NURSING PRACTICE B:
COMMUNITY HEALTH NURSING
AND CARE OF MOTHER AND CHILD
1. A child who is 13 months has fast breathing if he has:
A. 30 breaths per minute or more
B. 60 breaths per minute
C. 40 breaths per minute or more
D. 50 breaths per minute
2. Which of the following is true about discharge planning?
A. basic discharge plans involve referral to community resources
B. discharge plans involve referral to community resources
C. simple referral involves use of a discharge planner
D. complex referral includes interdisciplinary collaboration
3. A nurse may keep opened vials of OPV for use in the next session if:
A. you have taken out the vaccine at the health center for some other reasons
B. the expiry date has not passed
C. the vaccines have been stored at a temperature between 0 deg C and 8 deg C
D. the vaccines have change its color
4. The primary preventive measures against HIV-AIDS is:
A. withdrawal C. foams and gels use
B. virus killing drugs D. condom use
5. Ms. Amodia, RN works for a home health agency and cares for an older adult mental patient. On reporting to work, she observes numerous bruise and red marks on her patients face. Her patient seems upset. Ms. Amodia suspects that either abuse has occurred. Ms. Amodia should:
A. contact the mobile police to investigate the abuse
B. make an appointment with an elder adult counselor
C. wake her son and ask him who would hurt his mother
D. call her supervisor right away to report the findings
6. If there develops severe pre-eclampsia, what would be the drug you would anticipate to be prescribed and that you would have to administer?
A. a loop diuretic C. ranitidine (zantac)
B. magnesium sulfate D. a non-steroidal inflammatory agent
7. As a community health nurse you always bear in mind that the purpose of empowering victims of violence is to:
A. tell them how to solve their problems
B. convince victims to leave their abusers
C. help clients become aware that they have control over their lives
D. develop safety escape plans for them
8. Maria is developing constipation from being on bed rest. What measure would you suggest she take to help prevent this?
A. drink 8 full glasses of fluid such as water daily
B. drink more milk, increased calcium intake prevents constipation
C. eat more frequent small meals instead of three large ones daily
D. walk for at least half an hour daily to stimulate peristalsis
9. A bilateral amputee is assisted by his wife and children to the commode for bowel evacuation. This example best demonstrates the family’s assistance to meet which need?
A. Elimination C. nutrition and metabolism
B. activity D. health perception and health maintenance
10. Which of the following is the most important reason for doing a literature review for constructing a research study?
A. helpful information on demographic instrument development could be uncovered
B. existing knowledge about the identified problem can be found
C. a determination of the study’s feasibility could be extrapolated
D. the research design can be copied from another study
11. Martina develops endometritis. What would be the best activity for her?
A. lying in bed with a cold cloth on her forehead
B. reading while resting in a trendelenburg position
C. sitting with her feet elevated while playing cards
D. walking around her room listening to music
12. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins
13. Fely has diarrhea for 2 days. She has sunken eyes, skin pinch goes back very slowly, and she is drinking poorly and irritable. She is not able to drink and there is no blood in the stool. How will you classify Fely’s illness?
A. persistent diarrhea C. severe dehydration
B. some dehydration D. no dehydration
14. The infectious agent that causes pulmonary tuberculosis is:
A. mycobacterium tubercle C. Wuchereria bancrofti
B. Hansen’s bacillus D. mycobacterium diphtheria
15. Your client, who happens to be female resident of the barangay you are covering, is an adult survivor who states: “Why couldn’t I make him stop the abuse? If I were stronger person, I would have been able to make him stop. Maybe it was my fault to be abused”. Based on this, which would be your most appropriate nursing diagnosis?
A. social isolation C. chronic low self-esteem
B. anxiety D. ineffective family coping
16. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. What instructions would you give her before this procedure?
A. void immediately before the procedure to reduce your bladder size
B. no more amniotic fluid forms afterward, that is why only a small amount is removed
C. the intravenous fluid infused to dilate your uterus does not hurt the fetus
D. the x-ray used to reveal your fetus position has no long-term effects
17. When planning teaching strategy for a pregnant woman, the nurse should do which of the following?
A. give information about how the woman can manage the specific problems she identifies as relevant in her life
B. omit information related to minor pains of pregnancy to prevent the woman from developing hypochondria
C. provide all information to the woman in a group session with other pregnant women so she can have someone to discuss it with
D. during the first prenatal visit, teach a woman the care measures necessary for health promotion throughout the pregnancy
18. Which of the following symptoms is LESS commonly noted in EARLY pregnancy?
A. frequency of urination C. varicosities
B. chills and fever D. Braxton Hicks’ Contractions
19. Bonnie, 3 months pregnant, has reported for her first prenatal visit. The nurse should instruct her to do which of the following?
A. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day
B. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism
C. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra calories
D. limit intake of amino acids to prevent development of diabetic ketoacidosis
20. The nurse is assisting Mr. and Mrs. Cruz to prepare for childbirth in the home setting. Which of the following supplies should be readily available for the infant immediately after birth?
A. vitamin K to avoid bleeding
B. mild soap without perfume so as not to irritate the skin
C. bulb syringe to suction fluid and mucous from the mouth
D. heating lamp to avoid chilling from water evaporation
21. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis, “Knowledge deficit related to potential for altered tissue perfusion in fetus or mother related to maternal cardiovascular disease”?
A. bedrest is maintained at home after the 36th week of gestation
B. fetal heart rate will remain between 120 and 160 beats a minute
C. jugular vein distention is evident when lying at 45 degrees
D. maternal blood pressure maintained above 150 systolic
22. Pregnant women should be taught to be careful to avoid accidental injury. They are prone to falls for which of the following reasons?
A. additional weight from pregnancy may disturb balance when walking
B. fetal activity stimulates the nerves of the legs and causes weakness
C. high levels of hormones often impair judgment resulting in reckless behavior
D. increased adrenalin released during pregnancy causes women to move faster than usual
23. When a nurse uses the IMCI model, the IMCI chart uses illness classification, e.g. the pink row needs:
A. no specific treatments such as antibiotics C. appropriate antibiotics
B. urgent referral D. no urgent measures
24. Which of the four signs of good attachment is true in this statement?
A. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward more areola is visible above than below
B. the chin should touch the breast, the mouth is wide open while the lower lip turned outward and more areola visible above than below
C. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and more areola visible below than above
D. the chin should touch the breast while the mouth is wide open and the lower lip turned inward, more areola is visible above than below
25. Which type of research inquiry investigates the issues of human complexity ( e. g. understanding the human expertise?)
A. positivism C. logical position
B. quantitative research D. natural inquiry
26. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness?
A. a child at a general danger sign C. severe pneumonia
B. very severe febrile disease D. severe malnutrition
27. Why are small for gestational age newborns at risk for difficulty maintaining body temperature?
A. their skin is more susceptible to conduction of cold
B. they are preterm so are born relatively small in size
C. they do not have as many fat stored as other infants
D. they are more active than usual so they throw off comes
28. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure?
A. headache and vomiting C. a high choking voice
B. a swollen tender tongue D. abdominal bleeding and pain
29. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever?
A. use plan C if there is bleeding from the nose or gums
B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test
C. give aspirin
D. prevent low blood sugar
30. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to:
A. ask what are the child’s problem C. check for the four main symptoms
B. check the patient’s level of consciousness D. check for the general danger signs
31. A child with diarrhea is observed for the following EXCEPT:
A. how long the child has diarrhea C. presence of blood in the stool
B. skin Petechiae D. signs of dehydration
32. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for home management at this case?
A. give drugs every 4 hours C. give the child more fluids
B. continue feeding the child D. inform when to return to the health center
33. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to:
A. beneficence C. respect for person
B. nonmaleficence D. autonomy
34. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of:
A. justice and beneficence C. beneficence and nonmaleficence
B. fidelity and nonmaleficence D. fidelity and justice
35. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?
A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”
36. If a child with diarrhea has 2 or more signs in the IMCI pink row chart, the classification will be:
A. moderate dehydration C. no dehydration
B. some dehydration D. severe dehydration
37. If the capillary refill takes more than 3 seconds it may mean:
A. the child is in shock C. circulatory failure
B. the child is dehydrated D. the child is alright
38. Leprosy is a chronic disease of the skin and peripheral nerves. Which of the following signs are present in the early stage?
