Drills 2

Situation –Nurse should be confident and safe in the practice

of her profession
1. Nurse has a complaint from a parent for administering
wrong dose of vaccine to the child. This act in a form of
_________.
A. Battery
B. Assault
C. Negligence
D. Malpractice

2. When Nurse Ace submitted a report to the physician that

she committed an error in medication. This is an example of
_____.
A. Responsibility
B. Accountability
C. Commitment
D. Delegation

3. Who among the following is the BEST to sign an

informed consent during a surgical procedure of a child at
the health center?
A. A 26 year old brother who is a drug addict.
B. A father who is 40 years old and illiterate.
C. A sister, 21 years old but undergoing dialysis.
D. A mother, 35 years old with on and off seizure.

4. A nurse administer an extra dose of vaccine to a child

and the patient developed adverse reaction and died. She
can be sued for ____.
A. Negligence
B. Malpractice
C. Tort
D. Battery

5. A patient was for transfer to a tertiary hospital because

of severe asthma but the nurse did not prepare the patient
right away and the patient dies. Which of the following the
nurse is liable?
A. Malpractice
B. Assault
C. Murder
D. Battery

Situation – The indication of tracheostomy has changes

substantially in the last two decades, Nurse Robert is taking
care of Patient Irma, an eight year old female child, who was
admitted to the Pediatric ward due to Pneumonia, The child
is hooked to Tracheostomy tube. Nurse Robert is quite
anxious in taking care of the patient being her first day of
duty in the Pediatric Ward.

6. When preparing the patient for suctioning, what is the

FIRST step?
A. Perform hand hygiene
B. Gather equipment
C. Assess lung sounds, heart rate and rhythm
D. Check Physician’s order and patient care plan

7. Patient Irma will be placed in which of the following

position? Select all that apply
1. Fowler
2. Semi Fowler
3. Supine
4. Sim

A. 1, 2 & 3
B. 2 only
C. 1&2
D. 1 only

8. Usually the common indication (s) for the tracheostomy

in Patient Irma’s condition is which of the following? (Select
all that apply)
1. Prolonged Intubation
2. Sepsis
3. Hypoventilation associated with neurologic disorder
4. Severe sleep Obstructive Apnea Syndrome (SOAS)
A. 2 only
B. 1&2
C. 1, 2. 3. & 4
D. 1 only

9. The Priority nursing objective when caring a patient with

tracheostomy is __________
A. To increase tissue oxygenation
B. To provide patent airway
C. To decrease oxygenation
D. To improve ventilation

10. The TOP nursing expected outcome when performing

suctioning is
A. Lessened amount of secretion leading to decrease
frequency of suctioning
B. Secretions removed without complication
C. Tube-fed patient does not aspirate feeding.
D. Prevention of occurrence of hypoxemia and bradycardia.

Situation – Sony, 11 years old is admitted due to bronchitis,

upon admission, he manifested the following signs and
symptoms: Cough, Production of mucus (Sputum), Yellowish
in color, fatigue, shortness of breath, slight fever and chills
and chest discomfort. The physician orders 4L/min
oxygenation.

11. The first standard step in oxygen therapy that the nurse
should do is _________
A. Assess the client's condition.
B. Gather all the equipment and supplies
C. Prepare the client for the oxygen treatment
D. Check the chart for ordered flow rate and oxygen
delivery method

12. In planning for sonny’s oxygen therapy, the nurse should

consider which of the following, EXCEPT_________
A. Need for a humidifier
B. Length of tubing
C. Determine the age of excel
D. Manner of administering oxygen, continuous or
intermittent.

13. Which of the following is the PRIORITY action of the

nurse for Sonny who will be on oxygen therapy?
A. Check the flow
B. Connect the flow meter to the pipe in oxygen outlet
C. Turn on the oxygen
D. Attach the humidifier and connecting tubing to the
oxygen delivery device

14. What PRIORITY precautionary measure should be done

by the nurse during the oxygen therapy?
A. Humidifier’s water should be checked regularly
B. No Smoking sign
C. Turn on the oxygen
D. Attach the humidifier and connecting tubing to the
oxygen delivery device.

