 7.5 ml

b. 2.5 ml

c. 5 ml

d. 10 ml

Question39
Negligence is defined as a misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Which of the
following situations will most likely cause the nurse to be sued for negligence?
Choose one answer.
a. Nurse Abby mixed a medication in the wrong kind of IV fluid during
preparation in the medication room.

b. Nurse Anne noticed that she aspirated 1 ml of the medication

instead of the prescribed 0.5 ml in a syringe.

c. Nurse Pat gave the wrong antibiotic and after 30 minutes the
patient experienced an anaphylactic reaction.

d. Nurse Cecille is about to administer an oral medication when the

patient complained that it is not the one usually given to her.

Question40
The level of consciousness, which is a component of the neurologic examination, can be measured using theGlasgow Coma Scale (GCS). Marie, a
45-year-old woman, was brought in at the Emergency Department after a vehicular accident. She opens her eyes to verbal command, moves to
localized pain and makes sounds that are incomprehensible. What will be her score on the GCS that you, as her nurse, will document on her chart?
Choose one answer.
a. 11

b. 9

c. 10

d. 8

41
During physical assessment of the skin, the nurse may palpate it to locate skin lesions, which are any pathological skin changes. During palpation of
the skin, the nurse assesses skin lesions, which she documented in the client's chart as a nodule. Which of the following describes a nodule?
Choose one answer.
a. Solid mass that may extend deep through the subcutaneous tissue,
larger than 1-2 cm.

b. An elevated solid mass, deeper and firmer than a papule, that is 0.5-2
cm.
 c. Irregularly shaped, elevated area or superficial localized edema that
varies in size.

d. A palpable, circumscribed, solid elevation in the skin, smaller than 0.5

cm.

Question42
Determining the different variables in research is an important task of the researcher. In the research question, "What is the effect of progressive
muscle relaxation on the blood pressure of hypertensive residents in an urban community in Metro Manila?", which is the independent variable?
Choose one answer.
a. hypertensive residents

b. blood pressure

c. urban community in Metro Manila

d. progressive muscle relaxation

Question43
An enema is a solution introduced into the rectum and the large intestine to distend the intestine and sometimes to irritate the intestinal mucosa,
thereby increasing peristalsis and the excretion of feces and flatus. Which of the following clients is more likely to receive a retention enema?
Choose one answer.
a. A client experiencing excessive flatus.

b. A 28-year-old female client to undergo Caesarian section the next

day

c. A 5-year-old child with ascariasis

d. A 45-year-old man who will undergo colonoscopy on the following

day

Question44
Urinary incontinence, or involuntary urination is a symptom, not a disease. It can have a significant impact on the client's life, creating physical
problems such as skin breakdown and possibly leading to psychosocial problems such as embarrassment, isolation, and social withdrawal. Your
client, Melanie, is 8 months pregnant and she reports dribbling of urine whenever she laughs, coughs, or sneezes. What will be your appropriate
nursing diagnosis and intervention for her?
Choose one answer.
a. Functional urinary incontinence - encourage timed verbal toileting
reminders and positive social feedback for successful toileting

b. Stress urinary incontinence - encourage pelvic muscle exercises

c. Reflex urinary incontinence - regular periodic use of a catheter to

empty the bladder

d. Urge urinary incontinence - increase bladder's ability to hold urine

and the client's ability to suppress urination.

Question45
Nurses are almost often involved in the decision-making pertaining to some ethical issues. Which of these situations LEAST require the use of
complex ethical decision-making skills in nurses?
Choose one answer.
a. Your patient is depressed and does not respond to any of your questions.

b. Your pregnant client is considering abortion due to financial constraints.

c. Your client has just been recently diagnosed to be HIV-positive.

d. Your client is terminally-ill and his family is saying that he has lived a
good life and are considering ending his life.

