NURSING PRACTICE I

SET A D2010

GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheet. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES INSTRUCTIONS: 1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set 2. Write the subject title Nursing Practice I on the box provided. Situation: The nurse is performing a physical assessment of Mr. Go, age 50. The assessment includes the Rinne test auscultation of the heart and lungs, and assessment of the reflexes. 1.In performing the Rinne test on Mr. Go, the nurse uses: a. A tuning fork to test whether the patient hears better in one ear b. A tuning fork to compare sound conduction through air and bone c. A tuning fork to compare the patients bone conduction with her own d. An ophthalmologist to check the optic disk 2.While auscultating Mr. Gos lungs, the nurse hears short, discrete bubbling sounds during inspiration. These sounds are: a. Friction rubs b. Rhonchi c. Wheezes d. Crackles 3.While auscultating Mr. Gos heart, the nurse listens for the S1 sound. This sound is created by: a. Closure of the aortic valve c. Closure of the pulmonic valve b. Closure of the mitral tricuspid valves d. Rapid filling of the ventricle 4.S1 is heard best at the: a. Fifth left intercostals space along the midclavicular line b. Third intercostal space to the left of the midclavicular line c. Second right intercostals space at the sternal border d. Second left intercostals space at the sternal border 5.In assessing Mr. Gos plantar reflex, the nurse expects which of the following responses? a. Dorsiflexion of the great toe and fanning of the other c. Flexion of the knee toes d. Flexion of the toes b. Extension of the lower leg at the knee Situation: Mr. Bruce, age 40, is admitted to the hospital with a diagnosis of right lower lobe pneumonia. He is slightly dyspneic at rest and is receiving 2 liters of oxygen by nasal cannula. His vital signs are: temperature, 101.1 F (38.4 C); pulse rate, 100 beats/minute; respiratory rate, 22 breaths/minute; and blood pressure, 136/74 mmHg. The physician starts an IV line for antibiotic administration. 6.Which nursing diagnosis will be the first priority? a. Altered tissue perfusion related to inflammation b. Impaired skin integrity related to IV puncture c. Potential for impaired gas exchange related to infection and inflammation d. Impaired gas exchange related to infection 7.Which of the following breath sounds auscultated on Mr. Bruce are abnormal? a. Vesicular sounds over the left lung c. Bronchovesicular sounds between the scapulae b. Bronchial sounds over the trachea d. Bronchial sounds over the right lower lobe 8.Mr. Bruces skin should be assessed for: a. Temperature, moisture, and turgor b. Mobility, turgor and integrity c. Vascularity, evidence of bleeding and edema d. All of the above

9.During the nursing history, Mr. Bruce says he has had congestive heart failure. Which of the following would be most pertinent to this diagnosis? a. A family history of coronary artery disease, asthma and diabetes b. A history of periorbital edema and intermittent claudication c. A recent history of peripheral edema, emphysema and dyspnea d. A family history of hypertension, rheumatic heart disease, and tuberculosis Situation: Mrs. Wallace, an Aeta age 64, has returned from the recovery room after having a bronchoscopy. 10. Which aspect of Mrs. Wallaces mental status should the nurse assess at this point?

a.

b.

Memory Personality changes

c. Intellectual performance d. Level of consciousness

11. The nurse determines that Mrs. Wallace is lethargic because she: a. Responds immediately to people and c. Maintains consciousness only with constant surroundings stimulation b. Sleeps but can be easily roused by touch d. Cannot be roused from sleep 12. The nurse suspects that Mrs. Wallace has an acute bacterial respiratory tract infection because the sputum collected is: a. Pink and frothy b. Blood tinged c. Clear and watery d. Thick and yellow 13. The most appropriate site at which to evaluate Mrs. Wallace for cyanosis is her: a. Feet b. Fingers c. Skin d. Nail beds 14. Which of the following symptoms indicate beginning hypoxia? a. Cyanosis, tachycardia, and vertigo b. Dyspnea, restlessness and cyanosis c. Restlessness, tachypnea and tachycardia d. Cyanosis, tachypnea and tachycardia

15. Which of the following symptoms suggests long-term respiratory impairment? a. Clubbing of fingers b. Circumoral pallor c. Transudation phenomenon

d. Raynauds

Situation: Mrs. Kate, a 40-year-old mother of six, is admitted to the hospital with chronic, severe lower back pain. 16. Which of the following is most useful in determining the severity of Mrs. Kates pain? a. Vital signs c. A descriptive scale b. Facial grimaces d. The patients subjective account 17. Which of the following questions would be most appropriate in trying to pinpoint the characteristics of Mrs. Kates pain? a. Is your pain throbbing or c. Can you describe your pain for me? crushing? d. When does your pain hurt most? b. How severe is your pain?

