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1. The nurse is explaining the Bill of Rights for psychiatric
patients to a client who has voluntarily sought admission to an inpatient
psychiatric facility. Which of the following rights should the nurse include in
the discussion? Select all that apply:

__Right to select health care team members

__Right to refuse treatment
__Right to a written treatment plan
__Right to obtain disability
__Right to confidentiality
__Right to personal mail

RATIONALE: An inpatient client usually receives a copy of the Bill of Rights

for psychiatric patients, where they would find options 2, 3, 5, and 6 in writing.
However, a client in an inpatient setting can't select health team members. A client
may apply for disability as a result of a chronic, incapacitating illness; however,
disability isn't a patient right, and members of a psychiatric institution don't decide
who should receive it.

2. In the emergency department, a client reveals to the nurse a

lethal plan for committing suicide and agrees to a voluntary admission to
the psychiatric unit. Which information will the nurse discuss with the
client to answer the question, "How long do I have to stay here?" Select all
that apply:

__"You may leave the hospital at any time unless you are suicidal."
__"Let's talk more after the health team has assessed you."
__"Once you've signed the papers, you have no say."
__"Because you could hurt yourself, you must be safe before being
__"You need a lawyer to help you make that decision."
__"There must be a court hearing before you leave the hospital."

RATIONALE: A person who is admitted to a psychiatric hospital on a

voluntary basis may sign out of the hospital unless the health care team determines
that the person is harmful to himself or others. The health care team evaluates the
client's condition before discharge. If there is reason to believe that the client is
harmful to himself or others, a hearing can be held to determine if the admission
status should be changed from voluntary to involuntary. Option 3 is incorrect because
it denies the client's rights; option 5 is incorrect because the client doesn't need a
lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't
mandated before discharge. A hearing is held only if the client remains unsafe and
requires further treatment.

3. The nurse has developed a relationship with a client who has an

addiction problem. Which information would indicate that the therapeutic
interaction is in the working stage? Select all that apply:

__The client addresses how the addiction has contributed to family

__The client reluctantly shares the family history of addiction.
__The client verbalizes difficulty identifying personal strengths.
__The client discusses the financial problems related to the addiction.
__The client expresses uncertainty about meeting with the nurse.
__The client acknowledges the addiction's effects on the children.
RATIONALE: Options 1, 3, and 6 are examples of the nurse-client working
phase of an interaction. In the working phase, the client explores, evaluates, and
determines solutions to identified problems. Options 2, 4 and 5 address what
happens during the introductory phase of the nurse-client interaction.

4. If parents or legal guardians aren't available to give consent for

treatment of a life-threatening situation in a minor child, which of the
following statements is most accurate?

A. onsent may be obtained from a neighbor or close friend of the family.

B. Consent may not be needed in a life-threatening situation.
C. Consent must be in the form of a signed document; therefore, parents
or guardians must be contacted.
D. Consent may be given by the family physician.

RATIONALE: In emergencies, including danger to life or possibility of

permanent injury, consent may be implied, according to the law. In some books, sabi,
ung attending physician sa ER na ung mag-aako ang consent. Obviouslly, wala dun
ang family physician kc emergency nga. Parents have full responsibility for the minor
child and are required to give informed consent whenever possible. Verbal consent
may be obtained.

5. You're admitting a 15-month-old boy who has bilateral otitis

media and bacterial meningitis. Which room arrangements would be best
for this client?

A. In isolation off a side hallway

B. A private room near the nurses' station
C. A room with another child who also has meningitis
D. A room with two toddlers who have croup

RATIONALE: With meningitis, the child should be isolated for the first day
but be close to where he can be observed frequently. In isolation off a side hallway is
too far away for frequent observation. Putting the client in a room with another child
who has meningitis or with two toddlers who have croup present an infectious hazard
to the other children.

6. Which of the following points should a team leader consider

when delegating work to team members in order to conserve time?

A. Assign unfinished work to other team members.

B. Explain to each team member what needs to be done.
C. Relinquish responsibility for the outcome of the work.
D. Assign each team member the responsibility to obtain dietary trays.

RATIONALE: When all team members know what needs to be done, they
can work together on the most efficient plan for accomplishing necessary tasks.
Delegation can be flexible, ranging from telling a staff member exactly what needs to
be done and how to do it to allowing team members some freedom to decide how
best to carry out the tasks. Assigning unfinished work to other team members and
assigning each team member the responsibility to obtain dietary trays don't allow for
input from team members. It's the team leader's job to maintain responsibility for the
outcome of a task.
7. The nurse is caring for a client admitted to the emergency
department after a motor vehicle accident. Under the law, the nurse must
obtain informed consent before treatment unless:

A. the client is mentally ill.

B. the client refuses to give informed consent.
C. the client is in an emergency situation.
D. the client asks the nurse to give substituted consent.

RATIONALE: The law doesn't require informed consent in an emergency

situation when the client is unable to give consent and no next of kin is present
(NCLEX concept ito, sa Philippines, ang attending doctor sa ER na ang magcoconsent.
A mentally competent client may refuse or revoke consent at any time. Even though
a client who is declared mentally incompetent can't give informed consent, mental
illness doesn't by itself indicate that the client is incompetent to give informed
consent. Although the nurse may act as a client advocate, the nurse can never give
substituted consent. CBQ ito.

