NURSING PRACTICE III

Situation 1: Anthony, 55 years old and a music teacher sought B. 2, 3, 4, 5

admission to the hospital because of laryngeal tumor. The client is C. 3, 4, 5, 6
scheduled for total laryngectomy. D. 1, 2, 3, 4

1. Before the nurse can develop a relevant care plan, the nurse 8. The most controversial way of communicating doctor’s
understands that in post-laryngectomy, the trachea and the orders is by phone. It becomes valid and legal only when
esophagus are permanently separated. Therefore, which of
the following will the nurse expect? A. Countersigned by the receiving RN
B. Signed by the physician who gave the order
A. No risk of aspiration during swallowing; speech is
lost C. Signed by the resident physician on duty
B. Normal speaking, breathing and swallowing are D. Countersigned by the medical doctor
restored
C. Unable to communicate with difficulty of 9. To facilitate effective communication between an immediate
swallowing and breathing post-operative client and the nurse, he/she should
D. Permanent tracheostomy created; normal speech is
A. Maintain a clam attitude and just care for the
lost
client as needed
B. Encourage the client to discuss feelings/pain or
2. Pre-operatively, the nurse identified the nursing dagnosis,
discomfort openly
“Knowledge Deficit: Post-operative communication
strategies”. Which of the following is a relevant nursing C. Observe non verbal cues
intervention? D. Assist the client to comfortable and safe position
while he/she explains what measure are being
A. Clarify information on purpose, anticipate benefits done
and consequences of total laryngectomy
B. Explain that total laryngectomy results in loss of 10. The nurse instructs the nursing attendant to perform
ability to verbally communicate cleansing enema until the return flow is clear. The nursing
C. Arrange a visit to a post-laryngectomy client who attendant understood the instruction when she says, “I will
effectively uses an alternative form of verbal
communication A. Call you when the return flow is clear”
D. Illustrate means of communicating post- B. Stop the enema only if the return flow is without
operatively formed fecal material”
C. Need 1 liter of tap water to have clear return flow”
3. In the immediate post-operative period, the nurse assesses D. Put the client in left Sim’s position to achieve the
coarse, high-pitched sound on inspiration by listening over desired return flow.”
the trachea with a stethoscope. The nurse should
immediately Situation 3: Post-operative infection complication is still a concern in
surgical client’s care. Hospital staff needs to review practices to adhere
to the standards of care to improve quality and safe care delivery.
A. Position client to Fowler’s
B. Reassure the client that he is doing fine 11. Nurse Mercy is setting up for an emergency caesarian
C. Suction the tracheostomy tube section. The linen packs were damp although these were just
D. Report to the surgeon taken from the sterilizer. The nurse’s appropriate action is

4. Which of the following expected outcomes for the patient is A. Bring the linen packs back to the Central Supply
most relevant for the nursing diagnosis “At risk for section for quality control
imbalanced nutrition related to impaired swallowing”? B. Change the damp linen pack
C. Open the linen pack and allow to dry
A. Appropriate body weight maintained D. Do not use the damp linen
B. Fear of choking relieved
C. Oral intake increased 12. The clinical instructor assigned a nursing student to assist
D. Swallowing of soft foods facilitated the operation. When the nursing student entered the OR
suite, her curly long hair was not covered by the head cap.
5. The nurse is preparing Anthony for discharge. The following What would the circulating nurse do?
are instructions regarding stoma and post laryngectomy care
except A. Welcome the nursing student to the OR
B. Request the clinical instructor to tell the nursing
A. Avoid exposure to persons with upper respiratory student to use the head cap properly
disease C. Assist the nursing student to tuck-in all her hair
B. Instruct client to assume supine position as inside the head cap
necessary D. Do not allow the nursing student to scrub in
C. Avoid swimming and use care when using the
shower 13. After the surgeon finished doing the surgical hand scrub,
D. Prevent foreign body from entering the stoma she came in to the OR suite swinging her hands casually.
The scrub nurse should do which of the following
Situation 2: The communication process is essential to the manager or appropriate action?
leader in supervising client care
A. Offer a sterile towel to dry her hands
6. The nurse who effectively analyzes the communication B. Serve the surgeon her sterile gown and gloves as
process recognizes the messages are usual
C. Tell the circulating nurse to pour alcohol 70% to
A. Connotative and denotative the surgeon’s hands.
B. Learned and unlearned
D. Remind the surgeon to scrub again
C. Verbal and non-verbal
D. Native as well as foreign 14. When the intern-in-charge did the skin prep and
catheterized the client, the circulating nurse noticed when
7. Basically, communication is part and parcel of planning to the intern withdrew the catheter from the vagina. What is
manage client care. Which of the following skills should be your appropriate and immediate action?
included? Select all that apply.
1. Focusing 4. Clarifying A. Stop the intern and do the catheterization yourself
2. Observing 5. Responding
B. Offer to change the catheter
3. Attending 6. Teaching
C. Alcoholize the tip of the catheter before reinserting
A. 1, 3, 4, 5 the catheter
 D. Hold the hand of the intern to stop him from 24 hours. The most appropriate action of the narcotic nurse
reinserting the catheter is:

A. Log every injection of Demerol

15. After the last stitch, the surgeon is ready to apply dressing to
B. Make fraction dosage like 0.5 ml as 1 ml
the incision wound. Which of the following does the nurse
expect the surgeon to do? C. Demerol inventory must be checked every
endorsement by the narcotic nurse
A. Remove his gloves and apply the dressing D. Review endorsement of clients who received
B. Apply the dressings and tape and then remove his Demerol within the last 24 hours
gloves
C. Put the dressings and remove his gloves to apply 23. A staff nurse was found charting blood glucose result
the tape without actually doing the procedure. What is the
appropriate initial action of the senior nurse?
D. Tape the dressing and remove the gloves

Situation 4: A 57-year-ols male client, post Billroth II was admitted to A. Write and submit an explanation and reprimand
the Post Anesthesia Care Unit (PACU) from the OR. The client is still as necessary
sedated but responsive to commands. He has a nasogastric tube B. Go on leave without pay
draining orange-yellow fluid to a drainage bottle C. Write an incident report
D. Explain to the patient
16. The nurse who admitted the patient recognizes that Billroth
II procedure means 24. While making your PM shift endorsement, you saw the
nursing attendant receiving a package from a patient’s
A. Enterostomy watcher. Your appropriate action would be
B. Esophagojejunostomy
C. Gastroduodenostomy A. Reprimand the nursing attendant right away
D. Gastrojejunostomy B. Remind the patient that gift giving to any hospital
staff is not allowed
17. After admitting the patient to the PACU, the first action of C. Review with the nursing attendant the hospital
policy
the nurse would be to
D. Endorse to the incoming shift for proper action
A. Assess patency of the airway
25. The Code of Ethics states that the nurse’s primary
B. Check the rate of the IV infusion
commitment is to the client whether an individual of family,
C. Monitor the vital signs
group or community. Which nursing activity would best
D. Assess the clients pain
demonstrate the ethical principle called justice?
18. As the nurse monitors the client, she notices a bright red
spot on the dressings which measures 4cm in diameter. The A. The nurse providing care on a “first come – first
nurse should initially do which appropriate nursing served” basis
intervention? B. Referring the client for evaluation to the social
worker on duty regarding her socio-economic
A. Change the top dressing status
B. Continue to monitor the vital signs C. The client’s preference is least considered
C. Notify the clients surgeon of a potential D. The nurse’s providing care to maximize health
hemorrhage according to available resources
D. Assess the presence of a drain
Situation 6: Nurse Fely is in charge of a client who was admitted for
management of acute episode of cholecystitis.
19. In assisting the client to do deep breathing, coughing and
turning to the sides on the first post-operative day, which
26. Nurse Fely did her admission. She understands that the pain
nursing action would be most helpful for the client?
is characterized as
A. Restate the importance of respiratory exercises
A. Tenderness that is generalized in the upper
B. Give the client reassurance that can he can cough,
epigastric area
breathe deeply and turn to sides safely
B. Pain in the left upper quadrant radiating to the left
C. Administer the prescribed analgesic round the
shoulder
clock as prescribed
C. Tenderness and rigidity at the left epigastric area
D. Apply abdominal splint (pillow) while coughing radiating to the back
D. Tenderness and rigidity at the upper right
20. The client complained of abdominal pain, nausea and abdomen radiating to the midsternal area
vomiting with abdominal distention. The nurse anticipates
which of the following priority management after referring
27. To confirm the diagnosis of cholecystitis, the attending
to the surgeon?
physician ordered a procedure that can detect gallstones as
small as 1 – 2 cm and inflammation. The nurse would
A. Gastric decompression prepare the client for which specific diagnostic procedure?
B. Possible surgery
C. Endoscopy A. Cholangiography
D. Rectal tube insertion B. Ultrasonography
C. Gall bladder series
Situation 5: The behavior or actions of any professional nurse
D. Oral cholecystogram
especially while on duty are often the reflection of their values.
28. The diagnosis was confirmed as cholecystitis with
21. Mrs. C. Serdenio is currently enrolled in the master’s
gallstones. The doctor prepared the client for the removal of
program at the State University and is currently writing her
the gallbladder. The client asks the nurse how the procedure
thesis. She applied as a chief nurse in St. John’s hospital and
will affect digestion. The nurse’s most correct response
was accepted. Since her assumption to office, she has been
would be
signing documents as master’s graduate affixing “RN,
MAN” to her name. the action of the chief nurse constitutes
A. Removal of the gallbladder would significantly
interfere only with the digestion of fatty foods.
A. Misrepresentation B. Removal of the gallbladder does not usually
B. Malpractice interfere with digestion
C. Personification C. The body will adjust in due time
