NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice

SITUATIONAL

Situation 1 – Mr. Ibarra is assigned to the triage area and while on duty, he assesses the
condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her
respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg
subcutaneously.

1. The indication for epinephrine injection for Mrs. Simon is to:

A. Reduce anaphylaxis
B. Relieve hypersensitivity to allergen
C. Relieve respiratory distress due to bronchial spasm
D. Restore client’s cardiac rhythm

2. When preparing the epinephrine injection from an ampule, the nurse initially:

A. Taps the ampule at the top to allow fluid to flow to the base of the ampule
B. Checks expiration date of the medication ampule
C. Removes needle cap of syringe and pulls plunger to expel air
D. Breaks the neck of the ampule with a gauze wrapped around it

3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it

is best for the nurse to:

A. Inject needle at a 15 degree angle over the stretched skin of the client
B. Pinch skin at the injection site and use airlock technique
C. Pull skin of patient down to administer the drug in a Z track
D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree
angle

4. When preparing for a subcutaneous injection, the proper size of syringe and needle would
be:

A. Syringe 3-5 ml and needle gauge 21 to 23

B. Tuberculin syringe 1 ml with needle gauge 26 or 27
C. Syringe 2 ml and needle gauge 22
D. Syringe 1-3 ml and needle gauge 25 to 27

5. The rationale for giving medications through the subcutaneous route is:

A. There are many alternative sites for subcutaneous injection

B. Absorption time of the medicine is slower
C. There are less pain receptors in this area
D. The medication can be injected while the client is in any position

Situation 2 – The use of massage and meditation to help decrease stress and pain have been
strongly recommended based on documented testimonials.

6. Martha wants to do a study on this topic: “Effects of massage and meditation on stress
and pain”. The type of research that best suits this topic is:

A. Applied research
B. Qualitative research
 C. Basic research
D. Quantitative research

7. The type of research design that does not manipulate independent variable is:

A. Experimental design
B. Quasi-experimental design
C. Non-experimental design
D. Quantitative design

8. This research topic has the potential to contribute to nursing because it seeks to

A. include new modalities of care

B. resolve a clinical problem
C. clarify an ambiguous modality of care
D. enhance client care

9. Martha does review of related literature for the purpose of

A. determine statistical treatment of data research

B. gathering data about what is already known or unknown about the problem
C. to identify if problem can be replicated
D. answering the research question

10. Client’s rights should be protected when doing research using human subjects. Martha
identifies these rights as follows EXCEPT:

A. right of self-determination
B. right to compensation
C. right of privacy
D. right not to be harmed

Situation 3 – Richard has a nursing diagnosis of ineffective airway clearance related to

excessive secretions and is at risk for infection because of retained secretions. Part of Nurse
Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.

11. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes
of the lungs. The appropriate position to drain the anterior and posterior apical segments of
the lungs when Mario does percussion would be:

A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position
then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position

12. When documenting outcome of Richard’s treatment Mario should include the following in
his recording EXCEPT:

A. Color, amount and consistency of sputum

B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
13. When assessing Richard for chest percussion or chest vibration and postural drainage,
Mario would focus on the following EXCEPT:

A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat

14. Mario prepares Richard for postural drainage and percussion. Which of the following is a
special consideration when doing the procedure?

A. Respiratory rate of 16 to 20 per minute

B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client

15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The
difference between the procedures is:

A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while
vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand
action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the
secretions along with the inhalation of air

Situation 4 – A 61 year old man, Mr. Regalado, is admitted to the private ward for
observation after complaints of severe chest pain. You are assigned to take care of the
client.

16. When doing an initial assessment, the best way for you to identify the client’s priority
problem is to:

A. Interview the client for chief complaints and other symptoms

B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions

17. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:

A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions

18. Mr. Regalado says he has “trouble going to sleep”. In order to plan your nursing
intervention you will:

A. Observe his sleeping patterns in the next few days

B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up
19. Mr. Regalado’s lower extremities are swollen and shiny. He has pitting pedal edema.
When taking care of Mr. Regalado, which of the following interventions would be the most
appropriate immediate nursing approach?