8. The nurse is assigned to care for an elderly client who is

confused and repeatedly attempts to climb out of bed. The nurse asks the
client to lie quietly and leaves her unsupervised to take a quick break.
While the nurse is away, the client falls out of bed. She sustains no injuries
from the fall. Initially, the nurse should treat this occurrence as:

A. a quality improvement issue.

B. an ethical dilemma.
C. an informed consent problem.
D. a risk-management incident.

RATIONALE: The nurse should treat this episode as a risk-management

incident; her immediate responsibility is to fill out an incident report and notify the
risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The
facility may choose to look at these types of problems and make changes to deliver a
higher standard of care institutionally. Informed consent isn't a relevant issue in this

9. The nurse receives an assignment to provide care to 10 clients.

Two of them have had kidney transplantation surgery within the last 36
hours. The nurse feels overwhelmed with the number of clients. In addition,
the nurse has never cared for a client who has undergone recent
transplantation surgery. What's the appropriate action for the nurse to

A. Speak to the manager and document in writing all concerns related to

the assignment.
B. Refuse the assignment.
C. Ignore the assignment and leave the unit.
D. Trade assignments with another nurse.

RATIONALE: When a nurse feels incapable of performing an assignment

safely, the appropriate action is to speak to the manager or nurse in charge. Bawal
magmarunong lalo na sa patient care. The nurse should also document the concerns
in writing and ask that the assignment be changed. In the event that the manager
chooses to leave the assignment as given, the nurse should accept the assignment.
The nurse should never abandon the assigned clients by leaving the workplace or
asking another nurse to care for them. The nurse may, however, refuse to perform a
task outside the scope of practice.
10. The nurse works with a colleague who consistently fails to use
standard precautions or wear gloves when caring for clients. The nurse
calls the colleague's attention to these oversights. The colleague tells the
nurse that standard precautions and gloves aren't necessary unless the
client is known to have tested positive for the human immunodeficiency
virus. What's the most appropriate action for the nurse to take?

A. Ignore it because it isn't directly the nurse's problem.

B. Document the problem in writing for the manager.
C. Talk to other staff members to ascertain their practices.
D. Instruct the clients to remind this colleague to wear gloves.

RATIONALE: The nurse has spoken to her colleague under the appropriate
circumstances and the behavior hasn't changed. Therefore, the appropriate action is
to bring the problem to the manager's attention. It's unproductive to talk with other
staff members about the situation because they don't have the authority to bring the
colleague's practice into compliance. The nurse should never point out to a client
that another staff member's practice isn't meeting standards.

11. An adult client is diagnosed with acquired immunodeficiency

syndrome. The nurse who is caring for the client is also his friend. The
nurse tells the client's parents about the diagnosis; after all, they know
their son is the nurse's friend. Several weeks later, the nurse receives a
letter from the client's attorney stating that the nurse has committed an
intentional tort. Which intentional tort has this nurse committed?

A. Fraud
B. Defamation of character
C. Assault and battery
D. Breach of confidentiality

RATIONALE: A nurse shouldn't disclose confidential information about a

client to a third party who has no legal right to know; doing so is a breach of
confidentiality. Defamation of character is injuring someone's reputation through
false and malicious statements. Assault and battery occurs when the nurse forces a
client to submit to treatment against the client's will. A nurse commits fraud when
she misleads a client to conceal a mistake she made during treatment. CBQ ito.

12. A nurse accidentally administers 40 mg of propranolol

(Inderal) to a client instead of 10 mg. Although the client exhibits no
adverse reactions to the larger dose, the nurse should:

A. call the facility's attorney.

B. inform the client's family.
C. complete an incident report.
D. do nothing because the client's condition is stable.

RATIONALE: The nurse should file an incident report. Incident reports

highlight areas of potential liability. It's then the risk manager's responsibility to notify
the facility's attorney if the incident is believed to be serious. The risk manager, in
consultation with the physician and facility administrator, will decide who should
inform the family of the error. The quality assurance coordinator may choose to use
such incidents when trying to improve the quality of care received by clients in a
particular facility. Taking no action isn't an acceptable option. CBQ ito.

13. The nurse is assigned to care for a postoperative client who

has diabetes mellitus. During the assessment interview, the client reports
that he's impotent and says that he's concerned about its effect on his
marriage. In planning this client's care, the most appropriate intervention
would be to:
A. encourage the client to ask questions about personal sexuality.
B. provide time for privacy.
C. provide support for the spouse or significant other.
D. suggest referral to a sex counselor or other appropriate professional.

RATIONALE: The nurse should refer this client to a sex counselor or other
professional. Making appropriate referrals is a valid part of planning the client's care.
The nurse doesn't normally provide sex counseling.

14. The nurse is assigned to care for eight clients. Two

nonprofessionals are assigned to work with the nurse. Which statement is
valid in this situation?

A. The nurse may assign the two nonprofessionals to work independently

with a client assignment.
B. The nurse is responsible to supervise assistive personnel.
C. Nonprofessionals aren't responsible for their own actions.
D. Nonprofessionals don't require training before they work with clients.

RATIONALE: Assistive personnel may not be assigned to care for clients

without the supervision of a professional nurse. The nurse doesn’t delegate
responsibility, keep in mind respondeat superior. It's essential that assistive
personnel understand that they're responsible for their own actions. Assistive
personnel must be adequately trained to perform all tasks they're assigned to

15. Each state has guidelines that regulate the different levels of
nursing : licensed practical or vocational nurse, registered nurse, or
advanced practice nurse. Legal guidelines outlining the scope of practice
for nurses are known as:

A. consent to treatment.
B. client's bill of rights.
C. nurse practice acts.
D. licensure requirements.

RATIONALE: Each state has a nurse practice act that defines the scope of
nursing practice within the state. Consent to treatment refers to informed consent for
a treatment or procedure. The client's bill of rights defines the rights of clients.
Licensure requirements are constructed by the state board of nursing to set
standards for receiving a nursing license. CBQ ito.

