Situation 1: Nursing is a profession.

The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and population. This is the most accepted definition of nursing as defined by the: A. PNA B. ANA C. Nightingale D. Henderson Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT expanded career role for nurse? A. Nurse practitioner B. Clinical Nurse Specialist C. Nurse Researcher D. Nurse anaesthesiologist The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following EXCEPT: A. Issue, suspend revoke certificates of registration B. Issue subpoena duces tecum, ad testificandum C. Open and close colleges of nursing D. Supervise and regulate the practice A nursing student or a beginning staff nurse who has not yet experienced enough in a situation to make judgments about them is in what stage of Nursing Expertise? A. Novice B. Newbie C. Advanced Beginner D. Competent Benners Proficient nurse level is different from the other levels in nursing expertise in the context of having: A. The ability to organize and plan activities B. Having attained an advanced level of education C. A holistic understanding and perception of the client D. Intuitive and analytic ability in new situations

Situation 2: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer this. The nurse prepares an IM injection for an adult client using the Z track techniques, 4 ml of medication is to be administered to the client. Which of the following site will you choose? A. Deltoid

B. Rectus Femoris C. Ventrogluteal D. Vastus lateralis In infants 1 year old and below, which of the following is the site of choice in intramuscular injection? A. Deltoid B. Rectus Femoris C. Ventrogluteal D. Vastus lateralis In order to decrease discomfort in Z track administration, which of the A. Pierce the skin quickly and smoothly at 90 degree angle B. Inject the medication at around 10 minutes per millilitre C. Pull back the plunger and aspirate for 1 minute t make sure that the needle did not hit a blood vessel D. Pierce the skin slowly and carefully at a 90 degree angle After injection using the Z track technique, the nurse should know that she needs to wait for few second before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus decreasing the clients discomfort. How many seconds should the nurse wait before withdrawing the needle? A. 2 second B. 5 seconds C. 10 seconds D. 15 seconds The rationale in using the Z track technique in an intramuscular injection is: A. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissue. B. It will allow a faster absorption of the medication C. The Z track technique prevent irritation of the muscle D. It is much more convenient for the nurse Situation 3: A client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment: All of the following are correct methods in assessment of the blood pressure EXCEPT: A. Take the blood pressure reading on both arms for comparison B. Listen to and identify the phases of Korotkoff sound C. Pump the cuff to around 50mmHg above the point where the pulse is obliterated D. Observe procedures for infection control You attached a pulse oximeter to the client. You know that the purpose id to: A. Determine if the clients hemoglobin level is low and if he needs blood transfusion B. Check level of clients tissue perfusion C. Measure the efficacy of the clients anti-hypertension medications D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: A. Inconsistent B. Low systolic and high diastolic C. Higher than what the reading should be D. Lower than what the reading should be Through the clients health history, you gather that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the clients blood pressure for accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximiter is. Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of: A. 15 seconds B. 1 to 2 minutes C. 30 minutes D. 15 minutes 17. If the arm is said to be elevated when taking the blood pressure. It will create a: A. False high reading B. False low reading C. True False reading D. Indeterminate You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the clients oral temperature? A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes When auscultating the clients blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg: muffled sound continuing down to 80 mmHg and then silence. What is the clients pressure? A. 130/80 B. 150/100

C. 100/80 D. 150/100 . In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? A. 10 20 seconds B. 30 45 seconds C. 1 - 1.5 minutes D. 3 3.5 minutes Situation 4 Oral care is an important part of hygienic practices and promoting client comfort. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution . When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and an orderly progression The advantages of oral care for a client include all of the following, EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves clients appearance and self-confidence D. improves appetite and taste of food A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums D. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water

C. petroleum jelly D. mentholated ointment Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure: A. Clenching his fist every 2 minutes B. Breathing in and out through the nose with his mouth open C. Tensing the shoulder muscles while lying on his back D. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: A. Nausea and vomiting B. Shortness of breath and laryngeal stridor C. Blood tinged sputum and coughing D. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instructed Fernan to: A. Exercise the neck muscles B. Breathe deeply C. Refrain from coughing and talking D. Clear his throat . Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: A. Keep the sterile equipment from contamination B. Assist the physician C. Open and close the three-way stopcock D. Observe the patients vital signs 30. Right after thoracentesis, which of the following is most appropriate intervention? A. Instruct the patient not to cough or deep breathe for two hours B. Observe for symptoms of tightness of chest or bleeding C. Place an ice pack to the puncture site D. Remove the dressing to check for bleeding Situation 6: Knowledge of the acid base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the involvement at which type of acid base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis . A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimen are drawn? A. Guthing test B. Allens test C. Rombergs test D. Webers test 34. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Pco2 is 500 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 35. Allens test checks the patency of the: A. Ulnar artery B. Radial artery C. Carotid artery D. Brachial artery 37. 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. 38. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation? A. to the patients inner thigh B. to the patients lower thigh C. to the patients buttocks D. to the patient lower abdomen 39. Which of the following menu is appropriate for one with low sodium diet?

A. B. C. D.

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 40. 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: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. Somatotropin or the Growth Hormone releasing hormone is secreted by the anterior pituitary gland: A. Hypothalamus B. Anterior pituitary gland C. Posterior pituitary gland D. Thyroid gland 42. All of the following are secreted by the anterior pituitary gland except: A. Somatotropin/Growth hormone B. Follicle stimulating hormone C. Thyroid stimulating hormone D. Gonadotropin hormone releasing hormone 43. All of the following hormones are hormones secreted by the Posterior pituitary gland except: A. Vasopressin B. Oxytocin C. Anti-diuretic hormone D. Growth hormone 44. Calcitonin, a hormone necessary for calcium regulation is secreted in the: A. Thyroid gland B. Hypothalamus C. Parathyroid gland D. Anterior pituitary gland 45. While Parathormone, a hormone that regulates the effect of calcitonin is secreted by the: A. Thyroid gland B. Hypothalamus C. Parathyroid gland D. Anterior pituitary gland Situation 8 The staff nurse supervisor requests all the staff nurses to brainstorm and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes.

46. The plan of the nurse supervisor is an example of A. in service education process B. efficient management of human resources C. increasing human resources D. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra A. makes the assignment to teach the staff member B. is assigning the responsibility to the aide but not the accountability for those tasks C. does not have to supervise or evaluate the aide D. most know how to perform task delegated 48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should A. empathize with the nurse and listen to her B. tell her to take the day off C. discuss how she is adjusting to her new job D. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is A. grievance B. arbitration C. collective bargaining D. strike 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is A. professional course towards credits B. inservice education C. advance training D. continuing education

Situation 11: The nurse is responsible to accurately records and reports patients 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 patients 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? Accuracy and consciousness thoroughness and currentness systematic and orderly legibly, properly dated and signed 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

1. 2. 3. 4. 5.

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 familys grief and remain objective D. help the family plan for the funeral arrangement and burial services 69. One morning when the nurse enters the clients room. Mr. Principe asks the nurse to leave me alone and stop bothering me and I dont 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 dont 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 ones 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 clients 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 persons 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 ones 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. Patients 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 senders 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 clients 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 clients 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? C. Have you taken something to relieve the pain? B. Tell me what your pain feels like 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 C. teaching him B. advising him D. encouraging him to breathe deeply 100. Which of the following is the nurses 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