A. Moisturize lower extremities to prevent skin irritation

B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium

20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:

A. Making a final physical assessment before client leaves the hospital

B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data

Situation 5 – Nancy, 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.

21. Considering her level of anxiety, the nurse can best assist Nancy by:

A. Giving her activities to divert her attention

B. Giving detailed explanations about the treatments she will undergo
C. Preparing her and her family in case surgery is not successful
D. Giving her clear but brief information at the level of her understanding

22. Nancy 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 Nancy is
grieving for her self and is in the stage of:

A. bargaining
B. denial
C. anger
D. acceptance

23. The nurse visits Nancy and prods her to eat her food. Nancy replies “what’s the use? My
time is running out.” The nurse’s best response would be:

A. “The doctor ordered full diet for you so that you will be strong for surgery”
B. “I understand how you feel but you have to try for your children’s sake”
C. “Have you told your doctor how you feel? Are you changing your mind about your
surgery?”
D. “You sound like you are giving up.”

24. The nurse feels sad about Nancy’s illness and tells her head nurse during the end of shift
endorsement that “it’s unfair for Nancy to have cancer when she is still so young and with
two kids”. The best response of the head nurse would be:

A. Advise the nurse to “be strong and learn to control her feelings”
B. Assign the nurse to another client to avoid sympathy for the client
C. Reassure the nurse that the client has hope if she goes through all treatments
prescribed for her
 D. Ask the other nurses what they feel about the patient to find out if they share the
same feelings

25. Realizing that she feels angry about Nancy’s condition, the nurse learns that being self-
aware is a conscious process that she should do in any situation like this because:

A. This is a necessary part of the nurse – client relationship process

B. The nurse is a role model for the client and should be strong
C. How the nurse thinks and feels affect her actions towards her client and her work
D. The nurse has to be therapeutic at all times and should not be affected

Situation 6 – Mrs. Seva, 52 years old, asks you about possible problems regarding her
elimination now that she is in the menopausal stage.

26. Instruction on health promotion regarding urinary elimination is important. Which would
you include?

A. Hold urine as long as she can before emptying the bladder to strengthen her
sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding

27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what
physical changes predispose her to constipation?

A. inhibition of the parasympathetic reflex

B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines

28. The nurse understands that one of these factors contributes to constipation:

A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives

29. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling
urine when laughing or sneezing and when she has a full bladder. Your most appropriate
instruction would be to:

A. tell client to drink less fluids to avoid accidents

B. instruct client to start wearing thin adult diapers
C. ask the client to bring change of underwear “just in case”
D. teach client pelvic exercise to strengthen perineal muscles

30. Mrs. Seva asked for instructions for skin care for her mother who has urinary
incontinence and is almost always in bed. Your instruction would focus on prevention of skin
irritation and breakdown by:

A. Using thick diapers to absorb urine well

B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rising and drying of skin area that get wet with urine
D. Making sure that linen are smooth and dry at all times
Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse’s knowledge and ability to identify and
immediately intervene to meet these needs is important to save lives.

31. Which of these clients has a problem with the transport of oxygen from the lungs to the
tissues:

A. Carol with tumor in the brain

B. Theresa with anemia
C. Sonnyboy with a fracture in the femur
D. Brigitte with diarrhea

32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in
the blood. This condition is called:

A. Cyanosis
B. Hypoxia
C. Hypoxemia
D. Anemia

33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion
of the tubing for an adult would be:

A. tip of the nose to the base of the neck

B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches

34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the
area by:

A. Apply suction for at least 20-30 seconds each time to ensure that all secretions
are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction

35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath
effectively and comfortably. The nurse documents this condition as:

A. Apnea
B. Orthopnea
C. Dyspnea
D. Tachypnea

Situation 8 – You are assigned to screen for hypertension. Your task is to take blood pressure
readings and you are informed about avoiding the common mistakes in BP taking that lead
to false or inaccurate blood pressure readings.

