NURSING PRACTICE III

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATION (PART A)

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test items
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
3. AVOID ERASURES
4. Write the Subject title “NURSING PRACTICE III” on the box provided.

SITUATION 1- Upon discharge, the patient with Chronic Obstructive Pulmonary Disease (COPD) requires considerable patient
and family teaching
1. A nurse instructs a client diagnosed with COPD to use pursed lip breathing. The client inquires the nurse about the
advantage of this kind of breathing. The nurse answers, that the main purpose of pursed lip is to:
a. Prevent bronchial collapse c. Achieve maximum inhalation
b. Strengthen the intercostal muscle d. Allows air trapping
2. The nurse teaches a patient about the use of respiratory inhaler. Arrange the steps in using an inhaler chronologically
1. Press the canister down with your finger as you breathe in 3. Inhale the mist hold your breath at least 5 to 10
seconds before exhaling
2. Wait one minute between puffs if more than one puff is prescribed 4. Remove the cap and shake inhaler
a. 4,1,2,3 b. 3,4,2,1 c. 4.1,3,2 d. 1,2,3,4
3. The physician prescribed monitoring closely of clients oxygen saturation of the blood. Which of the following will you
prepare?
a. Electrocardiogram machine b. Pulse oximeter c. Spirometer d. Blood pressure
apparatus
4. Patients suffering from COPD are taught to avoid shifts to temperature and humidity. It should be emphasized that heat
increases body temperature and thereby raising the:
a. Risk for infection B. Fluid intake C. The oxygen requirements D. Anxiety level
5. COPD patients may be taught the following pulmonary hygiene measures to improve clearance of airway secretion,
EXCEPT.
a. Measure fluid intake B. Effective coughing C. Postural drainage D. Complete bedrest
SITUATION 2- Potential environment hazards exist in various modalities in the operating room that may affect the wellbeing
of the client and health care workers. It is the responsibility of the perioperative nurse to maintain a positive environment for
all concerned.
6. The circulating nurse are aware that many factors combine to contribute hypothermia or hyperthermia in the surgical
patients. Below are options that the perioperative nurse can adopt to maintain the desired temperature. Select all that
apply:
1.Adjusting the OR suite
2.Limiting area of skin preparation and surface surgical draping
3.Applying warm blankets to clients upon arrival in the OR and after sterile drapes have been removed
4.Keeping the OR door closed throughout the surgical procedure
5.Limiting the exposed skin area during positioning
6.Placing rolled linen on both sides of the client during skin preparation to catch excess water
a. All except 2 and 5 b. 1,2,4 and 5 c. 1,2,3 ad 6 d. All of these
7. During transport of post-operative clients, which of the following would you NOT recommend to be adopted?
a. Pushing the patient’s feet first avoiding rapid movement on the hallways and corners
b. Hanging and securing I.V containers over the client’s head
c. Elevating the side rails and using safety straps
d. Keeping the client warm with blanket
8. The surgeon of a client for dilatation and curettage (D&C) who is on triple Anti TB drugs complained why his case is
scheduled “last” for the day. The OR nurse offers which of the following BEST reason?
a. The case is relatively short and easy c. Foremost, we considered the safety of other clients
b. Your anesthesiologist preferred this time slot d. There is no emergent need to do the case ahead of other
schedule
9. You are preparing case-assignment for the following day. Which of the following assignment is safe for nurse Kamile who
is on her 1st trimester of pregnancy?
a. Cast room with X-ray facilities c. Billroth 11 under general anesthesia
b. Endoscopy room where clients are given intravenous d. Laparoscopic cholecystectomy
mild sedation
10. Before the end of the shift, waste management was discussed. The different kinds of waste and ther proper disposal
were presented. The following falls under pathologic waste category, EXCEPT:
a. Patients personal belongings b. Amputated limbs c. Blood and body fluids d. Specimens
SITUATION 3- Mrs. Magsingal, a 47 year old teacher sought admission to the hospital for hemorrhage due to diverculitis.
