Page 1 of 16
 Nurse Suzie is administering 12:000PM medication in
Ward 4. Two patients have to receive Lanoxin. What
should Nurse Suzie do when one of the clients does
NOT have a readable identification band?
o Ask the client his name
 Wilfred, 30 years old male, was brought to the
hospital due to the hospital dues to injuries
sustained from a vehicular accident. While being
transported to the X-ray department, the straps
accidentally broke and the client fell to the floor
hitting his head. In this situation, the nurse is:
o Liable along with the employer for the use
of a defective equipment that harms the
client
 While going on evening round, Nurse Edna saw Mrs.
Pascual meditating and afterwards started singing
prayerful hymns. What is the BEST response of
Edna?
o Respect the client’s actions as this provides
structure and support the client
 Which of the following situations would possibly
cause a nurse to be sued due to negligence?
o Nurse gave a client wrong medication and
an hour later, client complained of
dyspnea
 The nurse is in the hospital canteen and hears two
staff nurses talking about the client confined in room
612. They mentioned his name and discussed details
of his condition. Which of the following actions
should the nurse take?
o Approach the two nurses and tell them
that their actions are inappropriate
especially in a public place.
 When the nurse breaches the duty of confidentiality,
he or she can be disciplined by both employer and
the Board of Nursing. In addition to this discipline,
he or she can:
o Be held responsible or any damages that
result
 Which of the following best describes acquaintance
rape?
o Sexual intercourse committed with force
or with the threat of force without a
person’s consent
 You are the nurse in an Adult Care Unit. You over-
hear one of your co-staff nurse assigned to Aling
Josie who is 78 years old say, that if she refuses to
take her medications she will not be given her
favorite dessert. You report your co-staff’s behavior
as:
o Assault
 When a nurse volunteers to work in a hospital
setting and she commits a mistake, who is legally
responsible?
o Volunteer nurse, hospital and the nurse in
charge
 As a nurse, you accidentally administer 40 mg of
propranolol (Inderal) to a client instead of 10 mg.
although client exhibits no adverse reactions to the
larger dose. You should:
o Complete an incident report
 Baby Liza, 3 months old, with a congenital heart
deformity, has an order from her physician: “Give
3.00 cc of Lanoxin today for one dose only”. Which
of the following is the most appropriate action by
the nurse?
o Clarify the order with the attending
physician
 Which of the following nursing intervention should
be given the highest priority when receiving a client
in the OR?
o Verify the identification and informed
consent
 Situation – In the OR, there are safety protocols that
should be followed. The OR nurse should be well
versed with all these to safeguard the safety and
quality of patient delivery outcome.
 Which of the following should be given highest
priority when receiving patient in the OR?
o Verify patient identification and informed
consent
 Surgeries like I and D (incision and drainage) and
debridement are relatively short procedures but
considered ‘dirty cases.’ When are these procedures
best scheduled?
o Last case
 OR nurses should be aware that maintaining the
client’s safety is the overall goal of nursing care
during the intraoperative phase. As the circulating
nurse, you make certain that throughout the
procedure…
o strap made of strong non-abrasive
material are fastened securely around the
joints of the knees and ankles and around
the 2 hands around an arm board
 Another nursing check that should not be missed
before the induction of general anesthesia is:
o check baseline vital signs
 Some lifetime habits and hobbies affect
postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past 10
years, you will anticipate increased risk for:
o postoperative respiratory function
 Situation – One of the realities that we are
confronted with is our mortality. It is important for
us nurses to be aware of how we view suffering,
pain, illness, and even our death as well as its
meaning. That way we can help our patients cope
with death and dying.
 Irma is terminally ill, she speaks to you in
confidence. You now feel that Irma’s family could be
helpful if they knew what Irma has told you. What
should you do first?
 Obtain Irma’s permission to share the information
with the family
 Ruby who has been told she has terminal cancer,
turns away and refuses to respond to you. You can
best help her by:
 Coming back periodically and indicating your
availability if she would like you to sit with her
 Page 2 of 16
 Leo, who is terminally ill and recognizes that he is in
the process of losing everything and everybody he
loves, is depressed. Which of the following would
best help him during his depression?
o Sit down and talk with him for a while
 Situation: The nurse supervisor is observing the staff
nurses in her hospital to see how quality of care
provided for client can be improved.
 The nurse supervisor is not satisfied with the bed
bath that is provided by Nurse Arthur. To improve
the care provided to the patients in the unit by
Nurse Arthur, the nurse supervisor should:
o Bring the staff nurse to a client’s room and
demonstrate a cleansing bath
 The staff nurse discusses with the novice nurse the
type of wound dressing that is best to use for a
client. Together, they observe how well the
dressings absorb the drainage. In what step of the
decision making process are they?
o Testing options
 To check if the nurses under her supervision use
critical thinking, Mrs. David observes if the nurses
act responsibly when at work. Which of the
following actions of a nurse demonstrates the
attitude of responsibility?
o Following standards of practice
 The nurse who makes clinical judgment can be
dependent upon to improve the quality of care
clients. Nurse Julie uses such good clinical judgment
when she gives priority care to this client:
o A post-operative client, Rey, who has a
blood pressure of 90/50 mmHg
 A good nursing care plan is dependent on a correctly
written nursing diagnosis. It defines a client’s
problem and its possible cause. The following is an
example of a well written nursing diagnosis:
o Electrolyte imbalance related
hypocalcemia
 Situation - The practice of nursing goes with
responsibilities and accountability whether you work
in a hospital or in the community setting your main
objective is to provide safe nursing to your clients?
 To provide safe quality nursing care to various clients
in any setting, the most important tool of the nurse
is:
o Critical thinking to decide appropriate
nursing actions
 You ensure the appropriateness and safety of your
nursing interventions while caring for various client
groups by:
o Using standards of nursing care as your
criteria for evaluation
 The effectiveness of your nursing care plan for your
clients is determined by
o the outcome of nursing interventions
based on plan care
 You are assigned to Mrs. Amado, age 49, who was
admitted for possible surgery. She complained of
recurrent pain at the upper right quadrant of the
abdomen 1-2 hours after ingestion of fatty food. She
also had frequent bouts of dizziness, blood pressure
of 170/100, hot flashes. Which of the above
symptoms would be an objective cue?
o Blood pressure measurement of 170/100
 While talking with Mrs. Amado, it is most important
for the nurse to:
o Do an assessment of the client to
determine priority needs
 Situation – Errors while providing nursing care to
patients must be avoided and minimized at all times.
Effective management of available resources enables
the nurse to provide safe quality patient care.
 In a hospital were you work, increased incident of
medication error was identified as the number one
problem in the unit. During the brain storming
session of the nursing service department, probable
causes were identified. Which of the following is
process related?
o failure to identify client
 Miscommunication of drug orders was identified as a
probable cause of medication error. Which of the
following is a safe medication practice related to
this?
o Only officially approved abbreviations may
be used in the prescription orders
 The hospital has an ongoing quality assurance
program. Which of the following indicates
implementation of process standards?
o The nurses check client’s identification
band before giving medications
 Which of the following actions indicate that Nurse
Jerome is performing outcome evaluation of quality
care?
o Interviews nurses for comments regarding
staffing
 An order for a client was given and the nurse in
charge of the client reports that she has no
experience of doing the procedure before. Which of
the following is the most appropriate action of the
nurse supervisor?
o Assign another nurse to perform the
procedure
 Nursing audit aims to:
o Compare actual nursing done to
established standards
 In Community Health Nursing, despite the
availability and use of many equipment and devices
to facilitate the job of the community health nurse,
the best tool any nurse should well be prepared to
apply is a scientific approach. This approach ensures
quality of care even at the community setting. This in
nursing parlance is nothing less than the:
o nursing process
 Evidence-based care started in medicine as a way to:
o Integrate individual experience with
clinical research
 Page 3 of 16
 Situation - The psychiatric mental health nurse
adheres to standards that ensure quality
improvement. The following situations and
behaviors are means to achieve this goal.