36. When taking blood pressure reading the cuff should be:

A. deflated fully then immediately start second reading for same client
B. deflated quickly after inflating up to 180 mmHg
 C. large enough to wrap around upper arm of the adult client 1 cm above brachial
artery
D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial
or bronchial artery

37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death
world wide and is a preventable disease. The primary cause of COPD is

A. tobacco hack
B. bronchitis
C. asthma
D. cigarette smoking

38. In your health education class for clients with diabetes you teach them the areas for
control of Diabetes which include all EXCEPT

A. regular physical activity

B. thorough knowledge of foot care
C. prevention nutrition
D. proper nutrition

39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM)
diabetes. Which of the following is true?

A. both types diabetes mellitus clients are all prone to developing ketosis
B. Type II (NIDDM) is more common and is also preventable compared to Type I
(IDDM) diabetes which is genetic in etiology
C. Type I (IIDM) is characterized by fasting hyperglycemia
D. Type II (NIDDM) is characterized by abnormal immune response

40. Lifestyle-related diseases in general share areas common risk factors. These are the
following except:

A. physical activity
B. smoking
C. genetics
D. nutrition

Situation 9 – Nurse Rivera witnesses a vehicular accident near the hospital where she works.
She decides to get involved and help the victims of the accident

41. Her priority nursing action would be to:

A. Assess damage to property

B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police authorities
D. Assess the extent of injuries incurred by the victims of the accident

42. Priority attention should be given to which of these clients?

A. Linda who shows severe anxiety due to trauma of the accident

B. Ryan who has chest injury, is pale and with difficulty breathing
C. Noel who has lacerations on the arms with mild bleeding
D. Andy whose left ankle swelled and has some abrasions
43. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations
on the arms. While assessing the extent of the wound the nurse observes that the wound is
now starting to bleed profusely. The most immediate nursing action would be to:

A. Apply antiseptic to prevent infection

B. Clean the wound vigorously of contaminants
C. Control and reduce bleeding of the wound
D. Bandage the wound and elevate the arm

44. The nurse applies dressing on the bleeding site. This intervention is done to:

A. Reduce the need to change dressing frequently

B. Allow the pus to surface faster
C. Protect the wound from microorganisms in the air
D. Promote hemostasis

45. After the treatment, the client is sent home and asked to come back for follow-up care.
Your responsibilities when the client is to be discharged include the following EXCEPT:

A. Encouraging the client to go to the outpatient clinic for follow up care

B. Accurate recording of treatment done and instructions given to client
C. Instructing the client to see you after discharge for further assistance
D. Providing instructions regarding wound care

Situation 10 – While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctor’s appointment. As the clinic nurse, you are to assist the client fill up forms, gather
data and make an assessment.

46. The purpose of your initial nursing interview is to:

A. Record pertinent information in the client’s chart for health team to read
B. Assist the client find solutions to he her health concerns
C. Understand her lifestyle, health needs and possible problems to develop a plan of
care
D. Make nursing diagnoses for identified health prob;ems

47. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that
this pain occurs about an hour after taking black coffee without breakfast for a few weeks
now. You will record this as follows:

A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics

B. After drinking coffee, the client experienced severe abdominal pain
C. Client complained of intermittent abdominal pain an hour after drinking coffee
D. Client reported abdominal pain an hour after drinking black coffee for three weeks
now.

48. Geline tells you that she drinks black coffee frequently within the day to “have energy
and be wide awake” and she eats nothing for breakfast and eats strictly vegetable salads for
lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning
a healthy balanced diet with Geline, you will:

A. Start her off with a cleansing diet to free her body of toxins then change to a
vegetarian diet and drink plenty of fluids
B. Plan a high protein diet, low carbohydrate diet for her considering her favorite
food.
 C. Instruct her to attend classes in nutrition to find food rich in complex
carbohydrates to maintain daily high energy level.
D. Discuss with her the importance of eating a variety of food from major food
groups with plenty of fluids.