A. loss of eyebrows C. contractures
B. clawing of fingers D. thickening or painful nerves
39. In asking the mother about her child’s problem the following communication skills should be used EXCEPT:
A. use words that the mother understand C. listen attentively
B. give time for the mother to answer the question D. ask checking questions
40. Patients eligible under the short term chemotherapy (STC) are the following EXCEPT:
A. all newly discovered and reconfirmed sputum positive cases
B. those with cavitary lung findings after two successive negative sputum examination
C. patients without having been given consent for anti-TB treatment
D. patients willing to undergo treatment
41.When planning comfort measures to help the woman in active labor to tolerate her pain, the nurse must consider which of the following?
A. early labor contractions are usually regular, coordinated, and very painful
B. if women are properly prepared, they will require no pain medication to manage their pain
C. pain medication given during the latent phase of labor is not likely to impair contractions
D. the acceleration phase of labor can be a time of true discomfort and high anxiety
42. Francis is admitted in active labor. The nurse locates fetal heart sounds in the upper left quadrant of the mother’s abdomen. The nurse would recognize which of the following?
A. Francis will probably deliver very quickly and without problems]
B. This indicates Francis will probably have a breech delivery
C. The fetus is in the most common anterior fetal positions
D. this position is referred to as being left anteriopelvic
43. While interviewing a woman in labor, the nurse would address which of the following?
A. whether the pregnancy was planned C. maternal concerns regarding fetal health
B. the use of medications during pregnancy D. all of the above
44. If a woman will be placing her baby for adoption, which of the following nursing measures should be implemented during the labor stages?
A. avoid discussing the baby during the historical assessment to minimize the woman’s anxiety
B. support the woman as needed by accepting the decisions she makes regarding holding the baby
C. protect the woman from visitors and family members who might try to change her mind
D. take the baby away as soon as possible after birth to prevent bonding from occurring
45. During the third stage of labor, the nurse may have which of the following responsibilities?
A. administration of intramuscular Oxytocin to facilitate uterine contractility
B. monitoring for blood loss greater than 100 cc, which would indicate gross hemorrhage
C. noting if the placenta makes a Schultz presentation, which is a sign of gross complication
D. pushing down on the relaxed uterus to aid in the removal of the placenta
46. Immediately following episiotomy repair, the nurse would do which of the following?
A. cleanse the woman’s anal area, then perineum and vulva, to remove any fecal incontinence or vaginal secretions
B. monitor the woman for shaking and complaints of chill sensations, which may indicate an adverse reaction to medications
C. palpate the uterus fundus for size, consistency and position and take vital signs to obtain baseline data
D. remove all coverings except a clean, light hospital gown to prevent the development of postpartal fever
47. Mr. Tony has been hospitalized for months following special spinal cord surgery. The boys club in his hometown was renamed the Tony boys club, and a parade is planned to honor Mr. Tony. Such community action should positively influence Mr. Tony’s:
A. self-perception and self concept C. health perception and health maintenance
B. cognition and perception D. coping and stress tolerance
48. Which of the following conditions is not true about contraindication to immunization?
A. do not give BCG if the child has known hepatitis
B. do not give BCG if the child has known AIDS
C. do not give DPT to a child who has recurrent convulsion or active neurologic disease
D. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1
49. Which of the following might prevent the conduct of a research study?
A. in order to gather data for the research, excessive risk to subject is required
B. costs for conducting the study are low compared to the potential benefits from the researcher
C. the identified problem is covered in the literature
D. the research problem is based on untested nursing theories
50. Marsha is concerned she may loose an excessive amount of blood with cesarean surgery. What is the usual amount of blood loss with cesarean birth?
A. 250 – 350 ml C. 100 – 220 ml
C. 500 – 1000 ml D. 300 – 500 ml
51. If the child is 4 months, which of the following questions SHOULD NOT be included in checking the general danger signs?
A. ask if the child is eating well during illness C. ask if the child has had no convulsion
B. ask if the child is able to breastfeed D. ask if the child vomits everything
52. Arnie, like all newborns, can loose body heat by conduction. Under which conditions is this most apt to occur?
A. if the nursery is cooled by air conditioning C. if Arnie is placed in a cold bassinet
B. if the infant is wet from amniotic fluid D. if there is a breeze from an open window
53. You have just entered Mr. Tiangco’s room and observed him lying on the floor next to the bed. The side rails on the bed are down. When you asked Mr. Tiangco what happened, he replies. “I was asleep and the next thing I knew I was on the floor”. Which of the following examples of documentation is MOST APPROPRIATE for this situation?
A. Lying on floor next to bed. No complaints verbalized. Side rails down. Appears to have fallen out of bed while asleep.
B. Mr. Tiangco was found lying on the floor next to his bed. When asked what happened, he stated “I was asleep and the next thing I knew I was on the floor”.
C. Lying on the floor, side rails down. Rolled out of bed while asleep.
D. Mr. Tiangco fell out of bed while asleep; both side rails were left down.
54. The application of public health, medical and engineering practices to health services and effectiveness of workers may be termed as:
A. community health C. school health
B. occupational health D. mental health
55. A literature review should be:
A. brief and limited C. systematic and exhaustive
B. broad and theoretical D. general and context
56. The Santiago Family lives in a makeshift house in Julugan, Tanza, Cavite. Composed of 8 members, the eldest son Rhio is 7 years old. Rhean is 6, Queenie and Quency are twins 5, Peter is 4 and the youngest is 6 months old named Oscar. Aling Rosa works in a laundry earning Php 1,500.00 a month and husband Mang Sony works as fish vendor earning Php 150.00 per day. Peter and the twins are enrolled in the day care. Rhio and Rhean stopped studying to help
their parents for their younger brothers and sisters. With the current condition besetting the Santiago family, which of the following interventions can lend assistance to them?
A. refer the children to a hospice care facility
B. assist Aling Rosa to be referred to the DSWD for livelihood assistance
C. give Aling Rosa’s family a Php 2,000.00 worth of capital for them to put a fishball stand
D. advise Aling Rosa to use contraceptive pills
57. Every year we discover new methods or gadgets to improve man’s life. The research typed used of this nature is:
A. applied C. experimental
B. developmental D. quantitative
58. When should the mother give complementary foods to a 5 months old infant?
A. if the child gives adequate weight for his age
B. if the child shows interest in semi solid foods
C. supplementary foods should be given before breastfeeding
D. if the child is breastfed less than 8 times in 24 hours
59. Hepatitis A is differentiated from hepatitis B by their mode of transmission. Hepatitis B is transmitted through:
A. insect bites C. transfusion and injection
B. urine D. fecal waste
60. The nurse wants to immunize a 1 year old child for measles. The child has been classified as having pneumonia and no anemia and not very low weight. The child’s mother does not want her child to be immunized and instead they will just return as soon as the child is better. How will the nurse explain the importance of immunizing the child with measles now?