 This is a process wherein the client’s chart is
reviewed to compare criteria for quality care with
actual practice
o Psychiatric audit
 In order to assess “Reliability” as a behavioral
characteristic, the nurse would ask herself which of
the following questions regarding her recording:
o Did the history of the present problem
correlate with the review of growth and
development
 All of these are advantages of peer review EXCEPT:
o It requires the development of standards
for quality care
 The nursing team leader wants to involve all the
nurses in participating in their own personal and
professional growth through a brainstorming
session. One of the most important ground rules is:
o Follow the problem solving approach
 “Did the nurse perform in the best possible manner
without waste?” aims to describe the nurse’s:
 ANS: efficiency
 You are the nurse manager of the Medical Unit.
Which of the following is a priority for you to
consider when planning for the care of group of
clients utilizing evidence-based practice?
ANS: Clients’ needs are assessed
and individualized care plan are
developed for each client
 Situation - The purpose of the nursing care plan is to
identify the care for an individual patient based on
his problem should be included if it is known. The
nurse writes a nursing care plan for a patient based
on nursing care standards.
 Given the example of a problem: “Anxiety due to a
job interview”. Then “due to” or the reason for the
problem should be included if it is known. The initial
step in identifying problem is:
 ANS: Gather the data about the
patient
 Given the example of an expected outcome: “Openly
verbalize anxiety about job interview. Identify how
he can prepare for the job interview. “Which of
these is not a criterion of expected outcomes?
o ANS: An expected outcome is stated in
terms of what the nurse will do
 The following are reasons for setting deadlines
within which to achieve outcomes of care EXCEPT:
 ANS: Does not allow plans to be
changed
 Which of these is not a relevant nursing order?
 ANS: Discuss with a patient with
specific means he might prepare
for the job interview
 Which of these practices on evaluation support
nursing care? Review of care plan is:
o A nursing team responsibility
 Situation – Your director of nursing wants to
improve the quality of health care offered in the
hospital. As a staff nurse in that hospital you know
that this entails quality assurance programs.
 The following mechanisms can be utilized as part of
the quality assurance program of your hospital
EXCEPT:
 ANS: Use of the Nursing
Interventions Classification
 The use of the Standards of Nursing Practice is
important in the hospital. Which of the following
statements best describes what it is?
 ANS: The Standards of care
includes the various steps of the
nursing process and the standards
of professional performance
 You are taking care of critically ill client and the
doctor in charge calls to order a DNR (do-not-
resuscitate) for the client. Which of the following is
the appropriate action when getting DNR order over
the phone?
o Have 2 nurses validate the phone order,
both nurses sign the order and the doctor
should sign his order within 24 hours
 To ensure client safety before starting blood
transfusion the following are needed before the
procedure can be done EXCEPT:
o blood should be warmed to room
temperature for 30 minutes before blood
transfusion is administered
 Part of standards of care has to do with the use of
restraints. Which of the following statements is NOT
true?
o Check client’s pulse, blood pressure and
circulation every 4 hours
 Situation – Joint Commission on Accreditation of
Hospital Organization (JCAHO) patient safety goals
and requirements include the care and efficient use
of technology in the OR and elsewhere in the
healthcare facility.
 As the head nurse in the OR, how can you improve
the effectiveness of clinical alarm systems?
o Implement a regular maintenance and
testing of alarm systems
 Overdosage of medication or anesthetic can happen
even with the aid of technology like infusion pumps,
sphygmomanometer, and similar devices/machines.
As a staff, how can you improve the safety of using
infusion pumps?
o Check the functionality of the pump before
use
 JCAHOs universal protocol for surgical and invasive
procedures to prevent wrong site, wrong person,
and wrong procedure/surgery includes the following
EXCEPT:
o Take a video of the entire intra-operative
procedure
 You identified a potential risk of pre and
postoperative clients. To reduce the risk of patient
harm resulting from fall, you can implement the
following, EXCEPT:
o Allow client to walk with relative to the OR
 Page 4 of 16
 As a nurse, you know you can improve on accuracy
the of patient’s identification by 2 patient identifiers,
EXCEPT:
o call the client by his/her case and bed
number
 Which of the following statements would best
indicate that Ruffy, who is dying, has accepted his
impending death?
o “I’m ready to go.”
 Marla, 90 years old has planned ahead for her death-
philosophically, socially, financially, and emotionally.
This is recognized as:
 Acceptance that death is inevitable
 Situation – You are now working as a staff nurse in a
general hospital. You have to be prepared to handle
situations with ethico-legal and moral implications.
 You are on night duty in the surgical ward. One of
your patients Martin is a prisoner who sustained an
abdominal gunshot wound. He is being guarded by
policemen from the local police unit. During your
rounds you heard a commotion. You saw the
policeman trying to hit Martin. You asked why he
was trying to hurt Martin. He denied the matter.
Which among the following activities will you do
first?
 Make an incident report
 You are on morning duty in the medical ward. You
have 10 patients assigned to you. During your
endorsement rounds, you found out that one of your
patients was not in bed. The patient next to him
informed you that he went home without notifying
the nurses. Which among the following will you do
first?
 Make an incident report
 You are on duty in the medical ward. You were asked
to check the narcotics cabinet. You found out that
what is on record does not tally with the drugs used.
Which among the following will you do first?
 Find out from the endorsement any patient who
might have been given narcotics
 You are on duty in the medical ward. The mother of
your patient who is also a nurse, came running to
the nurses’ station and informed you that Fiolo went
into cardiopulmonary arrest. Which among the
following will you do first?
 Go to see Fiolo and assess for airway patency and
breathing problems
 You are admitting Jorge to the ward and you found
out that he is positive for HIV. Which among the
following will you do first?
 Take note of it and plan to endorse this to next shift
 Situation - RN’s should always be conscious that the
contents in charting are admissible in court as
evidence.
 If there is any deviation from normal practice or
procedure e.g. streptomycin was given by IV not IM,
this should documented in the:
o Incident report
 Documentation of all nursing activities performed is
legally and professionally vital. Which of the
following should NOT be included in the patient’s
chart?
o Arguments between nurses and residents
regarding treatments
 During your morning rounds, Mr. Tipol, 60 year old
widower, tried to sit up and instead of holding to the
side rail held the IV stand causing the IV bottle to fall
and break. You wrote an incident report to show:
o Document the incident
 Erasures, alterations, and additions in medical
records and the nurse’s notes can be avoided. The
following are some tips on how to do corrections,
EXCEPT:
o State the reason for any deviation from
normal procedure/practice
 Kathy is one of the patient’s. Her uncle, who is a
doctor, wants to read her chart. Your appropriate
action would be:
o Instruct Kathy’s uncle to present a written
authorization signed by the patient
 Situation 11 – Mr. Jose’s chart is the permanent legal
recording of all information that relate to his health
care management. As such, the entries in the chart
must have accurate data.
 Mr. Jose’s chart contains all information about his
health care. The functions of records include on
following EXCEPT:
o Recording of actions in advance to save
time
 An advantage of automated or computerized client
care system is:
o Information concerning the client can be
easily updated
 Information in the patient’s chart is inadmissible in
court as evidence when:
o The handwriting is not legible
 A telephone order is given to for a client in your
ward. What is your most appropriate action?
o Repeat the order back to the physician,
copy onto the order sheet and indicate
that it is a telephone order
 Because of increase incidents of medication error
due to wrong transcription of physician medication
orders by nurses, a tertiary hospital utilized a
computerized medication order system. Which of
the following procedures may be done through the
said system?
o Provide a list of drugs with their generic
name
 Situation – Records contain those comprehensive
descriptions of patient’s health conditions and needs
and at the same serve as evidences of every nurse’s
accountability in the care giving process. Nursing
records normally differ from the institution to
institution nonetheless they follow similar patterns
of meeting needs for specific types of information.
The following pertains to documentation/records
management.
 This special form is used when the patient is
admitted to the unit. The nurse completes the
information in this record particularly his/her basic
 Page 5 of 16
personal data, current illness, previous health
history, health history of the family, emotional
profile, environmental history as well as physical
assessment together with nursing diagnosis on
admission. What do you call this record?
o Nursing Health History and Assessment
Worksheet
 These are sheets/forms which provide an efficient
and time saving way to record information that must
be obtained repeatedly at regular and/or short
intervals of time. This does not replace the progress
notes; instead this record of information on vital
signs, intake and output, treatment, postoperative
care, post partum care, and diabetic regimen, etc.