15. One evening, Sonny complained of dyspnea despite

continuous oxygen therapy, what should be the FIRST
action of the nurse?
A. Reassess the patient.
B. Give PRN medication.
C. Assess the patency of the tubing
D. Refer client to the physician.

Situation – Gwen a unit manager is assigned to evaluate

applicants for the position in the OB unit. During the
interview, the applicant was asked 5 questions.

16. When a patient is admitted to the OB ward with

complains of dizziness and body weakness, this is an
example of?
A. Secondary source
B. Primary source
C. Objective data
D. Subjective data
17. What are the possible cases that need informed
consent?
A. Administering skin testing
B. Subjecting the patient to an invasive procedure
C. Hair shampooing of patient
D. Performing a laboratory procedure

18. The applicant was further asked about an incident

report. Which of the following is a PRIORITY case for an
incident report to be accomplished?
A. Patient fell from the bed
B. Refusal to go to the physical therapy session
C. A visitor encourages a patient on bed rest to ambulate
D. Nurse left before his duty ends

19. On which occasion would a nurse can be charged with

negligence?
A. Giving the patient the wrong medication
B. Giving competent care
C. Following standards of care
D. Communicating with another health team

20. What tasks can be delegated to his nursing assistant

during his tour of duty?
A. Changing wound dressings
B. Administering analgesic drug
C. Performing a physical assessment
D. Taking vital signs

Situation - Proper recording is a vital task that the nurse is

trained to do properly in nursing school and expected to
practice as a professional.

21. Nurses are taught as students that the ideal and

PROPER time for recording vital signs and notes on the
patient is ________.
A. To wait for lunch break to do the recording
B. After all the tasks are done, in order to conserve time
C. As soon as they obtain the signs or observations on
the patient
D. To wait for lunch break to do the recording

22. Right after endorsement and during the rounds, the

incoming nurse observes that the IV fluid is at 800 cc level
and not 400 cc, as endorsed. What is the CORRECT
information that she will chart?
A. Anything goes, nobody reads the charting anyway.
B. Record the 400 cc
C. Chart that she received 800
D. Refer to the Head Nurse on what to do.

23. Which is the APPROPRIATE way to correct an error in

the Nurses Notes?
A. Take the whole page out and replace with a fresh one
B. Draw a single line across the error and initial it
C. Use the sticky side of the plastic tape to erase the error
D. Use a rubber eraser to erase an error.

24. If a medicine is unavailable and therefore not given to

the patient, how is it charted? A. Leave it blank.
B. Sign and make an explanation in the Nurses Notes.
C. With an asterisk or mark, as per hospital protocol.
D. Write the letter.

25. If the patient is referred to another consultant and the

latter has made an order already, what can the nurse
CORRECTLY chart?
A. The attending physician has not yet ready read the
order.
B. Only one order has been left to be carried out.
C. She has carried out the orders of the consultant
D. That the consultant has seen the patient with new
orders.

Situation - The nurse when practicing the profession must

adhere to ethical principles.
26. When the nurse treats the patients in the air-conditioned
rooms favorably compared to those in the charity wing, she
violates which of the following ethical principles?
A. Veracity
B. Justice
C. Respect
D. Autonomy

27. The nurse has an obligation to tell the truth. When she
admits mistakes promptly, she manifests________.
A. Fidelity
B. Veracity
C. Respect
D. Autonomy

28. The cancer patient has been frequently complaining of

pain and demands that the pain reliever be administered
even before the due time. The nurse prepares to inject NSS
as a placebo. Which principle will she transgress?
A. Respect
B. Veracity
C. Justice
D. Fidelity

29. You are caring patient in a ward and you stated that you
will comback and answer inquiries about her management,
and you forgot to return, Which principle will she transgress?
A. Respect
B. Veracity
C. Justice
D. Fidelity