16. A client is dissatisfied with his hospitalization. He decides to

leave against medical advice and refuses to sign the paperwork. The
nurse's next course of action is to:

A. detain him until he signs the paperwork.

B. detain him until his physician arrives.
C. call security for assistance.
D. let him leave.

RATIONALE: The nurse is obligated to let him leave. Detaining him in any
form is a violation of the patient's bill of rights.

17. A nurse needs assistance transferring an elderly, confused

client to bed. The nurse leaves the client to find someone to assist her with
the transfer. While the nurse is gone, the client falls and hurts herself. The
nurse is at fault because she hasn't:
A. properly educated this client about safety measures.
B. restrained the client.
C. documented that she left the client.
D. arranged for continual care of the client.

RATIONALE: By leaving the client, the nurse is at fault for abandonment.

The better course of action is to turn on the call bell or elicit help on the way to the
client's room. Never ever leave a client na at risk for injury alone! Educating the
client about safety measures doesn't alleviate the nurse from responsibility for
ensuring the client's safety. The nurse can't restrain the client without a physician's
order and restraints won't ensure the client's safety. Documenting that she left the
client doesn't excuse the nurse from her responsibility for ensuring the client's safety.

18. When prioritizing a client's care plan based on Maslow's

hierarchy of needs, the nurse's first priority would be:

A. allowing the family to see a newly admitted client.

B. ambulating the client in the hallway.
C. administering pain medication.
D. placing wrist restraints on the client.

RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer.

Activity is on the second layer. Safety is on the third layer. Love and belonging are on
the fourth layer.

19. When developing a therapeutic relationship with a client, the

nurse should begin preparing the client for termination of the relationship:

A. at discharge.
B. during the first meeting.
C. at the midpoint of the relationship.
D. when the client demonstrates the ability to function independently.

RATIONALE: When initiating a therapeutic relationship with a client,

preparation for termination of the relationship should begin during the first meeting.
For example, the nurse should introduce herself to the client and tell him exactly
when she'll be involved in his care. This sets the boundaries of the relationship. In the
middle and at discharge of care, the relationship may be too involved to end abruptly
without warning. The client's ability to function independently isn't the deciding
factor in preparing the client for the termination of the therapeutic relationship. CBQ

20. To be effective, a clinical nurse-manager in a managed care

environment must:

A. expect all staff to accept change.

B. go along with a proposed change.
C. be a catalyst for change.
D. document staff nurses' reactions to change.

RATIONALE: The clinical nurse-manager is responsible for making things

happen, not just letting things happen. She must be more than a role model who
goes along with change , she must also encourage change and support staff during
change. Documentation of the nurses' reactions to change can be threatening and
serves no purpose in helping change to occur.

21. In community-based nursing, primary responsibility for

decisions related to health care belongs to the:
A. nurse.
B. client.
C. health care team.
D. physician.

RATIONALE: The client is primarily responsible for health care decisions in

community-based nursing. The nurse assists with monitoring of health treatment and
teaching and intervenes only as needed after assessing the client's ability to follow a
regimen. The health care team collaborates on decisions related to treatment. The
physician dictates medical orders related to treatment and medication.

22. A client became seriously ill after a nurse gave him the wrong
medication. After his recovery, he files a lawsuit. Who is most likely to be
held liable?

A. No one because it was an accident

B. The hospital
C. The nurse
D. The nurse and the hospital

RATIONALE: Nurses are always responsible for their actions. The hospital is
liable for negligent conduct of its employees within the scope of employment.
Consequently, both the nurse and the hospital are liable. Although the mistake wasn't
intentional, standard procedure wasn't followed. CBQ ito.

23. The nurse is providing care for a client who underwent mitral
valve replacement. The best example of a measurable client outcome goal
is to:

A. change his own dressing.

B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.

RATIONALE: Walking from his room to the end of the hall and back before
discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented
outcome goal. Having the client change his own dressing is incomplete and not as
significant. Just walking in the hall isn't measurable. The need for a special diet isn't
evident in this case.

24. A client with end-stage liver cancer tells the nurse he doesn't
want extraordinary measures used to prolong his life. He asks what he
must do to make these wishes known and legally binding. How should the
nurse respond to the client?

A. Tell him that it's a legal question beyond the scope of nursing
B. Give him a copy of the client's bill of rights.
C. Provide information on active euthanasia.
D. Discuss documenting his wishes in an advance directive.

RATIONALE: Advance directives give a competent client control over his

situation and a legal forum in which to express his wishes about his care. Discussion
of advance directives isn't outside the scope of nursing practice. The client's bill of
rights involves multiple client rights and doesn't provide detailed information about
advance directives. Active euthanasia is illegal. CBQ ito.
25. While admitting a client with pneumonia, the nurse notes
multiple bruises in various stages of healing. The client has Alzheimer's
disease and a history of multiple fractures. Legally, the most important
action for the nurse to take is to:

A. document findings thoroughly.

B. question the client about the bruising.
C. inform appropriate local authorities.
D. tell the client's physician.

RATIONALE: This client may be experiencing elder abuse based on her

history and symptoms. Authorities to be notified may include local social service or
law enforcement agencies. The nurse should also document findings and include
illustrations to support the assessment. The client with Alzheimer's disease may not
be able to accurately inform the nurse about what happened. Reporting findings to
the physician may not be sufficient for fulfilling the nurse's legal responsibility.

26. The nurse is providing care for a client with multiple myeloma,
a disorder characterized by episodes of remissions and exacerbations.
Which resource can best help the client adapt to the disease?

A. The client's family

B. Pastoral care
C. Support group
D. Hospice care

RATIONALE: Support groups consist of clients with the same diagnoses

who share experiences of the disease with each other. Sharing experiences helps the
client understand disease-related problems and gives him a forum in which he can
vent his feelings, which are usually similar to those of the group. The client's family
and clergy, although supportive, can't share similar disease experiences. Hospice
care is usually implemented late in the disease, at the end of life.

