NP1 Nursing Board Exam June 2008 Answer Key 'Foundation of Professional Nursing Practice' 100 Nursing Board Exam test questions of June 2008 Nurse Licensure Examination (NLE) Nursing Practice 1 ± Foundation of Professional Nursing Practice Fundamentals of Nursing PART 1 Board Exam test questions 1 - 50
June 2008 Situation ±
Accurate computation prior to drug administrati administration on is a basic skill all nurses must
have. 1. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days . Which of the following is the correct dose of the drug that the client will received per
oral administration? A. 1,000 mg tid B. 500 mg tid C. 1,500 mg tid D. 50 mg tid 2. Rhona, a 2 year old female was prescribed to receive 62 .5 mg suspension three times a day . The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose? A. 0.5 ml B. 1.5 ml C. 2.5 ml D. 10 ml 3. The physician ordered Potassium Chloride (K CL) in D5W 1 liter to be infused in 24 hours for Mrs . Gomez. Since Potassium Chloride is a high risk drug , Nurse Robert used an intravenous pump . Which of the following should Nurse Robert do to safely administer this d rug? A. Check the pump setting every 2 hours B. Teach the client how the infusion pump operates C. Have another nurse check the infusion pump setting D. Set the alarm of the pump loud enough to be heard 4. Baby Liza, 3 months old , with a congenital heart deformity , has an order from her phy sician: ³give 3 .00 cc of Lanoxin today for 1 dose only´ . Which of the following is the most appropriate action by the nurse? A. Clarify order with the attending physician B. Discuss the order with the pediatric heart specialist in the unit C. Administer Lanoxin intravenously as it is the usual route of administration D. Refer to the medication administration record for previous administration of Lanoxin 5. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client . Which of the following is
the most appropriate action by the nurse? A. Hold the nurse administration of the client¶s medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the client¶s medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurse¶s station and prepare accordingly
Situation ± You are a newly hired nurse in a tertiary hospital . You have finished your orientation program recently and you are beginning to assimilate the culture of the profession .
6. Using Benner¶s stages of nursing expertise , you are a beginning nurse practitioner . You will rank yourself as a/an: A. competent nurse B. novice nurse C. proficient nurse D. advanced beginner 7. Benner¶s ³Proficient´ 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 8. As you become socialized into the nursing ³cu lture´ you become a patient advocate . Advocacy is explained by the following EX CEPT: A. respecting a person¶s right to be autonomous B. demonstrating loyalty to the institution¶s rights C. shared respect , trust and collaboration in meeting health needs D. protecting and supporting another person¶s rights 9. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a: A. Clinical nurse specialist B. Critical care nurse C. community health nurse D. staff nurse 10. You join a continuing education program to help you: A. Earn credits for license renewal B. Get in touch with colleagues in nursing C. Enhance your basic knowledge D.
Update your knowledge and skills related to field of interest
Situation ± Mr. Jose¶s chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data . 11. Mr. Jose¶s chart contains all information about his health care . The functions of records include all except: A. means of communication that health team members use to communicate their
contributions to the client¶s health care B. the client¶s record also shows a document of how much health care a gencies will be reimbursed for their services C. educational resource for student of nursing and medicine D. recording of actions in advance to save time 12. An advantage of automated or computerized client care system is: A. The nursing diagnoses for a client¶s data can be accurately determined B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated D. The number of people to take care of the client will be reduced 13. Information in the patient¶s chart is inadmissible in court as evidence when: A. The client¶s family refuses to have it used
The client objects to its use The handwriting is not legible D. It has too many abbreviations that are ³unofficial´ B.
C.