This is used whenever specific measurements or
observations are needed to be documented
repeatedly. What is this?
o Graphic Flow Sheets
 These records show all medications and treatment
provided on a repeated basis. What do you call this
record?
o Medicine and Treatment Record
 This flip-over card is usually kept in a portable file at
the Nurses Station. It has 2-parts: the activity and
treatment section and a nursing care plan section.
This carries information about basic demographic
data, primary medical diagnosis, current orders of
the physician to be carried out by the nurse, written
nursing care plan, nursing orders, scheduled tests
and procedures, safety precautions in patient care
and factors related to daily living activities. This
record is used in the change-of-shift reports or
during the bedside rounds or walking rounds. What
record is this?
o Nursing Kardex
 Most nurses regard this as conventional recording of
the date, time, and mode by which the patient
leaves a healthcare unit but this record includes
importantly, directs of planning for discharge that
starts soon after the person is admitted to a
healthcare institution. It is accepted that
collaboration or multidisciplinary involvement (of all
members of the health team) in discharge results in
comprehensive care. What do you call this?
o Discharge Summary
 Situation – Records are vital tools in any institution
and should be properly maintained for specific use
and time.
 The patient’s medical record can work as a double
edged sword. When can the medical record become
the doctor’s/nurse’s worst enemy?
o When the medical record is inaccurate,
incomplete, and inadequate
 Disposal of medical records in government
hospitals/institutions must be done in close
coordination with what agency?
o Records Management Archives Office
(RMAO)
 In the hospital, when you need the medical record of
a discharged patient for research, you will request
permission through:
o Medical records section
 You readmitted a client who was in another
department a month ago. Since you will need the
previous chart, from whom do you request the old
chart?
o Medical records section
 Records Management and Archives Offices of the
DOH is responsible for implementing its policies on
record disposal. You know that your institution is
covered by this policy if:
o It obtained permit to operate from DOH
 The nurse notes effectiveness of interventions in
using subjective and objective data in the:
 progress notes
 The following are SOAP (subjective – Objective –
Analysis – Plan) statements on a problem: Anxiety
about diagnosis. What is the objective data?
o Has periods of crying; frequently verbalizes
fear of what diagnostic tests will reveal
 Nursing care plans provide very meaningful data for
the patient profile and initial plan because the focus
is on the:
o Patient’s responses to health and illness as
a total person in interaction with the
environment
 The use of interpersonal decision making,
psychomotor skills, and application of knowledge
expected in a role of a licensed health care
professional in the context of public health welfare
and safety is an example of:
 ANS. Competence
 Which of these feedbacks from individual
participants indicate maximum gain from the staff
development program?
 ANS: I have a “Do it now” project
for myself. i.e., to approach my
clinical supervisor regularly to
discuss nursing care of our clients
 Registered nurses can be identified as a:
 ANS: Organization
 a strategy for change that focuses on teaching
workers new technology is:
 ANS: training
 Some strategies to maintain professional health are
listed below. Which is NOT necessarily correct?
 ANS: Read fiction and nonfiction
materials
 a means of facilitating professional staff
development is by building upon skills, abilities, and
experience of each practitioner is called:
o the novice to expert model
 Situation– You are a newly hired nurse in a tertiary
hospital. You have finished your orientation program
recently and you are beginning to assimilate the
culture of the profession.
 Page 6 of 16
 Using Benner’s stages of nursing expertise, you are a
beginning nurse practitioner. You will rank yourself
as a/an:
o Novice nurse
 Benner’s “Proficient” nurse level is different from
the other levels in nursing expertise in the context of
having:
o A holistic understanding and perception of
the client
 As you become socialized into the nursing “culture”
you become a patient advocate. Advocacy is
explained by the following EXCEPT:
o Demonstrating loyalty to the institution’s
rights
 Modern day nursing has led to the development of
the expanded role of the nurse as seen in the
function of a:
o Clinical nurse specialist
 You join a continuing education program to help
you:
o Update your knowledge and skills related
to field of interest
 Situation - The PRC regulates the practice of 42
professions in the Philippines.
 What is the basic requirement of the state for a
nurse to practice her profession?
o A nursing licensure
 The Code of Good Governance for the profession in
the Philippines shall be adapted by:
o All Filipino professionals
 The standardized guidelines and procedures for the
implementation of Continuing Professional
Education (CPE) for all professional. Resolution
Numbers 2004-179 provides that the total CPE credit
units for registered professionals with baccalaureate
degree should be:
o 60 credit units for 3 years
 The Board of Nursing is vested with power to issue,
suspend, or revoke for cause, the:
o Certificate of Registration
 RA 9173 stipulates the removal examination of the
nurse licensure examination shall be taken:
o Within the same year after the last failed
examination
 Situation - For personal and professional
development, the nursing staff decided to hold a
staff development program, “Self enhancement
through Assertiveness”.
 An appropriate assessment tool to maximize
gathering of needs of nurses is through:
o Survey
 A priority objective of the program is:
o Develop art and skills of therapeutic use of
self
 The most effective way to practice assertiveness
skills is through:
o role play
 The least satisfactory method to evaluate the
effectiveness of the program is through:
o Attendance
 situation - The supervising nurse received report that
a staff nurse is displaying frequent irritation, anger
and even indifference toward client and co-workers.
 The initial action of the supervisor would be to:
o Call the nurse for a one on one conference
 The nurse expressed increasing feelings of
dissatisfaction. The supervising nurse intervenes
therapeutically by taking on the role of:
o Counselor by actively listening
 Coupled with poor work performance, mental and
physical fatigue and actual withdrawal from client
contact and nursing duties, the nurse can be said to
be suffering from:
o Personality maladjustment
 A priority in the nurse’s personal development
program would be to:
o Help her find value and meaning in her
work
 The most relevant professional program for her
would be:
o Behavior modification
 Situation – The staff nurse supervisor requests all
the staff nurses to “brainstorm” and learn ways to
instruct diabetic clients on self-administration of
insulin. She wants to ensure that there are nurses
available daily to do health education classes.
 The plan of the nurse supervisor is an example of
o primary prevention
 When Mrs. Guerrero, a nurse, delegates aspects of
the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guerrero
o is assigning the responsibility to the aide
but not the accountability for those tasks
 Kokey, the new nurse, appears tired and sluggish
and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor
should
o empathize with the nurse and listen to her
 Process of formal negotiations of working conditions
between a group registered nurses and employer is
o collective bargaining
 You are attending a certification program on
cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
o inservice education
 Situation – Management of nurse practitioners is
done by qualified nursing leaders who have had
clinical experience and management experience.
 An example of a management function of a nurse is:
o Directing and evaluating the staff nurses
 Your head nurse in the unit believes that the staff
nurses are not capable of decision making so she
 Page 7 of 16
makes the decisions for everyone without consulting
anybody. This type of leadership is:
o Autocratic leadership
 When the head nurse in your ward plots and
approves your work schedules and directs your
work, she is demonstrating:
o Authority
 The following tasks can be safely delegated by a
nurse to a non-nurse health worker EXCEPT:
o Change IV infusions
 You made a mistake in giving the medicine to the
wrong client. You notify the client’s doctor and write
an incident report. You are demonstrating:
o Accountability
 Situation – As the CPE is applicable for all
professional nurse, the professional growth and
development of Nurses with specialties shall be
addressed by a Specialty Certification Council. The
following questions apply to these special groups of
nurses.
 Which of the following serves as the legal basis and
statute authority for the Board of Nursing to
promulgate measures to effect the creation of a
Specialty Certification Council and promulgate
professional development programs for this group of
nurse-professionals?
o R.A. 7164
 By force of law, therefore, the PRC-Board of Nursing
release Resolution No. 14 Series of 1999 entitled:
“Adoption of a Nursing Specialty Certification
Program and Creation of Nursing Specialty
Certification Council.” This rule-making power is
called:
o Quasi-Legislative Power
 Under the PRC-Board of Nursing Resolution
promulgating the adoption of a Nursing Specialty
Certification Program and Council, which two (2) of
the following serves as the strongest justification for
its enforcement?