27. A client with brain cancer is deteriorating and the prognosis is

poor. The client meets brain-death criteria. Which nursing intervention is
most appropriate at this time?

A. Approach the client's family about organ donation.

B. Make the decision to withdraw life support.
C. Sedate the client.
D. Talk to the staff about their feelings.

RATIONALE: The most appropriate nursing intervention is to discuss organ

donation with the family. The decision to withdraw life isn't within a nurse's scope of
practice. Because the client is brain-dead, he doesn't need sedation. Although talking
to the staff is a viable strategy for staff decompression, it isn't the first action to take.
Ito ay controversial na tanong! Madaming nag-away na lecturers because of this.

28. A client is scheduled to have a descending colostomy. He's

very anxious and has many questions concerning the surgical procedure,
care of a stoma, and lifestyle changes. It would be most appropriate for the
nurse to make a referral to which member of the health care team?

A. Social worker
B. Registered dietitian
C. Occupational therapist
D. Enterostomal nurse therapist
RATIONALE: An enterostomal nurse therapist is a registered nurse who has
received advanced education in an accredited program to care for clients with
stomas. The enterostomal nurse therapist can assist with selection of an appropriate
stoma site, teach about stoma care, and provide emotional support. Social workers
provide counseling and emotional support, but they can't provide preoperative and
postoperative teaching. A registered dietitian can review any dietary changes and
help the client with meal planning. The occupational therapist can assist a client with
regaining independence with activities of daily living.

29. A 92-year-old client with prostate cancer and multiple

metastases is in respiratory distress and is admitted to a medical unit from
a skilled nursing facility. His advance directive states that he doesn't want
to be placed on a ventilator or receive cardiopulmonary resuscitation.
Based on the client's advance directive, which intervention should the
nursing care plan include?

A. Check on the client once per shift.

B. Provide mouth and skin care only if the family requests it.
C. Turn the client only if he's uncomfortable.
D. Provide emotional support and pain relief.

RATIONALE: When advance directives state that a client doesn't want life-
prolonging interventions, nursing care focuses on providing emotional and spiritual
support and comfort measures. The client still needs to be checked regularly. The
client and family shouldn't feel as if they've been abandoned. Providing mouth and
skin care makes the client more comfortable. Turning the client provides comfort and
prevents potentially painful complications such as pressure ulcers.

30. The registered nurse has an unlicensed assistant working with

her for the shift. When delegating tasks, the registered nurse understands
that the unlicensed assistant:

A. interprets clinical data.

B. collects clinical data.
C. is trained in the nursing process.
D. can function independently.

RATIONALE: Unlicensed personnel make observations, collect clinical data,

and report findings to the nurse. The registered nurse has learned critical thinking
skills and is able to interpret the clinical findings. Unlicensed assistants are trained to
perform skills, they don't learn the nursing process. Unlicensed assistants don't
function independently, they're assigned tasks by a registered nurse who retains
overall responsibility for the client. Other nursing responsibilities when delegating
tasks to unlicensed assistants include knowing the institutions policies regarding
delegation, knowing the assistant's training, knowing the client's needs, receiving
frequent updates from the assistant, asking specific questions, and making frequent
rounds of clients.

31. A nurse on a medical-surgical floor is making assignments for

an 8-hour shift. Which of the following considerations has the highest

A. Complexity of care required

B. Age of the clients
C. Skills of the assigned personnel
D. The number of clients

RATIONALE: The nurse is legally responsible for assigning personnel

according to skill level. All of the other factors are important but don't take priority.
32. The nurse is caring for a homeless client with active
tuberculosis. The client is almost ready for discharge; however, the nurse is
concerned about the client's ability to follow the medical regimen. Which
intervention will best ensure that the client complies with treatment?

A. Referring the client to a social worker for discharge planning

B. Providing individualized client education
C. Having the client attend a formal education session
D. Attempting to contact a member of the client's family to provide

RATIONALE: Referring the client to a health care professional with

knowledge of community resources is the best intervention to ensure compliance in a
homeless client. Educating the client about his condition may help, but basic needs
for shelter, food, and clothing must be met first. Providing formal education and
attempting to contact family members are inappropriate when seeking to help a
homeless client.

33. The nurse is following a critical pathway to help a client who

underwent hip replacement surgery meet specific objectives. What's a
critical pathway?

A. A nursing care plan that helps the nurse to decide which

intervention to perform first
B. A multidisciplinary care plan that helps the nurse to use a variety of
critical interventions
C. A standardized care plan that lists basic interventions for the nurse
to use with every client
D. A clinical management tool that organizes the major interventions
for a multidisciplinary health care team

RATIONALE: Critical pathways are management tools developed for

particular types of cases or conditions. They set forth expectations for interventions,
outcomes, and client progression. Elements of the nursing care plan are commonly
folded into the critical pathway. The descriptions of standardized and
multidisciplinary plans of care don't adequately describe the critical pathway.
Because the critical pathway is standardized and multidisciplinary, the nurse may
need to develop a separate care plan to document nursing diagnoses for an
individual client.

34. A train accident sends a large number of injured passengers

to the hospital. The hospital's disaster plan is put into effect. Which one of
the following nursing actions will best serve the hospital in a disaster

A. The nurse should know the hospital's disaster plan and what's
expected of her during a disaster.
B. During a disaster, the nurse should volunteer to help where she
thinks assistance is most needed.
C. The nurse should offer advice about how to keep the operation
running smoothly.
D. If told to do so, the nurse should perform tasks that are beyond her
scope of practice.