D. Misdemeanor
D. Removal of the gallbladder usually interferes with
digestion but can be remedied by dietary
22. The charge nurse reported to the chief nurse that the
modifications
Demerol 50 cc vial inventory has been incorrect for the last
 29. Reviewing the laboratory findings of the client, the nurse C. When the nurse does not understand the order
would found which findings are elevated? D. When the client refuses
1. White blood cell count
2. Total serum bilirubin 37. When do you carry out the order of the physician?
3. Alkaline phosphate A. When the consent has been signed by the client or
4. Red blood cell count any appropriate person
5. Cholesterol B. When the physician has signed the order
6. Serum amylase C. As soon as the medicine or therapy is available
D. When the guardian of the client is present
A. 1, 2, and 3
B. 2, 3, and 4 38. A nurse encounters a client who refuses to take a prescribed
C. 3, 5, and 6 medication. What is the appropriate action of the nurse?
D. 1, 2, and 6 A. Tell the client that he will be subjected to another
mode of treatment like surgery
30. A T-tube was inserted and the physician ordered, “Monitor B. Let the client sign the waiver
the amount, color, consistency and odor of drainage.” Which C. Explore the possible reason why the client refuses
of the following procedures can the nurse perform without the prescribed medication
the doctor’s order? D. Refer the client to the attending physician
A. Clamping 39. In case of telephone orders, the concerned physician needs
B. Aspirating to countersign the order within
C. Irrigating
D. Emptying the drainage A. The shift
B. As soon as possible
Situation 7: Mary Rose, 16 years old, is admitted to the hospital for C. A time frame according to hospital policy
observation due to vague epigastric pain. The doctor’s clinical D. The day
impression is appendicitis.
40. The nurse should ensure that all components of medications
31. Based on the initial manifestation on admission, the nurse is are documented. Identify all these components.
looking for positive manifestations of appendicitis which 1. Dosage, route and frequency
includes the following except 2. Name of client and medication
3. Date and time the medication was ordered
A. Abdominal tenderness on palpation 4. Dosage, route, frequency and strength
B. Low grade fever 5. Physician’s signature and specialty
C. Thrombocytopenia 6. Physician’s signature and PRC license number
D. Nausea and vomiting
A. All except 4 and 5
32. A positive sign of appendicitis is localized and rebound B. All except 4 and 6
tenderness on palpation at which quadrant of the abdomen? C. All except 5 and 6
D. All except 3 and 5
A. Left upper quadrant
B. Right upper quadrant Situation 9: Nurse Mercy is assigned in the medical-surgical unit and
C. Left lower quadrant most of the clients assigned to her were elderly clients.
D. Right lower quadrant
41. For a client complaining of mild musculoskeletal pain, the
33. The client is scheduled to undergo appendectomy. nurse will anticipate that the treatment for this client’s level
Preparation for appendectomy includes the following: of discomfort will include which of the following?
1. Intravenous infusion
2. Laxative A. Diazepam
3. Pubic area shaving B. Acetaminophen
4. Enema C. Meperidine HCl
5. Shower D. Fentanyl
6. Pain medication
42. The nurse is to inject Vitamin B intramuscularly to another
A. 2, 3, and 4 elderly client. Before injecting, the nurse explained that the
B. 1, 3, and 5 client may feel some discomfort. This is an example of
C. 1, 2, and 3
D. 1, 5, and 6 A. Reducing pain perception
B. Self-preservation
34. The nurse monitors for signs of peritonitis, a potential C. Anticipatory response
complication postoperatively. The manifestations include
D. Distraction
the following except
43. Mr. Gomez, 71 years old, has a history of chronic back pain.
A. Fever
He thinks that his family perceives him as a “weakling”
B. Tachycardia
because he often asks for pain medication. Which of the
C. Abdominal tenderness
following is the most therapeutic response of the nurse?
D. Soft abdomen
A. “It seems that you are worried. Which matter to
35. Intravenous therapy was prescribed. Which of the following you more? What people will say or getting relief
is not an indication of the therapy? from your pain?”
B. “Taking pain medication as prescribed will help
A. To replace blood and fluid loss
you become more active and your family will be
B. For antibiotic therapy happy to see you up and about.”
C. For parenteral nutrition C. “Chronic pain is very difficult to manage; use pain
D. To promote renal function medication because that is what it is for.”
D. “Don’t you think your family wants you to be
Situation 8: Drug administration is one of the collaborative functions of comfortable, and the only way is to take your
the nurse that require a written order of the physician. To date, errors medicine?”
in medication continue to be a problem in the health care setting across
the globe. 44. Mang Pedring has chronic pain due to osteoarthritis and has
impaired speech. Which of the following is the most
36. A nurse is obligated to carry out a physician’s order except appropriate to determine his medication needs for pain?