14. Nursing audit aims to: A. provide research data to hospital personnel B. study client¶s illness and treatment regimen closely
C. compare actual nursing done to established standards D. provide information to health-care providers
15. A telephone order is given for a client in your ward . What is your most appropriate action? A. Copy the order on to the chart and sign the physician¶s name a s close to his
original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the client¶s chart and have the head nurse co-sign it D. Tell the physician that you can not take the order but you will call the nurse supervisor Situation ± Errors while providing nursing care to patients must be avoided and minimized at all time . Effective management of available resources enables the nurse to provide safe , quality patient care . 16. In the hospital where you work , increased incidence of medication error was identified as the number one problem in the unit . During the brainstorming session of the nursing service department , probable causes were identified . Which of the following is process related? A. interruptions B. use of unofficial abbreviations C. lack of knowledge D.
failure to identify client
17. Miscommunication of drug orders was identified as a probable cause of medication errors . Which of the
following is safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Method C. Only officially approved abbreviations maybe used in prescription orders D. Encourage clients to ask question about their medications . 18. The hospital has an ongoing quality assurance program . Which of the following indicates implementation of
process standards? A. The nurses check client¶s identification band before giving medications B. The nurse reports adverse reaction to drugs C. Average waiting time for medication administration is measured D. The unit has well ventilated medication room 19. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. Interviews nurses for comments regarding staffing
Measures waiting time for client¶s per nurse¶s call equipment for its calibration schedule D. Determines whether nurses perform skin assessment every shift B.
C. Checks
20. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before . Which of the following is the most appropriate action of the nurse supervisor? A. Assign another nurse to perform the procedure B. Ask the nurse to find way to learn the procedure C. Tell the nurse to read the procedure manual D. Do the procedure with the nurse Situation ± comfort.
Oral
care is an important part of hygienic practices and promoting client
21. 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 22. 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.
D.
Wash hands and observe a ppropriate infection control Clean mouth with oral swabs in a careful and an orderly progression
23. 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 client¶s appearance and self-confidence D. improves appetite and taste of food 24. 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 - Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain . admission, he was diagnosed to have acute myocardial infarction and was placed in the I CU.
On
26. 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 tha t he will be una ble to make decisions for himself . This document is: A. living will B. informed consent C. last will and testament D. power of attorney 27. 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 28. Euthanasia is an ethical dilemma which confronts nurses in the I C U 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 29. A nurse who supports a patient and family¶s need to make decisions that is right for them is practicing whi ch of the following ethical principles? A. Autonomy B. confidentiality C. privacy D. truthfulness 30. 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 B. living will
informed consent D. medical records C.
Situation - Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela . first day of duty , she tried to remember the elements of administration she learned from her basic nursing education.
On
her
31. 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 M OST appropriately described to which elements of administration? A. planning B. controlling C. directing d. organizing 32. 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 B. evaluation C. organizing D. planning 33. 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 B. organizing C. evaluation D. planning 34. 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 35. In all of the various administrative functions , which of the following management skill is demanded efficiently and effectively of Ms . Castro? 2 . Forecasting skills 1. Decision making skills 3. Auditing skills 4. Communications skills A. 2 & 3 1&4 C. 1 & 2 D. 2 & 4 B.
Situation - Health is wealth specifically in this time of the century . The nurse is trained to promote well being of the people . 36. 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 37. 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
38. The nurse should N OT 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 . 39. Non-pharmacologic pain management includes all the following EX CEPT: a. relaxation techniques b. massage c. use of herbal medicines d. body movement 40. 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 ± The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials . 41. Martha wants to do a study on this topic: ³Effects of massage and meditation on stress and pain´ . The type of research that best suits this topic is: A. Applied research B. Qualitative research C. Basic research D. Quantitative research 42. The type of research design that does not manipulate independent variable is: A. Experimental design B. Quasi-experimental design C. Non-experimental design D. Quantitative design 43. This research topic has the potential to contribute to nursing because it seeks to A. include new modalities of care B. resolve a clinical problem C. clarify an ambiguous modality of care D. enhance client care 44. Martha does review of related literature for the purpose of A. determine statistical treatment of data research B. gathering data about what is already known or unknown about the problem C. to identify if problem can be replicated D. answering the research question 45. Client¶s rights should be protected when doing research using human subjects . Martha identifies these rights as follows EX CEPT: A. right of self-determination B. right to compensation C. right of privacy D. right not to be harmed Situation ± Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for inf ection because of retained secretions . Part of Nurse Mario¶s nursing care plan is to loosen and remove excessive secretions in the airway . 46. Mario listens to Richard¶s bilateral sounds and finds that congestion is in the upper lobes of the lungs . The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:
A.