RATIONALE: Before a disaster occurs, the nurse should know how the
hospital's disaster plan works and what she'll be required to do in a disaster. During a
disaster, the charge nurse will assign staff to areas where the needs are; therefore, a
nurse may find herself performing tasks outside of her usual practice. This practice is
permitted if the nurse has the knowledge, skill, and comfort level to perform assigned
tasks. However, the nurse should never perform activities outside of the nurse's
scope of practice as outlined in the state's nurse practice act.

35. The nurse-manager of a hospital unit holds monthly staff

meetings. During these meetings, she maintains control over the meeting
and agenda, resists consensus decision making, and uses discipline and
coercion to elicit desired behavior from staff. This manager uses what type
of leadership style?

A. Autocratic
B. Democratic
C. Participative
D. Laissez-faire

RATIONALE: Autocratic leaders obtain power with a group by maintaining

control over the group. Democratic leaders share power by allowing consensus
decision making and distribution of power. Participative leadership is another term for
democratic leadership. Laissez-faire leaders maintain no control over the group;
decision making is unstructured and commonly performed by an unofficial leader of
the group. CBQ ito, make sure that you know this by heart, kinda of leadership and
for what situations xa applicable.

36. The registered nurse of a hospital unit is acting as charge

nurse. The charge nurse's responsibility is to delegate client care
appropriately to the licensed practical nurse (LPN) and the nurse's aide.
Delegation of activities should be primarily based on which factors?

A. Whether the LPN or nurse's aide provided care for the client before
B. The staff member whose turn it is to perform certain, less pleasant
C. The job description and experience level of the LPN and the aide
D. The staff member who volunteers to perform the various tasks

RATIONALE: The primary considerations related to appropriate and

effective care delegation are the job descriptions of the assistive staff members and
their levels of expertise. Both factors must be considered together, neither in
isolation. The other options identify factors that may help determine client care
assignments, but only after considering job description and experience levels.

37. A task force is formed to analyze institutional problems, such

as inadequate staffing and a rise in the number of negative evaluations
from clients. During the meeting, members express their concerns,
disagree over the most significant factors contributing to these problems,
and compete for influence over the group. Which of the following four
stages of group development does their behavior represent?

A. Forming
B. Storming
C. Norming
D. Performing

RATIONALE: Storming refers to the stage when resistance to group

influence occurs and the objectives of the group aren't yet clearly established.
Forming is the first stage, when the members of the group first meet. During the
norming stage, which occurs after storming, consensus begins to evolve, cohesion
and norms develop, and conflict and resistance are resolved. Performing is the stage
when the group focuses on the task at hand and constructive group efforts improve
task performance.
38. A client in the final stages of terminal cancer tells his nurse, "I
wish I could just be allowed to die. I'm tired of fighting this illness. I've
lived a good life. I continue my chemotherapy and radiation treatments
only because my family wants me to." What's the nurse's best response?

A. "Would you like to talk to a psychologist about your thoughts and

B. "Would you like to talk to your minister about the significance of
C. "Would you like to meet with your family and your physician about
this matter?"
D. "I know you are tired of fighting this illness, but death will come in
due time."

RATIONALE: The nurse has a moral and professional responsibility to

advocate for clients who experience decreased independence, loss of freedom of
action, and interference with their ability to make autonomous choices. Coordinating
a meeting between the physician and family members may allow the client an
opportunity to express his wishes and promote awareness of his feelings, as well as
influence future care decisions. All other options are inappropriate. Haler!! Lalo na
ung option D.

39. The nurse works in a managed-care environment. The nurse is

expected to be oriented to which of the following criteria?

A. Performing tasks in the shortest time possible

B. Adhering to client preferences
C. Problem solving and time management
D. Quality of care and cost-containment

RATIONALE: Managed care principles mandate the most efficient use of

limited resources; therefore, quality of care and cost-containment are the main
issues. Nurses must look for the most cost-effective method of achieving a desired
outcome without compromising quality. Problem solving and time management are
skills used to implement the care plan, but aren't unique to the managed care
environment. Performing tasks quickly doesn't always achieve quality care. Adhering
to client preferences isn't a guiding principle.

40. A client asks to be discharged from the health care facility

against medical advice (AMA). What should the nurse do?

A. Take measures to prevent the client from leaving.

B. Ask the client to sign an AMA form.
C. Call a security guard to help detain the client.
D. Notify the physician.

RATIONALE: If a client requests discharge AMA, the nurse should notify the
physician immediately. If the physician can't convince the client to stay, the physician
will ask the client to sign an AMA form. This form releases the hospital from legal
responsibility. If the physician isn't available, the nurse should obtain the client's
signature on the AMA form. A client who refuses to sign the form shouldn't be
detained; forced detention violates the client's rights. After the client leaves, the
nurse should document the incident thoroughly and notify the physician that the
client has left. CBQ ito.

41. The nurse is caring for a client with renal failure who requires
peritoneal dialysis. The nurse doesn't feel comfortable performing the
procedure. What would be the most appropriate action for the nurse to
A. Omit the procedure and tell the next nurse in report that she'll need
to perform the dialysis.
B. Ask the nursing supervisor for assistance in using the equipment.
C. Ask the client how to use the equipment.
D. Perform the procedure to the best of her ability, utilizing her
knowledge of basic health principles.

RATIONALE: When a nurse is unsure about a procedure or piece of

equipment, she should tell the nursing supervisor that she isn't comfortable and ask
for assistance with the task. Bawal na bawal magmarunong and maglider-lideran lalo
na sa Area wherein everything you do has direct impact on the client. A nurse must
always be prudent, therefore, pick options wherein safety is also addressed. If
appropriate training or assistance isn't available, the nurse should ask for a different
assignment. The procedure shouldn't be omitted for the shift because this could lead
to serious complications for the client. The nurse should never perform a procedure
that she doesn't feel prepared to perform.