 Advances made in science and
technology have provided the
climate for specialization in almost
all aspects of human endeavor;
and
 As necessary consequence, there
has emerged a new concept known
as globalization which seeks to
remove barriers in trade, industry
and services imposed by the
national laws of countries all over
the world; and
 Awareness of this development
should impel the nursing sector to
prepare our people in the services
sector to meet the above
challenge; and
 Current trends of specialization in
nursing practice recognized by the
International Council of Nurses
(ICN) of which the Philippines is a
member for the benefit of the
Filipino in terms of deepening and
refining nursing practice and
enhancing the quality of nursing
care.
 ANS: a & d are strong justifications
 Which of the following IS NOT a correct statement as
regards Specialty Certification?
o The Board of Nursing intended to create
the Nursing Specialty Certification Program
as a means of perpetuating the creation of
an elite force of Filipino Nurse
Professionals.
 The NSCC was created for the purpose of
implementing the Nursing Specialty policy under the
direct supervision and stewardship of the Board of
Nursing. Who shall comprise the NSCC?
o A Chairperson, chosen from among the
Regulatory Board Members; a Vice
Chairperson appointed by the BON at
large; two other members also chosen at-
large; and one representing the consumer
group;
 Situation – As a Nurse, you have specific
responsibilities as professional. You have to
demonstrate specific competencies.
 The essential components of professional nursing
practice are all the following EXCEPT:
 Culture
 You are assigned to care for four (4) patients. Which
of the following patients should you give first
priority?
 Emy, who was previously lucid but is now
unarousable
 Brenda, the Nursing Supervisor of the intensive care
unit (ICU) is not on duty when a staff nurse
committed a serious medication error. Which
statement accurately reflects the accountability of
the nursing supervisor?
 Brenda should be informed when she goes back on
duty
 Which barrier should you avoid, to manage your
time wisely?
 Procrastination
 You are caring for Vincent who has just been
transferred to the private room. He is anxious
because he fears he won’t be monitored as closely
as he was in the Coronary Care Unit. How can you
allay his fear?
 Assign the same nurse to him when possible
 Situation 18 – There are various developments in
health education that the nurse should know about:
 The provision of health information in the rural areas
nationwide through television and radio programs
and video conferencing is referred to as:
o Telehealth program
 A nearby community provides blood pressure
screening, height and weight measurement, smoking
cessation classes and aerobics class services. This
type of program is referred to as
o outreach program
 Page 8 of 16
 Part of teaching client in health promotion is
responsibility for one’s health. When Ciara states she
needs to improve her nutritional status this means:
o Client will decide the goals and
interventions required to meet her goals
 Nurse Eunice is providing tertiary prevention to Mrs.
Vento. An example of tertiary prevention is
o Identifying complication of diabetes
 Mrs. Olivia has schedule for Pap Smear. She has a
strong family history of cervical cancer. This is an
example of
o secondary prevention
 Situation – Ensuring safety is one of your most
important responsibilities. You will need to provide
instructions and information to your clients to
prevent complications.
 Randy has chest tubes attached to a pleural drainage
system. When caring for him you should:
 change the dressing daily using aseptic techniques
 Fanny, came in from PACU after pelvic surgery. As
Fanny’s nurse you know that the sign that would be
indicative of a developing thrombophlebitis would
be:
 a tender, painful area on the leg
 To prevent recurrent attacks on Terry who has acute
glomerulonephritis, you should instruct her to:
 seek early treatment for respiratory infections
 Herbert had a laryngectomy and he is now for
discharge. He verbalized his concern regarding his
laryngectomy tube being dislodged. What should
you teach him first?
 Notify the physician at once
 When caring for Larry after an exploratory chest
surgery and pneumonectomy, your priority would be
to maintain:
 ventilation exchange
 Situation - As a perioperative nurse, you are aware
of the correct processing methods for preparing
instruments and other devices for patient use to
prevent infection.
 Items that enter sterile tissue or vascular system are
categorized as critical items and should be:
o Sterilized
 As an OR nurse, what are your foremost
considerations for selecting chemical agents for
disinfection?
o Material compatibility and efficiency
 Before you use a disinfected instrument, it is
essential that you:
o Wrap the instrument with sterile towel
 You have a critical heat labile instrument to sterilize
and are considering to use a high level disinfectant.
What should you do?
o Prolong the exposure time according to
manufaturer’s direction
 As a nurse, you know that the intact skin acts as an
effective barrier to most microorganisms. Therefore,
items that come in contact with the intact skin
should be:
o Disinfected
 Situation 6- The OR is divided into three zones to
control traffic flow and contamination.
 What OR attires are worn in the restricted area?
o Head cap, scrub suit, mask, OR shoes
 Which of the following nursing intervention should
be given the highest priority when receiving a client
in the OR?
o Verify the identification and informed
consent
 Conversation while in the operation is ongoing is
minimized because:
o It enhances the spread of microorganism
to the incision site
 Spaulding categorized instruments according to use.
Where do you classify endoscopic instrument?
o High level disinfected instruments
 In the OR, “Surgical Conscience” means:
o Honest adherence to surgical aseptic
techniques all the time
 Medical gases are used a lot in the OR. Some gases
are used to operate equipment and some are used
to administer genral anesthesia through inhalation.
What is the identifying color of the tank which
contains “laughing gals”?
o Blue
 On a traffic light, yellow means “proceed with
caution”. In the field of healthcare, where do you
discard your used tissue papers?
o Green bin
 An instrument tray with black striped
autoclave/steam chemical indicator tape
communicates that the instrument tray.
o Is sterile
 During a meal, a client with hepatitis B dislodges her
IV line and bleeds on the surface of the over-the-bed
table. It would be most appropriate for the nurse to
instruct a housekeeper to clean the table with:
o bleach
 Situation – In the hospital, you aware that we are
helped by the use of a variety of equipment/devices
to enhance quality patient care delivery.
 You are to initiate an IV line to your patient, Ken, 5,
who is febrile. What IV administration set will you
prepare?
o Microset
 Ken is diagnosed to have measles. What will your
protective personal attire include?
o . Face mask
 What will you do to ensure that Ken, who is febrile,
will have a liberal oral fluid intake?
o Provide a calibrated pitcher of drinking
water and juice at the bedside and monitor
 Page 9 of 16
 Before bedtime, you went to ensure Ken’s safety in
bed. You will do which of the following:
o Put the side rails up
 Ken’s room is fully mechanized. What do you teach
the watcher and Ken to alert the nurses for help?
o C. Call system
 Situation – Infection can cause debilitating
consequences when host resistance is compromised
and virulence of microorganisms and environmental
factors are favorable. Infection control is one
important responsibility of the nurse to ensure
quality of care.
 Honrad, who has been complaining of anorexia and
feeling tired, develops jaundice. After a workup he is
diagnosed of having Hepatitis A. His wife asks you
about gamma globulin for herself and her household
help. Your most appropriate response would be:
 “You should contact your physician immediately
about getting gammaglobulin.”
 Voltaire develops a nosocomial respiratory tract
infection. He asks you what that means? Your best
response would be:
 “You acquired the infection after you have been
admitted to the hospital.”
 As a nurse you know that one of the complications
that you have to watch out for when caring for Omar
who is receiving total parenteral nutrition is:
 infection
 A solution used to treat Pseudomonas wound
infection is:
 Dakin’s solution
 Which of the following is most reliable in diagnosing
a wound infection?
 Culture and sensitivity
 Situation – NURSES are involved in maintaining a
safe and healthy environment. This is part of quality
care management.
 The first step in decontamination is:
 removal of the patients clothing and jewelry and
then rinsing the patient with water
 For a patient experiencing pruritus, you recommend
which type of bath
ANS: colloidal (oatmeal)
 Induction of vomiting is indicated for the accidental
poisoning patient who has ingested.
 aspirin
 Which of the following term most precisely refer to
an infection acquired in the hospital that was not
present or incubating at the time of hospital
admission?
 Nosocomial infection
 Which of the following guidelines is not appropriate
to helping family members cope with sudden death?