46
To guide wound care, the nurse can use the RYB color code of wounds, which is based on the concept on the color of an open wound - red, yellow,
or black (RYB) - rather than the depth or size of the wound. Which of these is the correct scheme for the wound care using the RYB color code?
Choose one answer.
 a. Protect red, debride yellow, cleanse black

b. Cleanse red, protect yellow, debride black

c. Debride red, cleanse yellow, protect black

d. Protect red, cleanse yellow, debride black

Question47
One of the most potentially hazardous procedures that health care personnel face is using and disposing of needles and sharps. Needlestick
injuries can be prevented if these guidelines are followed, EXCEPT:
Choose one answer.
a. When recapping a needle, use a one-handed "scoop" method.

b. Never bend or break needles before disposal.

c. Recap used needles.

d. Use appropriate puncture-proof disposal containers to dispose

of uncapped needles and sharps.

Question48
The age and developmental stage of a client is an important variable that will influence both the reaction to and expression of pain. You are a nurse
in the pediatric ward and your client, Jenny, 5 years old, is often crying because of pain. How will you best divert her attention from the pain
experience?
Choose one answer.
a. Clarify misconceptions on pain.

b. Appeal to the child's belief in magic by using a "magic" blanket to take

away pain.

c. Provide a behavioral rehearsal of what to expect and how it will look and
feel.

d. Play music or tapes of a heartbeat.

Question49
Bioethical principles are statements about broad, general, philosophical concepts that guide one's particular actions. You are the nurse of a
chronically-ill patient. Once, you have promised him that you will come back to talk to him and answer his questions after you have made your
rounds to your other patients. However, you have forgotten to keep your word because of the more critical conditions of your other patients. What
bioethical principle have you ignored?
Choose one answer.
a. fidelity

b. justice

c. non-maleficence

d. autonomy

Question50
Several positions are frequently required during the physical assessment, however it is important to consider the client's ability to assume a position
as well as their physical condition, energy level, and age.Mrs. AF, 65 years old, is diagnosed to have cervical cancer for 5 years already, however,
there are no co-morbidities present. She is in the clinic for a follow-up and the nurse is to assess her genital area. What position should the nurse
ask Mrs. AF to assume?
Choose one answer.
a. Prone