A. the child’s condition is not a hindrance to immunization according to W.H.O.
B. the child has lower resistance and more prone to disease
C. the child will recover faster if the child will be immunized
D. it is the child’s schedule to have the immunization
61. To implement the case finding aspect of TB control, sputum examination should be done to the following groups:
A. children 0-9 years old with cough for 2 weeks or more
B. all persons of all ages above 1 year with symptoms indicative of tuberculosis
C. children below 10 years old with fever for 3-5 days
D. all persons ages 10 years and over with progressive loss of weight
62. Mr. Barmonte was brought home with an advance directive, but the nurse is not sure that she can follow his wishes. The nurse should:
A. follow the directive even though the nurse is uncomfortable with the directives
B. call Mr. Barmonte’s lawyer
C. discuss with the interdisciplinary team in charge of Mr. Barmonte and the organization’s ethics committee
D. ignore the advance directive
63. A term concerning body resistance which refers to protein present in the serum of the blood:
A. antibodies C. antigen
B. antitoxin D. allergen
64. A health care service in which risk factors are identified, occupational safety measures reduce, and a public education program begun is:
A. health promotion C. treatment facility
B. illness prevention D. rehabilitation
65. A community health nurse (CHN) visits the Gomez family weekly. Although family income seems adequate, Mrs. Gomez is unable to budget it over a 4-week period. The nurse asks what may be done to help Mrs. Gomez shrugs her shoulders and says, “Tomorrow may never come.” Mrs. Gomez’s reaction is described as:
A. reflecting her culture, values, and time orientation
B. one of not caring about her family’s needs
C. her belief that income may not be adequate as perceived by the CHN
D. indicating that her budget needs is a private matter
66. A positive or negative feeling toward a person, object, or idea is known as a/an:
A. merit C. moral
B. value D. attitude
67. When the nurse assists the clients in understanding personal values, this is an example of value:
A. validation C. clarification
B. discovery D. choice
68. While doing a nutritional assessment of a low-income family, the community health nurse determines the family’s diet is inadequate in protein content. The nurse could suggest which of the following foods to increase protein content with little increase in food expenditure?
A. oranges and potatoes C. rice and macaroni
B. potatoes and rice D. peas and beans
69. A new mother who is breast-feeding her baby asks the nurse when she should start her feeding baby vegetables. The nurse would suggest the MOST APPROPRIATE age to begin vegetables is:
A. 3 to 4 months C. 6 to 8 months
B. 4 to 5 months D. 9 to 12 months
70. Assessment areas for the nurse is working with the family on health promotion strategies would include:
A. the television shows that they watch C. the perceived health status and illness patterns of the family
B. the family and all the relative’s statuses D. the mental status of family and friends
71. The nurse manager wishes to implement a new way of determining the vacation schedule for the staff. The senior staff opposes the change while the newer staff seems more accepting of the change. An effective strategy for resolving this difference in acceptance would be to:
A. explain that the change will occur as designed, regardless of the staff’s preference
B. tell the staff that if they really do not want the change, it will not be implemented
C. provide extensive and detailed rationale for the proposed change
D. encourage each side to share their views with each other
72. The following are the duties of the Public Health Nurse EXCEPT:
A. leave to the BHW the responsibilities of educating the community
B. provision of nursing care to the sick and well individuals
C. provision of technical and administrative support to rural health midwives
D. conduct of pre and post consultation conference for clinic patients
73. An 8 month old has fast breathing if he has:
A. 40 breaths per minute C. 38 breaths per minute
B. 55 breaths per minute D. 45 breaths per minute
74. The following are the concerns of the Public Health Nurse on the third trimester of pregnancy EXCEPT:
A. advice for the mother to take oral contraceptive
B. where to give birth
C. proper timing in the separation of mother to other siblings
D. type of feeding
75. When a child with persistent diarrhea returns for follow-up visit after 5 days, the nurse should ask the mother if the diarrhea has stopped when:
A. the child has less than 3 loose bowels per day
B. the child has 4 semi formed stool
C. the child has 5 formed stools
D. the child has 3 loose stools/day
76. In barangay Y, one of the identified problems is unavailability of toilet facility for the residents. The appropriate intervention is:
A. secure donations in the form of toilet bowls
B. ask help from local government
C. none of the above
D. conduct a community assembly and discuss the consequences of this problems
77. A home visit is a professional interaction between the community health nurse and his patient or the family. Where could the nurse get available information about the patient or the family to be visited?
A. document file C. doctor’s office
B. records and reports D. family health record
78. In planning a home visit, the nurse considers the individual needs. Which of the following is a priority?
A. needs of all family members C. follow-up of medication and treatment
B. needs recognized by the family D. clinic schedules after home visit
79. Which of the following is the FIRST action of the nurse during a home visit?
A. greet the client or the household members
B. state the purpose or objective of the visit
C. give necessary health teaching
D. inquire about welfare and health condition of the client
80. Which factor must be considered by the nurse as vital to determine frequency of the home visit?
A. available resources C. acceptance of the family
B. policy of the agency D. past nursing services
81. Eating habits of the family has changed due to the existing fast food establishment in the area. What health risk should you warn the family?
A. food-borne infection C. increase weight
B. indigestion D. hand washing
82. To show a mother how to help her to have good attachment of the infant during breast feeding. Which of the following statement SHOULD NOT be included?
A. place the infant in your most convenient position
B. touch the infant’s lips with her nipples
C. wait until the infant’s mouth is widely open
D. move the infant quickly onto her breast, aiming the infant’s lips well below the nipple
83. When members of the community identify needs, work on its solutions with confidence in the spirit of cooperation. The process is:
A. nurse’s professional effort C. community organizing
B. government assistance D. leadership through traditional leaders
84. In assessing the level of family cohesion, you have determined that the family is very close and has very high loyalty, and members are highly dependent on one another. You would document this as which level of cohesion:
A. separated C. connected
B. enmeshed D. disengaged
85. Mrs. Ayuyao, 77 year old, has been admitted with pneumonia. Her husband asks the nurse about the living will. As a license nurse, you remember that living wills:
A. are legally binding in all states
B. allow the court to decide when the care can be given
C. allow the individual to express his or her wishes regarding care
D. allow health workers to withhold fluids and medications
86. Maybelle is scheduled to have an ultrasound examination. What instructions would you give her before her examination?
A. The intravenous fluid infused to dilate your uterus does not hurt the fetus
B. you will need to drink at least 3 glasses of fluid before the procedure
C. void immediately before the procedure to reduce your bladder size
D. you can have medicine for pain for any contractions cause by the test
87. What is the most common type of health problem seen in the health care system?
A. poor prenatal care C. immobility
B. lack of information available to patients D. increased rate of chronic disease
88. Which of the following is the best type of disease prevention?
A. immunization C. community social events
B. yearly physical exam D. behavior that promotes health
89. Nurses who deliver community-based care must have which of the following qualities?
A. adaptability C. ability to be self-directed
B. tolerance of various lifestyle D. all of the above
90. A nurse has scheduled a hypertension clinic. This service would be an example of which of the following types of health care?
A. tertiary prevention C. primary prevention
B. secondary prevention D. protection
91. When providing care in a home, how might the nurse best implement infection control?
A. cleanse the hands before and after giving direct patient care
B. remove the patient’s wound dressings from the home
C. dispose off patient’s syringes in the patient’s garbage
D. disinfect all work areas in the patient’s home
92. Which of the following is a leading health problem of school-age children?
A. earaches C. obesity
B. attention disorders D. malnutrition
93. If the child does not have ear problem, what should the nurse do?
A. check for tender swelling behind the ear C. check for ear drainage
B. check for ear pain D. got to diet question, check for malnutrition
94. Nona had her pelvic measurement taken. What size should the ischial tuberosity diameter be, to be considered adequate?
A. have the width of the symphysis pubis C. 11 cm
B. 8 cm D. twice the width of the conjugate diameter
95. In classifying the child’s illness using the IMCI color-coded triage, each illness is classified according to whether it requires the following EXCEPT:
A. urgent pre-referral treatment and referral C. immunization
B. simple advice on home management D. specific medical treatment
96. Which of the following is an example of hostile environment in terms of sexual harassment?
A. the boss assures you of a big promotion if you go out on a couple of dates with him
B. your supervisor makes masturbatory gestures every time you walk pass him
C. the personnel manager hints that the job will be yours if you cooperate sexually with him
D. your boss suggests that your “raise” is dependent upon having sex with him
97. Which among these activities is the concern of the Primary Level?
A. administration of BCG vaccine for a 10 days old baby
B. insertion of a nasogastric tubes to patients
C. administer diuretics such as furosemide per doctors order
D. regulate intravenous fluid drop rates
98. Which of the following vaccine in the Expanded Program of Immunization have a 4 weeks interval?
A. OPV C. BCG
B. AMV D. Tetanus Toxoid
99. The nurse who is planning a health promotion program with clients in the community will have the LEAST focus on:
A. assisting the clients to make informed decisions
B. organizing methods to achieve optimal mental health
C. reducing genetic risk factors for illness
D. providing information and skills to maintain lifestyle changes
100. A holistic belief system by the nurse would be most evident if the nurse:
A. incorporates client perceptions of health when planning care
B. encourages behavior modification program
C. supports goal-directed learning to improve health
D. accepts death as an outcome of life
6.12.2010
NLE Practice December 2006
NURSING PRACTICE 1:
FOUNDATION OF PROFESSIONAL NURSING PRACTICE
Situation 1: Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU.