 Obtain orders for sedation of family members
 The code of ethics for nurses has an interpretive
statement that provides:
o Guide for carrying out nursing
responsibilities that provide quality care
and for the ethical obligation of the
profession
 Which of the following is the best example of the
ethical principle of fidelity?
o Keeping a promise to return to the client’s
room at a given time
 The Code of Nurses
o Delineates all obligations and responsibility
of the nurse
 The obligation to correctly perform one’s assigned
duties is:
o Responsibility
 Among children candidates for organ transplant,
when all selected children have appropriate tissue
matches for the same donated organ, the basis for
the decision as to which child gets the organ is that
the organ is given to the child who:
o Will receive the most benefit from the new
organ
 Situation - any hospitals form bioethical review
committees to ensure better quality of life of
patients. You are invited by the nursing service
department to participate in their bioethical review
committee. You are expected to know the purpose
and apply bioethical principles.
 Which of the following is the purpose of the ethical
review committee?
o Promote implementation of general
standards
 Daria who is admitted to the hospital with
autoimmune thrombocytopenia and a platelet count
of 20,000/æL develops epistaxis and melena.
Treatment with corticosteroids and immunoglobulin
has not been successful. Her physician
recommended splenectomy. Daria state “I don’t
need surgery. This will go away on its own.” In
considering your response
o Advocacy
 Zorayda is terminally ill and is experiencing severe
pain. She as bone and liver metastasis. She has been
on morphine for several months now. Zorayda is
aware that they are having financial problem. She
decides to sign a DNR form. What ethical form did
Zorayda and her family utilize as basis for their
decision to sign a DNR.
 Advocacy
 Tricia, a staff nurse in a cancer unit, is considered a
role model not only by her colleagues, but also by
her patients. She goes out of her way to help other.
She is very active in their professional organization
and she practices what she teaches. What ethical
principle is she practicing?
o Justice
 You are commuting to work riding the LRT. An older
person collapsed and nobody seems to notice her.
The security guard tried to make her sit down but
she remained unconscious. You saw what happened
and you decided to help. With help, you brought the
patient to the nearest hospital. You learned later
that woman was diabetic. She was on her way to the
diabetes clinic to have her fasting blood sugar
tested. She developed hypoglycemia. You were able
 Page 10 of 16
to save a life. You felt good. What principle was
applied?
o Beneficence
 Situation - Ninety year old Purita is confined at the
medical unit for respiratory ailment for which a
breathing apparatus is prescribed for her to use
while she sleeps. She refuses to wear it continuously
though she fully understands the medical indication
for it
 Which of these ethical principles can guide the nurse
in her action?
o Nonmaleficence
 Purita has six children who are already adults. They
differ in their opinion whether or not to allow their
mother to decide for herself. The nurse would
encourage family conference for:
o Consensus building
 Breathing treatments are to be given to Purita. In
anticipation that Purita might refuse, Dinio, one of
the children requests that he be the one to sign
consent in behalf of their mother. The nurse explains
that Purita is rational in her thinking and which of
these clients’ right must be regarded?
o Right to refuse treatment
 Which of these would be the nurse’s priority
following the treatment principle of least restrictive
alternative?
o One to one staffing
 Purita talks about her joy in having responsible and
accomplished children and recalls challenging career
as a lawyer. She is demonstrating a sense of:
o Ego integrity
 Situation – The nurse’s understanding of ethico-legal
responsibilities will guide his/her nursing practice.
 The principles that govern right and proper conduct
of a person regarding life, biology and the health
professions is referred to as:
o Bioethics
 The purpose of having a nurses’ code of ethics is:
o To help the public understand professional
conduct expected of nurses
 The most important nursing responsibility where
ethical situations emerge in patient
o Be accountable for his or her own actions
 You inform the patient about his rights which include
the following EXCEPT:
o Right to obtain information about another
patient
 This principle states that a person has unconditional
worth and has the capacity to determine his own
destiny:
o Autonomy
 Situation – As Filipino Professional Nurses we must
be knowledgeable about the Code of Ethics for
Filipino Nurses and practice these by heart. The next
questions pertain to this Code of Ethics.
 Which of the following is TRUE about the Code of
Ethics of Filipino Nurses?
o The Philippine Nurses Association for being
the accredited professional organization
was given the privilege to formulate a
Code of Ethics for Nurses which the Board
of Nursing promulgated.
 Based on the Code of Ethics for Filipino Nurses, what
is regarded as the hallmark of nursing responsibility
and accountability?
o Health, being a fundamental right of every
individual
 Which of the following nurses’ behavior is regarded
as a violation of the Code of Ethics of Filipino
Nurses?
o A nurse endorsing a person running for
congress.
 A nurse should be cognizant that professional
programs for specialty certification by the Board of
Nursing are accredited through the:
o Nursing Specialty Certification Council
 Mr. Jimmy, R.N. works in a nursing home, and he
knows that one of his duties is to be an advocate for
his patients. Mr. Santos knows a primary duty of an
advocate is to:
o safeguard the well being of every patient
 Lizette, a head nurse in a surgical unit, hears one of
the staff nurse say that she does not touch any client
assigned to her unless she performs nursing
procedures or conducts physical assessment. To
guide the staff nurse in the use of touch, which of
the following would be the BEST response of Lizette?
o “Touch serves as a connection between
the nurse and the patient”
 George, a 43 year old executive is scheduled for
cardiac bypass surgery. While being prepared of
surgery, he says to the nurse “I am not going to have
the surgery. I may die because of the risk”. Which
response by the nurse is most appropriate?
o “This must be very frightening for you. Tell
me how you feel about the surgery”
 Mr. Chris Martinez has been confined for three days.
His wife helped take care of him and he has
observed her to be “too involved” in his care. He
complained to the head nurse about this. Which of
the following would be the BEST response of the
nurse.
o “What are your thoughts about your
wife’s involvement in your care?”
 The major components of the communication
process are:
o Message, sender, channel, receiver and
feedback
 Informal communication takes place when
individuals talk and is best described by saying the
participants:
o have no particular agenda or protocol
 The mother of a 9-month old infant is concerned
that the head circumference of her baby is greater
than the chest circumference. The BEST response by
nurse is:
 Page 11 of 16
o “This is normal until the age of 1 year,
when the chest will be greater.”
 Which of the following will work best when the
nurse is communicating with an infant?
o Use an adult voice just as you would for
anyone
 The tone and pitch of the voice, volume, inflection,
speed, grunts and other vocalization are preferred to
by which of the following terms?
o Paraverbal clues
 Which of the following remark indicates that the
client’s relative understood the discharge instruction
for wound care?
o “I will report any redness or swelling of the
wound”
 After cystoscopy, Mr. Santos asked you to explain
why there is no incision of any kind. What do you tell
him?
o “Cystoscopy is an endoscopic procedure of
the urinary tract”
 Situation - The nurse visited the Reyes family to
check on their two growing children, aged 7 and 4
years. Upon her visit she observed that common
areas of arguments between Mr. and Mrs. Reyes are
about conflicting ways of bringing up their children.
Mrs. Reyes is lax and tolerant while Mr. Reyes often
insists strict ways to a point of over protectiveness
from what he perceives as unsafe i.e., community
and neighbours that cannot be trusted.
 Mr. Reyes remarked “I am way about visiting- with
all the media news about child kidnapping and
robberies.” – The Nurse’s BEST response would be:
o “I acknowledge what you are saying. My
concern is the health care of your family
and information are strictly confidential.”
 Mrs. Reyes expressed that her socializing with
neighbors is limited because her husband thinks she
is getting overly friendly with a guy next door. Which
of the following would the nurse emphasize as
basic?
o Keeping trust in the relationship
 For the nurse to be effective in developing rapport
with the family it is essential that she keeps her
appointment on time and stick to a care plan. She is
applying the principle of:
o Consistency and predictability
 Which of these communicate unconditional
acceptance of Anita and her situation?
o “You are safe here and I am ready to
listen”
 Situation - Through the nurse-patient relationship,
the nurse intervenes utilizing effective
communication techniques. The following are varied
situations in a psychiatry ward.