A. When the nurse is very busy A. Observe typical pain behavior through facial
B. Believes an order to be inappropriate or inaccurate expressions
 B. Asking the client to rate his pain on a scale of 0 to D. Supine lying on either left or right side with one
10 by writing on a magic slate pillow to elevate the head
C. Medicate the client with analgesic as often as
ordered 52. The nurse is aware that pericarditis pain varies from mild to
D. Record frequency of client’s complaint of pain and severe and is typically aggravated by
administer medication accordingly
A. Coughing, talking and eating
45. Aling Juana, 67, diabetic, complained of elevated blood B. Inspiration, coughing, movement of the upper
glucose since she strained her back a week ago despite body
following her diet and drug prescription. Your best C. Breathing, coughing and voiding
explanation would be D. Coughing, inspiration and movement of the lower
extremities
A. Physiologic and psychologic stress can elevate
blood glucose level 53. Albert’s mother asks why the client’s breathing is shallow.
B. Client is consuming more food as a coping The correct response of the nurse would be
mechanism
C. It is a usual occurrence among the elderly A. “The client is conserving his energy.”
D. Parasympathetic stimulation from the body’s B. “That is good because the client is not wasting the
normal response to pain much needed oxygen.”
C. “He is preventing unnecessary movement.”
Situation 10: Research is essential to the development of any D. “Respiratory movement intensifies pericardial
profession. Through research, knowledge can be validated and pain.
defined, and new knowledge can be generated. A team of researchers
proposed a study on the individual effect of preoperative teaching on 54. Albert is prescribed NSAID every four hours to relieve,
the early ambulation of women who have undergone abdominal fever, inflammation, and pericardial pain. To maximize the
hysterectomy. Target populations are women admitted on the same effect of the drug, the nurse would administer it
day for total abdominal hysterectomy.
A. When the client asks for it
46. Which of the following is the most appropriate method to B. On an empty stomach
use? C. Round the clock on a consistent basis
D. When the client is awake only
A. Non-experimental method
B. Qualitative method 55. The nurse wants to know if the client is aware of the side
C. Quantitative method effects of NSAID. What would be the most appropriate
D. Experimental method question of the nurse?