b. Sims

d. Air passing through narrowed air
passages as a result of secretions,
swelling, and tumors.
c. freedom from constraints, or any
undue influences to participate in a
study
c. experimental design
b.content validity
a. The client will not experience
aspiration.
b. "I cannot eat or drink anything at least
8 hours before my surgery."
c. Comparing patterns with norms
c. MIS is designed to facilitate the
organization and application of data used
to manage an organization or
management. HIS focuses on the types
of data needed to manage client care
activities and health care
organizations.
c. This immobilizes the chest wall and
c. Lithotomy
d. Dorsal recumbent
- The primary cause of rhonchi (gurgles) is the passage of air through narrowed air
passages as a result of secretions, swelling, and tumors. It can be best heard
during expiration but can be heard on both inspiration and expiration. Crackles
(rales) and crackles are caused by air passing through fluid or mucus in any air
passage. It can be described as fine, short, interrupted crackling sounds that are
best heard on inspiration. Wheezes are caused by air passing through a constricted
bronchus as a result of secretions, swelling, and tumors, which can be described as
continuous, high-pitched, squeaky musical sounds and are best heard on expiration.
Meanwhile, Rubbing together of inflamed pleural surfaces is the cause of pleural
friction rubs which are superficial grating or creaking sounds that can be heard
during inspiration and expiration (Kozier).
- freedom from constraints, or any undue influences to participate in a study.
The right to self-determination means that prospective participants have the right to
decide voluntarily whether or not to participate in a study, without risking any
penalty or prejudicial treatment. The right not to be harmed refers to avoidance of
any exposure to the possibility of injury beyond everyday situations. This involves
avoidance of any risk that can be physical, emotional, legal, financial, or social. The
right to privacy and confidentiality is wherein participants have the right to expect
that any data they provide will be kept in strictest confidence. The right to full
disclosure is wherein the researcher should fully describe the nature of the study,
the person's right to refuse treatment, the researcher's responsibilities, and likely
risks and benefits (Kozier and Polit & Beck).
- experimental design. An experimental design is used by a researcher wherein the
researcher controls (manipulates) the independent variable and randomly assigns
subjects to different conditions. A pretest-posttest design is an example of an
experimental study. A quasi-experimental design is an intervention study in which
subjects are not randomly assigned to treatment conditions, but the researcher
exercises certain controls to enhance the study's validity by manipulating the
independent variable. Anonexperimental design is wherein the researcher does no
manipulation of the independent variable.
- content validity. Content validity concerns the degree to which an instrument has
an appropriate sample of items for construct being measured. This kind of validity is
necessarily based on judgment and it is becoming increasingly common to use a
panel of substantive experts to evaluate and document the content validity of
instruments. Face validity, on the other hand, refers to whether the instrument looks
as though it is measuring the appropriate construct (Polit & Beck).
- the client will not experience aspiration. This statement is more of a goal
because goals are broad statements about the client's status while objectives are