30. Nurses were overheard talking about the patient and his
prognosis. What ethical principle is violated?
A. Autonomy
B. Confidentiality
C. Non-maleficence
D. Beneficence

Situation – The following scenarios are potential routines

that could check work ethics of a professional nurse.
31. A patient asks to be discharged from the health care
facility against medical advice (AMA). What should the nurse
do?
A. Notify the physician
B. Prevent the patient from leaving
C. Have the patient sign an AMA form
D. Call a security guard to help detain the patient

32. A nursing assistant is assigned to provide morning care

to a patient. How should the nurse document care given by
the nursing attendant?
A. “Morning care rendered”.
B. “Morning care rendered by Grace Go, NA”.
C. “Morning care provided by G.G., nursing assistant”.
D. “Morning care refused to be given by nursing assistant”.

33. A nurse administers the wrong intravenous fluid to a

patient. She should accomplish which of the following
documents to be submitted to her immediate supervisor?
A. Patient Kardex
B. Incident report
C. Progress report
D. Endorsement record

34. When developing a care plan for a patient with a do-not-

resuscitate order, the nurse should NOT include which
intervention on the care plan?
A. Allow access to individuals who can provide spiritual
care.
B. Administer pain medications as ordered by physician.
C. Provide usual routine and nursing care as ordered by
physician.
D. Administer lethal doses of medication as patient
request.

35. A patient is to undergo a laminectomy in the morning.

The physician asks the nurse to witness the patient’s signing
of the consent form. What is the BEST action the nurse?
A. Provide emotional support for the patient while the
patient signs the consent.
B. Make sure the physician explains the risks of undergoing
the procedure.
C. Make sure the physician thoroughly describes the
procedure
D. Make sure the patient is competent, awake and alert
before he/she signs the consent form.

Situation – Charge Nurse Tessie works at the surgical ward.

She ensures good record management is implemented in
her unit at all times.

36. A patient is having elective surgery under general

anesthesia. Who is responsible for obtaining the informed
consent?
A. Surgeon
B. Nurse
C. Nurse anesthetist
D. Anesthesiologist

37. Which statement by the patient indicates that he

understands the explanation of the surgeon?
A. “I refuse to sign the consent form; another family
member can sign for me.”
B. “Now I know what the alternative treatments and
procedures are.”
C. “If I refuse to sign the consent form, other treatment will
be withdrawn.”
D. “I can’t refuse the procedure after the consent is signed.”

38. The unit secretary who transcribes the physicians order

asks the nurse to interpret an order because she cannot
read the writing. The nurse’s BEST action is to
___________.
A. Clarify the order with the pharmacies
B. Clarify the order by calling the physician
C. Interpret the order according to the patient’s previous
medication record
D. Clarify the order with junior staff
39. The physician orders to transfuses 500ml packed RBC
blood postoperatively. The nurse must check the name on
the label of the blood with the name on the
patient’s___________.
A. Medication administration record
B. Wristband in the presence of another nurse
C. Medical chart
D. Wristband

40. The patient’s wife is so anxious about the condition for

her husband. The MOST appropriate INITIAL intervention for
the nurse to make is to__________.
A. Describe her husband’s medical treatment since
admission
B. Reassure her that the important fact is her presence
C. Explain the nature of the injury and reassure her that
husband’s condition is stable
D. Allow her to verbalize her feelings and concerns

-------------PLEASE DISREGARD THANKS---------------

Situation– Patient Fe, 15 years old, G0P1, AOG 39 weeks,
has been admitted at 6:30 in the morning for lumbo-sacral
pains and strong uterine contractions every 10 minutes.
Nurse Jocele was there to admit her. She uses Focus, Data,
Action and Response (FDAR) as the form of charting.