11. Nurse Ellen read the order of the attending physician, “start blood transfusion of 2 unit’s compatible blood to run for four
hours each unit. Monitor closely and report untoward reactions.” The nurse prepared for cross matching. Which of the
following is an appropriate action of the nurse?
a. Obtain blood transfusion set from the supply room c. Start intravenous infusion of normal saline solution
b. Have blood sample extracted by the medical d. Call blood bank for the prescribed blood
technologist
12. Nurse Ellen is successful in collaborating with the rest of the team if she understands that the diverticulum may bleed
due to:
a. Erosion of the adjacent blood vessel by a fecalith c. Prolonged constipation
b. Irritable bowel syndrome d. Severe inflammation of the sigmoid
13. Additionally, the physician ordered to asses for evidence of lower intestinal bleeding. The nurse does which of the
following?
a. Visual examination of the stool c. Guaiac testing of stool for occult blood
b. Accurate measuring hourly output d. Routine stool examination
14. When collaborating with the health team members, which of the following BEST describe the nurse’s role?
a. Shares and implements doctor’s order effectively c. Helps client understand the treatment plan
b. Listens to the different views of the “significant others” d. Encourages participation of the client in the total care
15. Total parenteral nutrition was started. The nurse understands that the calorie nutrient content and amount of this
intervention is determined by the following EXCEPT
a. Physician b. Pharmacist c. Nutritionist d. Nurse
SITUATION 4- Mr. Sta. Ana, a post-acute myocardial infarction (AMI) on his 2 nd day post attack is assigned to you. The
physician said his recovery is uneventful. The following questions apply.
16. Morphine sulfate intravenous (IV) was prescribed for pain. The nurse understands that morphine sulfate I.V. was
preferred because of two reasons. These are
1. Rapid onset of action 3. Increases cardiac output
2. Elevates enzyme level 4. Bypasses the variable rates of absorption
a. 2 and 3 b. 3 and 4 c. 1 and 2 d. 1 and 4
17. Mr. Sta. Ana is taking Aspirin, a platelet inhibitor. The client understood the nurse’s instruction on how to take the drug if
he:
a. Swallowed medicine with small amount of water c. Chewed and allowed the drug to dissolve with saliva
b. Took the medicine with meals d. Took the medicine two hours before meals
18. The client’s wife observes the facial expression of Mr. Sta Ana and interprets that her husband is in “pain”. She asks the
nurse, “What is causing the pain?” The nurse responded that:
a. Release of tissue substances during inflammatory process can stimulate pain receptors
b. Pain is felt when the myocardial muscles contract rapidly
c. Pain is triggered by high blood pressure
d. Chest pain occurs when the oxygen demand of the heart muscles is not met
19. One of the priority nursing diagnosis is “Ineffective tissue perfusion”. Which of the following would you watch for as the
FIRST indication of altered perfusion?
a. Adventitious lung sounds c. Change in level of consciousness
b. Abnormal heart sounds d. Presence of dysrhythmias
20. During episodes of chest pain, which of the following procedures would the nurse expect to be prescribed to provide
assessment for myocardial infarction?
a. Echocardiography b. Electrocardiography c. Radionuclide imaging d.Angiography
SITUATION 5- A group of nursing students decided to conduct a phenomenological research project on the lived experience
of being isolated among patients who have experienced isolation as a technique in infection prevention.
21. In a phenomenological research, the research team understands that the experience of being isolated will be
a. Interpreted by the participant for the researcher. c. Interpreted by the researcher for the participant
b. Explained by the researcher to the participant d. Interpreted by the researcher with the participant
22. When determining adequate number of participants, the research team will consider which of the following?
a. Sample size of the participant will be determined before the study
b. Number of participants will be adequate when data obtained are saturated
c. Participants should be representative of the target population
d. The convenience type of sampling will be the most appropriate sampling method
23. The research team planned to utilize audio-recorded interviews as their method of collecting data. Which of the following
techniques would ensure that data obtained will be adequately analyzed?
1. Simultaneously listen to the recording and read the written transcript then note observations
2. Repeatedly listen to the audio-tape recording
3. Make notations while listening to the audio-tape recordings
4. Transcribe audio-recorded interview word for word
a. 1 only b. All of these c. 1 and 4 d. 1,3,and 4
24. After the research team has “dwelled with the data” the team decided to conduct data reduction. Which of the following
is the team expected to do?
a. Classify data based on a theoretical perspective c. Break text down into subparts and label accordingly
b. Eliminate data which are not related d. Identify patterns in the obtained data
25. During the interpretation phase, the research team is expected to answer which of the following questions?
a. What do the findings show? d. Are the themes justifiable and grounded from the
b. What is going on? data?
c. What is the meaning of the experience of isolation?
SITUATION 6- You are caring for a client who is with nasogastric tube (NGT) for feeding.