 The patient verbalizes, “Masama ang pakiramdam
ko. Hindi ako nakatulog kagabi.” A therapeutic
response of the nurse would be:
o “Maari mo bang sabihin sa akin ang mga
naiisip at nararamdaman mo?”
 Soledad is terminally ill of cancer. Looking sad she
expresses. “Wala na yata akong pag-asang mabuhay
pa.” A response which fosters hope is:
o “Mukhang napakabigat ang dinaramdam
ninyo. Andito po ako at puwede tayong
mag-usap.”
 Camilia verbalizes, “Pinaguusapan nila ako. Ayaw nila
ako.” A therapeutic response is:
o “Nalulungkot ba ang pakiramdam mo?”
 During socialization Nicanor was provoked, became
furious and started shouting “Walang hiya kayo! Ako
ang bida ditto!” The nurse’s action is:
o Take him away from the group until he
manages to have control of himself
 Nicanor become verbally assaultive to the nurse. He
says, “Ikaw, nurse, wala kanga lam! Marunong pa
ako saiyo, e. Ano ba ang pinagmamalaki mo!” The
nurse responds therapeutically by:
o Acknowledging his behavior, put him in his
right senses; respond with, “Oo nga, galit
ka sa nurse pero hindi tama na naninigaw
ka.”
 Situation – As a nurse, you should be aware and
prepared of the different roles you play.
 What role do you play when you hold all client’s
information entrusted to you in the strictest
confidence?
o Patient’s advocate
 As a nurse, you can help improve the effectiveness
of communication among healthcare givers by:
o One-on-one oral endorsement
 As a nurse, your primary focus in the workplace is
the client’s safety. However, personal safety is also a
concern. You can communicate hazards to your co-
workers through the use of the following EXCEPT:
o Posting IR in the bulletin board
 As a nurse, what is one of the best way to reconcile
medications across the continuum of care?
o Communicate a complete list of the
patient’s medication to the next provider
of service
 As a nurse, you protect yourself and co-workers
from misinformation and misrepresentations
through the following EXCEPT:
o Endorsement thru trimedia to advertise
your favorite disinfectant solution
 Situation – The nurse engages the client in a nurse-
patient interaction
 The best time to inform the client about terminating
the nurse-patient relationship is:
o at the start of the relationship
 The client says, “I want to tell you something but can
you promise that you will keep this a secret?” A
therapeutic response of the nurse is:
o “Yes, our interaction is confidential
provided the information you tell me is not
detrimental to your safety.”
 Page 12 of 16
 When the nurse respects the client’s self-disclosure,
this is a gauge for the nurse’s”
 ANS: professionalism
 Rapport has been established in the nurse-client
relationship. The client asks to visit the nurse after
his discharge. The appropriate response of the nurse
would be:
o “The best time to talk is during the nurse-
client interaction time. I am committed to
have this time available for us while you
are at the hospital and ends after your
discharge.”
 The client has not been visited by relatives for
months. He gives a telephone number and requests
the nurse to call. An appropriate action of the nurse
would be:
o Assist the client to bring his concern to the
attention of the social worker.
 Situation – The nurse is often met with the following
situations when clients become angry and hostile.
 To maintain a therapeutic eye contact and body
posture while interacting with angry and aggressive
individual, the nurse should:
o keep an “open posture, e.g. Hands by sides
but palms turned outwards
 During the pre-interaction phase of the N-P
relationship, the nurse recognizes this normal
INITIAL reaction to an assaultive or potentially
assaultive person.
o Display empathy towards the patient
 Which of the following is an accurate way of
reporting and recording an incident?
o “When asked about his relationship with
his father, client clenched his jaw/teeth,
made a fist and turned away from the
nurse.”
 To encourage thought, which of the following
approaches is NOT therapeutic?
o “Why do you feel angry?”
 A patient grabs a chair and about to throw it. The
nurse best responds saying,
o “Stop! Put that chair down.”
 Situation – It is common that clients ask the nurse
personal questions.
 Anticipation of personal questions is given adequate
attention during which phase of the nurse patient
relationship?
o Working phase
 If the client asks for the nurse’s telephone number,
which of these responses is NOT appropriate?
o “It is confidential I just don’t give it to
anyone.”
 When the client asks about the family of the nurse,
the MOST appropriate response is:
o Give a brief and simple response and focus
on the client.
 When the nurse is asked a personal question, which
of these reactions indicate a need for her to
introspect?
o His/Her right to privacy is being intruded.
 It is 10 o’clock on your watch. The client asks, “What
time is it?” The nurse’s appropriate response is:
o “It is 10 o’clock.”
 Situation – Cathy, mother of 2 young kids, 36 years
old, had a mammogram and was told that she has
breast cysts and that she may need surgery. This
causes her anxiety as shown by increase in her pulse
and respiratory rate, sweating and feelings of
tension.
 Considering her level of anxiety, the nurse can best
assist Cathy by:
o Giving her clear but brief information at
the level of her understanding
 Cathy blames God for her situation. She is easily
provoked to tears and wants to be left alone,
refusing to eat or talk to her family. A religious
person before, she now refuses to pray or go to
church stating that God has abandoned her. The
nurse understands that Cathy is grieving for her self
and is in the stage of:
o anger
 The nurse visits Cathy and prods her to eat her food.
Cathy replies, “What’s the use? My time is running
out.” The nurse’s best response would be:
o “You sound like you are giving up.”
 The nurse feels sad about Cathy’s illness and tells her
head nurse during the end of shift endorsement
that, “it’s unfair for Cathy to have cancer when she is
still so young and with two kids.” The best response
of the head nurse would be:
o Advise the nurse to “be strong and learn to
control her feelings”
 Realizing that she feels angry about Cathy’s
condition, the nurse learns that being self-aware is a
conscious process that she should do in any situation
like this because:
o The nurse has to be therapeutic at all times
and should not be affected
 Situation - while working in a tertiary hospital, you
are assigned to the medical ward.
 Your client, Mr. Diaz, is concerned that he cannot
pay his hospital bills and professional fees. You refer
him to a:
o Social worker
 Mr. Magno has lung cancer and is going through
chemotherapy. He is referred by the oncology nurse
to a self-help group of clients with cancer to:
o Receive emotional support
 A diabetic hypertensive client, Mrs. Linao, needs a
change in diet improve her health status. She should
be referred to a:
o Dietician
 When collaborating with other health team
members, the best description of Nurse Rita’s role is:
 Page 13 of 16
o Shares and implements orders of the
health team to ensure quality care
 Nurse Rita is successful in collaborating with health
team members about the care of Mr. Linao. This is
because she has the following competencies:
o Communication, trust, and decision
making
 Situation - The following questions refers to nurse’s
efforts to do collaboration and teamwork. Select the
best answer.
 The most important role of the nurse as a member
of the team is to:
o Coordinate the physiological care and
management of clients
 A biological/medical approach to patient care utilizes
which of the following?
o Somatic therapy
 Which of these nursing actions belong to the
secondary level of preventive intervention?
o Providing emergency psychiatric services
 When the nurse identifies a client who has attempt
to commit suicide the nurse should:
o Refer the client to the psychiatrist
 The community health nurse was invited by the
principal of an elementary school and was asked to
give a task to parents. An appropriate topic would
be:
o Disciplining children at home and in school
 Situation - Collaborative planning is essential if
nursing and health care are to be made available to
all people.
 Perioperative examples of collaboration are the
following EXCEPT:
o Collaboration with other OR personnel
regarding the practices of surgeons
collecting exobirant professional fees.
 the nurses collaborate with other members of the
health profession to improve the integrity of the
hospital working environment through the following
ways EXCEPT:
o Joining the Mayo Uno Labor Union
 An example of a collaborating effort on public
service particularly during summer is:
 c. Clean and Green
 When does a nurse reject the interdependence of
providers and patients in achieving access to health
care?
o “Our hospital does not honor visiting
doctors”
 Individual patients and society as a whole benefit
from nursing participation in decisions made about
health care. This is exemplified in:
o Following the decision of CGFNS to retake
Test III and V to validate the visa screen for
the U.S.
 Situation - The perioperative nurse collaborates with
the client, significant others healthcare providers.