more specific, observable criteria used to evaluate whether the goals have been
met. Also, objectives should be measurable and time-bound (Kozier).
- "I cannot eat or drink anything at least 8 hours before my surgery." There is
aneed to restrict food and oral fluids (NPO) at least 8 hours before surgery to
prevent aspiration during the operation. Usually, dietary alterations are
necessary post-operatively because some foods are not yet tolerated
immediately after surgery. Deep breathing and coughing exercises post-op are
needed to enhance lung expansion and mobilize secretions, thereby preventing
atelectasis and pneumonia. The client should be taught how to splint his/her
incision to reduce pain while coughing if the incision is near any of the breathing
muscles (ie, diagphragm). Clients should also be encouraged to carry out deep
breathing and coughing exercises at least every 2 hours. (Kozier).
c. "I will only do deep breathing exercises when I am experiencing pain."
- comparing patterns with norms. This activity is included in the diagnosis phase
of the nursing process. Meanwhile, assessment is the systematic and continuous
collection, organization, validation, and documentation of data. The data
gathered in the assessment phase are used in the next phase, diagnosing
wherein they are analyzed and synthesized into nursing problems (Kozier)
- MIS is designed to facilitate the organization and application of data used to
manage an organization or management. HISfocuses on the types of data
needed to manage client care activities and health care organizations. HIS is a
type of MIS but is more specific to health care. In MIS, all levels of management
benefit from the ability to access data. Typically, an HIS will have subsystem in
the areas of admission, medical records, clinical laboratory, pharmacy, order
entry and finance. (Kozier).
- Holding the breath while inserting the needle during liver biopsy immobilizes
the chest wall and liver and keeps the diaphragm in its highest position, avoiding
 liver and keeps the diaphragm in its injury to the lung and liver. Also, penetration of the diaphragm is avoided when it
highest position, avoiding injury to the is in its highest position and the risk of lacerating the liver is minimized (Kozier
and Brunner). The other choices are unrelated.
lung and liver.

- tertiary prevention. Tertiary prevention involves minimizing the effects of long-

c. Tertiary prevention
term disease or disability by interventions directed at preventing complications
and deterioration. Primary prevention, meanwhile, is aimed at health promotion
that includes health education programs, immunization and physical and
nutritional fitness programs. Secondary prevention, on the other hand, focuses
on individuals who are experiencing health problems or illnesses and includes
screening techniques and treating early stages of disease to limit disability by
preventing or delaying the consequences of advanced disease (Potter & Perry).

d. A nurse performing internal
examination of a woman during labor
who experienced minimal vaginal
bleeding during the second
trimester.
- a nurse performing internal examination of a woman during labor who
experienced minimal vaginal bleeding during the second trimester. This is not
included in the scope of nursing as defined by R.A. 9173 because the law states
that a nurse is only to do internal examinations during labor provided that there is
an absence of antenatal bleeding and delivery. All the other choices are correct:
a nurse can conduct essential health teachings, administration of written
prescription for medications and executing comfort measures (Bellosillo, et al.)