42. A registered nurse suspects that another nurse has been

drinking. She smells alcohol on the nurse's breath and notes slurred
speech. What's the best course of action for the registered nurse to take?

A. Cover for the nurse because the profession depends on loyalty from
B. Call the police and ask them to arrest the nurse because she's
endangering the lives of clients.
C. Tell the nurse she has one more chance, but if she drinks on duty
again she'll be reported.
D. Immediately notify the nursing supervisor.

RATIONALE: A nurse who suspects another nurse of impaired practice has

a duty to report the colleague to the nursing supervisor, not the police. A nurse who
fails to report an impaired nurse may face disciplinary action. The nurse shouldn't
cover for an impaired nurse or give her one more chance. These actions place clients
at risk, place the nurse at risk for disciplinary action, and prevent the impaired nurse
from receiving help. Remember, pantay lang kau ng level ng co staff nurse mo, you
don’t have the authority na maglider-lideran amd pagsabihan xa.

43. When documenting care in a client's medical record, the nurse


A. record the nurse's interpretation of data.

B. correct a mistake using a correcting fluid.
C. record the time and date for all entries.
D. leave blank spaces to record information at a later time, if

RATIONALE: All entries in the medical record should include the time and
date they were written. The nurse should document observations and measurements,
but avoid giving an interpretation of the data, kc the nurse’s interpretation is
considered subjective and dapat, objective data lang dinodocument. Correcting fluid
is never used to correct an error, hahaha! Kc uso ngaun micropore (jowk). When a
mistake in documentation is made, the nurse should draw a single line through the
entry, write the word error next to it, and sign her name; otherwise, it may appear as
if a nurse is trying to alter or hide information. Never leave blank spaces in the
medical record. The nurse should draw a line through any blank spaces and sign her
name at the end to prevent others from adding information to the entry.

44. The nurse is completing a change-of-shift report. Which

statement wouldn't be appropriate for a nurse to include in the report?
A. The client was admitted with a diagnosis of myocardial infarction.
B. The client lives at home with his wife and two children.
C. The client had chest pain relieved with one sublingual nitroglycerin
D. The client is scheduled for a cardiac catheterization in the morning
and will be nothing by mouth after midnight.

RATIONALE: Biographical data provided in the client's Kardex or care plan

shouldn't be repeated in a change-of-shift report. The shift report should include
essential information, such as the client's name, sex, age, changes in the client's
condition, treatments, and the client's response to treatment. Other significant
information, such as scheduled tests and preparations, may be included.

45. A 19-year-old male client is diagnosed with prostate cancer.

Which nursing action constitutes an invasion of the client's privacy?

A. Covering the client with a blanket before transporting him through

the hospital corridors
B. Pulling a curtain around the bed before performing a prostate
C. Refusing to discuss the details of the young man's condition with
coworkers in an elevator filled with staff
D. Telling the family that the client has cancer without the client's

RATIONALE: Providing information to an adult client's family without the

client's knowledge or permission is an invasion of the client's privacy. Walang lugar sa
ospital ang intrimitida and atribidang nurse. The other options, properly covering a
client before moving him through hospital corridors, shielding a client during personal
care, refusing to discuss client information with people who don't have a need to
know , all demonstrate appropriate respect for the client's privacy.

46. The parents of a 4-year-old with sickle cell anemia tell the
nurse that they would like to have other children, but they're concerned
about passing sickle cell anemia on to them. Which health care team
member would be the most appropriate person for the nurse to refer them

A. Clergy
B. Social worker
C. Certified nurse midwife
D. Genetic counselor

RATIONALE: A genetic counselor can educate the couple about an inherited

disorder, screening tests that can be done, and treatments and can provide
emotional support. Clergy are available to provide spiritual support. A social worker
can provide emotional support and help with referrals for financial problems. A nurse
midwife cares for women during pregnancy and birth.

47. The family of a child dying from leukemia asks the nurse about
organ donation. Who must give consent for the child's organs to be

A. Member of the clergy

B. Physician
C. Parents
D. Court-appointed surrogate, as designated under the Uniform
Anatomical Gift Act
RATIONALE: A parent or legal guardian may give permission for organ
donation. A member of the clergy can't give permission for organ donation; however,
a family member may seek the clergy's guidance in making this decision. The
physician may only ask the family to consider organ donation. The Uniform
Anatomical Gift Act provides clients and family members with the right to choose
organ donation, but doesn't allow for designation of a surrogate to make decisions
related to organ donation.

48. Parents whose first child has celiac disease ask the nurse if all
of their children will have the disease. To whom should the nurse refer

A. Registered dietitian
B. Genetic counselor
C. Certified nurse midwife
D. Social worker

RATIONALE: Celiac disease is believed to be a dominantly inherited, inborn

error of metabolism. A genetic counselor could explain about inherited disorders, how
they're inherited and, when appropriate, provide screening tests. A registered
dietitian could provide in-depth education about a gluten-free diet and help the
family adapt the diet to their special needs. A social worker could provide the family
with emotional support and help with referrals for financial problems. A nurse midwife
cares for women during pregnancy and childbirth.

49. The nurse is caring for a school-age child with cerebral palsy.
The child has difficulty eating using regular utensils and requires a lot of
assistance. Which of the following referrals is most appropriate?