47. Which of the following designs would be most appropriate A. “Are you aware that you can be addicted to the
to use in attempting to determine the participants’ early drug?”
ambulation after they will be given preoperative teachings? B. “Have you ever vomited blood or noticed very
black stools?”
A. Time series design C. “How familiar are you with the drug?”
B. Pretest – posttest control group design D. “Have you noticed something unusual with your
C. Solomon four – group design urination?”
D. One shot case study
Situation 12: Nurse Carla admitted Harry for management of
48. In the proposed study, the researchers defined the selected acromegaly.
groups and ask what sample size should be used. Since there
are many qualifiers that to some extent samples must be 56. The nurse is aware that acromegaly is a condition when
specific to the study, the general rule in the sample size is to growth hormone occurs in excess in adulthood or after
epiphyses of the long bones have fused. The following are
A. Determine the duration of the study the typical features of the disorder except
B. Consider the type of the study
C. Establish the number of variables A. The soft tissues continues to grow
D. Make the sample as large as possible B. Hands and feet are enlarged
C. The client grows taller
49. The independent variable that is manipulated is D. Broad and bulbous nose

A. Women 57. The client was prescribed Ocreotide acetate (Sandostatin).

B. Abdominal hysterectomy Nurse Carla would monitor for which of the following side
C. Health outcomes effects?
D. Preoperative teachings
A. Abdominal pain
50. In treating the data to be collected, the researcher will use B. Dysuria
which of the following statistical tools? C. Hypotension
D. Constipation
A. Pearson r coefficient of correlation
B. Weighted mean 58. For effective dosing, Ocreotide acetate must be administered
C. Chi square test by which appropriate route, three times weekly?
D. T-test
A. Intravenously
Situation 11: Pain brings client to the hospital more than any other B. Intramuscularly
symptoms. Nurses should therefore be skillful to assess pain and C. Orally
reduce discomfort both for the client and family. D. Subcutaneously

51. Albert came to the hospital with chest pain and fever. After a 59. Priority discharge plans should include which of the
thorough assessment by the doctor, he was admitted for following?
pericarditis management. The nurse positions the client to 1. Fasting blood sugar monitoring
reduce pain and discomfort. Describe this position. 2. Bone assessment
3. Intake and output
A. Prone position with one pillow to support the 4. Urine output
head
B. Put two pillows to elevate the head and one pillow A. 2 and 3
under the knees B. 1, 2, and 3
C. Sit the client upright and lean forward C. All except 1
D. 1 and 2
 60. Acromegaly often develops insidiously that nurses should 66. From the nursing history obtained from the client, which
understand that the client with this disorder would seek information is most likely related to the development of
medical care because of gangrene on the client’s left toe?