26. When assessing for the NGT placement, which three methods are often recommended?
1. Measurement of exposed tube length 3. Auscultation method after air injection
2. Visual assessment of aspirate 4. pH measurement of aspirate
a. 2,3 and 4 b. All except 2 c. 1,2,and 3 d. 1,2,and 4
27. It is important to maintain patency of the nasogastric tube. The tube is irrigated every 4 to 6 hours. Which solution
would you use?
a. Tap water b. Bottled water c. Normal saline d. Lactated ringer’s
28. When giving tube feedings and medications, which position of the client will reduce risk of reflux and pulmonary
aspiration?
a. Supine position with one pillow supporting the head c. Supine position with the head turned to one side
b. Semi-Fowler’s position with head elevated from 30-45 0 d. Dorsal recumbent
29. When giving single compressed tablet medication by NGT, it should be crushed and dissolved in water. How would the
nurse APPROPRIATELY administer enteric-coated tablet?
a. Let the client swallow the tablet as is c. Request the pharmacist to change the tablet form
b. Pulverize the tablet finely to change the tablet form d. Crush and dissolve in distilled water
30. Diarrhea is a one of the most common complications of tube feeding. Which of the following nursing actions will prevent
this complication?
a. Administer feeding by continuous drip rather than bolus c. Dilute formula to half the concentration strength
b. Give high fiber formula d. Instill liberal amounts of water to flush the tubing before and after
feeding
SITUATION 7- Appropriate and ethical nursing practice should always respect the patient’s right in any health care setting.
The following questions apply.
31. With the advancement of information technology, the nurse understands that the breach of confidentiality can happen
LEAST in which of the following scenario?
a. Keeping the X-ray plate hanging in the negatoscope
b. Client’s laboratory results are transmitted to the patient care unit through a “Hospital Computerized System”
c. Allowing “telephone orders” as means to transmit doctor’s order
d. Patient’s hospital account viewed in computers placed in the hospital corridors
32. When restoration of health is no longer the goal of care and end life care is the goal, artificial nutrition and hydration can
be prepared and continued to be administered. The nurse can administer artificial nutrition through the following
aventies EXCEPT:
a. Intravenous (IV) infusion c. Ileostomy tube
b. Nasogastric tube d. Gastrostomy tube
33. Nurse Sofia is in charge of an elderly client with chronic severe COPD with complications. She recalls that hospice care
might be of benefit to the client. Which of the following statements is TRUE about hospice care?
a. In hospice care, practical support is provided based on the needs of the family
b. Health care workers are not offering hospice care because they don’t like clients to think that they are giving up on them
c. Hospice care is a part of normal life and provides support for dignified individuals
d. Hospice care concept leads client to think that they are hopeless cases
34. Nurse Sofia is about to request an elderly client with emphysema to sign the consent for thoracotomy but assess the
client as incompetent. With the client in the hospital, is a 15 years old “Boy watcher”. Which of the following options
would be MOST ethical for the nurse to follow?
a. Send the “Boy watcher” to fetch the client next of kin c. Refer to the attending physician
immediately d. Inform the head nurse
b. Call the client’s next of kin right away
35. Health care providers need always to point out to clients and significant others that the order of “Do not resuscitate”
(DNR) means the following EXCEPT:
a. Allow natural death to happen (AND) c. Food and food supplements are sustained
b. Comfort measures are withheld d. “no heroic measures “ done
Situation 8 – Editha, 22 years old was brought to the hospital by her mother for chief complaints of pallor, shortness of
breath and weakness. The doctor’s impression was anemia

36. The nurse knows that the BEST areas used to assess pallor that are characteristic of anemia are the:
a. Conjunctivae and lips b. Palms and fingernails c. Lips and fingernails d. Tongue and finger
37. establish a diagnosis the nurse would expect the following laboratory tests to be ordered by the physician EXCEPT:
a. Iron studies c. Bone marrow aspiration
b. Complete blood count d. Erythrocyte sedimentation rate
38. Based on the initial assessment, the nursing diagnosis identified “Activity intolerance related to weakness and shortness
of breath”. Which of the following is the MOST relevant nursing intervention?
a. Passive regular exercise of lower extremities c. Auscultate lungs for abnormal breath sounds
b. Change position every two hours d. Maintain on high fowler’s position
39. The nurse was instructed by her senior t stay with the patient for at least 15 minutes after initiating blood transfusion
PRIMARILY because of which of the following reasons?
a. Vital signs must be monitored every 15 minutes c. Transfusion reaction can occur
b. Be patients’ needs assistance d. It is nursing order
40. When the nurse checked the patient’s vital signs 15 minute after blood transfusion was initiated, the nurse observed the
blood pressure to have increased. The nurse suspects which of the following to have occurred?
a. Blood transfused is contaminated c. Infusion of incompatible blood products
b. Circulatory system could not accommodate blood d. Hypersensitivity to the donor’s plasma proteins
volume transfused
SITUATION 9- Indicators are essential in the measurement and monitoring of quality health care. The nurse plays a key role
in the consistent implementation of standards of care in any unit in the hospital. The following questions apply.