1. While in the ICU, he executes the document tat 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. living will C. last will and testament
B. informed consent D. power of attorney
2. After one day, the patient’s condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should:
A. follow the patient because it is his right to die gracefully
B. follow the patient as it is his right to determine the medical regimen he needs
C. refuse the patient and encourage him to verbalize hid feelings
D. refuse the patient since euthanasia is not accepted in the Philippines
3. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurse’s professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions
4. A nurse who supports a patient and family’s need to make decisions that is right for them is practicing which of the following ethical principles?
A. Autonomy C. privacy
B. confidentiality d. truthfulness
5. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as:
A. power f attorney C. informed consent
B. living will D. medical records
Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education.
6. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration?
A. planning C. directing
B. controlling d. organizing
7. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of administration:
A. monitoring C. organizing
B. evaluation d. planning
8. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring C. evaluation
B. organizing d. planning
9. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied
10. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro?
1. Decision making skills 2. Forecasting skills
3. Auditing skills 4. Communications skills
A. 2 & 3 B. 1 & 4 C. 1 & 2 D. 2 & 4
Situation 3: Meldy. 40 years old. is waiting for her doctor’s appointment at the clinic where you work.
11. You are to interview her as an initial nursing action so that you can.
A. Document important data in her client records for health team to read.
B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop plan of care
C. provide solutions to her immediate health concern
D. identify the most appropriate nurse diagnosis for her heath problem
12. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as:
A. Client complains of intermittent abdominal pain an hour alter eating fatty foods
B. After eating fatty food the client experienced severe abdominal pain
C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication
D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods.
13. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.
14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her pre-menopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation because:
A. these products increase calcium loss from the bones
B. These products have stimulant effect n the body
C. these products encourage increase in sugar consumption
D. these products are addicting
15. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT:
A. Cancer B. DM C. Osteoporosis D. Cardiovascular diseases
Situation 4: Changes in technology, the nation’s economy and the increasing number of population have brought about changes in the Health Care System.
16. At present, government hospitals are expected to offer comprehensive health services to include illness prevention and health promotion. In which of the following unit of services are these services integrated?
A. Wellness center C. Rehabilitation Center
C. Intensive Care unit D. newborn screening unit
17. Which of the following is the MOST recent government initiative to help subsidize the cost of health services for both the employed and the unemployed?
A. National Health Insurance Act C. Medicare Act
B. Worker’s Compensation Act D. Magna Carta for Public Health Workers
18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of these conditions are preventable and have implications are preventable and have implications in the development of which nursing competencies?
A. Execution of nsg. procedure and technique
B. Therapeutic use of self
C. Administration of treatment and medication
D. Health education
19. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These facts will MOST LIKELY bring about development in which of the following?
A. acute services C. home care services
B. managed care services D. advance practice nursing
20. Which of the following latest trend has expanded health services based on prepaid fees with emphasis on health promotion and illness prevention?
A. Government Insurance Plan C. Health Maintenance Organization
B. Preferred Provider Organization D. Private Insurance Plan
Situation: It is Safety Awareness Week in the Community and the nurse checks on the presence of hazards at home. The nurse plan is to have the residents themselves identify the physical hazards in their own homes.
21. Which of the following is NOT a physical hazard in the home?
A. unstable and slippery stairway
B. Large windows that allow good ventilation.
C. obstacle people cam trip over like door mats, rugs, electric cords
D. inadequate lighting in and out of the house
22. Risk factors exist for each of the different developmental levels. From infancy to preschool age, the most common cause of death is injury rather than disease. To protect children from harm, that parents should be aware that MOST injuries for this age group are due to:
A. Accidents at home caused by the swallowed poisonous materials, small objects, exploring electrical sockets
B. Accidents from self inflicted wounds
C. accidents from sports related activities at school or the neighborhood
D. accidents in the Playground Park, school and presence of strangers who may abduct of molest the child.
23. To promote safety at home, the nurse identifies ways and means of “child proofing” the house. Which of the following is NOT safe?
A. apply child proof caps and medicine bottles and chemicals
B. covering electrical outlets, tying up long and loose electrical and telephone cords, securing cabinets or doors within reach o the child
C. giving colorful grocery bags to play with or to store toys and materials
D. removing objects that the child could easily dismantle and swallow like small parts of a mechanical toy, buttons, materials inside, stuffed animals, liquid chemicals.
24. The nurse knows that a person’s hygienic practices are influenced family customs and traditions. Which of the following is NOT part of Basic Hygienic Practices?
A. bathing practices, frequency and time, care of eyes, ear and nose
B. oral hygiene practices such as brushing and flossing teeth, gum care
C. care of skin with lesions, cuts with infection
D. hair and skin such as washing hair and face, feet, hand and nail care
25. Falls are the common home accident among elderly and these are due to physical limitations imposed by aging and some hazards in the home setting. The nurse reduces the risk of falling through the following EXCEPT:
A. rearranging furniture frequently
B. having the bed or mattress close to the floor
C. providing a nonskid and well fitted shoes or slippers
D. having a call bell within the persons reach and answering call bells immediately
Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
26. Given the above assessment data, the most immediate goal of the nurse would be which of the following?
A. Prevent urinary complication
B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea
27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.
28. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh C. to the patient’
B. to the patient’s lower thigh D. to the patient lower abdomen
29. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
30. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed diabetic patient. She is beginning to write objectives of her teaching plan.
31. Which of the following objectives is written in behavioral terms?
A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out
B. Mang Carlos daughter should learn about DM within the week
C. Mang Carlos wife needs to understand the side effects of insulin
D. Mang Carlos sister will be able to determine in two days his insulin requirement based on blood glucose levels obtained from glucometer
32. Which of the following is the BEST rationale for written objectives?
A. ensure communication among staff members
B. facilitate evaluation of the nurse’s performance
C. ensure learning on the part of the nurse
D. document the quality of care
33. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease condition?
A. frequent use of technical terms for familiarization
B. drawing him into discussion about diabetes
C. detailed lengthy explanation about his condition
D. loosely structured teaching session
34. Miss Tingson should encourage exercise in the management of diabetes, because it:
A. decrease total triglyceride levels C. lowers blood glucose
B. improves insulin utilization D. accomplishes all of the above
35. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is:
A. dehydration B. hypertension C. hypoglycemia D. glucosuria
Situation 8: Caring for the perioperative patient.
36. An appendectomy during a hysterectomy would be classified as:
A. Major, emergency, diagnosis C. Minor, elective, ablative
B. major, urgent, palliative D. minor, urgent, reconstructive
37. An informed consent is required for:
A. closed reduction of a fracture C. irrigation of the external ear canal
B. insertion of intravenous catheter D. urethral catheterization
38. The circulating nurse’s responsibilities, in contrast to the scrub nurse’s responsibilities, include:
A. assisting the surgeon C. setting up the sterile tables
B. monitoring aseptic practices D. all of the above functions
39. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:
A. Laryngospasm C. hypoxemia and hypercapnea
B. hyperventilation D. pulmonary edema ad embolism
40. Unless contraindicated, any unconscious patient should be positioned:
A. flat on his of her back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications
B. in semi-fowlers position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand.
c. in fowler’s position, which most closely stimulates a sitting position, thus facilitating reparatory as well as gastrointestinal functioning.
D. on his or her side without a pillow at the patient’s back and his or her chin extended to minimize the danger of aspirations
Situation 9: To prevent further injury to patients with problems of immobility / mobility, the nurse should observe certain principles of body mechanics for herself and her patients.
41. Which of the following are appropriate goals for client with positioning and mobility needs?
A. developing of contractures C. sensory alterations
B. proper body alignment D. decrease in activity tolerance
42. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair?