 Patient outcomes reflect the collaborative
interdisciplinary effort and independent nursing
activities. Who is the primary partner of the nurse in
health care?
 c. The client
 To control environmental hazards in the OR, the
nurse collaborates with the following departments
EXCEPT:
o Chaplaincy services
 Waste disposal poses a big problem for the hospital.
Biological wastes (i.e., amputated limbs) disposal
should be coordinated with the following agencies
EXCEPT:
o Crematorium . MMDA
o DOH DILG
 Tess, the PACU nurse discovered that Malou, who
weighs 110lbs prior to surgery, is in severe pain 3
hours after cholecystectomy. Upon checking the
chart, Malou found out that she has an order of
Demerol 100 mg I.M. pm for pain. Tess should verify
the order with:
 c. Surgeon
 Rosie, 57, who is diabetic, is for debridement of
incision wound. When the circulating nurse checked
the present IV fluid, she found out that there is no
insulin incorporated as ordered. What should be
circulating nurse do?
o Communicate with the ward nurse to
verify if insulin was incorporated or not
 Situation – Concerted work efforts among members
of the surgical team is essential to the success of the
surgical procedure.
 The sterile nurse or sterile personnel touch only
sterile supplies and instruments. When there is a
need for sterile supply which is not in the sterile
field, who hands out these items by opening its
outer cover?
 ANS: Circulating nurse
 The OR team performs distinct roles for one surgical
procedure to be accomplished within a prescribed
time frame and deliver a standard patient outcome.
While the surgeon performs the surgical procedure,
who monitors the status of the client like urine
output, blood loss?
o ANS: Anesthesiologist
 Surgery schedules are communicated to the OR
usually a day prior to the procedure by the nurse of
the floor or ward where the patient is confined. For
orthopedic cases, what department is usually
informed to be present in the OR?
o ANS Radiology department
 Minimally invasive surgery is very much into
technology. Aside from the usual surgical team, who
else has to be present when a client undergoes
laparoscopic surgery?
o ANS: Laboratory technician
 In massive blood loss, prompt replacement of
compatible blood is crucial. What department needs
to be alerted to coordinate closely with the patient’s
family for immediate blood component therapy?
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o Pathology department
 Situation – Nurses hold a variety of roles when
providing care to a perioperative patient.
 Which of the following role would be the
responsibility of the scrub nurse?
o Account for the number of sponges,
needles, supplies, used during the surgical
procedure
 As a perioperative nurse, how can you best meet the
safety need of the client after administering
preoperative narcotic?
o Put side rails up and ask client not to get
out of bed
 It is the responsibility of the pre-op nurse to do skin
prep for patients undergoing surgery. If hair at the
operative site is not shaved, what should be done to
make suturing easy and lessen chance of incision
infection?
 ANS. Clipped
 It is also the nurse’s function to determine when
infection is developing in the surgical incision. The
perioperative nurse should observe for what signs of
impending infection?
o Serosanguinous exudates and skin
blanching
 Which of the following nursing interventions is done
when examining the incision wound and changing
the dressing?
o Wash hands
 Situation – Team efforts is best demonstrated in the
OR
 If you are the nurse in charge for scheduling surgical
cases, what important information do you need to
ask the surgeon?
o Who is your assistant and anesthesiologist,
and what is your preferred time and type
of surgery
 In the OR, the nursing tandem for every surgery is:
o Scrub and circulating nurses
 While team effort is needed in the OR for efficient
and quality patient care delivery, we should limit the
number of people in the room for infection control.
Who comprise this team?
o Surgeon, assistants, scrub nurse,
circulating nurse, anesthesiologist
 When surgery is on-going, who coordinates the
activities outside, including the family?
o Nurse supervisor
 The breakdown in teamwork is often times a failure
in:
o Communication
 Situation – As a member of the health and nursing
team you have a crucial role to play in ensuring that
all the members participate actively is the various
tasks agreed upon.
 While eating his meal, Matthew accidentally
dislodges his IV line and bleeds. Blood oozes on the
surface of the over-bed table. It is most appropriate
that you instruct the housekeeper to clean the table
with
o Bleach
 You are a member of the infection control team of
the hospital. Based on a feedback during the
meeting of the committee there is an increased
incidence of pseudomonas infection in the Burn Unit
(3 out of 10 patients had positive blood and wound
culture). What is your priority activity?
o Establish policies for surveillance and
monitoring.
 Part of your responsibility as a member of the
diabetes core group is to get referrals from the
various wards regarding diabetic patients needing
diabetes education. Prior to discharge today, 4
patients are referred to you. How would you start
prioritizing your activities?
o Determine their learning needs then
prioritize
 You have been designated as a member of the task
force to plan activities for the Cancer Consciousness
Week. Your committee has 4 months to plan and
implement the plan. You are assigned to contact the
various cancer support groups in your hospital. What
will be your priority activity?
o Clarify objectives of the activity with the
task force before contacting the support
groups
 You are invited to participate in the medical mission
activity of your alumni association. In the planning
stage everybody is expected to identify what they
can do during the medical mission and what
resources are needed. You thought it is also your
chance to share what you can do for others. What
will be your most important role where you can
demonstrate the impact of nursing in health?
o Conduct health education on healthy
lifestyle
BOARD EXAMINATION – NURSING PROCEDURES
COLOSTOMY CARE
1. Gather equipment.
2. Place the patient in supine position.
3. Wash hands.
4. Don gloves.
5. Remove old pouch by grasping pouch and gently
pulling away from skin. (You may use warm water
or an adhesive solvent to loosen the seal.)
6. Discard gloves.
7. Wash hands and don new pair of gloves.
8. Gently wash stoma area with warm, soapy water.
9. Dry skin thoroughly.
10. Assess (and document after procedure):
Stoma: Appearance
Peristomal skin: Condition
Feces: Amount, color, consistency, and presence of
unusual odor
Emotional status
11. Temporarily cover stoma with a gauze pad to
absorb drainage during ostomy care.
12. Apply skin prep in a circular motion. (Allow to air
dry for approximately 30 seconds.)
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13. Apply skin barrier in a circular motion.
14. Measure stoma using a stoma guide.
15. Cut ring to size.
16. Moisten ring with warm water and rub it until
sticky, or remove paper backing from adhesivebacked
ring.
17. Center ring over the stoma, gently pressing it to the
skin. (Smooth out any wrinkles to prevent seepage
of effluent.)
18. Center faceplate of bag over stoma and gently press
down until completely closed.
19. Document procedure and assessments from step 10
(above):
Example: Colostomy bag changed, stoma pink, peristomal
skin intact without signs of irritation. 70 mL of
liquid greenish stool discarded with old colostomy
bag. Patient looked away during procedure and
appeared to ignore nurse’s verbal communication.
COLOSTOMY IRRIGATION
1. Explain procedure to the patient and encourage
participation.
2. Position in a side-lying position or sitting on the
toilet in bathroom if bed rest is not necessary.
3. Place bedpan on top of a disposable pad beneath
stoma (if patient is in bed).
4. Fill solution bag with prescribed type and amount
of irrigating solution, expelling air from irrigating
tube prior to insertion.
5. Hang solution bag 12 to 18 inches above the
stoma.
6. Don gloves.
7. Remove stoma appliance.
8. Place irrigation drainage sleeve over the stoma,
attaching it snugly to prevent seepage of fluid onto
the skin.
9. Place opposite end of drainage sleeve into bedpan
or toilet.
10. Dilate stoma, if ordered, by gently inserting the
lubricated tip of gloved fifth finger into stoma (use
a massaging motion to relax the intestinal muscle
until maximum dilation is accomplished).
11. Lubricate tip of stoma cone or catheter.
12. Insert stoma cone or catheter by using a rotating motion
until it fits snugly (about 3 inches). Do not
insert against resistance.
13. Open tubing clamp, allowing irrigating solution to
flow into the bowel slowly. (If cramping occurs,
stop flow until cramps subside.)
14. After instillation of fluid, remove cone or catheter,
and allow colon to empty.
15. Gently massage the abdomen to encourage
emptying of colon (usually takes up to half an
hour).
