NURSING PRACTICE III

Situation 1: Anthony, 55 years old and a music teacher sought

admission to the hospital because of laryngeal tumor. The
client is scheduled for total laryngectomy.
1. Before the nurse can develop a relevant care plan,
the nurse understands that in post-laryngectomy, the
trachea and the esophagus are permanently
separated. Therefore, hich of the folloing ill the
nurse e!pect"
A. #o ris$ of aspiration during salloing%
speech is lost
B. #ormal spea$ing, breathing and salloing
are restored
C. &nable to communicate ith di'culty of
salloing and breathing
D. (ermanent tracheostomy created% normal
speech is lost
). (re-operatively, the nurse identi*ed the nursing
dagnosis, +,noledge -e*cit: (ost-operative
communication strategies.. /hich of the folloing is
a relevant nursing intervention"
A. 0larify information on purpose, anticipate
bene*ts and conse1uences of total
laryngectomy
B. 2!plain that total laryngectomy results in
loss of ability to verbally communicate
C. Arrange a visit to a post-laryngectomy client
ho e3ectively uses an alternative form of
verbal communication
D. 4llustrate means of communicating post-
operatively
5. 4n the immediate post-operative period, the nurse
assesses coarse, high-pitched sound on inspiration
by listening over the trachea ith a stethoscope. The
nurse should immediately
A. (osition client to 6oler7s
B. 8eassure the client that he is doing *ne
C. Suction the tracheostomy tube
D. 8eport to the surgeon
9. /hich of the folloing e!pected outcomes for the
patient is most relevant for the nursing diagnosis +At
ris$ for imbalanced nutrition related to impaired
salloing."
A. Appropriate body eight maintained
B. 6ear of cho$ing relieved
C. :ral inta$e increased
D. Salloing of soft foods facilitated
5. The nurse is preparing Anthony for discharge. The
folloing are instructions regarding stoma and post
laryngectomy care e!cept
A. Avoid e!posure to persons ith upper
respiratory disease
B. 4nstruct client to assume supine position as
necessary
C. Avoid simming and use care hen using
the shoer
D. (revent foreign body from entering the
stoma
Situation ): The communication process is essential to the
manager or leader in supervising client care
;. The nurse ho e3ectively analy<es the
communication process recogni<es the messages are
A. 0onnotative and denotative
B. =earned and unlearned
C. >erbal and non-verbal
D. #ative as ell as foreign
?. Basically, communication is part and parcel of
planning to manage client care. /hich of the
folloing s$ills should be included" Select all that
apply.
1. 6ocusing 9. 0larifying
). :bserving 5. 8esponding
5. Attending ;. Teaching
A. 1, 5, 9, 5
B. ), 5, 9, 5
C. 5, 9, 5, ;
D. 1, ), 5, 9
@. The most controversial ay of communicating
doctor7s orders is by phone. 4t becomes valid and
legal only hen
A. 0ountersigned by the receiving 8#
B. Signed by the physician ho gave the order
C. Signed by the resident physician on duty
D. 0ountersigned by the medical doctor
A. To facilitate e3ective communication beteen an
immediate post-operative client and the nurse,
heBshe should
A. Caintain a clam attitude and Dust care for
the client as needed
B. 2ncourage the client to discuss feelingsBpain
or discomfort openly
C. :bserve non verbal cues
D. Assist the client to comfortable and safe
position hile heBshe e!plains hat measure
are being done
1E. The nurse instructs the nursing attendant to perform
cleansing enema until the return Fo is clear. The
nursing attendant understood the instruction hen
she says, +4 ill
A. 0all you hen the return Fo is clear.
B. Stop the enema only if the return Fo is
ithout formed fecal material.
C. #eed 1 liter of tap ater to have clear
return Fo.
D. (ut the client in left Sim7s position to
achieve the desired return Fo..
Situation 5: (ost-operative infection complication is still a
concern in surgical client7s care. Gospital sta3 needs to revie
practices to adhere to the standards of care to improve 1uality
and safe care delivery.
11. #urse Cercy is setting up for an emergency
caesarian section. The linen pac$s ere damp
although these ere Dust ta$en from the sterili<er.
The nurse7s appropriate action is
A. Bring the linen pac$s bac$ to the 0entral
Supply section for 1uality control
B. 0hange the damp linen pac$
C. :pen the linen pac$ and allo to dry
D. -o not use the damp linen
1). The clinical instructor assigned a nursing student to
assist the operation. /hen the nursing student
entered the :8 suite, her curly long hair as not
covered by the head cap. /hat ould the circulating
nurse do"
A. /elcome the nursing student to the :8
B. 8e1uest the clinical instructor to tell the
nursing student to use the head cap
properly
C. Assist the nursing student to tuc$-in all her
hair inside the head cap
D. -o not allo the nursing student to scrub in
15. After the surgeon *nished doing the surgical hand
scrub, she came in to the :8 suite singing her
hands casually. The scrub nurse should do hich of
the folloing appropriate action"
A. :3er a sterile toel to dry her hands
B. Serve the surgeon her sterile gon and
gloves as usual
C. Tell the circulating nurse to pour alcohol
?EH to the surgeon7s hands.
D. 8emind the surgeon to scrub again
19. /hen the intern-in-charge did the s$in prep and
catheteri<ed the client, the circulating nurse noticed
hen the intern ithdre the catheter from the
vagina. /hat is your appropriate and immediate
action"
A. Stop the intern and do the catheteri<ation
yourself
B. :3er to change the catheter
C. Alcoholi<e the tip of the catheter before
reinserting the catheter
D. Gold the hand of the intern to stop him from
reinserting the catheter