41. You admitted Laura, a 26 year old mother, from Emergency Room for emergency appendectomy. Which of the following
will you use PROPERLY identify the client?
a. Request the client to state her name and the complete name of her physician c. Ask the client to state her name
and birthday
b. Ask the companion to state the client’s name and address d. Read the name of the client from the chart and
name tag
42. You are to do the initial assessment. Which STANDARD PRECAUTION guidelines should be observed?
a. Greet the client by her first name b. Introduce yourself c. Observe hand hygiene d. Drape the client
appropriately
43. It is medication time. The nurse is aware that distraction during any phase of drug administration can cause errors.
Select which strategy can give MOST protection while preparing the medication?
a. Don a medication vest with visible warning. “don’t disturb”
b. Put your cell phone on silent mode
c. Inform your co-staff that you are going to prepare medications for your clients
d. Prepare medication at the bedside
44. Upon entry to the opening room, the client was properly identified. Correct site and procedure shall likewise be identified
by which of the following?
a. Noting proper markings and endorsement c. Asking the client and reading the chart
b. Allowing the client and reading the chart d. Verifying from the OR schedule and patient’s chart
45. Personal protective Equipment (PPE) like the face mask when worn correctly offers maximum protection against
transmission of droplets. Below are descriptions of how a mask is worn. Which statement describes a CORRECTLY
WORN MASK?
a. With the two loops on either side of the mask, anchor it to both ears and adjust to cover the nose and the mouth
b. Place the mask to cover the nose and mouth with two ties tied at the back of the head
c. The mask is placed to cover the nose and mouth with the four sides snugly fitting against the skin and with the two
pairs of ties separately at the back of the head
d. The mask is placed to cover the nose, ear and mouth tied at the back of the head

SITUATION 10- Ginger, 45 years old male diagnosed with gastric cancer was admitted to the Post Anesthesia Care Unit
(PACU) post partial gastrectomy and gastrojejunostomy. Though still sedated patient responds to commands
46. The nurse who admitted the patient performed an initial “head to toe” assessment. Which of the following assessments
done FIRST by the nurse?
a. Assess level of consciousness c. Observe general appearance
b. Determine level of discomfort and pain d. Take vital signs
47. When the patient has been stabilized, the PACU nurse transferred the patient to a private room. While encoding, the
receiving nurse in the private room performed her initial assessment and noticed that the nasogastric tube of the patient
was out of place. Which of the following will the receiving nurse do FIRST? She will:
a. Remove the NGT and report to the surgeon c. Ask the PACU nurse to validate her observation
b. Secure the NGT with tape and refer to the surgeon d. Document observation and report to the surgeon
48. The nurse understands that the immediate post-operative intervention that PREVENTS disruption of the gastric suture
lines post partial gastrectomy and gastrojejunostomy is maintaining:
a. Pressure dressing c. Complete bedrest
b. Fluid and electrolytes d. Nasogastric tube to drainage system
49. In the nursing care plan the nurse identified dumping syndrome as a potential problem when patient starts to take clear
liquids. Which of the following symptoms should the nurse watch for as a result of peristaltic stimulation?
a. Nausea and vomiting epigastric pain,borborygmus c. Abdominal cramping, light headedness, confusion
b. Tachycardia,diaphoresis,hypoglycemia d. Orthostatic hypotension, dizziness, palpitation
50. To promote adequate nutrition which of the following interventions would LEAST helpful for the client?
a. Liquids and solids are taken at separate time c. Assume recumbent position for 30 minutes post meal
b. Meals should be small and more frequent d. Increase intake of carbohydrates

SITUATION 11- Marissa, a 21 year old college student was admitted at 12 noon because of a generalized abdominal pain
which became localized after midnight on the right lower quadrant accompanied by nausea and vomiting. In the emergency
department the diagnosis of acute appendicitis was confirmed. Marissa was scheduled for Appendectomy.
51. The development of appendicitis usually follows a pattern that correlates with the clinical signs. The admitting nurse
understands that the appendix initially becomes distended with fluid secrete by its mucosa following:
a. Fibrotic changes in the inner wall of the appendix c. Impairment of blood supply to the appendix
b. Obstruction of the appendiceal lumen d. Proliferation of microorganism inside the appendix
52. The physician noted upon palpation of the McBurney’s point localized and rebound tenderness. Which of the following
demonstrates this observation?
a. Pain aggravated by coughing c. Rigid “board like” abdomen
b. pain increased with internal rotation of the right hip d. Relief of pain with direct palpation and pain on release of
pressure
53. Perioperative nursing care plan includes “potential complications related to ruptured appendix” as one of the nursing
diagnoses. Which of the following is the nurse expected to report immediately as a possible sign of a ruptured appendix?