Client
lying on his back then flat on his abdomen on Trendelenburg position Client seated upright in bed or on a chair then leaning forward in sitting B. position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position 47. When documenting outcome of Richard¶s treatment Mario should include the following in his recording EX A. Color, amount and consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of client before and after the procedure D. Significant changes in vital signs
CEPT:
48. When assessing Richard for chest percussion or chest vibration and postural drainage , Mario would focus on the following EX CEPT: A. Amount of food and fluid taken during the last meal before treatment B. Respiratory rate , breath sounds and location of congestion C. Teaching the client¶s relatives to perform the procedure D. Doctor¶s order regarding position restrictions and client¶s tolerance for lying flat 49. Mario prepares Richard for postural drain age and percussion . Which of the following is a specia l consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 50. The purpose of chest percussion and vibration is to loosen secretions in the lungs . The difference between the
procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. In both percussion and vibration the hands are on top of each other and hand action is in tune with client¶s breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air . Situation ± A 6 1 year old man , Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain . You are assigned to take care of the client. 51. When doing an initial assessment , the best way for you to identify the client¶s priority
problem is to: A.
Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness C.
Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions 52. Upon establishing Mr . Regalado¶s nursing needs , the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease B. Give client and relatives a brief tour of the physical set up the unit C.
Take his vital signs for a baseline assessment
D.
Establish priority needs and implement appropriate interventions
53. Mr. Regalado says he has ³trouble going to sleep´ . In order to plan your nursing
intervention you will: A.
Observe
B. Ask
his sleeping patterns in the next few days
him what he means by this statement
C. Check
his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up 54. Mr. Regalado¶s lower extremities are swollen and shiny . He has pitting pedal edema .
When taking care of Mr . Regalado, which of the following interventions would be the most appropriate immediate nursing approach? A. Moisturize lower extremities to prevent skin irritation B. Measure fluid intake and output to decrease edema C. Elevate lower extremities for postural drainage D. Provide the client a list of food low in sodium 55. Mr. Regalado will be discharged from your unit within the hour . Nursing actions when
preparing a client for discharge include all EX CEPT: A. Making a final physical assessment before client leaves the hospital B. Giving instructions about his medication regimen C. Walking the client to the hospital exit to ensure his safety D. Proper recording of pertinent data
Situation ± Using Maslow¶s need theory , Airway, Breathing and
Circulation
are the
physiological needs vital to life . The nurse¶s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives . 56. Which of these clients has a problem with the transport of oxyg en from the lungs to the tissues:
A.
Carol
with tumor in the brain
B.
Theresa with anemia
C.
Sonnyboy with a fracture in the femur
D. Brigitte with diarrhea 57. You noted from the lab exams in the chart of M . Santos that he has reduced oxygen in the blood . This condition
is called: A.
Cyanosis
B. Hypoxia C. Hypoxemia D. Anemia 58. You will do nasopharyngeal suctioning on Mr . Abad. Your guide for the length of
insertion of the tubing for an adult would be: A. tip of the nose to the base of the neck B. the distance from the tip of the nose to the middle of the neck C. the distance from the tip of the nose to the tip of the ear lobe D. eight to ten inches 59. While doing nasopharyngeal suctioning on Mr . Abad , the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed B. Using gloves to prevent introduction of pathogens to the respiratory system C.
Applying
no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction 60. Nurse Suzie is administering 12:00 PM medication in Ward 4 . Two patients have to receive
Lanoxin.
What
should Nurse Suzie do when one of the clients does N OT have a readable identification band? A. Ask
the client if she is Mrs . Santos
B. Ask the client his name C.
Ask the room mate if the client is Mrs . Santos
D.
Compare
the ID band with the bed tag
Situation ± During the NUTRITI ON EDUCATION class discussion a 58 year old man , Mr. Bruno, shows increased interest. 61. Mr. Bruno asks what the ³normal´ allowable salt intake is . Your best response to Mr . Bruno is: A. 1 tsp of salt/day with iodine and sprinkle of MSG B. 5 gms per day or 1 tsp of table salt/day C.
1 tbsp of salt/day with some patis and toyo
D.