49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also
smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of
pregnancy but does not want to become fat that is why she limits her food intake. You warn
or caution her about which of the following?

A. Caffeine products affect the central nervous system and may cause the mother to
have a “nervous breakdown”
B. Malnutrition and its possible effects on growth and development problems in the
unborn fetus
C. Caffeine causes a stimulant effect on both mother and the baby
D. Studies show conclusively that caffeine causes mental retardation

50. Your health education plan for Geline stresses proper diet for a pregnant woman and the
prevention of non-communicable diseases that are influenced by her lifestyle. These include
the following EXCEPT:

A. Cardiovascular diseases
B. Cancer
C. Diabetes Mellitus
D. Osteoporosis

Situation 11 – Management of nurse practitioners is done by qualified nursing leaders who

had clinical experience and management experience.

51. An example of a management function of a nurse is:

A. Teaching patient do breathing and coughing exercises

B. Preparing for a surprise party for a client
C. Performing nursing procedures for clients
D. Directing and evaluating the staff nurses

52. Your head nurse in the unit believes that the staff nurses are not capable of decision
making so she makes the decisions for everyone without consulting anybody. This type of
leadership is:

A. Laissez faire leadership

B. Democratic leadership
C. Autocratic leadership
D. Managerial leadership

53. When the head nurse in your ward plots and approves your work schedules and directs
your work, she is demonstrating:

A. Responsibility
B. Delegation
C. Accountability
D. Authority

54. The following tasks can be safely delegated by a nurse to a non-nurse health worker
EXCEPT:
 A. Transfer a client from bed to chair
B. Change IV infusions
C. Irrigation of a nasogastric tube
D. Take vital signs

55. 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:

A. Responsibility
B. Accountability
C. Authority
D. Autocracy

Situation 12 – Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of
hypertension, flushed face, severe headache, and nausea. You are doing the initial
assessment of vital signs.

56. You are to measure the client’s initial blood pressure reading by doing all of the following
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

57. A pulse oximeter is attached to Mr. Dizon’s finger 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

58. After a few hours in the Emergency Room, Mr. Dizon 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

59. Through the client’s health history, you gather that Mr. Dizon 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

60. 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

Situation 13 – The nurse’s understanding of ethico-legal responsibilities will guide his/her

nursing practice.

61. The principles that govern right and proper conduct of a person regarding life, biology
and the health professionals is referred to as:

A. Morality
B. Religion
C. Values
D. Bioethics

62. The purpose of having a nurses’ code of ethics is:

A. Delineate the scope and areas of nursing practice

B. Identify nursing action recommended for specific health care situations
C. To help the public understand professional conduct expected of nurses
D. To define the roles and functions of the health care givers, nurses, clients

63. The most important nursing responsibility where ethical situations emerge in patient
care is to:

A. Act only when advised that the action is ethically sound

B. Not takes sides, remain neutral and fair
C. Assume that ethical questions are the responsibility of the health team
D. Be accountable for his or her own actions

64. You inform the patient about his rights which include the following EXCEPT:

A. Right to expect reasonable continuity of care

B. Right to consent to or decline to participate in research studies or experiments
C. Right to obtain information about another patient
D. Right to expect that the records about his care will be treated as confidential

65. This principle states that a person has unconditional worth and has the capacity to
determine his own destiny:

A. Bioethics
B. Justice
C. Fidelity
D. Autonomy

Situation 14 – 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.

66. The following mechanisms can be utilized as part of the quality assurance program of
your hospital EXCEPT:

A. Patient satisfaction surveys

B. Peer review to assess care provided
 C. Review of clinical records of care of client
D. Use of Nursing Interventions Classification

67. The use of the Standards of Nursing Practice is important in the hospital. Which of the
following statements best describes what it is?