c. Place a pillow at the lower back.
- place a pillow at the lower back. Placing a supportive device such as a pillow
on the lumbar region will support this part of the body when placed in a Fowler's
position. This will prevent the posterior flexion of the lumbar curvature. Placing a
pillow under the lower legs will prevent pressure on the heels. Placing a pillow
under the forearms will prevent shoulder muscle strain and possible dislocation
of the shoulders. Placing a pillow to support the head, neck and upper back will
prevent hyperextension of the neck (Kozier).

b. Around his mid-thigh with the bladder - around his mid-thigh with the bladder over the posterior aspect of the thigh and
over the posterior aspect of the thigh and the bottom edge around the knee. There are some situations wherein there is a
need to take the blood pressure other than that in the arms, which is the one
the bottom edge around the knee normally done. This position of the cuff should be done to ensure that the
bladder is directly over the posterior popliteal artery if the reading is to be
accurate (Kozier).

- Kardex. The Kardex is a widely used, concise method of organizing and

b. Kardex recording data about a client, making information quickly accessible to all
members of the health team. The Kardex reveals specific data about the client,
including the therapeutic management done and a nursing care plan to be able to
meet the goals and relieve the problems. The flow sheet enables nurses to
record nursing data quickly and concisely to provide an easy-to-read record of
the client's condition over time. Progress notes, on the other hand, provide
information about the progress a client is making. Lastly, the nursing discharge
summary is completed only when the client is being discharged (Kozier) .

b. Assume a broad stance with both feet
parallel to each other.
- Assume a broad stance with both feet parallel to each other. Assuming a broad
stance is correct, however one foot should be in front of the other. A broad
stance widens your base of support while placing one foot behind the other
allows you to rock backward and use the femoral muscles when supporting the
client's weight and lowering the center of gravity, thus preventing back strain.
Meanwhile, bringing the client's weight backward against your body allows
gradual movement to the floor without injury to the client (Kozier).

a. Does not have the legal capacity to
give consent
- does not have the legal capacity to give consent. An individual is legally unable
to sign a consent until the age of 18 years. The only exceptionwherein a minor is
allowed to sign a consent is when he/she is considered anemancipated minor - a
minor who is self-sufficient or married. Other kinds of people who cannot sign an
informed consent are those who are unconscious or injured in such a way that
they are unable to give consent, and those who arementally ill persons who have
been judged by professionals to be incompetent (Kozier and Mosby NCLEX)

- battery. Battery is the willful touching of a person (or the person's clothes or
even something the person is carrying) that may or may not cause harm. It may
d. battery be actionable by law if the touching is done in a wrong way, such as touching
without permission or consent. Assault, on the other hand, can be described as
an attempt or threat to touch another person unjustifiably. Assault precedes
battery; it is the act that causes the person to believe a battery is about to occur.
Negligence and malpractice are examples of unintentional torts (Kozier).

The client undergoing thoracentesis can assume the sitting position with his arms above
c. 1, 2 and 3 the head, with his arm elevated and stretched forward and in which he leans over a pillow
or overbed table. These positions allow easy access to the intercostal spaces wherein the
needle will be inserted to remove the excess fluid or air (Kozier).

a. 30 compressions:2 - 30 compressions:2 breaths. Based on the latest guidelines of the American Heart
Association (2005), this is changed from 15:2 (adults) and 5:1 (child and infant) to simplify
breaths training and to ensure a longer series of uninterrupted chest compressions. This is also
changed because of the rationale that blood flow to the lungs is less than normal during
CPR, therefore the victim needs less ventilation than normal (Kozier).