A. Alteration in fat and carbohydrate metabolism A. Preferred open toed sandals to closed leather
B. Changes in blood sugar level shoes
C. Changes in appearance B. Type 2 diabetic diagnosed 15 years ago
D. Alteration in their voice C. Father had type 2 diabetes; post-above-knee
amputation right leg
Situation 13: Part of your duty while on PM shift at the medical ward D. Accidental cut in big toe while cutting toe nails
is to give health instructions to clients and significant others especially
during visiting hours. 67. The physician ordered bilateral lower extremities Doppler
ultrasound. Which of the following is the physician
61. A client with gout asks the nurse what food must be avoided interested to find out through this diagnostic test?
so that the family can provide support. Which food has the
highest in purine content and must be excluded from the A. Distal paresthesias
dietary plan? B. Oxygenation of the tissues in the lower extremities
C. Occlusion of large vessels and arterioles
A. Chicken D. Isolated peripheral neuropathies
B. Carrots
C. Chocolate 68. The senior asked Marina to list nursing interventions for the
D. Liver nursing diagnosis “Ineffective tissue perfusion: peripheral”.
From the following list, which intervention will the senior
62. A 30-year-old client had cholesterol blood test before nurse consider to be contraindicated?
admission to the hospital. The nurse in charge would teach
the family and significant others that the client should A. Regular passive and active exercises of all
exercise to help keep the total cholesterol to a desired level extremities
of B. Keep extremities warm using a foot cradle
C. Encourage frequent changes in position
A. 140 mg/dl D. Maintain both extremities in a dependent position
B. 200 mg/dl
C. 250 mg/dl 69. When Marina checked the capillary blood glucose of the
D. 300 mg/dl client at 6 PM before meals as instructed by the senior nurse,
the result showed 65 mg/dl. Which of the following will
63. A hypertensive client is taking herbal supplement for his Marina do first?
hypertension. He was prescribed antihypertensive
medication. The client wants to continue taking his herbal A. Give juice as prescribed in the insulin scale pre-
medication to lower his blood pressure. The nurse’s most meals
appropriate action is to B. Recheck CBG
C. Check the physician’s order in case CBG is below
A. Advise the client to discuss this concern with the 70 mg/dl
attending physician D. Look for the senior nurse and report
B. Tell the client that herbal supplements have no
proven therapeutic effects 70. The senior nurse observes that Marina occasionally does not
C. Tell the client that herbal and the prescribed follow agreed upon interventions. The senior nurse reports
medications are not compatible that Marina should improve in which of the following?
D. Instruct the client to have a more frequent BP
checking A. Identifying own learning needs
B. Attitute toward criticism
64. The client was placed on a low sodium diet. The wife asks C. Compliance to standards
the nurse which foods to include in the client’s diet while at D. Demonstration of proper decorum
home. The nurse should instruct to include which of these?
Situation 15: A 34-year-old female client with Grave’s disease was
A. Canned foods admitted for treatment. The physician prescribed Propylthiouracil to
B. Preserved foods treat the disorder.
C. Fruits and vegetables
D. Salt water fish 71. Before the nurse administers the medication, which of the
following is most relevant for the nurse to ask?
65. While the nurse was checking the BP of the client, the wife
was intently observing the nurse. The wife asks the nurse A. “Do you experience gastric discomforts?”
how to ensure accurate measurement of BP reading. Identify B. “When was the last time you tool alcohol?”
all the nurse mentioned that will ensure accurate BP reading. C. “When was your last menstruation?”
1. Taking the BP 15 minutes after intake of D. “Do you prefer a liquid form of medication?”
antihypertensive drug
2. Measuring the BP after the client has been 72. The client is to have surgery in 10 days. Lugol’s solution 4
seated for 5 minutes gtts po was prescribed in 10 days. The client asked the nurse
3. Seating the client with arm bared supported and for the purpose of the drug. Which response of the nurse is
at the heart level correct?
4. Using the cuff with rubber bladder that encircles
at least 80% of the arm
A. It decreases the risk of bleeding
5. Gauges of BP apparatus should be calibrated
every 8 hours B. It eliminates the needs to take hormone
6. The client should rest quietly for 5 minutes replacement
before reading and can talk while BP is being C. It stabilizes your immune system to withstand
checked surgery
D. It decreases the risk for thyroid crisis
A. 1, 2, 3, and 4
73. When the client returns to the unit after surgery, which
B. 3, 4, 5, and 6
technique is most appropriate to monitor bleeding from the
C. 2, 3, 4, and 5
incision?
D. 2, 4, 5, and 5
A. Weigh all gauze dressing before and after
Situation 14: Marina, a newly hired staff nurse in the medical surgical
changing wound dressings
unit was assigned to work with a senior nurse. A female client was
admitted with a diagnosis of diabetic foot, gangrene left toe, type 2 B. Assess for dampness at the back of the client’s
diabetes. neck
 C. Pass a flashlight across the incision wound on top name of the chief nurse. The proper way to sign for the chief
of the dressings nurse who is on leave is
D. Remove the dressings to directly inspect the
incision wound A. Sign your name over the printed name of the chief
nurse
74. Which of the following assessment findings when observed B. Write “for” before the title of the chief nurse then
in a post-thyroidectomy client is indicative of a thyroid sign your name above it
crisis? C. Erase the name of the chief nurse and write your
name then sign
A. Falling blood pressure D. Sign on a separate line as OIC
B. Regular and noisy respiration
C. High fever Situation 17: Sponge count should be performed by two members of
D. Spasm in the hand the surgical team in any surgical procedure where there is a possibility
that the sponge can be retained.
75. At the start of thyroid replacement post-total thyroidectomy,
the nurse must monitor for side effects. Which side effects 81. The scrub and circulating nurse should perform sponge
would the nurse expect to assess? count during which phases of an abdominal hysterectomy
1. Hypertension procedure?
2. Tremors 1. Before the procedure
3. Hirsutism 2. Before closing the endometrium
4. Insomnia 3. Before closing the peritoneum
5. Tachycardia 4. At the skin closure
6. Hyperglycemia 5. When the scrub nurse goes for a lunch break