a. Severe nausea and vomiting c. Sudden increase in body temperature
b. Unbearable excruciating localized pain d. Pain subsides
54. To prevent perforation of the inflamed appendix, which of the following will the nurse consider as an effective
intervention?
a. Keep on NPO c. Maintain on complete bed rest
b. Monitor progress of pain d. Apply hot compress to abdomen
55. Postoperative medical diagnosis of the client as “Perforated appendix”. Client has a nasogastric tube connected to
continuous drainage. Which of the following is the purpose of this intervention?
a. Medium to cleanse the upper GI tract c. Drain out blood
b. Relieve pain due to abdominal distention d. Intestinal decompression
SITUATION 12- You are assigned in the medical unit and assigned to take care of 5 patients with various cardiovascular
conditions. One of your initial activities is to gather data about your patients.
56. During a physical examination of Anna, you palpated the PMI (point of maximum impulse) in the 5 th intercostal space
lateral to the midclavicular line. Which of the following is the MOST appropriate action for you to do?
a. Assess Anna for symptoms of left ventricular c. Auscultate both the carotid arteries for a bruit
hypertrophy d. Document that the PMI is in the normal location
b. Ask Anna about risk factors for coronary artery
disease
57. You are admitting a new patient, Bernie, for coronary artery disease and started to obtain his health history. Which of
the following questions would you use when obtaining subjective data related to Bernie’s health perception-health
management functional health pattern?
a. How often do you have your cholesterol level and blood pressure checked?
b. Have you had any episodes of fever, sore throat, or streptococcal infections?
c. Are there any symptoms that seem to occur when you are feeling very low?
d. Do you ever experience any discomfort or indigestion resulting from exercise or activity?
58. While doing a physical examination on Maria who is a thin 72 year old patient, you observe pulsation of the abdominal
aorta in the epigastric area just below the xiphoid process. You inform Maria that this is:
a. An indication that an abdominal aortic aneurysm has probably developed
b. Related to normal elevated systemic arterial pulse
c. Most likely due to age-related sclerosis and inelasticity of the aorta
d. A normal assessment finding for a thin individual
59. While doing assessment on Grace, who has heart failure, you note that she has jugular venous distension (JVD) when
lying flat in bed. Your next action will be:
a. Palpate the jugular veins and compare the volume and pressure on both sides
b. Use a centimeter ruler to measure and document accurately the level of the JVD
c. Elevate Grace gradually to an upright position and continue to examine the JVD
d. Ask her to perform the Valsalva maneuver and observe the jugular veins.
60. A nursing student is assigned to Lucia, who is one of your patients and she is doing a physical assessment. You will need
to intervene IMMEDIATELY if the nursing student:
a. Palpate both carotid arteries simultaneously to compare pulse quality
b. Uses the palm of the hand to assess extremity skin temperature
c. Places Lucia in the left lateral position to check for PMI
d. Presses on the skin over the tibia for 10 seconds to check for edema
SITUATION 13- Nurse Daisy has three discharged client during this early part of the PM shift. The senior nurse assigned her
to take charge of any admission during the shift. A lethargic female client came in for thyroid work-up.
61. As prescribed by the attending physician the nurse instructed the client to undergo radioactive iodine uptake test the
following morning. The client asks to be educated on the test. Nurse Daisy would explain that the purpose of the test is to:
a. Demonstrate the extent of damage compression rendered by the nodule to the trachea
b. Detect if the thyroid noddle is malignant or benign
c. Determine the functional activity of the thyroid gland and differentiate pituitary from thyroid function
d. Measure the ability of the thyroid gland to remove and concentrate iodine from the blood
62. Before the radioactive iodine uptake test the nurse should verify which of the following would affect the result of the
test?
a. Over the counter drug intake B. Sleeping habits C. Height and weight d. Food preference
63. The doctor prescribed levothyroxine sodium 0.15mg per orem daily after the diagnosis of hypothyroidism was confirmed.
Nurse Daisy administer the medication at which time to obtain the drug optimum therapeutic level?
a. In the morning before breakfast c. At various times of the day
b. At the patient’s most convenient time d. Before bedtime
64. Nurse Daisy included in her health instruction about foods that inhibit thyroid secretions. Identify these fruits/vegetables.
1. Spinach 2. Cauliflower 3. Squash 4. Radish 5. Strawberries 6. Guavas
a. All except 3 and 6 b. All of these c. All except 2 and 4 d. All except 1 and 5
65. Nurse Daisy would include in her discharge plan for the client and significant others the regular intake of which product
that would insure iodine intake?
a. Lugol’s solution b. Seafood c. Warm salt solution gargle d. Iodized salt
SITUATION 14- Maricar, a staff nurse assigned in the medical ward reports during morning shift. All the clients assigned to
Maricar have ongoing intravenous therapy. To ensure safe and quality nursing care, Maricar implements policies, procedures
and guidelines set by the hospital regarding intravenous therapy.