18. Mrs. Kate consistently requests her pain medication hour earlier than the 4-hour time span ordered between doses.
The nurse is convinced the patient requests the medication earlier because she fears no one will be available when she really needs it. The nurse can best help Mrs. Kate by: a. Promptly attending to her needs and establishing a strong therapeutic relationship b. Explaining that she doesnt feel Mrs. Kate needs the pain medication as frequently as requested c. Telling her that if she promises to wait until the recommended time, the nurse will give her the medication on time d. Telling her that she should try to extend the time between doses to increase her pain tolerance

19. Mrs. Kates pain prevents her from having a restful night. Which of the following interventions would be non-therapeutic in
this situation? a. Tuning the radio to soft, relaxing music b. Administering a soothing back rub c. Saying, I believe this will help while administering an analgesic d. Having the client talk about her pain 20. Which of the following subjects is most controversial in discussions about pain perception? a. Physiologic factors c. The gate control theory b. Psychological factors d. Endorphins Situation: All individuals share basic needs that are necessary for their survival. Nurses should be sensitive towards these needs since they are important factors that will determine the plan of care. 21. Which of the following statements about mans basic needs is correct? a. Hospitalized clients have basic needs that should all be met by the nurse b. Basic human needs are the same in priority in all individuals c. Environment has nothing to do with the ability of man to meet his needs d. Unmet needs render the individual clients at risk for illness and/or complications 22. Which of the following client groups require the fullest resistance in meeting their physiological needs? a. A toddler with venoclysis and under treatment for LBM b. A severely malnourished school-aged child c. Premature infants d. A 6-year-old admitted for parasitism and ambulatory 23. Which of the following are groups are at greatest risk for unmet needs? 1. Very young 2. Very old

3. Adolescent 4. School-age children a. 1 and 2 b. 2 and 4 c. 3 and 4 d. 2 and 3

24. Which of the following needs is a primary consideration in determining the priorities in meeting clients unmet needs? a. Self-esteem needs c. Physiological needs b. Security needs d. Spiritual needs 25. Which of the following observations is best closely associated with patients physical safety? a. Lack of confidence c. Skin breakdown as in bedsore b. Fear of the unknown d. Threat to body image Situation: Health care services are classified into categories. Nurses should be cognizant of these categories to be able to render appropriate nursing intervention. 26. Which of the following interventions are classified as primary care? a. Screening patients for tuberculosis b. Provision of direct nursing care to patients in the ward c. Counseling newly married couples on appropriate family planning methods d. Teaching diabetic patients how to self-inject 27. Which of the following can be classified under the secondary levels of care? 1. Assisting in an open heart surgery 2. Implementing directly observed therapy (DOT) in the rehabilitation control of tuberculosis 3. Attending to the delivery of a G2P1 mother 4. Participate in the immunization campaign against policy 5. Doing active and passive exercise with a CVA patient after a bed bath a. 2, 3 and 4 b. 3, 4 and 5 c. 1, 4 and 5 d. 1, 2 and 3

28. Applying sandbags against the sole of the feet of a stroke patient to prevent foot drop is an example of what level of care? a. Primary b. Acute care c. Secondar d. Tertiary care care y care

29. Establishing a nurse-client relationship with a suicidal patient is an example of which of the following level of care? a. Tertiary care b. Psychological care c. Secondary care d. Primary care
30. Which of the following nursing interventions are considered primary care? 1. Conducting mothers class on how to bathe newborns 2. Conducting group classes on Lamaze technique to couples 3. Conducting groups classes to diabetic patients 4. Doing adolescent reproductive health counseling 5. Doing health education classes on how to stop smoking

a.