A. bending at the knees
B. standing with feet together
C. using body weight to assist with the movement
D. standing with feet apart
43. Which of the following is the CORRECT guideline when positioning patients?
A. put pillows above a joint to immobilize it
B. position of the joint should be slightly extended
C. joints of patient to be supported with pillow
D. patient’s position should be changed at least three or four times a day
44. Which of the following can be used by clients with problem of immobility to enable them raise their body from bed to wheelchair or perform some bed exercises?
A. sandbag B. side-rail C. trochanter roll D. trapeze bar
45. The importance of forcing fluids with an immobilized patient is to:
A. prevent pneumonia C. prevent skin breakdown
B. prevent urinary stasis D. maintain peristalsis
46. Which of the following is the least nursing activity in performing assessment of the patient?
A. laboratory test C. Health history
B. physical examination D. systemic review
47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of the four assessment techniques
did he utilize?
1. auscultation 3. palpation
2. percussion 4. inspection
A. 1,2 & 3 B. 3 &4 C. 1 & 2 D. 1,3 & 4
48. Which of the following are the purpose of performing a physical assessment?
1. gather baseline data about the client’s health
2. confirm and identify nursing diagnosis
3. evaluate physiological outcome of care
4. make clinical judgment of patients’ diagnosis
A. 1,2 & 4 B. 2, 3 & 4 C. 1, 3 & 4 D. 1,2 & 3
49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient?
A. preparation of the equipment
B. psychological preparation of the client
C. preparation of the environment
D. physical preparation of the client
50. During the assessment phase of the nursing process, the nurse is concerned with:
A. interpreting data
B. designing nursing strategies
C. establishing a data base
D. comparing client responses with the anticipated outcome
Situation 11: The nurse is responsible to accurately records and reports patient’s progress. She is able to communicate to the other member of the team by documenting the nursing care plan and the appropriate nursing intervention.
51. A main function of the patient’s records is to:
A. prepare the nurse for the shift worked
B. serve as a record of financial charges
C. serve as a vehicle for communication
D. ensure that the message is received
52. When the nurse writes in the chart and discovers an error has been made, which is the BEST approach?
A. erase the erroneous material
B. carefully ink out the erroneous material
C. place as asterisk next to the statement, then footnote it
D. draw a straight line through the error and initial it.
53. Which of the following persons cannot have the access to the patient record?
A. physical therapist C. the patient
B. lawyer of the family D. speech therapist
54. POMR charting is different from traditional method because of which of the following practices?
1. SOAP charting 3. narrative charting
2. use of flow sheet 4 . use of checklist
A. 3 & 4 B. 1 & 2 C. 1 & 3 D. 2 & 3
55. Which of the following qualities are relevant in documenting patients care?
1. Accuracy and consciousness
2. thoroughness and currentness
3. systematic and orderly
4. legibly, properly dated and signed
5. use of locally accepted abbreviation
A. 1,3,4 & 5 B. 2,3,4 & 5 C. 1,2,3 & 5 D. 1,2,3 & 4
Situation 12: The practice of primary nurse in primary nursing is preferred by many nurses because it supports professional autonomy and accountability of the nurses>
56. What is the function of the primary nurse in primary nursing?
A. acts as patient advocate and coordinate the health care team for specific group of patients
B. act as the charge nurse, organizing staff assignments and help in solving problem in the unit
C. plans and coordinate the patient care assigned to her from admission to discharge
D. coordinates the care given to a group of patients by support staff
57. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the following principles?
A. autonomy and authority for planning care are best delegated to a nurse
B. accountability is clearest since our nurse is responsible for the overall plan and implementation of care
C. the holistic approach provides fro a therapeutic relationship continuity of care and efficient nursing care
D. continuity of patients care promotes efficient nursing care.
58. Which is the role of the associate nurse in primary nursing?
A. over-all manager of the unit
B. responsible for the over-all care of the patient during off days of primary nurse
C. patient advocate in the health care team
D. coordinator of comprehensive, holistic patient care
59. In primary nursing, the nurse is responsible for which of the following group of patient?
A. the whole ward
B. small group of patient like 3-5 patients
C. big group of patients like 10-15 patients
D. the whole unit
60. In primary nursing who among the following is needed to her leadership and quality control in the ward?
A. the chief nurse C. the nurse supervisor
B. the head nurse D. the service director
Situation 13: Your nursing unit plans to conduct a study on the use of structured preoperative preparation in lessening the demand for post-operative pain medications.
61. Which of the following research activities should you initially do?
A. find out from interview how many patients are willing to participate
B. get the permission from the hospital director
C. review literature on the topic
D. prepare the tool for collecting data
62. Which of the following statements do NOT contribute to the researchabilty of your proposed problem?
A. potential use of findings C. well-defined problem statement
B. readability of findings D. measurability of variables
63. A study /research table should NOT contain which of the following ?
A. categories of data collected C. specific title of table
B. relevant rows and columns D. names and sample of the selected
64. Which of the following actions will facilitate analysis of research data?
A. consult a physician C. consult a complete expert
B. consult an adviser D. categorize data collected
65. The research methodology that is appropriate for the above problem would be:
A. descriptive B. normative C. experimental D. quasi experimental
Situation 14: The nurse meets a new client, Mr. Principe, 50 years old. During the initial interview, the nurse begins to feel irritated towards the client. Shortly after, he becomes uncomfortable and politely leaves the room. The nurse realizes the behavior and mannerism of Mr. Principe reminds him of his strict disciplinarian father who abused him physically.
66. The recognize that his feeling for the client is known as:
A. denial B. counter transference C. revenge D. transference
67. Seeing that his negative feelings for Mr. Principe could affect his nursing care, the nurse applies the concept of therapeutic use of self when:
A. the nurse talks about his personal feelings towards the client
B. the nurse suppresses his feelings and continue to take care of the client
C. the nurse uses his awareness and asks to be reassigned to another client
D. the nurse uses self-awareness to manage his feelings and thoughts towards the client
68. Mr. Principe is terminally ill and his family is coping with his impending death. The nurse has to deal with his own thoughts and personal feelings about death and grieving in order to:
A. avoid sharing personal thought about their impending loss and feeling of grief since this is very subjective
B. get self out of the way while he assists the client and his family express their feelings of impending loss
C. prevent self from being affected by the family’s grief and remain objective
D. help the family plan for the funeral arrangement and burial services
69. One morning when the nurse enters the client’s room. Mr. Principe asks the nurse to “leave me alone and stop bothering me and I don’t want your pity”. The following response by the nurse would be MOST appropriate?
A. “You seem upset this morning” and remains with the client
B. “You are probably upset because you don’t feel well”
C. “Why you are angry with me? What did I do anything to upset you?
D. “I understand and will leave you for a while”
70. The nurse understands that the nurse-client relationship is a therapeutic alliance when:
A. the nurse is a role model for a client
B. this is an essential part of the nursing process
C. the nurse has to be therapeutic at all times
D. how the nurse thinks and feels affects her actions and behavior towards her client and her work
Situation 15: Mr. Ong is for admission to the medical unit and you are his nurse.
71. The MOST important initial nursing approach when admitting client is to:
A. introduce the client to the ward staff
B. orient the client to the physical set up of the unit
C. identify the most immediate needs of the client and implement the necessary intervention
D. take V/S fro baseline assessment
72. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to:
A. talk to the relatives C. do auscultation
B. interview the client D. do a physical assessment
73. You want to know the sleeping pattern of Mr. Ong You will:
A. interview the clients and relatives
B. take his BP before sleeping and upon waking up
C. observe his sleeping pattern over a period of time
D. perform physical assessment
74. Mr. Ong has severe pedal edema. Which accessory device would be appropriate for his condition?
A. footboard B. cradle C. bed board D. rolled pillows
75. A student nurse is observed putting a standard size cuff on an obese client. The action would probably result in BP reading that is:
A. false high B. false low C. normal D. undetectable
Situation 16: Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people.
76. How does a nurse promote one’s well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple lifestyle
C. run away from polluted, stressful areas
D. avoid sleepless, over fatigue nights
77. The nurse can be involved with health promotion as a significant person in helping the family:
A. become a better family
B. prevent disease
C. control their symptoms
D. modify health promotive behaviors
78. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.
79. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques c. use of herbal medicines
b. massage D. body movement
80. When assessing a client’s blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10 b. 30 c. 45 d. 60
Situation 17: Safe nursing practice involves an understanding of the law.
81. In the Philippines, this law is :
a. The Philippine Nursing Act of 2002 or R.A. 9173
b. the Philippine Nursing Act of 1991 or R.A. 7164
c. IRR or Resolution 425 of 2003
d. Republic Act No. 8981
82. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for:
a. health promotion and prevention of illness
b. administration of written prescription for treatment and therapies
c. rehabilitative aspect of care
d. Collaborating with other healthcare providers for health restoration and alleviation of suffering
83. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions include all EXCEPT:
a. used by nurse experts to define what appropriate nursing practice is in a given situation
b. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances
c. used to delineate the scope, function and role of the nurse
d. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields
84. As a standard in ethics, this represents an understanding and agreement to respect another person’s right to decide a course his or her own destiny:
a. Autonomy c. Beneficence
b. justice d. nonmalifecence
85. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and stand by one’s action refers to:
a. accountability c. advocacy
b. veracity d. responsibility
Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change, create better ways of providing nursing care and develop new nursing roles.
86. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities?
A. maintain maximum functions C. promote health habits
B. reduce the costs of health care D. identify disease symptoms
87. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST?
A. maintain maximum function C. promote habits related to health care
B. reduce risk factor D. manage stress
88. By experience, which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital?
A. illness prevention C. diagnosis and treatment
B. health promotion D. rehabilitation of patients
89. Which of the following health care agencies is usually family-centered, relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness?
A. non-government organization C. community health center
B. hospice D. support group
90. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting?
A. Bill of rights as provided in the Philippine Constitution
B. Scope of nursing practice as defined in R.A. 9173
C. Patient’s Bill of Rights ( as adopted by American Nurses Association )
D. Board of Nursing resolution adopting the Code of Ethics
Situation 19: One of the professional competencies that nurse must always demonstrate is in the area of communication:
91. Which communication technique would be MOST effective in eliciting detailed information from the client?
A. open-ended questioning C. active listening
B. verbalizing observations D. summarizing clients views
92. Which of the following terms refer to the sender’s attitude towards the self, the message and the listener?
A. verbal communication C. non-verbal communication
B. double-bind communication D. meta communication
93. In interacting with patients, the nurses should remember that a client’s personal space is:
A. that which revolves around the client
B. highly mobile depending upon certain situation
C. clearly visible to others
D. the same as that of the nurse
94. In interpersonal communication is LEAST threatening during what type of relationship?
A. social C. personal
B. intimate D. professional
95. In demonstrating the method for deep breathing exercises, the nurse places the hands on the client’s abdomen to explain diaphragmatic movement. This technique involves the use of which element of communication?
A. appropriateness C. channel
B. feedback D. message
Situation 20: Roy, an adolescent, was diagnosed to have pneumonia. He constantly complains of chest pain and has a standing order of Morphine SO4.
96. Which of the following MOST appropriately describe pain sensation that has periods of remission and exacerbation?
A. chronic C. acute
B. intractable D. Psychosomatic
97. Roy is constantly asking to be relieved from pain. Since morphine is an addicting drug, which of the following is BEST for the patient?
A. administer morphine SO4 PRN
B. administer morphine on a routine schedule as ordered
C. give instructions on relaxation technique to reduce frequency of pain sensation D. divert the attention by not limiting visitors
98. To get accurate information about the quality of pain the patient is experiencing, which of the following statements would be MOST APPROPRIATE?
A. “What cause you the pain?”
B. “ Tell me what your pain feels like”
C. “Have you taken something to relieve the pain?”
D. “Is it stubbing or radiating pain?”
99. As the nurse assigned to Ray, which of the following can decrease his chest pain?
A. supporting his rib cage when he coughs
B. advising him
C. teaching him
D. encouraging him to breathe deeply
100. Which of the following is the nurse’s primary goal in caring for clients with chronic pain?
A. change the clients perception of pain
B. reduce the clients perception of pain
C. change the clients reaction to pain
D. enumerate the source of pain
FOUNDATION OF PROFESSIONAL NURSING PRACTICE
Situation 1: Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU.
1. While in the ICU, he executes the document tat 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. living will C. last will and testament
B. informed consent D. power of attorney
2. After one day, the patient’s condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should:
A. follow the patient because it is his right to die gracefully
B. follow the patient as it is his right to determine the medical regimen he needs
C. refuse the patient and encourage him to verbalize hid feelings
D. refuse the patient since euthanasia is not accepted in the Philippines
3. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurse’s professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions
4. A nurse who supports a patient and family’s need to make decisions that is right for them is practicing which of the following ethical principles?
A. Autonomy C. privacy
B. confidentiality d. truthfulness
5. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as:
A. power f attorney C. informed consent
B. living will D. medical records
Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education.
6. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration?
A. planning C. directing
B. controlling d. organizing
7. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of administration:
A. monitoring C. organizing
B. evaluation d. planning
8. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring C. evaluation
B. organizing d. planning
9. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied
10. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro?
1. Decision making skills 2. Forecasting skills
3. Auditing skills 4. Communications skills
A. 2 & 3 B. 1 & 4 C. 1 & 2 D. 2 & 4
Situation 3: Meldy. 40 years old. is waiting for her doctor’s appointment at the clinic where you work.
11. You are to interview her as an initial nursing action so that you can.
A. Document important data in her client records for health team to read.
B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop plan of care
C. provide solutions to her immediate health concern
D. identify the most appropriate nurse diagnosis for her heath problem
12. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as:
A. Client complains of intermittent abdominal pain an hour alter eating fatty foods
B. After eating fatty food the client experienced severe abdominal pain
C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication
D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods.
13. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.
14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her pre-menopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation because:
A. these products increase calcium loss from the bones
B. These products have stimulant effect n the body
C. these products encourage increase in sugar consumption
D. these products are addicting
15. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT:
A. Cancer B. DM C. Osteoporosis D. Cardiovascular diseases
Situation 4: Changes in technology, the nation’s economy and the increasing number of population have brought about changes in the Health Care System.
16. At present, government hospitals are expected to offer comprehensive health services to include illness prevention and health promotion. In which of the following unit of services are these services integrated?
A. Wellness center C. Rehabilitation Center
C. Intensive Care unit D. newborn screening unit
17. Which of the following is the MOST recent government initiative to help subsidize the cost of health services for both the employed and the unemployed?
A. National Health Insurance Act C. Medicare Act
B. Worker’s Compensation Act D. Magna Carta for Public Health Workers
18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of these conditions are preventable and have implications are preventable and have implications in the development of which nursing competencies?
A. Execution of nsg. procedure and technique
B. Therapeutic use of self
C. Administration of treatment and medication
D. Health education
19. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These facts will MOST LIKELY bring about development in which of the following?
A. acute services C. home care services
B. managed care services D. advance practice nursing
20. Which of the following latest trend has expanded health services based on prepaid fees with emphasis on health promotion and illness prevention?
A. Government Insurance Plan C. Health Maintenance Organization
B. Preferred Provider Organization D. Private Insurance Plan
Situation: It is Safety Awareness Week in the Community and the nurse checks on the presence of hazards at home. The nurse plan is to have the residents themselves identify the physical hazards in their own homes.
21. Which of the following is NOT a physical hazard in the home?
A. unstable and slippery stairway
B. Large windows that allow good ventilation.
C. obstacle people cam trip over like door mats, rugs, electric cords
D. inadequate lighting in and out of the house
22. Risk factors exist for each of the different developmental levels. From infancy to preschool age, the most common cause of death is injury rather than disease. To protect children from harm, that parents should be aware that MOST injuries for this age group are due to:
A. Accidents at home caused by the swallowed poisonous materials, small objects, exploring electrical sockets
B. Accidents from self inflicted wounds
C. accidents from sports related activities at school or the neighborhood
D. accidents in the Playground Park, school and presence of strangers who may abduct of molest the child.
23. To promote safety at home, the nurse identifies ways and means of “child proofing” the house. Which of the following is NOT safe?