A. 3, 4, 5, and 6 A. All except 5

B. 1, 2, 3, and 6 B. All except 1
C. 1, 3, 4, and 5 C. 3 and 4 only
D. 1, 2, 4, and 5 D. All except 2

Situation 16: The willingness of nurses to accept a set of professional 82. The OR nurse knows that the correct way to count sponge is
and ethical principles and apply it in their daily affairs is the hallmark
of a true professional. A. Scrub nurse counts singly followed by the
circulating nurse
76. A client is being positioned for radical vulvectomy and a B. Scrub and circulating nurse count by packs of tens
couple of clinical clerks wanted to come in to watch the C. Scrub nurse and circulating nurse count audibly
surgery. The circulating nurse advise them to enter the OR by packs of fifties
suite later. Foremost, this decision of the nurse is directed D. Scrub nurse and circulating nurse count singly,
towards audibly and concurrently

A. Respecting the client’s rights 83. The scrub nurse and circulating nurse also counted the
B. Preventing infection sharps and miscellaneous items like instruments before the
C. Minimizing a crowd in the room procedure. Continuous accounting for these items can
D. Preserving privacy primarily

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP A. Expedite the procedure thus shortening the
(transurethral resection of the prostate) client who is in pain. surgical time
When she checked the narcotic cabinet, she found out a vial B. Improve hospital miscellaneous revenue
that is almost empty. She was able to aspirate 60 mg only. C. Minimize injuries and/or liabilities to sterile
Nurse Kristine decided to inject it instead of making the surgical team
client wait until the next Demerol vial is available. The D. Shorten surgical cases turnover by 15 – 30 minutes
action of the nurse violates which of the following ethical
principles? 84. The circulating nurse will document “surgical count” in
which of the following?
A. Justice
B. Beneficence A. Observation notes
C. Truth B. Intraoperative record
D. Autonomy C. Nurse’s notes
D. Checklist
78. Nurse Nora is assigned on PM shift for the month of June.
She requested the head nurse if she can be on night or 85. When the surgeon asked for suture to close the abdomen,
morning instead to be able to tutor her 2 sons in the sponge count has not been completed. Which of the
elementary. The head nurse emphasized that it is her turn to following is the appropriate action of the scrub nurse?
go on PM duty. The action of the head nurse exemplifies
which of the following? A. Requests the surgeon to recheck the abdomen for
sponges, if any
A. Authority B. Continues to count the sponges
B. Fidelity C. Hands obligingly the suture for closure to the
C. Autonomy surgeon
D. Justice D. Informs the surgeon that sponge count has not
been completed
79. A scrub nurse is assisting an emergency Cesarian section on
a 39-year-old laundry woman. Before closing the Situation 18: The continuum of care is facilitated by effective
peritoneum, the surgeon asks, “How old is the client?” communication among the members of the health care team. This
Holding the fallopian tube, the surgeon asks for a hemostat. activity is facilitated by documenting reports.
The scrub nurse sensing that the surgeon is about to ligate
the tube said, “Doctor there is no signed consent for tubal 86. The change of shift report of nurses describes the following
ligation.” The nurse just demonstrated which of the except
following?
A. Priority clients and impending needs
A. Insubordination B. Client health status
B. Abandonment of duty
C. Nurses priority needs
C. Advocacy
D. Client special needs
D. Malpractice

80. An officer-in-charge signs a document for the chief nurse

who went on leave. The OIC signs her full name over the
 87. When the staff nurse on duty encounters a problem that
cannot be solved using nursing knowledge, skills and A. Malpractice
available resources, it is best for the nurse to consult the B. Motu proprio
C. Subjudice
A. Nurse supervisor D. Sine-qua-non
B. Medical director
C. Head nurse Situation 20: A nursing student was assigned to take care of a client
D. Chief nurse with polycythemia vera.