1 tsp of salt/day but no patis and toyo
62. Your instructions to reduce or limit salt intake include all the following EX CEPT: A. eat natural food with little or no salt added B.
limit use of table salt and use condiments instead
C.
use herbs and spices
D. limit intake of p reserved or processed food 63. Teaching strategies and approaches when giving nutrition education is influenced by age, sex and immediate concerns of the group . Your presentation for a group of young mothers would be best if you focus on: A. diets limited in salt and fat B. harmful effects of drugs and alcohol intake C.
commercial preparation of dishes
D.
cooking demonstration and meal planning
64.
Cancer
cure is dependent on
A. use of alternative methods of healing B. watching out for warning signs of cancer C.
proficiency in doing breast self-examination
D.
early detection and prompt treatment
65. The role of the health worker in health education is to A. report incidence of non-communicable diseases to community health center B.
educate as many people about warning signs of non-communicable
diseases C.
focus on smoking cessation projects
D. monitor clients with hypertension Situation ± As you begin to work in the hospital where you are on probation , you are tasked to take care of a few patients . The clients have varied needs and you are expected to provide care for them .
66. An ambulatory client . Mr. Zosimo, is being prepared for bed . Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote rest and sleep B. Instructing the client about the use of call system C. Raising the side rails D. Placing the bed in high position
67. Mikka, a 25 year old female client , is admitted with right lower quadrant abdominal pain . The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed . Twelve hours following surgery , the patient complained of pain . Which of the following is the most appropriate nursing diagnosis? A. Impaired mobility related to pain secondary to an abdominal incision B. Impaired movements related to pain due to surgery C.
Impaired mobility related to surgery
D.
Severe pain related to surgery
68. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy . Which of the following should be included in the nursing care plan? A.
Encourage the client to log roll when turning
B. Encourage the client to do self-care C.
Instruct the client to do deep breathing exercises
D. Ambulate the client in ward premises every twenty minutes 69. Mr. Lozano, 50 year old executive , is recovering from severe myocardial infarction . For the past 3 days , Mr. Lozano¶s
hygiene and grooming needs have been met by the nursing staff . Which of the following activities should
be implemented to achieve the goal of independence for Mr . Lozano? A. Involving family members in meeting client¶s personal needs B. Meeting his needs till he is ready to perform self-care C.
Preparing a day to day activity list to be followed by client
D.
Involving Mr. Lozano in his care
70. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family . What nursing action are best initiated to prepare the family of Mr . Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B.
Provide support to the family members by teaching ways to care for their
loved one C. Convince
the client to stay in the hospital for professional care
D. Tell the client to be with his family Situation ± Myrna , a researcher, proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing . 71. In both quantitative and qualitative research , the used of a frame of reference is required . Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursing¶s body of knowledge
B.
Organizes the development of study and links the findings to nursing¶s body
of knowledge C.
Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts 72. Myrna need to review relevant literature and studies . The following processes are undertaken in rev iewing literature EXCEPT: A. locating and identifying resources B. reading and recording notes C. clarifying a research topic D. using the library 73. The primary purpose for reviewing literature is to: A. organize materials related to the problem of interest B. generate broad background and understanding of information related to the research problem of interest C.
select topics related to the problem of interest
D.
gather current knowledge of the problem of interest
74. In formulating the research hypotheses , researcher Myrna should state the research question as: A. What is the response of the staff nurses to the health values? B. How is variable ³health value´ perceived in a population? C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 75. The proposed study shows the relationship between the variables . Which of the following is the independent variable? A. Staff nurses in a selected college of nursing B.
Health values
C.
Health promotion activities
D. Relationship between health values and health promotion activities Situation ± While working in a tertiary hospital , you are assigned to the medical ward . 76. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees . You refer him to a: A. Nurse supervisor B. Social worker C.
bookkeeping department
D. physician 77. Mr. Magno has lung cancer and is going through chemotherapy . He is referred by the oncology nurse to a selfhelp group of clients with cancer to: A. receive emotional support B. to be a part of a research study C.
provide financial assistance
D. assist with chemotherapy
78. A diabetic hypertensive client , Mrs. Linao, needs a change in diet to improve her health status . She should be referred to a: A. nutritionist B. dietitian C.
physician
D. medical pathologist 79. When collaborating with other health team members , the best description of Nurse Rita¶s role is: A. encourages the client¶s involvement in his care B.
shares and implements orders of the health team to ensure quality care
C.
she listens to the individual views of the team members
D. helps client set goals of care and discharge 80. Nurse Rita is successful in collaborating with health team members about the care of Mr . Linao. This is because she has the following competencies: A.