1, 2, 3 and 5

b. 2, 3, 4 and 5

c. 1, 2, 3 and 4

d. 1, 2, 4 and 5

Situation: Post partum blues sometimes happen among women who recently gave birth. 31. From research findings, the pregnant women have tendencies to have post partum blues are those is: a. High risk pregnancy c. Infectious cases b. Cardiovascular ailments d. Primigravida state 32. Post partum blues usually happen within the: a. First week and lasts 5 to 10 days b. Fourth week and lasts 10 to 15 days c. Second week and lasts 5 to 12 days d. Third week and lasts 4 to 8 days

33. Post partum depression on the other hands is more serious and lasts longer. The nurse should know that the cause from a. Unrecognized and untreated c. Disorganized behavior depression d. Inability to sleep for a long time b. Missing meals habitually 34. One promotive measure to avoid post partum psychosis is having a. Collegial friends and classmates c. Outing and recreation activities b. Good food and long hours of d. Healthy and supportive family life sleep 35. Guilt feelings when not verbalized can be a factor in having which condition? a. Depression b. Anxiety c. Fear

d. Anger

Situation: Ms. Janet, a school nurse, was invited to speak at a career for high school students organized by the school. In the open forum, she was asked whether nursing is a profession. 36. Which of the following BEST describes nursing as a profession? a. It is highly paid especially in developed countries b. It is service oriented and a universal profession c. It is highly skilled and purely technical d. It has a culture of autonomy in decision-making especially in responding to patients nursing problems 37. When asked How do you define nursing Ms. Janet quoted the statement It is assisting the individual sick or well in the performance of activities contributing to health or recovery in a manner that will help the client gain independence. Who among the following is the source of this definition? a. Virginia Henderson b. Dorothy Orem c. Clara Barton d. Florence Nightingale 38. Ms. Janet was proud to tell the graduating high school students that she enjoys being a nurse because of the many independent functions inherent in her practice. Which of the following is NOT an independent function of the school nurse? a. Applying cold compress to a localized hematoma caused by a fall b. Injecting quick acting pain reliever to a girl with severe dysmenorrhea c. Teaching a non teaching personnel with diabetes how to self-inject insulin d. Referring a grade one pupil with speech problem to a special therapist 39. One student in the convocation asked, How can nurses prevent themselves from a malpractice suit? Which of the following would be the BEST answer? a. Always ask your supervisor before doing anything for the patient b. Ask the watcher or relative to assist you in doing nursing care to patients c. Always observe teamwork d. Ensure competence through continuing professional education

40. Which of the following is the main nursing function of a school nurse?
a. b. c. d. Develop programs to increase workers health and safety Provide a variety of health related to services within a designated locality Provide health education and care for clients with non emergency illnesses Teach clients and family to provide home nursing activities

SITUATION: Ms. Juana de la Cruz is the charge nurse of the Rehabilitation Unit. She is responsible for the management of the unit. 41. Mrs. De la Cruz observes that the one of the female staff is not performing his duties very well. Which of the following strategies will she implement to assist the staff nurse? a. Allow the staff nurse to select own assignment b. Discuss with the staff nurse her performance and ways she can improve c. Assign the staff nurse several clients with physical disabilities d. Ask the staff nurse to work as an assistant charge nurse

42. The charge nurse notes that the one of the male staff nurse is frequently absent and his absence have adversely affected
the quality of care given to the clients in the unit. Which of the following approaches would be best? a. Talk with the staff and remind him the standards of the agency b. Place on record the absences of the staff nurse c. Write the staff nurses a memorandum regarding his absences d. Inform the staff nurse that the absences will be ground for termination 43. The charge nurse presents to the administration of the agency a plan to decrease the client to nurse ration from 8:1 to 6:1. She should emphasize the effect of the proposed ratio in: a. Institutional resources c. Standards of nursing practice b. Nursing recruitment policy d. Client-care quality 44. The charge nurse assigns a new staff nurse to administer the medication of a client undergoing rehabilitation. Which detail of the client's drug therapy is the staff nurses legally responsible to document? a. Client's reaction to the drug c. peak concentrating time of the drug b. Client's socio-economic status d. Safe ranges of the drug