36. In any type of charting or documentation, which of the

following should the nurse refer to and use to generate and
describe the status of patient Fe? Nursing __________.
A. Assessment
B. Process
C. Actions
D. Diagnosis

37. Which of the following are the purposes of

documentation? To ________.
I. Ensure the development of organized comprehensive
care plan
II. Have a clear and accurate record of what was done to
the patient.
III. Have an evidence of the health care member’s
accountability in giving care
IV. Detect patients who are clinically deteriorating

A. II, III, IV
B. I, II, III, IV
C. I, II, III
D. I, III, IV

38. Which of the following is the CORRECT definition of

focus charting
A. It is an electronically form of documentation of nursing
care done to a patient by a registered nurse.
B. It is a note, written or electronically generated, to
provide documentation related to a specific focus.
C. It is a nurse-centered way of documentation that
describes the patient status and nursing care rendered.
D. It is a nurse-centered approach to documentation.

39. In the given situation, which is the FOCUS?

A. Jocele as the admitting nurse
B. Lumbo-sacral pains and strong uterine contractions
C. 15 years old, G0P1, AOG of 36 weeks
D. Admission at 6:30 in the morning

40. What is the term used to describe the patient’s data or

assessment, the action done based on the assessment and
response based on the action made:
A. Progress Note
B. Flow sheets
C. Standard of Care
D. Focus Format
--------------------------------------------------------------------------------
Situation– Mr. M.E., 37 years old, was accompanied by his
wife and teen-age daughter to the out-patient department for
complaints of fever, fatigue, malaise and painful swollen
joints. The physician ordered that Mr. M.E. be admitted to
the hospital for observation and treatment. You are the
admitting nurse in the OPD. You found out during the
interview that Mr. M.E. does not have a regular job. His wife
works as a laundry woman.

41. Before admitting the client, you should FIRST make sure
that:
A. The consent for admission is signed by the client.
B. The consent for admission is signed by the wife and
witnessed by the daughter.
C. The client can pay his hospital bills.
D. The consent form is signed by the social worker.

42. Mr. M.E id brought to the medical ward. The next day, he
wants to know about his illness. The nurse on duty replied,
“You don’t need to know your diagnosis”. Which of following
rights of the patient is violated? Right to ______.
A. Obtain from his physician complete current
information concerning his diagnosis, treatment and
prognosis.
B. Receive from his physician information necessary to give
informed consent.
C. Expect reasonable continuity of care.
D. Considerate and respectful care, irrespective of one’s
socio- economic status.

43. After five days of hospitalization, the physician said Mr.

M.E can be discharged. He ordered medications to be taken
at home. The client is still weak and symptomatic. Which of
the following rights could be violated in this case? Right to
____.
A. Know hospital rules and regulation
B. Privacy
C. Refuse treatment
D. Continuity of care

44. Because Mr. M.E cannot pay for his medical bills, he is
referred to the social worker. Which of the following rights is
applicable on this case? The right to ___.
A. Considerate and respectful care irrespective of his
socio-economics status.
B. Expect reasonable continuity of care
C. Examine and receive an explanation of his medical bills
regardless of the source of payment
D. Know what hospital rules and regulation apply to his
conduct as a client.

45. The nurse discusses and shares the medical records of

Mr. M.E to a group of visiting members of a medical mission
team. Which of the following rights could be violated? The
right to ___:
A. Expect that all communications and records pertaining to
his care should be treated as confidential.
B. Obtain information regarding any relationship of the
hospital to another health care and educational institution in
so far as his care is concerned.
C. Informed consent
D. Privacy

Situation– Ms. Ada is a nurse working in the surgical unit.

She is aware her legal responsibilities as she assists in the
care of post-operative patients.