A. Registered dietitian
B. Physical therapist
C. Occupational therapist
D. Nurse's aide

RATIONALE: An occupational therapist helps physically disabled clients

adapt to physical limitations and is most qualified to help a child with cerebral palsy
eat and perform other activities of daily living. A registered dietitian manages and
plans for the nutritional needs of children with cerebral palsy, but isn't trained in
modifying or fitting utensils with assistive devices. A physical therapist is trained to
help a child with cerebral palsy gain function and prevent further disability but not to
assist the child in performing activities of daily living. A nurse's aide can help a child
eat; however, the nurse's aide isn't trained in modifying utensils.

50. An 18-year-old pregnant woman tells the nurse that she's

concerned that she may not be able to take care of herself during her
pregnancy. She states that prenatal care is expensive and her job doesn't
provide insurance. The nurse should recognize that she:

A. may not take care of herself.

B. may not be fit to take care of a child.
C. needs to take up a second job.
D. should be referred to community resources available for pregnant

RATIONALE: The client needs to know that resources are available to her,
and the nurse should help her to find those resources. Health care can be costly, but
it doesn't necessarily mean that the client has no interest in caring for herself or her
child. Taking up a second job doesn't necessarily rectify this situation.
51.The nurse is caring for a client with hyperemesis gravidarum
who will need close monitoring at home. When should the nurse begin
discharge planning?

A. On the day of discharge

B. When the client expresses readiness to learn
C. When the client's vomiting has stopped
D. On admission to the hospital

RATIONALE: Discharge planning should begin when a client is first

admitted to the hospital. Initially, discharge planning requires collecting information
about the client's home environment, support systems, functional abilities, and
finances. This information is used to determine what support services will be needed.
Notifying support services on the day of discharge won't be sufficient to ensure
meeting the client's needs in a timely fashion. Waiting until the day of discharge to
begin planning is also likely to cause the client to become overwhelmed and anxious.
Factors such as when the client stops vomiting or expresses readiness to learn
shouldn't influence when the nurse begins discharge planning.

52. The parents of a 5-year-old call the clinic to tell the nurse that
they think their child has been abused by her day-care provider. What
should the nurse advise them to do?

A. Take the child to the emergency department of the local hospital.

B. Schedule an immediate appointment with their health care
C. Call the child protective services to file a complaint.
D. Talk to their attorney to file charges against the accused.

RATIONALE: Because more information needs to be obtained from the child

and family, an immediate appointment is most appropriate. It's unclear what type of
abuse the parents are concerned about. Taking the child to the emergency
department would be appropriate if the child had been sexually abused within the
past few hours or if the child needed immediate treatment for trauma. Calling child
protective services is appropriate but isn't the first action to take; neither is talking to
an attorney.

53. The nurse is concerned about another nurse's relationship

with the members of a family and their ill preschooler. Which of the
following behaviors would be most worrisome and should be brought to the
attention of the nurse-manager?

A. The nurse keeps communication channels open among herself, the

family, physicians, and other health care providers.
B. The nurse attempts to influence the family's decisions by
presenting her own thoughts and opinions.
C. The nurse works with the family members to find ways to decrease
their dependence on health care providers.
D. The nurse has developed teaching skills to instruct the family
members so they can accomplish tasks independently.

RATIONALE: When a nurse attempts to influence a family's decision with

her own opinions and values, the situation becomes one of overinvolvement on the
nurse's part and a nontherapeutic relationship. Bawal talaga an glider-lideran and
nagmamarunong na nurse. When a nurse keeps communication channels open,
works with family members to decrease their dependence on health care providers,
and instructs family members so they can accomplish tasks independently, she has
developed an appropriate therapeutic relationship.
54. When meeting with parents who will learn that their 3-year-
old is seriously ill, which action demonstrates the nurse's role as
collaborator of care?

A. Provide the parents with information about financial assistance

B. Inform the family of the diagnosis and recently discovered findings.
C. Coordinate the multidisciplinary services and provide information
about them.
D. Refer and consult with other specialties to help in treating the

RATIONALE: The nurse can coordinate care when multiple services are
involved, explaining the function of each service (social services, case management,
counseling services, and so forth). For instance, providing parents with information
about financial assistance programs is the responsibility of social services. Informing
the family of the diagnosis and recently discovered findings is a physician's
responsibility, as are referring and consulting with other specialties. CBQ ito.

55. In planning a presentation that advocates a decrease in the

client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:

A. institutional resources.
B. standards of practice.
C. client-care quality.
D. nursing recruitment.

RATIONALE: Client-care quality should always be the first consideration

when proposing a change in care provision. Institutional resources, standards of
practice, and nursing recruitment will all influence the decision but none as much as
client-care quality should.

56. The employer of a client on the psychiatric unit calls the

nursing station inquiring about the client's progress. The nurse doesn't
know if the client has given consent to allow the staff to give information
out to callers on the phone. Which of the following would be the nurse's
best response?

A. "I'm not permitted to discuss her progress."

B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."

RATIONALE: The nurse's release of information to the client's employer

without the client's consent is a breach of confidentiality. The stigma associated with
psychiatric illness may affect the client's employment; therefore, it's better to
maintain confidentiality and refrain from disclosing any information about the client,
including whether she's a client in the hospital. As a patient advocate, we must
always protect the privacy of our patient except on situations of national security, eg.
Politician or prominent figure ung tao. Nagrerelease ng medical bulletin pag ganun
but it’s usually the hospital director or the physician who does that and hindi ang

57.Based on multiple referrals, the nurse determines that

childhood injuries are increasing in the community in which she practices.
The first step the nurse would take in developing an educational program
A. assessing for a decrease in referrals following a pediatric safety
B. assessing the strengths and needs of the community while
identifying barriers to learning.
C. choosing a health promotion or health belief model as a framework.
D. developing and implementing a specific plan to decrease childhood

RATIONALE: Following the identification of a learning need, the first step is

to assess the strengths and needs of the community while identifying barriers to
learning. Pancinin, kapag community setting, kapag you really really don’t know the
answer, madalas it’s the longest statement.