88. When the nurse ensures that the client has plan for 96. You planned the nursing care of the client together with the
continuous care after leaving the health care facility and nursing student. You asked the nursing student to
assists from the transition from one environment to another, enumerate the clinical manifestations of a client with
she is doing a polycythemia vera. You expect the nursing student to
enumerate the following manifestations except
A. Discharge plan
B. Admission plan A. Generalized pruritus
C. Referral B. Hepatomegaly
D. Nursing care plan C. Splenomegaly
Answer: A D. Ruddy complexion
Rationale: “Discharge planning is the process of preparing a client
to leave one level of care for another within or outside the current 97. The nursing student reviews the laboratory findings and
health care agency. Usually, discharge planning refers to the client finds which blood results are elevated?
leaving the hospital for home. However, discharges occur among
many other settings. Within a facility it can occur from one unit to A. RBC, WBC, and platelets
another.”
Reference: - p. 113, Kozier et al, 2004 B. WBC, platelet, and cholesterol
C. Bilirubin, RBC, and platelet
89. A nurse has to attend a committee meeting for two hours. D. BP, WBC, and hematocrit
She delegates her work to another nurse. What primary
consideration should be observed? 98. Phlebotomy was ordered as part of the therapy. You
instructed the client and emphasized that the procedure can
A. Availability of resources be repeated. The client inquired, “What is the primary aim of
B. Time needed to perform delegated function the procedure?” Your appropriate response is
C. Willingness to assist A. “It removes the excess blood and donate to
patients of the same blood type.”
D. Competency to perform the given function
B. “It prevents headache and dizziness.”
C. “It keeps the BP reading within normal range.”
90. When a telephone order is made, it should be documented
D. “It keeps the hematocrit within normal range.”
by the nurse who is receiving the order. The following
should be included in the order to be executed except
99. The companion asks why the client was advised to avoid
iron supplements or vitamins. The correct response of the
A. Time the call was made and its duration
nurse would be
B. Who made the call and who received the order
A. “These supplements enhance the production of
C. What information was given and for whom was
RBC.”
the order
D. When the order was made and who made the B. “The vitamins and iron can suppress bone marrow
order function.”
C. “Actually the patient does not need these
Situation 19: Nurse Abe receives a subpoena as a witness in a court supplements.”
case. D. “It is best that the client gets these supplements
from natural sources.”
91. Which of the following best describes the responsibility of
the nurse as a witness in a case of court? 100. The client complained of generalized pruritus. The following
are appropriate nursing interventions except
A. Protect the patient A. Administer routine antihistamine ‘round the clock
B. State the truth B. Regulate the temperature to 25 degrees centigrade
C. Collaborate with the primary physician or lower
D. Relate a dramatic experience C. Bathe in tepid or cool water followed by cocoa-
based lotion application
92. Which doctrine is invoked if an abdominal X-ray of a D. Wear light material loose-fitting camisa
postoperative patient shows a forcep inside the abdomen?

A. Force majeure
B. Borrowed servant doctrine
C. Res ipsa loquitor
D. Doctrine of captain of the ship

93. When the nurse is called to witness and was told to bring the
patient’s chart, what is needed to legally summon the
client’s chart in court?

A. Request order
B. Notarized letter from the complainant
C. Permission from the client
D. Subpoena from the judge

94. When Nurse Abe presents the patient’s chart as evidence of

a case, this is called a/an

A. Duces tecum
B. Appendices
C. Exhibit
D. Documentation

95. When a case is already filed in court, it is a court rule not to

discuss the matter outside the court. This is