Communication, trust, and decision making
B.
Conflict
C.
Negotiation, decision making
management, trust, negotiation
D. Mutual respect, negotiation and trust Situation ± The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to provide safe nursing to your clients? 81. To provide safe , quality nursing care to various clients in any setting , the most important tool of the n urse is: A.
critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses C.
observation skills for data collection
D. possession of in scientific knowledge about client nee ds 82. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. creating plans of care for particular clientele B. identifying the correct nursing diagnoses for clients C. making a thorough assessment of client needs and problems D. using standards of nursing care as your criteria for evaluation 83. The effectiveness of your nursing care plan for your clients is determined by A. the number of nursing procedures performed to comfort the client B. the amount of medications administered to the client as ordered C.
the number of times the client calls the nurse
D.
the outcome of nursing interventions based on plan of care
84. You are assigned to Mrs . Amado, age 49, who was admitted for possible surgey . She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food . She also had frequent bouts of dizziness , blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue?
A. Blood
pressure measurement of 17 0/100
B.
Complaint
of hot flashes
C.
Report of pain after ingestion of fatty food
D.
Complaint
of frequent bouts of dizziness
85. While talking with Mrs . Amado, it is most important for the nurse to: A. schedule the laboratory exams ordered for her B.
do an assessment of the client to determine priority needs
C.
tell the client that your shift ends after eight hours
D. have the client sign an informed consent Situation - 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
0
C.
86. 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
87. After IVP a renal stone was confirmed , a left nephrectomy was done . Her post operative order includes ³daily 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 f rom the collecting bag into the specimen container
C.
disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int 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 . 88. Where would the nurse tape Eileen¶s indwelling catheter in order to reduce urethral irritation? A.
to the patient¶s inner thigh
B. to the patient¶s lower thigh C.
to the patient¶ D. to the patient lower abdomen
89. Which of the following menu is a ppropriate 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
90. How 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 ± You are assigned to take care of 10 patients during the morning shift . The endorsement includes the IV infusion and medications for these clients . 91. Mr. Felipe, 36 years old is to be given 2700 ml of D 5LR to infuse for 18 hours starting at 8 am . At what rate should the IV fluid be flowing hourly? A. 100 ml per hour B. 210 ml per hour C. 150 ml per hour D. 190 ml per hour 92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of 1800ml. He is also losing gastric fluid which must be replaced every two hours . Between 8 am and 10 am, Mr.
Atienza has lost 2 50 ml of gastric fluid . How much fluid should he receive at 11 am? A. 350 ml/hour B. 275 ml/hour C. 400 ml/hour D. 200 ml/hour 93. You are to apply a transdermal patch of nitoglycerin to your client . The following are important guidelines to observe EX CEPT: A. Apply to hairless clean area of the skin not subject to much wrinkling B.
Patches may be applied to distal part of the extremities like forearm
C. Change
application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand 94. You will be applying eye drops to Miss Romualdez . After checking all the necessary information and cleaning the affected eyelid and eyelashes , you administer the ophthalmic drops by instilling the eye drops: A. directly onto the cornea B. pressing the lacrimal duct C. into the outer third of the lower conjunctival sac D. from the inner canthus going towards the side of the eye 95. When applying eye ointment , the following guidelines apply EX CEPT: A. squeeze about 2 cm of ointment and gently close but not squeeze the eye B. apply the ointment from the inner canthus going outward of the affected eye C. discard the first bead of the eye ointment before application because the tube is likely to expel more than desired amount of ointment D. hold the tube above the conjunctival sac , do not let tip touch the conjunctiva Situation ± The staff nurse supervisor requests all the staff nurses to ³brainstorm´ 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 . 96. 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 97. 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 98.
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 99. Process of formal negotiations of working conditions betwee n a group of registered nurses and employer is A. grievance B. arbitration C. collective bargaining D. strike 100. 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