58. A registered nurse who usually works on a medical-surgical

unit is told to report to the cardiac care unit (CCU) for the day because the
CCU is short staffed and needs additional help to care for the clients. The
nurse has never worked in the CCU. Which of the following responses is the
most appropriate nursing action?

A. Call the hospital lawyer.

B. Report to the CCU and identify tasks that she feels she can safely
C. Speak to the nursing supervisor.
D. Refuse to go to the CCU.

RATIONALE: When the nurse is placed in this situation, the most

appropriate action is to set priorities and identify potential areas of harm to the
client. Reassignment to another nursing area is an acceptable legal practice used by
hospitals to meet their staffing needs. A nurse can't legally refuse to be reassigned
unless there's a specific clause in her union contract. Safety is always a priority!

59. A nurse-manager is explaining the unit's performance

improvement (PI) program to a newly hired nurse. Which of the following
should she include as one of the primary purposes of the PI program?

A. Evaluation of client outcomes

B. Evaluation of staff member performance
C. Improvement in the efficiency of care
D. Preparation for accreditation

RATIONALE: PI programs ensure that the best care is delivered to clients.

This can be measured by evaluating client outcomes. Staff performance evaluations
focus on staff, not client outcomes. Improvement in the efficiency of care may be an
aspect of quality care but it isn't the goal. Although PI is one component required for
accreditation, the goal is to ensure that the best care is delivered, not to ensure

60. Two family members are arguing in a child's room. They start
to hit each other and the child is crying. What's the most appropriate
nursing action?

A. Call security to come and intervene.

B. Remove the child from the room.
C. Ask one of the family members to leave the room.
D. Try to reason with both family members.

RATIONALE: The first action would be to protect the child by removing him
from the room. Calling security is necessary but only after ensuring the safety of the
child. Asking one of the family members to leave the room or reasoning with them
would be ineffective at this point and may even escalate the situation. Wag makialam
sa mga away ng family members ng patient ok.

61. The nursing supervisor is called to the emergency department

to assist with a 10-month-old infant with injuries consistent with child
abuse. The nursing supervisor confers with the emergency department
physician. To whom must she report the incident?

A. A social worker
B. The medical director of the emergency department
C. A Children's Protective Services (CPS) representative
D. A public health nurse

RATIONALE: Suspected child abuse must be reported to a CPS

representative. Sa Pilipinas, bantay Bata or DSWD. Reporting a potential abuse
doesn't indicate guilt, only suspicion or risk. The CPS and the judicial system will
follow the correct legal process to establish the need for prosecution and counseling.

62. The nurse-manager has noticed a sharp increase in the

mediation errors with I.V. antibiotics over the last month. She discusses the
situation with each nurse involved. What other action should she take?

A. Document it on their evaluation.

B. Ask them to attend inservice training for administration of I.V.
C. Report them to the supervisor.
D. Report the incidents to the hospital attorney.

RATIONALE: Identification of causes of medication errors requires in-

service education to inform the staff of strategies to decrease these errors. Errors are
frequently the result of systemic problems that can be identified and rectified through
problem-solving techniques and changes in procedures. Documenting or reporting
the situation wouldn't directly assist the nurses in eliminating errors. Reporting the
incidents to the hospital attorney isn't necessary.

63. When reporting to the surgeon that a chest tube is

malfunctioning, the nurse is ordered to reposition the tube and obtain a
chest radiograph. The nurse should:

A. inform the surgeon this isn't within her scope of practice.

B. report the surgeon to the Ethics Committee.
C. report the surgeon to the nursing supervisor.
D. follow the order as requested by the surgeon.

RATIONALE: Initially, the nurse needs to inform the surgeon that the task is
outside the scope of nursing practice. Bawal ang atribida nad nagmamarunong na
nurse kea, If the surgeon still requests the activity, the nurse should refuse to
perform the task and should follow the chain of communication for reporting unsafe
practice according to the hospital's policy. The nurse must not comply with any order
that goes beyond the scope of nursing practice.

64. An Iranian mother and father admit their 14-month-old son to

the pediatric unit for treatment of leukemia. When the female pediatric
oncologist, who isn't Muslim, introduces herself, they became
uncooperative and refused treatment. The nurse should be aware that this
change of behavior is probably related to:

A. the gender of the physician.

B. fear of being accused of child abuse and neglect by an authority
C. religious barriers that prevent the family from accepting care from
someone who isn't of their religion.
D. aggressiveness of Middle Easterners.

RATIONALE: The Iranian tradition of male authority is still strong. Accepting

a woman making life-and-death decisions for their son may be very difficult for these
parents. Discussing with the parents other options, such as the idea of turning the
case over to a male Muslim oncologist, would be appropriate. The gender issue is a
stronger cultural factor than the religious difference. There's no basis to relate the
parents' behavior to fear of being charged with abuse or neglect. Attributing the
behavior to Middle Eastern aggressiveness reflects a stereotype, not a culture value.

65. Which of the following clients would be a priority for the nurse
to evaluate when assuming responsibility for their care at the beginning of
the day shift?

A. The client who had a total laryngectomy the previous day

B. The client with diabetes who had a fasting blood glucose of 150
C. An elderly client who has Alzheimer's disease and periods of
D. A client with a pneumothorax who had a chest tube inserted earlier
in the day

RATIONALE: Based on the information provided, the client who is on day 1

after a total laryngectomy would be the priority client for the nurse to evaluate. This
client is at risk for impaired respiratory status and should be monitored closely coz
edematous ang neck area nya and baka magkaron ng airway obstruction. Clients
with acute conditions that can affect their respiratory status are a high priority for
nursing care.

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