16. Empty and remove irrigation sleeve.
17. Discard old gloves and don new pair.
18. Clean area around stoma.
19. Apply colostomy appliance.
20. Wash hands.
21. Document type and amount of irrigation solution
instilled; size, color, and consistency of returned
solution; patient response; and complications.
Example: Colostomy irrigated with ——mL NS.
Solution returned with moderate amount loose,
greenish fecal material. No complaints during procedure.
States she irrigates colostomy once a day at
home.
Medical-Surgical
DRESSING CHANGE, STERILE
1. Explain procedure to the patient.
2. Wash hands.
3. Place bedside table near the area to be dressed.
4. Gather supplies and place on bedside table.
5. Place a disposable cuffed bag within reach of the
work area.
6. Position and drape the patient in a comfortable
position, exposing the area to be dressed.
7. Open sterile gloves and retain the inside of the
glove package for use as a sterile field.
8. Open sterile gauze pads and all supplies needed,
and drop them onto the sterile field.
9. Open the prescribed cleansing agents and pour onto
at least two gauze pads.
10. Don nonsterile gloves.
11. Place a towel or waterproof pad under wound area.
12. Remove tape and soiled dressing (soak dressing in
sterile saline if it adheres to wound), noting the
appearance of the wound, drain placement (if any),
suture or skin closure integrity; and amount, color,
and consistency of the drainage on the dressing.
13. Discard the dressing in a cuffed trash bag.
14. Remove and place gloves into the trash bag.
15. Wash hands.
16. Don sterile gloves.
17. Use gauze pads (which may be lifted with sterile
forceps) to cleanse the wound with prescribed antiseptic
solution. Cleanse the wound from the center
outward, using a new gauze pad for each outward
motion.
NOTE: Iodine solutions may cause skin irritation
if they are left on the skin between dressing
changes.
18. Discard used gauze pads into the cuffed bag, away
from the sterile field.
19. Apply sterile dressings to the incision or wound site
one at a time. (If a drain is present, use a precut
dressing to fit around the drain.)
20. Apply ABD pad if needed. (The blue line down the
middle of the pad marks the outside surface.) the technique
of applying several layers (the
number of layers depends on the size of the
wound area and the patient) of saline-soaked
dressings next to the wound and covering these
with dry dressings.
21. Apply tape over the dressing or secure it with
Montgomery ties.
22. Discard supplies and used gloves into a trash bag.
23. Wash hands.
24. Document observations of the wound, dressing,
drainage, dressing change, and patient response.
Example: Abdominal dressing changed. Small amount
serosanguineous drainage on old dressing. Wound
cleansed with H2O2. Wound edges approximated well.
ENEMA ADMINISTRATION
1. Explain procedure to the patient.
2. Provide privacy.
3. Gather all equipment.
4. Position the patient in left side-lying position with
the right knee flexed (dorsal recumbent position for
infants and small children).
5. Place waterproof pad under the patient’s hips and
buttocks, and drape to expose anal area only.
6. Prepare the solution as ordered.
7. Lubricate 2 inches of rectal tube to facilitate insertion.
8. Open the clamp to allow solution to run through
and expel air from tubing. Reclamp tubing.
 Page 16 of 16
9. Place a bedpan near the bedside.
10. Don gloves.
11. Instruct the patient to take slow deep breaths to
facilitate relaxation.
12. Separate the buttocks and insert rectal tube, directing
it toward the umbilicus about 3 to 4 inches.
13. Raise the enema container about 12 to 18 inches
above the rectum and open the regulating clamp.
14. Administer the fluid slowly.
15. Lower the container or clamp the tubing if the
patient experiences cramping.Medical-Surgical
16. After the solution is instilled, close the clamp and
remove the rectal tube.
17. Instruct the patient to retain solution as long as possible
(5 to 10 minutes for cleansing enema, 30 minutes
for retention enema).
18. Assist the patient to the bathroom or position him
or her on the bedpan.
19. Discard equipment.
20. Remove gloves and wash hands.
21. Document the type and amount of enema solution
administered; approximate amount, color, and consistency
of expelled material; and patient response.
Example: Positioned on left side, NS enema, 500 mL
given. Lg. amt. formed brown stool returned with
enema solution. Complained of abdominal cramping
during procedure. Quietly watching TV following procedure.
PEDIATRIC ADAPTATION
The amount of enema solution used for infants and small
children ideally is ordered by the physician. Caution should
be used if it is necessary to give an enema to a premature
or low-birth-weight infant. A 5- to 10-mL syringe attached
to a number 5 feeding tube can be used for the procedure.
Solutions may usually be given to other children as follows:
Age Amount of Solution Tube Insertion
Infant 100 mL 1 in
2–4 yr 200 mL 2 in
4–10 yr 200–400 mL 3 in
Over 10 yr 500 mL 3 in
NASOGASTRIC TUBE INSERTION
1. Gather the necessary equipment.
2. Explain procedure to the patient.
3. Wash hands.
4. Position the patient in a sitting position.Medical-Sur 5.
Check nostrils for patency by asking the patient to
breathe through one naris while occluding the
other.
6. Measure length of NG tubing to be inserted by
measuring the distance from tip of nose to ear-lobe
and from ear-lobe to about 1 inch beyond base of
xiphoid process. Use a small strip of adhesive tape
to mark the measured distance on the tube.
7. Don gloves and lubricate tube in water or a watersoluble
lubricant. (Never use mineral oil or petroleum
jelly.)
8. Ask the patient to tilt his or her head backward, and
gently advance the NG tube into an unobstructed
nostril; direct tube toward back of throat and down.
9. As the tube approaches the nasopharynx, ask the
patient to flex head toward chest (to close the trachea)
and allow him or her to swallow sips of water
or ice chips as the tube is advanced into the esophagus
(about 3 to 5 inches each time the patient swallows).
NOTE: If the patient coughs or gags, check the
mouth and oropharynx. If the tube is curled in
the mouth or throat, withdraw the tube to the
pharynx and repeat attempt to insert the tube.
10. Ask the patient to continue swallowing until the
tube reaches the premeasured mark.
11. Check for proper tube placement in the stomach by
aspirating with a syringe for gastric drainage or by
instilling about 20 mL of air into the NG tube while
listening with a stethoscope for a gurgling sound
over the stomach.
12. Secure the tube after checking for proper placement
by cutting a 3-inch strip of 1-inch tape and then
splitting the tape lengthwise at one end, leaving 1
inch intact at the opposite end
13. Place the intact end of the tape on top of the
patient’s nose, and wrap one side of the split tape
end around the tube and secure on a nostril. Repeat
with the other split tape end.
14. Connect the NG tube to suction if ordered, or
clamp.Medical-Surgical
15. Wrap adhesive tape around the distal end of the
tubing and attach a safety pin through the tape tab
to the patient’s gown.
16. Document the size and type of tube inserted. Note
the nostril used and the patient’s tolerance of the
procedure. Document how placement was validated
and whether tubing was left clamped or attached to
other equipment.
Example: Number 10 NG tube placed per R naris and
secured with tape. Procedure tolerated well. Tube
placement validated by auscultation while instilling
air into stomach. Distal tubing clamped.
PEDIATRIC ADAPTATION
Infant
Follow adult procedure with these adaptations:
1. Sharply bend NG tube about 1/4 to 1/2 inch from tip.
(There is a sharp bend “downward” almost immediately
after insertion of tube into the nostril.)
2. Flex the infant’s head gently onto the chest with your
nondominant hand. Nasogastric tube insertion; method of
securing tube with tape3. With the dominant hand, insert the
tube using a
downward motion almost immediately after the tube
enters the nostril.
4. Because the infant’s chest is small and sounds are
conducted throughout the chest and abdomen, auscultation
of sounds may give a false impression of
placement. Other standard methods of placement validation
may be used. A sensitive method of placement
validation for the infant is to place your hand
flat over the stomach area while forcing 2 to 3 mL of
air through the tube. Vibrations that reveal the location
of the tube tip can usually be felt through the
abdominal wall.
Toddler or Preschooler
1. Demonstrate the procedure on a doll.
2. One or two additional people are usually needed to
help restrain the child. The parent should not be
asked to assist with child restraint.