A. These are statements that describe the maximum or highest level of acceptable
performance in nursing practice
B. It refers to the scope of nursing practice as defined in Republic Act 9173
C. It is a license issued by the Professional Regulation Commission to protect the
public from substandard nursing practice
D. The Standards of Care includes the various steps of the nursing process and the
standards of professional performance

68. 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?

A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor
should sign his order within 24 hours
C. Have the registered nurse, family and doctor sign the order
D. Have 1 nurse take the order and sign it and have the doctor sign it within 24
hours

69. To ensure client safety before starting blood transfusions the following are needed before
the procedure can be done EXCEPT:

A. take baseline vital signs

B. blood should be warmed to room temperature for 30 minutes before blood
transfusions is administered
C. have two nurses verify client identification, blood type, unit number and
expiration date of blood
D. get consent signed for blood transfusion

70. Part of standards of care has to do with the use of restraints. Which of the following
statements is NOT true?

A. Doctor’s order for restraints should be signed within 24 hours

B. Remove and reapply restraints every 2 hours
C. Check client’s pulse, blood pressure and circulation every 4 hours
D. Offer food and toileting every 2 hours

Situation 15 – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr.
Bruno, shows increased interest.

71. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr.
Bruno is:

A. 1 tsp of salt/day with iodine and sprinkle of MSG

B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo

72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
 A. eat natural food with little or no salt added
B. limit use of table salt and use condiments instead
C. use herbs and spices
D. limit intake of preserved or processed food

73. Teaching strategies and approaches when giving nutrition education is influenced by
age, sex and immediate concerns of the group. Your presentation for a group of young
mothers would be best if you focus on:

A. diets limited in salt and fat

B. harmful effects of drugs and alcohol intake
C. commercial preparation of dishes
D. cooking demonstration and meal planning

74. Cancer cure is dependent on

A. use of alternative methods of healing

B. watching out for warning signs of cancer
C. proficiency in doing breast self-examination
D. early detection and prompt treatment

75. The role of the health worker in health education is to

A. report incidence of non-communicable diseases to community health center

B. educate as many people about warning signs of non-communicable diseases
C. focus on smoking cessation projects
D. monitor clients with hypertension

Situation 16 – You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.

76. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8
am. At what rate should the IV fluid be flowing hourly?

A. 100 ml per hour

B. 210 ml per hour
C. 150 ml per hour
D. 190 ml per hour

77. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8
am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he receive
at 11 am?

A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour

78. You are to apply a transdermal patch of nitoglycerin to your client. The following are
important guidelines to observe EXCEPT:

A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
 C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand

79. You will be applying eye drops to Miss Romualdez. After checking all the necessary
information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic
drops by instilling the eye drops:

A. directly onto the cornea

B. pressing the lacrimal duct
C. into the outer third of the lower conjunctival sac
D. from the inner canthus going towards the side of the eye

80. When applying eye ointment, the following guidelines apply EXCEPT:

A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the tube is
likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva

Situation 17 – 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.

81. The plan of the nurse supervisor is an example of

A. in service education process

B. efficient management of human resources
C. increasing human resources
D. primary prevention

82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra

A. makes the assignment to teach the staff member

B. is assigning the responsibility to the aide but not the accountability for those
tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated

83. Connie, 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

A. empathize with the nurse and listen to her

B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life

84. Process of formal negotiations of working conditions between a group of registered

nurses and employer is

A. grievance
B. arbitration
C. collective bargaining
D. strike
85. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is

A. professional course towards credits

B. inservice education
C. advance training
D. continuing education

Situation 18 – There are various developments in health education that the nurse should
know about:

86. The provision of health information in the rural areas nationwide through television and
radio programs and video conferencing is referred to as:

A. Community health program

B. Telehealth program
C. Wellness program
D. Red Cross program

87. 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

A. outreach program
B. hospital extension program
C. barangay health program
D. wellness program

88. Part of teaching client in health promotion is responsibility for one’s health. When Danica
states she needs to improve her nutritional status this means:

A. Goals and interventions to be followed by client are based on nurse’s priorities

B. Goals and intervention developed by the nurse and client should be approved by
the doctor
C. Nurse will decide goals and interventions needed to meet client goals
D. Client will decide the goals and interventions required to meet her goals

89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary
provestion is

A. Marriage counseling
B. Self-examination for breast cancer
C. Identifying complication of diabetes
D. Poison Control

90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical
cancer. This is an example of

A. tertiary prevention
B. secondary prevention
C. health screening
D. primary prevention
Situation 19 – Ronnie was in a vehicular accident where he sustained injury to his left ankle.
In the Emergency Room, you notice how anxious he looks.

91. You establish rapport with him and to reduce his anxiety you initially:

A. Take him to the radiology section for X-ray of affected extremity

B. Identify yourself and state your purpose in being with the client
C. Talk to the physician for an order of Valium
D. Do inspection and palpation to check extent of his injuries

92. While doing your assessment, Ronnie asks you “Do I have a fracture? I don’t want to
have a cast.” The most appropriate nursing response would be:

A. “You have to have an x ray first to know if you have a fracture”.

B. “Why do you sound so scared? It is just a cast and it’s not painful”.
C. “You seem to be concerned about being in a cast”.
D. “Based on my assessment, there doesn’t seem to be a fracture”.

93. Ronnie is very anxious and is unaware of the extent of his injury. The nurse can best
assist him by:

A. Asking the doctor to give an order for a sedative to call him down
B. Informing him that he is being treated by a very competent health team so he has
nothing to worry about
C. Identifying his level of anxiety to determine how much information he can
understand
D. Allaying his anxiety by telling him that he only sustained a minor injury

94. After cleaning the abrasions and applying antiseptic, the nurse applies cold compress to
the swollen ankle as ordered by the physician. This statement shows that the nurse has
correct understanding of the use of cold compress:

A. Cold compress reduces blood viscosity in the affected area

B. It is safer to apply than hot compress
C. Cold compress prevents edema and reduces pain
D. It eliminates toxic waste products due to vasodilation

95. After receiving prescription for pain medication, Ronnie is instructed to continue applying
30 minute cold at home and start 30 minute hot compress the next day. You explain that the
use of hot compress:

A. Produces anesthetic effect

B. Increases nutrition in the blood to promote wound healing
C. Increase oxygenation to the injured tissues for better healing
D. Induces vasoconstriction to prevent infection

Situation 20 – A nursing professor assigns a group of students to do data gathering by

interviewing their classmates as subjects.

96. She instructed the interviewees not to tell the interviewees that the data gathered are
for her own research project for publication. This teacher has violated the student’s right to:

A. Not be harmed
B. Disclosure
C. Privacy
 D. Self-determination

97. A nurse preceptor observes that many clients are being readmitted in the ward for post-
operative infections. She suggests to the students that they do a research on this topic.
What research activity is this?

A. Sharing research results with colleagues

B. Identifying clinical problem
C. Developing guidelines for patient care
D. Data collection

98. Quantitative research involves numerical data. Which of the following is based on
quantitative research?

A. A study on the effects of the white uniform of hospital personnel on pediatric

patients
B. The effects of regular nurse visits to client’s bedside on the number of client’s
calls to the nurse
C. A study on benefits of pre-operative health instructions to client’s feeling of
anxiety
D. A study on the effevts of touch on the client’s feelings of isolation

99. Before the nurse researcher starts her study, she analyzes how much time, money,
materials and people she will need to complete the research project. This analysis prior to
beginning the study is called:

A. Validity
B. Feasibility
C. Reliability
D. Researchability

100. Data analysis is to be done and the nurse researcher wants to include variability. These
include the following EXCEPT:

A. Variance
B. Range
C. Standards of Deviation
D. Mean