d.Increased PaCO2, decreased
PaO2, and decreased pH.
- increased PaCO2, decreased PaO2, and decreased pH. As the severe asthma attack
worsens, the client becomes fatigued and there is the development of alveolar
hypoventilation. This can eventually lead to carbon dioxide retention (thus increased
PaCO2) and hypoxemia (decreased PaO2). The pH also decreases because the hydrogen
ions are also retained as the carbon dioxide is retained (Lippincott NCLEX, Kozier).

thirst, increased urine output and warm flushed skin. These are the main symptoms of
a. Thirst, increased urine output hyperglycemia. The most common metabolic complication in TPN is hyperglycemia.
and warm flushed skin
a. Martha Rogers
b.Identification
d. Word the statement so that it there is legal liability in the part of the health care team. Nursing terminology should be
is legally advisable
d. The leader leaves the
decision-making up to the
group.
b. The hallmark of accurate
documentation of actions and
outcomes of delivered care is a
nursing responsibility.
d. veracity
c.Restoring health
b. It considers the nursing care
of older adults to be the art and
practice of nurturing, caring,
and comforting rather than
merely the treatment of
disease.
c. All of the choices.
a.Implementation
Metabolic complications in TPN is most common because metabolic requirements
(electrolytes and energy) differ from patient to patient. Hyperglycemia can be treated by
adding insulin to the solution, reducing the dextrose load, or ensuring the total kcaloric
load is not excessive (Goodner).
TIP: If it's hot and dry, the sugar is high. Cold and clammy, give some candy.
- Martha Rogers. Her Theory of Unitary Human Beings emphasized that the person is an
irreducible whole and that the nurse should seek to promote interaction between two
energy fields (human and environment) to strengthen the coherence and integrity of the
person and to promote maximum health potential.Imogene King, on the other hand,
described the nature of and standard for nurse-patient interactions that lead to goal
attainment (Goal Attainment Theory). Florence Nightingale stressed the importance
of utilizing the environment in assisting the patient towards recovery. Lastly, Dorothea
Orem's General Theory of Nursing included three related concepts of self-care, self-care
deficit, and nursing systems (Kozier).
- identification. During the identification phase, the client assumes a position of
dependence, interdependence, or independence in relation to the nurse. When the client
assumes this role, he/she is completely dependent on his/her caregiver until he/she
derives understanding of his/her condition, which is achieved in the exploitation phase.
New needs and goals are adopted during the resolution phase (Kozier).
- word the statement so that it is legally advisable. The statement shouldnot imply that
used rather than medical terminology to describe the probable cause of the client's
response. The diagnosis should be specific and precise to provide direction for planning
the nursing intervention. Nursing diagnostic statements should not be judgmental, but
instead objective (Kozier).
- the leader leaves the decision-making up to the group. Laissez-faire leadership is
passive and permissive and the leader defers decision-making. Members may work
independently and possibly at cross purposes because there is no planning or
coordination and little cooperation. Chaos is likely to develop unless an informal leader
emerges. Authoritarian leadershipmaintains strong control, does the planning, makes the
decisions, and gives the orders. Meanwhile, democratic leaders maintain less control; ask
questions and make suggestions rather than issue orders (Marriner-Tomey and Kelly-
Heidenthal).
- the hallmark of accurate documentation of actions and outcomes of delivered care is a
nursing responsibility. Instead of responsibility, accurate documentation is a nursing
ACCOUNTABILITY. The other choices are included in the nurses' code of ethics (Kozier
and Balita).
- veracity. The principle of veracity refers to the practice of telling the truth. Autonomy
refers to the right to make one's own decisions. Nurses who follow this principle should
recognize that each client is unique. Non-maleficence is the duty to "do no harm". This
requires nurses to act in such a way as to avoid causing harm to clients. Meanwhile, the
bioethical principle of beneficencemeans "doing good" and it requires nurses to act in
ways that benefit clients. (Balita's Ultimate Learning Guide and Kozier).
- restoring health. This area of nursing practice focuses on the ill client, and it covers early
detection of the disease to helping the client during the recovery period. Promoting health
and wellness involves enhancing the individual's or community's lifestyle. In illness
prevention, maintenance of health through prevention of disease is the goal. This can be
achieved through immunizations, prenatal care, etc. Caring for the dying includes helping
clients live as comfortably as possible until death and helping significant others cope with
death (Kozier).
- Gerontics considers the nursing care of older adults to be the art and practice of
nurturing, caring, and comforting rather than merely the treatment of disease. Geriatrics is
the branch of medicine that deals with the physiological and psychological aspects of
aging and with diagnosis and treatment of diseases affecting older adults. Gerontological
Nursing is concerned with the assessment of health and functional status of older adults;
diagnosis, planning and implementing health care and services, and; evaluating the
effectiveness of such care. Gerontology is the study of all aspects of aging process and its
consequences (Potter & Perry).
The answer is D - all of the choices. The Theory X view is that in bureaucratic
organizations, employees prefer security, direction, and minimal responsibility. Coercion,
threats, or punishment are necessary because people do not like the kind of work that
they are doing. On the other hand, Theory Y's assumptions are that in the right conditions,
people enjoy their work; can show self-control and discipline; are able to contribute
creatively and are motivated by ties to the group, the organization, and the work itself
(Kelly-Heidenthal).
- implementation. Implementation is the phase in the nursing process wherein the nurse
performs the nursing interventions. It also consists of doing and documenting the activities
that are the specific nursing actions needed to carry out the interventions. Completion of
the implementation phase is done by recording the interventions and the client's