46. Which principle is applicable in a situation where a

sponge was left inside the abdomen of a patient who had an
exploratory laparotomy?
A. Doctrine of Force Majeure
B. Doctrine of Res Ipsa Loquitor
C. Doctrine of Viz major
D. Doctrine of Respondeat Superior

47. Under the Doctrine of Respondeat Superior, who

among the following is liable if the patient who had
exploratory previously was reopened and a piece of gauze
was found in the abdominal cavity? The:
A. Instrument nurse
B. Surgeon
C. Operating room nurse
D. Assistant surgeon

48. The Doctrine of Respondeat Superior holds that:

A. The employer is responsible for the actions of
his/her employee
B. The employer is not responsible for the action of his/her
employee
C. The employee is not responsible for his/her own action
D. Using restraints without the patient’s permission
constitue

49. Performing an act which a reasonable and prudent nurse

would not do or the failure to perform an act which a
reasonable and prudent nurse would have done under
similar situation is construed as:
A. Misdemeanor
B. Malfeasance
C. Malpractice
D. Negligence

50. Ms. Ada learns of a nurse in the orthopedic ward who

applied hot water bottle over a paralyzed leg which
consequently burned. This is an example:
A. Malfeasance
B. Misdemeanor
C. Malpractice
D. Negligence

Situation- Charting is part of the professional nurse’s

responsibility related to record management. The following
questions refer to this statement.

51. One of the characteristics of charting is brevity. Which of

the following example of charting shows this characteristics?
A. Nurse brought the patient to OR via stretcher at 10:15
B. Patient left for surgery via stretcher at 10:15 am
C. To surgery via stretcher at 10:15
D. patient brought by the nurse to OR via stretcher at 10:15
accompanied by the “bantay”

52. Which of the following is NOT a requirement for a late

entry in charting?
A. Nurse’s initials above the time
B. May be made if something has been forgotten
C. Circle it and write “late entry”
D. Reason for the late entry

53. There is a blank space after your last entry in your

charting. You will ______.
A. Draw a double line after your last entry
B. Sign your full name after your last entry
C. Draw a horizontal line through the center of an
empty line
D. Draw a perpendicular line across the empty space

54. Which of the following should the nurse’s notes focus

on?
A. Immediate past and the present
B. The present only
C. The future
D. The recent past

55. Which of the following sample charting would show the

characteristic of ACCURACY?
A. Intake from 700-1000 ml: 80 ml of coffee; 240 ml of
orange juice; 500ml of water
B. Patient on forced fluid but refused to take it most of the
time
C. Patient on forced fluids observed
D. Given fluid at frequent intervals but takes only a few sips

Situation– Preparation and administration of medications is a

nursing function that cannot be delegated. It is important that
the nurse has a deep understanding of this responsibility that
is meant to save patient’s lives.

56. You are to administer an intramuscular injection to

Dulce, 1 ½ year old girl. The most appropriate site to
administer the drug is:
A. Dorso gluteal region
B. Vastus lateralis
C. Ventral forearm
D. Gluteal region
57. An infant is ordered to receive 500ml of D5NSS for 24
hours. The intravenous drip is running at 60 drops/ml. How
many drops per minute should the flow rate be?
A. 60 drops per minute
B. 30 drops per minute
C. 21 drops per minute
D. 15 drops per minute

58. Following surgery, Henry is to receive 20 mEq

(milliequivalent) of potassium chloride to be added to 1000
ml of D5W to run for 8 hours. The intravenous infusion set is
calibrated at 20 drops per milliliter. How many drops per
minute should the rate be to infuse 1 liter of D5W for 8
hours?
A. 42 drops
B. 60 drops
C. 20 drops
D. 32 drops

59. Mr. Lagro is to receive 1 liter of D5LR to run for 12

hours. The drop factor of the IV infusion set is 10 drops per
minute. Approximately how many drop per minutes should
the IV be regulated?
A. 13-14 drops
B. 10-12 drops
C. 17-18 drops
D. 15-16 drops

60. The physician ordered Nembutal Na 200mg po OD. The

bottle contains 100mg/capsule. How many capsule will be
administered to the client?
A. 1 capsule
B. 2 capsule
C. 1 ½ capsule
D. ½ capsule

Situation– You are taking care of Mrs. Leyba, 66 years old,

who is terminally ill with ovarian cancer stage IV.
61. When caring for a dying client, you will perform which of
the following activities?
A. Encourage the client to reach optimal health
B. Assist client perform activities of daily living
C. Assist the client towards a peaceful death
D. Motivate client to gain independence