45. The charge decides what is best for the rehabilitated client and acts on the decision without consulting the client. The
charge nurse is applying a moral principle which is: a. Fidelity b. Autonomy c. Beneficence d. Paternalism

SITUATION: R.A. 9173 was enacted into law on October 21, 2002. Considering that it governs nursing practice in the Philippines. Nurses must be cognizant of its provisions. 46. Which of the following provisions is embodied in R.A. 9173?

a. Students entering Nursing must belong to upper 40% of the graduating high school student b. The board recognizes nursing specialty organization. c. A refresher course is required to those who failed for three times. d. The board is composed of five members 47. Which of the following foreign licensed nurse may be allowed to practice nursing in the Philippines? a. Filipinos who are educated and licensed in the foreign country b. Those who were born in the Philippines but has required Canadian citizenship c. Those who are working as missionary to practice in medical mission for less than one month d. Those who are foreign national but married to Filipino national

48. Which of the following duties and responsibilities of a nurse are considered within the scope of nursing practice?
a. Applies sublingually nitroglycerium sulfate to a hypertensive patient then refer to physician b. Does internal examination to determine cause of antenatal bleeding. c. Does Episiotomy. d. Attends to normal deliveries 49. Which of the following DOES NOT govern the practice of nursing in the Philippines? a. Board resolution on the standards of nursing practice c. R.A. 7164 b. Board resolution on the code of ethics of nurses d. R.A. 9173 50. Under the current law, there are seven members of the board of Nursing. The membership of the board shall represent which of the following? 1. Nursing Education 2. Nursing Service 3. Community health nursing 4. Mother and Child nursing a. 2, 3 and 4 c. 1, 4 and 5 b. 3, 4 and 5 d. 1, 2 and 3 SITUATION: Piling is two months pregnant. Her parents do not know this. Piling informed her friend, Milling about the problem. Milling referred Piling to Juaning, An abortionist. Piling had an abortion. 51. If those involved will be charged legally, who is the principal? a. Piling b. Juaning 52. Who is considered as an accomplice: a. Piling b. Juaning c. Miling c. Miling d. None of them d. None of them

53. If during the investigation, the pieces were not found because Carling, the maid of Juaning burned it. Carling is considered as: a. Accomplice b. Accessory c. Principal d. Co-principal 54. A Nurse is liable as an accomplice in an abortion if she: a. Assist in the escape of the offender b. Refers the pregnant mother to the abortionist c. Conceals the evidence of the crime d. None of these d. all of these

55. Which manifestation is NOT present in missed abortion? a. Pain b. Bleeding c. Cervical opening

SITUATION: One of the best ways to prevent psychiatric disorders is the development of skills in handling crisis intervention. 56. Who would be a good candidate for crisis intervention? a. A client with a previous melancholia b. A client with a fixed coping mechanism c. A client without support system or significant others d. A client with a known precipitating cause.

57. Which of the following is NOT an accurate assumption about crisis intervention? a. A therapist assumes a passive indirect role. b. Little importance is attached to past emotional understanding. c. It is an expensive short time therapeutic approach. d. It is important to help the client achieve an intellectual understanding of the immediate crisis. 58. In doing crisis assessment, which of the following is LEAST important? a. Successful past coping mechanism c. Assessment of long term need b. Identification of precipitating events. d. Urgent availability of resources 59. A patient with heart problem was admitted in the ward. The nurse learned that the patient has been widowed for a month. The patient often talks about her husband with practically all the staff nurses in ward. Which of the following is the appropriate focus of crisis intervention approach for this patient?

a. Revolving her dependency needs b. Re-evaluating her marriage

c. Teaching her to live as productively as possible d. Supporting a grief reaction

60. In counseling patient in crisis, the nurse applies the client centered therapy of Carl Rogers who interprets client's
experiences by using which of the following groups of term? a. Behavior and feelings b. Self-awareness and Self-actualization 61. Specific causes of back pain are: a. Diagnosed through a medical history b. Diagnosed by a x-ray 62. Acute low back pain most often originates: a. In the bony portion of the spine b. In discs 63. The majority of clients with acute low back pain: a. Have herniated discs b. Develop chronic low back pain syndrome c. d. c. Scripts and Counterscripts d. Group interaction and responsibility

c. Diagnosed by neurological exam d. Difficult to diagnosed

c. Within muscles or ligaments d. Within spinal canal Are incapacitated no longer than 1 to 2 weeks Require surgery