c. Delegation is an opportunity
to transfer one's accountability
to a task.
a. Withhold the medication,
further assess the patient and
inform the attending physician
of your findings.
c. The research study was done statement best manifests confidentiality as there were no specific information given to link
in the pediatric wards of a
tertiary hospital in Manila.
b. Calcium
c. The Board of Nursing shall
designate the places and dates
of the Nursing Licensure
Examination.
a. Care plans are based on the
nurse's clinical experience and
from the latest research
findings.
c.5 ml
c. Nurse Pat gave the wrong
antibiotic and after 30 minutes
the patient experienced an
anaphylactic reaction.
c.10
b. An elevated solid mass,
deeper and firmer than a
papule, that is 0.5-2 cm.
d.progressive muscle relaxation - progressive muscle relaxation. The independent variable is the presumed cause of or
c. A 5-year-old child with
ascariasis
responses in the nursing progress notes (Kozier).
- Delegation is an opportunity to transfer one's accountability to a task.Accountability is
still retained by the nurse-manager even if tasks are delegated. They are still accountable
for the performance of the task, the selection of the person to complete it, and both the
staff's and their own performance (Tomey). When delegating, authority is transferred,
responsibility shared and accountability retained.
- withhold the medication, further assess the patient and inform the attending physician of
your findings. According to the nurses code of ethics, the nurse's first loyalty is to the
client. The nurse's actions should always give the highest priority to the client's needs
before that of other members of the health team (Kozier).
- the research study was done in the pediatric wards of a tertiary hospital in Manila. This
the individual identities. Measures to be included to ensure confidentiality is the use of
pseudonyms, code numbers or reporting only aggregate or group data in published
research ((Kozier and Polit & Beck).
Calcium. Numbness, tingling of the extremities and around the mouth, muscle tremors,
cramps and hyperactive deep tendon reflexes, with positive Trousseau's and Chvostek's
signs and cardiac dysrhythmias are manifestations of hypocalcemia or decreased serum
calcium. Clients at greatest risk for hypocalcemia are those whose parathyroid glands
have been removed. Hypomagnesemia and chronic alcoholism also increase the risk of
hypocalcemia (Kozier).
- the Board of Nursing shall designate the places and dates of the Nursing Licensure
Examination. It is the responsibility of the Professional Regulation Commission (PRC) to
designate the places and dates of the licensure exam. TheBoard of Nursing is primarily
responsible in the conduction of the licensure exam. All the other choices are features of
R.A. 9173.
- care plans are based on the nurse's clinical experience and from the latest research
findings. Evidenced-based practice uses outcome research and other current research
findings to guide the development of appropriate strategies to deliver quality, cost-
effective care. Research provides evidence about benefits, risks, and results of treatments
so individuals can make informed decisions and choices to improve their quality of life
(Kelly-Heidenthal).
- 5 ml. The amount of drug to be given is computed using the formula: amount to
administer (x)=desired dose or dose ordered/dose on hand multiplied by the quantity on
hand. For this item, we compute the amount to administer (x) by using 2.5 g/5 g x 10 ml.
The answer will be therefore, 5 ml (Lippincott NCLEX Reviewer).
- Nurse Pat gave the wrong antibiotic and after 30 minutes the patient experienced an
anaphylactic reaction. An act of negligence can be seen if the following are present:
a) duty - the nurse must have (or should have had) a relationship with the client that
involves providing care and following an acceptable standard of care; b) breach of duty -
there must be a standard of care that is expected in the specific situation but that the
nurse did not observe; c) foreseeability - a link must exist between the nurse's act and the
injury suffered; d) causation - it must be proved that the harm occurred as a direct result
of the nurse's failure to meet standard of care, and; e) injury - the client must demonstrate
some type of harm or injury (physical, financial, or emotional) (Kozier).
- 10. The Glasgow Coma Scale tests three (3) major areas that determines the client's
level of consciousness: eye opening (spontaneous-4, to verbal command-3, to pain-2, no
response-1), motor response (to verbal command-6, to localized pain-5, flexes and
withdraws-4, flexes abnormally-3, extends abnormally-2, no response-1) and verbal
response (oriented and converses-5, disoriented and converses-4, uses inappropriate
words-3, makes incomprehensible sounds-2 and no response-1). The higher the score,
the more improved or normal the level of functioning. An assessment totaling 15 points
indicates that the client is alert and completely oriented. A comatose patient scores 7 or
less (Kozier and Potter & Perry)
- A nodule is an elevated solid mass, deeper and firmer than a papule, that is 0.5-2 cm. A
common example of a nodule is a wart. A wheal is an irregularly shaped, elevated area
or superficial localized edema that varies in size and common examples of which are
hives and mosquito bites. A papuleis a palpable, circumscribed, solid elevation in the
skin, smaller than 0.5 cm and an elevated nevus is an example of which. A tumor is a
solid mass that may extend deep through the subcutaneous tissue, larger than 1-2 cm and
a common example of which is an epithelioma (Potter and Perry).
influence on the dependent variable. The dependent variable, on the other hand, is the
behavior, characteristic, or outcome that the researcher wishes to explain or predict. In
the statement above, the blood pressure is the dependent variable (Kozier).
- A 5-year-old child with ascariasis. A retention enema introduces oil or medication into
the rectum and sigmoid colon. The liquid is retained for a relatively long period (e.g. 1 to 3