62. The client prepares for her eventual death and discusses
with the nurse and her family how she would like her funeral
to look like and what dress she will use. This client is in the
stage of:
A. Acceptance
B. Denial
C. Resolution
D. Bargaining

63. The nurse is to administer Demerol 50 mg IM to Mrs.

Leyba. Demerol is available in a mutidose vial labelled 100
mg/ml and Vistaril comes in an ampule labelled 50 mg/ml.
You are to give the both medications in one injection. You
will:
A. Withdraw the medication from the vial first then from
the ampule
B. Inject air into the vial, then into the ampule
C. Inject air into the ampule, aspirate the desired dose, then
into the vial
D. Withdraw medication from the ampule then from the vial

64. Mrs. Leyba is emaciated and is at risk for developing

which problem in skin integrity? A. Blisters
B. Pressure sores
C. Reddening of the skin
D. Pustules

65. What assessment tool the nurse should use to

determine the risk of Mrs. Leyba to pressure ulcers?
A. Physical scale
B. Head to toe assessment
C. Wound assessment
D. Braden scale

Situation– oral care is an important part of hygienic practices

and promoting client comfort.

66. An elderly client, 84 years old, is unconscious.

Assessment of the mouth reveals excessive dryness and
presence of sores. Which of the following is best to use for
oral care?
A. Lemon glycerine
B. Mineral oil
C. Hydrogen peroxide
D. Normal saline solution

67. When performing oral care to an unconscious client,

which of the following is a special consideration to prevent
aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of
bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly
progression

68. The advantages of oral care for a client include all of the
following, except:
A. Decreases bacteria in the mouth and teeth
B. Reduces need to use commercial mouthwash which
irritate the buccal mucosa
C. Improves client’s appearance and self-confidence
D. Improves appetite and taste of food

69. A possible problem while providing oral care to

unconscious clients is the risk of fluid aspiration to lungs.
This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with
mouthwash to avoid rinsing the buccal cavity
B. Swabbing the inside of the cheeks and lips, tongue and
gums with dry cotton swabs
C. Use fingers wrapped with wet cotton washcloth to rub
inside the cheeks, tongue, lips and gums
D. Suctioning as needed while cleaning the buccal
cavity

70. Your client has difficulty of breathing and is mouth

breathing most of the time. This causes dryness of the
mouth with unpleasant odor. Oral hygiene is recommended
for the client and in addition, you will keep the mouth
moistened by using:
A. Salt solution
B. Petroleum jelly
C. Water
D. Mentholated ointment

Situation– errors while providing nursing care to patients

must be avoided and minimized at all time. Effective
management of available resources enables the nurse to
provide safe, quality patient care.

71. In the hospital where you work, increased incidence of

medication error was identified as the number one problem
in the unit. During the brainstorming session of the nursing
service department, probable causes were identified. Which
of the following is process related?
A. Interruptions
B. Lack of knowledge
C. Use of unofficial abbreviations
D. Failure to identify client

72. Miscommunication of drug orders was identified as a

probable cause of medication errors. Which of the following
is safe medication practice related to this?
A. Maintain medication in its unit dose package until point
of actual administration
B. Note both generic and brand name of the medication in
the medication administration method
C. Only officially approved abbreviations maybe used
in prescription orders
D. Encourage clients to ask question about their
medications.

73. The hospital has an ongoing quality assurance program.

Which of the following indicates implementation of process
standards?
A. The nurses check client’s identification band before
giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is
measured
D. The unit has well ventilated medication room

74. Which of the following actions indicate that nurse jerome

is performing outcome evaluation of quality care?
A. Interviews nurses for comments regarding staffing
B. Measures waiting time for client’s per nurse’s call
C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment
every shift

75. An order for a client was given and the nurse in charge
of the client reports that she has no experience of doing the
procedure before. Which of the following is the most
appropriate action of the nurse supervisor?
A. Assign another nurse to perform the procedure
B. Ask the nurse to find way to learn the procedure
C. Tell the nurse to read the procedure manual
D. Do the procedure with the nurse

Situation– accurate computation prior to drug administration

is a basic skill all nurses must have.