A. apply child proof caps and medicine bottles and chemicals
B. covering electrical outlets, tying up long and loose electrical and telephone cords, securing cabinets or doors within reach o the child
C. giving colorful grocery bags to play with or to store toys and materials
D. removing objects that the child could easily dismantle and swallow like small parts of a mechanical toy, buttons, materials inside, stuffed animals, liquid chemicals.
24. The nurse knows that a person’s hygienic practices are influenced family customs and traditions. Which of the following is NOT part of Basic Hygienic Practices?
A. bathing practices, frequency and time, care of eyes, ear and nose
B. oral hygiene practices such as brushing and flossing teeth, gum care
C. care of skin with lesions, cuts with infection
D. hair and skin such as washing hair and face, feet, hand and nail care
25. Falls are the common home accident among elderly and these are due to physical limitations imposed by aging and some hazards in the home setting. The nurse reduces the risk of falling through the following EXCEPT:
A. rearranging furniture frequently
B. having the bed or mattress close to the floor
C. providing a nonskid and well fitted shoes or slippers
D. having a call bell within the persons reach and answering call bells immediately
Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
26. Given the above assessment data, the most immediate goal of the nurse would be which of the following?
A. Prevent urinary complication
B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea
27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.
28. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh C. to the patient’
B. to the patient’s lower thigh D. to the patient lower abdomen
29. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
30. Howe will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed diabetic patient. She is beginning to write objectives of her teaching plan.
31. Which of the following objectives is written in behavioral terms?
A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out
B. Mang Carlos daughter should learn about DM within the week
C. Mang Carlos wife needs to understand the side effects of insulin
D. Mang Carlos sister will be able to determine in two days his insulin requirement based on blood glucose levels obtained from glucometer
32. Which of the following is the BEST rationale for written objectives?
A. ensure communication among staff members
B. facilitate evaluation of the nurse’s performance
C. ensure learning on the part of the nurse
D. document the quality of care
33. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease condition?
A. frequent use of technical terms for familiarization
B. drawing him into discussion about diabetes
C. detailed lengthy explanation about his condition
D. loosely structured teaching session
34. Miss Tingson should encourage exercise in the management of diabetes, because it:
A. decrease total triglyceride levels C. lowers blood glucose
B. improves insulin utilization D. accomplishes all of the above
35. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is:
A. dehydration B. hypertension C. hypoglycemia D. glucosuria
Situation 8: Caring for the perioperative patient.
36. An appendectomy during a hysterectomy would be classified as:
A. Major, emergency, diagnosis C. Minor, elective, ablative
B. major, urgent, palliative D. minor, urgent, reconstructive
37. An informed consent is required for:
A. closed reduction of a fracture C. irrigation of the external ear canal
B. insertion of intravenous catheter D. urethral catheterization
38. The circulating nurse’s responsibilities, in contrast to the scrub nurse’s responsibilities, include:
A. assisting the surgeon C. setting up the sterile tables
B. monitoring aseptic practices D. all of the above functions
39. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:
A. Laryngospasm C. hypoxemia and hypercapnea
B. hyperventilation D. pulmonary edema ad embolism
40. Unless contraindicated, any unconscious patient should be positioned:
A. flat on his of her back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications
B. in semi-fowlers position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand.
c. in fowler’s position, which most closely stimulates a sitting position, thus facilitating reparatory as well as gastrointestinal functioning.
D. on his or her side without a pillow at the patient’s back and his or her chin extended to minimize the danger of aspirations
Situation 9: To prevent further injury to patients with problems of immobility / mobility, the nurse should observe certain principles of body mechanics for herself and her patients.
41. Which of the following are appropriate goals for client with positioning and mobility needs?
A. developing of contractures C. sensory alterations
B. proper body alignment D. decrease in activity tolerance
42. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair?
A. bending at the knees
B. standing with feet together
C. using body weight to assist with the movement
D. standing with feet apart
43. Which of the following is the CORRECT guideline when positioning patients?
A. put pillows above a joint to immobilize it
B. position of the joint should be slightly extended
C. joints of patient to be supported with pillow
D. patient’s position should be changed at least three or four times a day
44. Which of the following can be used by clients with problem of immobility to enable them raise their body from bed to wheelchair or perform some bed exercises?
A. sandbag B. side-rail C. trochanter roll D. trapeze bar
45. The importance of forcing fluids with an immobilized patient is to:
A. prevent pneumonia C. prevent skin breakdown
B. prevent urinary stasis D. maintain peristalsis
46. Which of the following is the least nursing activity in performing assessment of the patient?
A. laboratory test C. Health history
B. physical examination D. systemic review
47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of the four assessment techniques
did he utilize?
1. auscultation 3. palpation
2. percussion 4. inspection
A. 1,2 & 3 B. 3 &4 C. 1 & 2 D. 1,3 & 4
48. Which of the following are the purpose of performing a physical assessment?
1. gather baseline data about the client’s health
2. confirm and identify nursing diagnosis
3. evaluate physiological outcome of care
4. make clinical judgment of patients’ diagnosis
A. 1,2 & 4 B. 2, 3 & 4 C. 1, 3 & 4 D. 1,2 & 3
49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient?
A. preparation of the equipment
B. psychological preparation of the client
C. preparation of the environment
D. physical preparation of the client
50. During the assessment phase of the nursing process, the nurse is concerned with:
A. interpreting data
B. designing nursing strategies
C. establishing a data base
D. comparing client responses with the anticipated outcome
Situation 11: The nurse is responsible to accurately records and reports patient’s progress. She is able to communicate to the other member of the team by documenting the nursing care plan and the appropriate nursing intervention.
51. A main function of the patient’s records is to:
A. prepare the nurse for the shift worked
B. serve as a record of financial charges
C. serve as a vehicle for communication
D. ensure that the message is received
52. When the nurse writes in the chart and discovers an error has been made, which is the BEST approach?
A. erase the erroneous material
B. carefully ink out the erroneous material
C. place as asterisk next to the statement, then footnote it
D. draw a straight line through the error and initial it.
53. Which of the following persons cannot have the access to the patient record?
A. physical therapist C. the patient
B. lawyer of the family D. speech therapist
54. POMR charting is different from traditional method because of which of the following practices?
1. SOAP charting 3. narrative charting
2. use of flow sheet 4 . use of checklist
A. 3 & 4 B. 1 & 2 C. 1 & 3 D. 2 & 3
55. Which of the following qualities are relevant in documenting patients care?
1. Accuracy and consciousness
2. thoroughness and currentness
3. systematic and orderly
4. legibly, properly dated and signed
5. use of locally accepted abbreviation
A. 1,3,4 & 5 B. 2,3,4 & 5 C. 1,2,3 & 5 D. 1,2,3 & 4
Situation 12: The practice of primary nurse in primary nursing is preferred by many nurses because it supports professional autonomy and accountability of the nurses>
56. What is the function of the primary nurse in primary nursing?
A. acts as patient advocate and coordinate the health care team for specific group of patients
B. act as the charge nurse, organizing staff assignments and help in solving problem in the unit
C. plans and coordinate the patient care assigned to her from admission to discharge
D. coordinates the care given to a group of patients by support staff
57. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the following principles?
A. autonomy and authority for planning care are best delegated to a nurse
B. accountability is clearest since our nurse is responsible for the overall plan and implementation of care
C. the holistic approach provides fro a therapeutic relationship continuity of care and efficient nursing care
D. continuity of patients care promotes efficient nursing care.
58. Which is the role of the associate nurse in primary nursing?
A. over-all manager of the unit
B. responsible for the over-all care of the patient during off days of primary nurse
C. patient advocate in the health care team
D. coordinator of comprehensive, holistic patient care
59. In primary nursing, the nurse is responsible for which of the following group of patient?
A. the whole ward
B. small group of patient like 3-5 patients
C. big group of patients like 10-15 patients
D. the whole unit
60. In primary nursing who among the following is needed to her leadership and quality control in the ward?
A. the chief nurse C. the nurse supervisor
B. the head nurse D. the service director
Situation 13: Your nursing unit plans to conduct a study on the use of structured preoperative preparation in lessening the demand for post-operative pain medications.