b. Stress urinary incontinence -
encourage pelvic muscle
exercises
a. Your patient is depressed
and does not respond to any of
your questions.
d.Protect red, cleanse yellow,
debride black
c. Recap used needles.
b. Appeal to the child's belief in
magic by using a "magic"
blanket to take away pain.
a. fidelity
d. Dorsal recumbent
hours). Antihelminthics can be given through enema to kill helminths such as worms and
intestinal parasites. Those who will undergo surgery or have an invasive diagnostic
procedure (e.g., colonoscopy) are more likely to receive a cleansing enema and this kind
of enema is intended to remove feces. Cleansing enemas are given chiefly to prevent the
escape of feces during surgery; prepare the intestine for certain diagnostic tests such as
x-ray or visualization tests, and; remove feces in instances of constipation or impaction.
Other types of enema includecarminative (to expel flatus) and return-flow (used
occasionally to expel flatus and is repeated several times until it is expelled) enemas
(Kozier).
- stress urinary incontinence - encourage pelvic muscle exercises. Stress urinary
incontinence is the sudden loss of urine occurring with activities that increase abdominal
pressure, such as that in pregnancy. The main goal for this kind of incontinence
is symptom control that may be done through strengthening and training the levator ani
and urogenital muscles through repetitive contractions to decrease stress, urge or mixed
types of incontinence (pelvic muscle exercises). Functional incontinence is the inability
of the usually continent person to reach toilet in time to avoid unintentional loss of urine
and this can be avoided through prompted voiding . Reflex incontinence, on the other
hand, is the involuntary loss of urine at somewhat predictable intervals when a specific
bladder volume is reached and this can be managed throughintermittent urinary
catheterization. Urge incontinence is the involuntary passage of urine occurring after a
strong sense of urgency to void and the best way to manage this is through urinary
bladder training (Kozier).
- your patient is depressed and does not respond to any of your questions. This is the
least priority among all the choices. Abortion is a highly publicized issue about which
many people feel very strongly. However, nurses have no right to impose their values on a
client but support clients' right to information and counseling in making decisions.
Concerning HIV and AIDS, there has been a strong social stigma and the moral obligation
to care for this kind of client cannot be set aside unless the risk exceeds responsibility.
In end-of-life issues, it is of utmost importance during this time is to provide them with
information and professional assistance, as well as the highest quality of care and caring
(Kozier).
- protect red, cleanse yellow, debride black. Red wounds are usually in the late
regeneration phase of tissue repair. They need to be protected to avoid disturbance to
regenerating tissue. Yellow wounds are characterized primarily by liquid to semiliquid
"slough" that is often accompanied by purulent drainage or previous infection. Yellow
wounds are cleansed to remove nonviable tissue. Black woundsare covered with thick
necrotic tissue, or eschar. They require debridement or removal of the necrotic material.
Removal of nonviable tissue from a wound must occur before the wound can heal (Kozier).
- recap used needles. Used needles (i.e. has been inserted into a client)should NEVER
be recapped except under special circumstances(e.g. when transporting a syringe to
the laboratory for an arterial blood gas or blood culture). Recapping a needle is also done
only after drawing up a medication into a syringe prior to administration (hence, use the
one-handed "scoop" method). The other 2 choices are other essential guidelines to
prevent needlestick injuries (Kozier).
- appeal to the child's belief in magic by using a "magic" blanket to take away
pain. Preschool children develop the ability to describe pain and its intensity and
location, and may consider pain as a punishment therefore reasoning with a child at this
stage is not always successful. Preschoolers are magical thinkers, therefore this strategy
may succeed. Clarifying misconceptions on pain is for the elderly because they perceive
pain as part of the aging process. Playing music or tapes of a heartbeat is applicable
for infants because of their need for tactile stimulation. Providing a behavioral rehearsal
of what to expect and how it will look and feel is for the school-age children because at
this age they already rationalize in an attempt to rationalize the pain (Kozier).
- fidelity. The bioethical principle of fidelity means to be faithful to agreements and
promises. Clients take such problems seriously and nurses should, too.Autonomy refers
to the right to make one's own decisions. Nurses who follow this principle should
recognize that each client is unique. Justice is fair, equitable, and appropriate treatment
according to what is due or owed to persons. Non-maleficence is the duty to "do no
harm". This requires nurses to act in such a way as to avoid causing harm to clients.
Meanwhile, the bioethical principle of beneficence means "doing good" and it requires
nurses to act in ways that benefit clients. Lastly, the principle of veracity refers to the
practice of telling the truth (Balita and Kozier).
- dorsal recumbent position. This position, together with lithotomy, are the most
common positions to assume when assessing the female genitals, rectum and the female
reproductive tract. However, the lithotomy position may be uncomfortable and tiring for
elders and often embarrassing. The dorsal recumbent position is contraindicated only to
those with cardiopulmonary problems. Theprone position is often not tolerated by elders
and the sim position may be difficult for them because of limited joint movement (Kozier).