64. Most clients with acute low back pain do not have neurological deficits. Recommended treatment for these clients includes all of the following EXCEPT: a. Bed rest for 1 week b. Anti-inflammatory drugs c. Analgesics d. Muscle relaxants 65. The hallmark of myofascial pain is: a. Improvement with bed rest b. Referred numbness and tingling

c. A decrease in motor function d. Trigger points in muscles

66. Which of the following is true regarding pain in children? a. Children have poorly developed nociceptors, so they do not frequently experience severe pain b. Pain management in children is similar to management in adults c. Pain management in children is frequently more challenging than in adults d. Children metabolize medications more quickly than adults 67. Which assessment parameter is essential in evaluating a pediatric client for pain management? a. Height and weight b. Developmental stage c. Social support 68. Behaviors used to express pain in children: a. Always involve regression in developmental stage b. Frequently seen unrelated to the source of pain c. Do not differ from behaviors seen in adults d. Are unreliable and should not be considered as part of pain assessment 69. Acute pain in children: a. Is always the result of trauma b. May be related to illness, intervention, or trauma c. Is less commonly seen than chronic pain d. Is seen only in specific healthcare settings

d. All of the above

70. Use of medication administered on a PRN or as-needed basis for children with pain: a. Frequently results in poor pain management because of inappropriate assessment b. Is restricted to use only in critical care settings c. Provides excellent pain management d. Is never used as an alternative in planning that clients care 71. The first step in designing a plan for pain management in pediatric clients is: a. Height and weight c. Offering distraction and play therapy b. Interview with parents, grandparents, and siblings d. A complete and thorough assessment 72. Preschool-age children, although often able to verbalize their pain, frequently do not report it accurately as a result of all of the following except: a. Fear b. Magical thinking c. Concerns about bodily mutilation d. Lack of maternal trust 73. Safe and routine pediatric doses of medication are: a. Always half of the appropriate adult dose b. Specific to each medication c. Never shared with parents d. Found on the label of unit-dosed packages

74. Use of opioid medications with small children may result in sedation. The most important nursing intervention for these
small clients is to: a. Position the child to maintain a patent airway b. Not use adjuvant medications to treat unpleasant side effects c. Caution against operating heavy machinery d. Reduce the dose of medication until sedation is no longer apparent 75. Rectal administration of medication is frequently most appropriate in which age group? a. Toddlers b. Adolescents c. Pre-school age children above 76. Pain in the elderly population is: a. A less frequent problems due to diminished sensation b. More common due to increased healthcare needs c. Difficult to manage due to widespread chronic malnutrition d. Successfully managed only by gerontology specialist 77. Considerations in choosing a route of administration for medication in the elderly include: a. Loss of subcutaneous tissue and muscle mass c. Hearing difficulties b. Noncompliance d. None of the above 78. Manifestations of pain related to vascular changes in the elderly include: a. Macular degeneration c. Intermittent claudication b. Osteoarthritic pain d. Pain related to ill-fitting dentures 79. Acute pain in the elderly client: a. Is always easily assessed b. May be masked by over-the-counter medication use

d. None of the

c. Is responsive to NSAID therapy d. Rarely reflects the severity of illness or trauma

80. Changes in mental status associated with senility, dementia, or Alzheimers disease may result in inadequate pain management because of: a. Masking of manifestations of acute pain b. Inability to perceive pain due to central nervous system changes c. Inability to vocalize or describe pain d. All of the above 81. Allan is a fresh nursing graduate and took the board exam but was not able to pass the licensure examination. When does a retaker supposed to take a removal exam? a. He must undergo a refresher course in an approved nursing school for a period of one year b. Anytime he wants to take the licensure examination again provided he submits the complete requirements c. He will take the licensure examination again after 2 years d. He is advised to perform 3 more operating room and delivery room scrubs 82. Which is one of the functions of the BON? a. Issue, suspend and revoke certificates of registration b. Close down a school of nursing c. Plan out and implement the salary grades for nurses d. Set the standards of the nursing profession