76. Rudolf is diagnosed with amoebiasis and is to received

metronidazole (flagyl) tablets 1.5 gm daily in 3 divided doses
for 7 consecutive days. Which of the following is the correct
dose of the drug that the client will received per oral
administration?
A. 1,000 mg tid
B. 1,500 mg tid
C. 500 mg tid
D. 50 mg tid

77. Rhona, a 2 year old female was prescribed to receive

62.5 mg suspension three times a day. The available dose is
125 mg/ml. Which of the following should nurse paolo
prepare for each oral dose?
A. 0.5 ml
B. 2.5 ml
C. 1.5 ml
D. 10 ml

78. The physician ordered potassium chloride (kcl) in d5w 1

liter to be infused in 24 hours for mrs. Gomez. Since
potassium chloride is a high risk drug, nurse robert used an
intravenous pump. Which of the following should nurse
robert do to safely administer this drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard

79. Baby liza, 3 months old, with a congenital heart

deformity, has an order from her physician: “give 3.00 cc of
lanoxin today for 1 dose only”. Which of the following is the
most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in
the unit
C. Administer lanoxin intravenously as it is the usual route
of administration
D. Refer to the medication administration record for
previous administration of lanoxin

80. When nurse norma was about to administer the

medications of client lennie, the relative of lennie told the
nurse that they buy her medicines and showed the container
of medications of the client. Which of the following is the
most appropriate action by the nurse?
A. Hold the nurse administration of the client’s medication
and refer to the head nurse
B. Put aside the medications she prepared and instead
administer the client’s medications
C. Tell the client that she will inform the physician
about this
D. Bring the medications of the client to the nurse’s station
and prepare accordingly

Situation- Enterostomal therapy is now considered a

specialty in nursing. You are participating in the ostomy care
class.

81. During colostomy irrigation, the client complains of a

cramping sensation with the fluid was introduced. Which of
the following is a correct nursing action?
A. Temporarily stop the irrigation
B. Lower the solution
C. Pinch or kink the irrigating tube temporarily
D. Continue the irrigation

82. When are the colostomy appliance best emptied?

A. When there is the sensation of pressure
B. When there is the sensation of taste
C. When there is the sensation of smell
D. When it is full

83. The client asked the nurse, when is the best time to
perform irrigation? The nurse would answer:
A. Early morning, before meals, upon arising
B. Early morning, before meals
C. Early morning
D. Early morning, after meals

84. The nurse is teaching a client how to irrigate his stoma.

Which action indicates that the client needs more teaching?
A. Hanging the irrigation bag 24" To 36" (60 to 90 cm)
above the stoma
B. Filling the irrigation bag with 500 to 1,000 ml of
lukewarm water
C. Stopping irrigation for cramps and clamping the tubing
until cramps pass
D. Washing hands with soap and water when finished

85. The physician orders a stool culture to help diagnose a

client with prolonged diarrhea. The nurse who obtains the
stool specimen from the colostomy stoma should:
A. Take the specimen to the laboratory immediately.
B. Collect the specimen in a clean container.
C. Collect the specimen in a sterile container.
D. Perform a midstream clean catch collection.

86. You plan to teach fermin how to irrigate the colostomy

when:
A. The perineal wound heals and fermin can sit comfortably
on the commode
B. Fermin can lie on the side comfortably, about the 3rd
postoperative day
C. The abdominal incision is closed and contamination is
no longer a danger
D. The stools starts to become formed, around the 7th
postoperative day

87. When preparing to teach fermin how to irrigate

colostomy, you should plan to do the procedure:
A. When fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After fermin accepts alteration in body image