61. Which of the following research activities should you initially do?
A. find out from interview how many patients are willing to participate
B. get the permission from the hospital director
C. review literature on the topic
D. prepare the tool for collecting data
62. Which of the following statements do NOT contribute to the researchabilty of your proposed problem?
A. potential use of findings C. well-defined problem statement
B. readability of findings D. measurability of variables
63. A study /research table should NOT contain which of the following ?
A. categories of data collected C. specific title of table
B. relevant rows and columns D. names and sample of the selected
64. Which of the following actions will facilitate analysis of research data?
A. consult a physician C. consult a complete expert
B. consult an adviser D. categorize data collected
65. The research methodology that is appropriate for the above problem would be:
A. descriptive B. normative C. experimental D. quasi experimental
Situation 14: The nurse meets a new client, Mr. Principe, 50 years old. During the initial interview, the nurse begins to feel irritated towards the client. Shortly after, he becomes uncomfortable and politely leaves the room. The nurse realizes the behavior and mannerism of Mr. Principe reminds him of his strict disciplinarian father who abused him physically.
66. The recognize that his feeling for the client is known as:
A. denial B. counter transference C. revenge D. transference
67. Seeing that his negative feelings for Mr. Principe could affect his nursing care, the nurse applies the concept of therapeutic use of self when:
A. the nurse talks about his personal feelings towards the client
B. the nurse suppresses his feelings and continue to take care of the client
C. the nurse uses his awareness and asks to be reassigned to another client
D. the nurse uses self-awareness to manage his feelings and thoughts towards the client
68. Mr. Principe is terminally ill and his family is coping with his impending death. The nurse has to deal with his own thoughts and personal feelings about death and grieving in order to:
A. avoid sharing personal thought about their impending loss and feeling of grief since this is very subjective
B. get self out of the way while he assists the client and his family express their feelings of impending loss
C. prevent self from being affected by the family’s grief and remain objective
D. help the family plan for the funeral arrangement and burial services
69. One morning when the nurse enters the client’s room. Mr. Principe asks the nurse to “leave me alone and stop bothering me and I don’t want your pity”. The following response by the nurse would be MOST appropriate?
A. “You seem upset this morning” and remains with the client
B. “You are probably upset because you don’t feel well”
C. “Why you are angry with me? What did I do anything to upset you?
D. “I understand and will leave you for a while”
70. The nurse understands that the nurse-client relationship is a therapeutic alliance when:
A. the nurse is a role model for a client
B. this is an essential part of the nursing process
C. the nurse has to be therapeutic at all times
D. how the nurse thinks and feels affects her actions and behavior towards her client and her work
Situation 15: Mr. Ong is for admission to the medical unit and you are his nurse.
71. The MOST important initial nursing approach when admitting client is to:
A. introduce the client to the ward staff
B. orient the client to the physical set up of the unit
C. identify the most immediate needs of the client and implement the necessary intervention
D. take V/S fro baseline assessment
72. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to:
A. talk to the relatives C. do auscultation
B. interview the client D. do a physical assessment
73. You want to know the sleeping pattern of Mr. Ong You will:
A. interview the clients and relatives
B. take his BP before sleeping and upon waking up
C. observe his sleeping pattern over a period of time
D. perform physical assessment
74. Mr. Ong has severe pedal edema. Which accessory device would be appropriate for his condition?
A. footboard B. cradle C. bed board D. rolled pillows
75. A student nurse is observed putting a standard size cuff on an obese client. The action would probably result in BP reading that is:
A. false high B. false low C. normal D. undetectable
Situation 16: Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people.
76. How does a nurse promote one’s well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple lifestyle
C. run away from polluted, stressful areas
D. avoid sleepless, over fatigue nights
77. The nurse can be involved with health promotion as a significant person in helping the family:
A. become a better family
B. prevent disease
C. control their symptoms
D. modify health promotive behaviors
78. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.
79. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques c. use of herbal medicines
b. massage D. body movement
80. When assessing a client’s blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10 b. 30 c. 45 d. 60
Situation 17: Safe nursing practice involves an understanding of the law.
81. In the Philippines, this law is :
a. The Philippine Nursing Act of 2002 or R.A. 9173
b. the Philippine Nursing Act of 1991 or R.A. 7164
c. IRR or Resolution 425 of 2003
d. Republic Act No. 8981
82. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for:
a. health promotion and prevention of illness
b. administration of written prescription for treatment and therapies
c. rehabilitative aspect of care
d. Collaborating with other healthcare providers for health restoration and alleviation of suffering
83. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions include all EXCEPT:
a. used by nurse experts to define what appropriate nursing practice is in a given situation
b. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances
c. used to delineate the scope, function and role of the nurse
d. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields
84. As a standard in ethics, this represents an understanding and agreement to respect another person’s right to decide a course his or her own destiny:
a. Autonomy c. Beneficence
b. justice d. nonmalifecence
85. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and stand by one’s action refers to:
a. accountability c. advocacy
b. veracity d. responsibility
Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change, create better ways of providing nursing care and develop new nursing roles.
86. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities?
A. maintain maximum functions C. promote health habits
B. reduce the costs of health care D. identify disease symptoms
87. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST?
A. maintain maximum function C. promote habits related to health care
B. reduce risk factor D. manage stress
88. By experience, which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital?
A. illness prevention C. diagnosis and treatment
B. health promotion D. rehabilitation of patients
89. Which of the following health care agencies is usually family-centered, relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness?
A. non-government organization C. community health center
B. hospice D. support group
90. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting?
A. Bill of rights as provided in the Philippine Constitution
B. Scope of nursing practice as defined in R.A. 9173
C. Patient’s Bill of Rights ( as adopted by American Nurses Association )
D. Board of Nursing resolution adopting the Code of Ethics
Situation 19: One of the professional competencies that nurse must always demonstrate is in the area of communication:
91. Which communication technique would be MOST effective in eliciting detailed information from the client?
A. open-ended questioning C. active listening
B. verbalizing observations D. summarizing clients views
92. Which of the following terms refer to the sender’s attitude towards the self, the message and the listener?
A. verbal communication C. non-verbal communication
B. double-bind communication D. meta communication
93. In interacting with patients, the nurses should remember that a client’s personal space is:
A. that which revolves around the client
B. highly mobile depending upon certain situation
C. clearly visible to others
D. the same as that of the nurse
94. In interpersonal communication is LEAST threatening during what type of relationship?
A. social C. personal
B. intimate D. professional
95. In demonstrating the method for deep breathing exercises, the nurse places the hands on the client’s abdomen to explain diaphragmatic movement. This technique involves the use of which element of communication?
A. appropriateness C. channel
B. feedback D. message
Situation 20: Roy, an adolescent, was diagnosed to have pneumonia. He constantly complains of chest pain and has a standing order of Morphine SO4.
96. Which of the following MOST appropriately describe pain sensation that has periods of remission and exacerbation?
A. chronic C. acute
B. intractable D. Psychosomatic
97. Roy is constantly asking to be relieved from pain. Since morphine is an addicting drug, which of the following is BEST for the patient?
A. administer morphine SO4 PRN
B. administer morphine on a routine schedule as ordered
C. give instructions on relaxation technique to reduce frequency of pain sensation D. divert the attention by not limiting visitors
98. To get accurate information about the quality of pain the patient is experiencing, which of the following statements would be MOST APPROPRIATE?
A. “What cause you the pain?”
B. “ Tell me what your pain feels like”
C. “Have you taken something to relieve the pain?”
D. “Is it stubbing or radiating pain?”
99. As the nurse assigned to Ray, which of the following can decrease his chest pain?
A. supporting his rib cage when he coughs
B. advising him
C. teaching him
D. encouraging him to breathe deeply
100. Which of the following is the nurse’s primary goal in caring for clients with chronic pain?
A. change the clients perception of pain
B. reduce the clients perception of pain
C. change the clients reaction to pain
D. enumerate the source of pain
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