66. At 1000H the attending physician prescribed for a client who is on her 2 nd day post hemicolectomy, “Dextrose in water
1000ml with 20mEq potassium chloride to run for 8 hours. “If the intravenous therapy was started at 1100H, how many ml
of intravenous solution will Maricar anticipate to have been infused when she hands off her client to the incoming shift nurse
at 1400H.?
a. 375 ml b. 350 ml c. 300 ml d. 320 ml
67. After incorporating 20 mEq potassium chloride into Dextrose 5% water 1000 ml bag, the nurse AVOIDS doing which of
the following nursing interventions?
a. Shake the IV bag c. With a pen maker, label the IV bag with the
b. Place calibration label on the IV bag incorporated drug
d. Check for color changes in the IV bag
68. When Maricar checked on the intravenous infusion of one of her clients, she noted a label attached to the intravenous
tubing with the date 6/23/12. She understands that the intravenous set will be changed on:
a. 6/25/12 b. 6/24/12 c. 6/27/12 d. 6/26/12
69. The client with ongoing intravenous infusion of Dextrose 5% lactated ringer’s solution rings the call bell and when the
nurse approached her, she pointed to her intravenous (IV) site. When the nurse assessed the IV site she noted that phlebitis
has developed. The nurse does the following nursing interventions EXCEPT:
a. Restart an IV line in a proximal portion of the c. Applies colds mist compress over the IV site
same arm d. Elevate the affected arm on a pillow
b. Reinstruct the clients what not to do while with IV
infusion
70. An elderly client with ongoing IV infusion of dextrose 5% in NaCl 0.9% 1000 ml hung at 1545H was assessed to be
slightly dyspneic, chilling and with increased pulse rate. The IV bag has 400 ml remaining and it was 1630H. The nurse
should take which IMMEDIATE nursing action?
a. Refer to the attending physician STAT c. Slow down the IV infusion
b. Remove the IV cannula d. Put the client in a sitting position
SITUATION 15- Andrew, a 12 year old boy with TYPE I diabetes mellitus, is admitted in the medical ward from the intensive
care unit after having recovered from an episode of diabetic ketoacidosis. Andrew has been diagnosed since he was 6 years
old. History showed that during the past 2 months, Andrew missed some of his insulin injections as he got himself engrossed
playing tennis.
71. The admitting nurse noted that Andrew is under weight and short of stature. The nurse consider which of the following
reasons BEST explain Andrew’s retarded growth?
a. Large amount of protein and fat are used for energy c. Increased breakdown of fats for cell utilization
 b. Occurrence of electrolyte imbalance leading to dehydration d. Inability to use glucose as a source of energy
72. When the nurse plans for Andrews insulin injection sites, which of the following sites will the nurse NOT include in her
plan?
a. Upper outer part of dominant arm d. Abdominal subcutaneous tissue just below the
b. Outer part of the thighs waist
c. Four inches above the knee of both thighs
73. To ensure that an injection site will not be repeated when nurses administer insulin on Andrew, which of the following
nurse’s action would be MOST effective?
a. Have nurses record in the child’s chart the injection site
b. Every shift, verbally endorse to the receiving nurse the injection site
c. Instruct the patient to tell the nurse, the site used during the previous injection
d. Mark with a ball pen the injection site previously used
74. In the teaching plan being prepared by the nurse for Andrew, which of the following strategies would be most relevant
for Andrew to avoid overuse of an injection site for insulin self-administration?
a. On a teaching doll, injection sites are marked with green colored pins. After injection, the pins are replaced with red
colored pins to indicate site has been used
b. A chart is prepared illustrating body parts where injection site are determined for a month. After injection sites is marked
with date and time of injection
c. On a record book, injection sites are enumerated daily for one month. Every after injection, date and time are recorded
across the used injection site
d. “Paper doll” is constructed. Injection sites are determined for a week. Injection sites are marked on the paper doll. Site is
crossed out
75. Which of the following statements of Andrew will the nurse consider as an indication that Andrew is ready to self-
administer his insulin?
a. Will you allow me to do it now? c. When I go home I will do it myself
b. Let me hold the syringe for you d. Are you sure I can do it myself?

SITUATION 16- The medical and surgical unit where you work just hired 3 nurses to augment the present nursing human
resources. The following questions apply
76. You are assigned one new nurse to work with during the shift. An admission from the post anesthesia care unit (PACU)
of a post thoracotomy with wedge resection with a chest tube came in and you assigned the nurse to do initial assessment.