88. When observing a return demonstration of a colostomy

irrigation, you know that more teaching is required if fermin:
A. Lubricates the tip of the catheter prior to inserting into
the stoma
B. Hangs the irrigating bag on the bathroom door cloth
hook during fluid insertion
C. Discontinues the insertion of fluid after 500 ml of fluid
has been instilled
D. Clamps of the flow of fluid when felling uncomfortable
89. You are aware that teaching about colostomy care is
understood when fermin states, “I will contact my physician
and report:
A. If I have any difficulty inserting the irrigating tub into
the stoma.”
B. If I noticed a loss of sensation to touch in the stoma
tissue.”
C. The expulsion of flatus while the irrigating fluid is running
out.”
D. When mucus is passed from the stoma between the
irrigations.”

90. You would know after teaching fermin that dietary

instruction for him is effective when he states, “it is important
that i eat:
A. Soft food that is easily digested and absorbed by my
large intestines.”
B. Bland food so that my intestines do not become
irritated.”
C. Food low in fiber so that there are fewer stools.”
D. Everything that I ate before the operation, while
avoiding foods that cause gas.”

Situation- Informed consent is taken to assure that the

client’s autonomy is respected. As a nurse, you should know
the principles and your responsibility in securing the
informed consent.

91. Performing a procedure on a client in the absence of an

informed consent can lead to which of the following
charges?
A. Fraud
B. Harassment
C. Assault and battery
D. Breach of confidentiality

92. Which of the following is the essence of informed

consent?
A. It should have a durable power of attorney
B. It should have coverage from an insurance company
C. It should respect the client’s freedom from coercion
D. It should disclose previous diagnosis, prognosis and
alternative treatments available for the client

93. Kristie, a 19 year old client, has been rushed to the

hospital by his father due to severe head trauma and is now
unconscious. To whom will the physician obtain the informed
consent?
A. The father
B. The physician
C. Kristie
D. There is no need for consent because this is an
emergency

94. The main responsibility of the nurse when the physician

obtains the informed consent is:
A. Explain the procedure, alternatives, prognosis and
diagnosis
B. Listen to the physician’s explanation
C. Make sure that the client fully understood the
instructions, the consent was given voluntarily, the signature
is authentic and the client is competent when receiving the
consent.
D. Make sure that the client fully understood the
instructions, the consent was given voluntarily, the
signature is authentic and the client is competent when
giving the consent.

95. Autonomy is said to be the bioethical principle respected

in Enlightened consent. If the nurse made sure that the client
received enough information when the physician obtained
the consent, asked and verifies if the client understood the
procedure and informs the physician if the client have some
questions with regards to the diagnosis, procedure,
alternatives and prognosis, The nurse is playing which role?
A. Mother surrogate
B. Client Advocate
C. Care provider
D. Collaborator
SITUATION- A Client was rushed to the emergency room
and you are his attending nurse. You are performing a vital
sign assessment.

96. All of the following are correct methods in assessment of

the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for
comparison
B. Listen to and identify the phases of Korotkoff’s sound
C. Pump the cuff to around 50 mmHg above the point
where the pulse is obliterated
D. Observe procedures for infection control

97. You attached a pulse oximeter to the client. You know

that the purpose is to:
A. Determine if the client’s hemoglobin level is low and if he
needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive
medications
D. Detect oxygen saturation of arterial blood before
symptoms of hypoxemia develops

98. After a few hours in the Emergency Room, The client is

admitted to the ward with an order of hourly monitoring of
blood pressure. The nurse finds that the cuff is too narrow
and this will cause the blood pressure reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be

99. Through the client’s health history, you gather that the
patient smokes and drinks coffee. When taking the blood
pressure of a client who recently smoked or drank coffee,
how long should the nurse wait before taking the client’s
blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes

100. While the client has pulse oximeter on his fingertip,

you notice that the sunlight is shining on the area where the
oximeter is. Your action will be to:
A. Set and turn on the alarm of the oximeter
B. Do nothing since there is no identified problem
C. Cover the fingertip sensor with a towel or bedsheet
D. Change the location of the sensor every four hours