83. What is the basic requirement of the state for a nurse to practice her profession? a. Willingness to practice the c. A nursing license profession d. An NCLEX and CGFNS passer b. A BSN degree 84. Doing a nursing procedure without the patients informed consent may bring nurse Nina to the court of law for this violation: a. Negligence b. Assault c. Battery d. Tort 85. Nurse Sheryll may be proven to be negligent in her job if: i. A patient is injured ii. Nurse Nina did not follow nursing standards iii. Nurse Nina failed to do his duty iv. The injury that the patient sustained is foreseeable a. All of the above b. NOTA c. i and ii d. iii only 86. Charting should be legible and standard abbreviation should be used. What is not standard abbreviation? a. NPO b. PRN c. TIW d. BRP

87. Which of the following reflects an example of a collaborative function of the nurse?
a. The nurse executes the interventions according to her judgment of the clients health responses

b. The nurse refers to the doctors order before doing an intervention like giving medications and treatment modalities c. The nurse shares his expertise to others and also elicits the expertise of other members of the health team d. The client shares his expertise to others and also elicits the expertise of the other member of the health team

88. While in the ICU, he executes the document that list the medical treatment he chooses to refuse in case his condition
becomes severe to a point that he will be unable to make decisions for himself. This document is: a. Informed consent b. Living will b. Last will and testament c. Power of attorney 89. A client wants to place himself in a DNR status. What should be the initial intervention of the nurse? a. Discourage the client from doing so b. Ask the client if the doctor of the family was already notified c. Explain to the client that he is not competent to execute a DNR d. Let the client sign the DNR agreement form 90. What is the use of the Code of Ethics for Nurses? a. To guide clients in making ethical decisions b. To guide nurses in making ethical decisions c. To guide nurses in their practice to correctly perform basic procedures d. To guide nurses in making clinical judgments 91. A document required to lawfully practice a particular skill: a. Diploma b. Transcript of records c. License d. Related Learning Experience Certificate

92. A client had a miscarriage 12 weeks ago. Which of the following is an expected manifestation? a. The client is still on her grieving process c. The client will continue to grieve until 16 weeks b. The client has recovered d. The client is still in denial of the event 93. When will the client fully recover after her miscarriage? a. After the arrival of a new baby b. After 6-8 months c. After discharge from the hospital d. After seeking professional help from a psychiatrist

94. In lifting heavy objects, how should the nurse perform proper body mechanics? a. Feet close together c. Spread both feet apart d. Never bending the knees when lifting b. Back reaching over the other side of the bed 95. A nurse should be aware of proper body mechanic to avoid unnecessary injuries. Which is correct? a. Push while your feet moves forward and pull while your legs move backward b. Always bending through the hips when reaching things on the ground c. Push while your feet moves backward and pull while your legs move forward d. Not identifying the weight of the object before lifting it 96. Which of the following clients would the nurse see first? a. A client with wound having purulent discharges b. A client with wound that has black scars c. A hospitalized client that was just instructed to perform insulin injection d. A client with a post operative wound on the anterior abdominal wall complaining of pain 97. Which of the following can be safely delegated to an unlicensed personnel? a. Calculate intake and output b. Maintain the label ALWAYS BELOW THE BED c. Educated the client about foods that contain high amounts of sodium d. Prepare the client that will be sent to the radiology department 98. Which of the following practices belong to the infection control precautions for client with AIDS? a. Recapping needles after injecting medications b. Washing hands only after contact with an AIDS client c. Dispose used needles in puncture proof container d. Wearing gloves for all client contact 99. A nurse will assess the client in her room with the family present. a. Ask the family if they want to stay b. Ask the client if he wants the family to stay c. Ask the client to go with the nurse in a private place and perform assessment d. Wait for all family members to go out before assessing 100. The following are proper procedures in administering a blood transfusion except a. The serial number and blood type must be checked

b. The doctors order must be checked for specifications c. One nurse checks the blood expiry date while another nurse checks the order d. A gauge 18 needle is preferably used in transfusion