Which assessment if observed will you report to the surgeon right away?
a. 80 ml of dark red output from the drainage bottle d. The drainage system is hanged at the bed side
b. Intermitted bubbling in the suction control below the client’s chest
c. Intact and dry dressings
77. You put the client in fowler’s position and explained the rationale before the client and significant others the benefit of
this position. If you were the nurse, which would be the BEST reason for the fowler’s position?
a. Relaxes the sternal muscles and enhances breathing c. Reduces pressure on the diaphragm and permits
optimal lung expansion
b. Promotes deep breathing and reduces pain during inspiration d. Increases pressure on the diaphragm and allows
expulsion of secretion
78. The new nurse reads the doctor’s order, “Maintain patent chest tube and drainage and close drainage. “Milk tubing prn”.
The APPROPRIATE action of the nurse is to:
a. Pinch the tubing alternately towards the drainage c. Milk feeding
chamber if there is visible fibrin or clots d. Empty the drainage tube prn
b. Clamp the tubing every time the client coughs
79. The new nurse encouraged the client to assume a comfortable position while maintaining body alignment despite the
presence of the drainage system. While the patient was looking for a more comfortable position, the tubing was accidentally
disconnected. The INITIAL and APPROPRIATE action of the nurse is to:
a. Clamp the tubing site c. Pull out the tubing and apply an air tight dressing to
b. Place the open end of the tubing in a sterile water the site
d. Immediately reconnect the tube
80. The senior nurse was emphasizing to the new nurse that intermittent bubbling of the water seal chamber is normal but
should continuous bubbling be observed this can indicate:
a. Presence of leak c. No more air is leaking into the pleural cavity
b. That pressure is equal to the water seal d. Negative pressure in the mediastinal cavity
SITUATION 17- Nurse Linda is assigned to the pediatric surgical unit to take care of JV and Billy.
81. JV, 18 months, was admitted for repair of hypospadias. During assessment, which of the following will Linda expect to
observe?
a. Absence of urethral meatus c. Defect of the urethra on the dorsal surface of the penis
b. Termination of urethra is in the ventral surface of the shaft
penis d. Penis has 2 urethral opening located dorsally and
ventrally
82. Surgery is the treatment of choice for JV. The nurse understands that the best time for surgery is before the child:
a. Is weaned from diapers b. Is toilet training c. Goes to school d. Walks
83. Linda prepares a nursing care plan for JV. Postoperatively, which of the following is a PRIORITY nursing diagnosis?
a. Risk of infection c. Potential malnutrition
b. Alteration of fecal elimination d. Altered body image
84. Billy, 1 year old, was admitted to the unit from the recovery room post cheiloplasty. Linda would place Billy in which of
the following positions?
a. Lateral b. Fowler’s c. Supine d. Prone
85. When Billy fully recovered from anesthesia the doctor ordered clear liquids as tolerated. Which of the following is the
APPROPRIATE action of the nurse?
a. Allow infant to sip from a cup b. Use spoon and feed slowly and gently
 c. Administer liquids through a medicine dropper d. Bottle feed the infant
SITUATION- 18- Nurse Carmina is preparing Ike a 28 year old newly-wed for surgery for a repair of multiple trauma from a
car accident. Ike is in severe pain and comforted by his wife and significant others.
86. There exist a hierarchy who should sign the consent to be legally valid if the client is not competent. Rank the following
next-of-kin who shall sign the consent for Ike’s surgery.
1. Grandparents from paternal or maternal side 4. Legitimate spouse
2. Adult competent children 3. Brother or Sister 5. Guardian whether appointed by court or not
a. 4,5,3,2 and 1 b. 4,3,1,2 and 5 c. 4,2,1,3 and 5 d. 5,3,4,2 and 1
87. Legally, nurse Carmina shall assume which role during the signing of the consent?
a. Advocate b. Witness c. Interpreter d. Counselor
88. Ike underwent exploratory Laparotomy for multiple organ injuries in his abdomen. Which doctrine is applied when the
surgeon is held when there is an incorrect surgical count?
a. Res Ipsa liquitor c. Doctrine of viracious liability
b. Captain of the ship d. Doctrine of independent contractor
89. During the surgery, the client was profusely bleeding that prompted the surgeon to verbally order “transfuse all available
blood”. Which of the following options would the nurse take so that she will not be held liable if blood transfusion
complication occurs?
a. Document as ordered and have the surgeon sign as soon as feasible
b. Transfuse the blood with the anesthesiologist
c. Send the blood for proper cross-matching and transfuse immediately after
d. Leave the anesthesiologist to follow the order
90. The surgeon is such in a hurry to “close” because of the deteriorating condition of the client. The perioperative nurses
cannot account for an operating sponge (OS). Which is the MOST appropriate action of the scrub nurse at this point?
a. Hands the suture for closing and tell the surgeon that one OS cannot be accounted for.
b. The scrub nurse asks the circulating nurse to recheck the sponges one more time
c. The scrub nurse informs the surgeon that one OS cannot be accounted for
d. Obligingly, the scrub nurse hands the suture for close and continue to locate the missing OS
SITUATION 19- Nurse Alpha is caring for Edwin, 40 year old 3 rd day post bowel resection, NPO with D5 LR IV 1000 ml at 125
ml/hr. Laboratory findings show a hemoglobin level of 8 g/dl and hematocrit of 30%.
91. During the physician’s rounds, Dr. Grande made the following orders:
-Gentamycin 80mg IV piggy back in 50 ml D5 water over 30 minutes -Ranitidine 50mg IV in 50 ml D5 water piggy back in
30minutes
- Packed Red blood cells (RBC) 250 ml to run for 3 hours
How many milliliters should Nurse Alpha document as the total intake for the 8 hours shift?
a. 1000 ml b. 350 ml c. 1350 ml d. 1300 ml
92. While reading Edwin’s chart, you are read the laboratory findings as:
-serum potassium 2.2h mEq/L -Sodium 129 mEq/L -Calcium 7.5 mg/L
The nurse would anticipate / prepare which of the following IV solutions to be prescribed?
a. Sodium chloride 0.45% c. Dextrose 5% in lactated ringers solution
b. Dextrose 5% in water d. Normosol
93. Nurse Alpha continued to monitor Edwin who has an ongoing IV and Packed red blood cells (PRBC) transfusion. The
client complains of headache, back ache and the temperature began to spike. Rank the action of the nurse according to
PRIORITY:
1. Refer to the attending physician 4. Keep the vein open with NSS
2. Assess the client 5. Document observation and intervention
3. Close the roller clamp of the PRBC
a. 2,3,4,1 and 5 b. 3,2,1,4 and 5 c. 3,4,2,1 and 5 d. 1,2,34 and 5
94. Nurse Alpha identifies risk for wound complications. In case of wound evisceration, the IMMEDIATE action of the nurse is
to:
a. Instruct the client to stay quiet in bed as you call for help c. Cover the wound with sterile gauze wet with sterile NSS
b. Apply clean abdominal binder and place the pillow on top d. Call for the surgeon stat
of the wound
95. Edwin has been on NPO since he was operated and asks the nurse when he can have food. Nurse Alpha’s most
APPROPRIATE response is:
a. The dietitian will make their rounds in a while to assess you and other postoperative clients
b. The surgeon will make their rounds to assess your readiness to take in your preferred diet
c. Clear soup will be served as soon as you have bowel sounds
d. You can have sips of water for the mean time
SITUATION 20- Susan, 40 years old and weighs 180lbs, underwent cholecystectomy for cholelitheasis and gall stones.
96. Susan complained of incisional wound pain as soon as she recovered from anesthesia. She has an order of Demerol 75
mg every four hours round the clock for pain. The nurse’s CORRECT intervention is:
a. Inject Demerol 75 mg as ordered for pain c. Offer the client some hot tea and crackers
b. Instruct the client to apply pressure over the operative d. Encourage Susan to do deep breathing
site
97. Because of the fear of wound gaping and pain. Susan was observed suppressing her cough reflex. The MOST appropriate
nursing intervention to minimize pain in every coughing episode is to:
a. Splint the operative site with wide plaster c. Give sedation round the clock to minimize coughing and pain
b. Advise the client to turn to side every 30 minutes d. Instruct the client to splint the incision wound with pillow
98. Which psychological nursing intervention can you offer to minimize postoperative pain?
a. Stay with the client and offer to comb her hair and put some make-up in front of the mirror
b. Allow client to converse with other clients regarding their experience in coping post-operative pain
c. Instruct client and significant others to avoid talking about pain within hearing distance of the client
d. Restrict visitors that can aggravate noise and destruction of rest.
99. One cause of post-operative pain is incision wound contamination. Hence, nurses and other members of the health team
are expected to do cheap and effective infection prevention measures such as:
a. No touch technique c. Hand washing between client
b. Change gloves in between patient d. Use alcohol swab if hand washing is not permissible
100. Post-operative pain keeps surgical clients in bed. Most surgical client’s like Susan are encouraged to ambulate:
a. As soon as indicated c. Between 10 and 12 hours after surgery
b. Within 6 to 8 hours after surgery d. On the second postoperative day