15. After the last stitch, the surgeon is ready to apply
dressing to the incision ound. /hich of the
folloing does the nurse e!pect the surgeon to do"
A. 8emove his gloves and apply the dressing
B. Apply the dressings and tape and then
remove his gloves
C. (ut the dressings and remove his gloves to
apply the tape
D. Tape the dressing and remove the gloves
Situation 9: A 5?-year-ols male client, post Billroth 44 as
admitted to the (ost Anesthesia 0are &nit I(A0&J from the :8.
The client is still sedated but responsive to commands. Ge has
a nasogastric tube draining orange-yello Fuid to a drainage
bottle
1;. The nurse ho admitted the patient recogni<es that
Billroth 44 procedure means
A. 2nterostomy
B. 2sophagoDeDunostomy
C. Kastroduodenostomy
D. KastroDeDunostomy
1?. After admitting the patient to the (A0&, the *rst
action of the nurse ould be to
A. Assess patency of the airay
B. 0hec$ the rate of the 4> infusion
C. Conitor the vital signs
D. Assess the clients pain
1@. As the nurse monitors the client, she notices a bright
red spot on the dressings hich measures 9cm in
diameter. The nurse should initially do hich
appropriate nursing intervention"
A. 0hange the top dressing
B. 0ontinue to monitor the vital signs
C. #otify the clients surgeon of a potential
hemorrhage
D. Assess the presence of a drain
1A. 4n assisting the client to do deep breathing, coughing
and turning to the sides on the *rst post-operative
day, hich nursing action ould be most helpful for
the client"
A. 8estate the importance of respiratory
e!ercises
B. Kive the client reassurance that can he can
cough, breathe deeply and turn to sides
safely
C. Administer the prescribed analgesic round
the cloc$ as prescribed
D. Apply abdominal splint IpilloJ hile
coughing
)E. The client complained of abdominal pain, nausea and
vomiting ith abdominal distention. The nurse
anticipates hich of the folloing priority
management after referring to the surgeon"
A. Kastric decompression
B. (ossible surgery
C. 2ndoscopy
D. 8ectal tube insertion
Situation 5: The behavior or actions of any professional nurse
especially hile on duty are often the reFection of their
values.
)1. Crs. 0. Serdenio is currently enrolled in the master7s
program at the State &niversity and is currently
riting her thesis. She applied as a chief nurse in St.
Lohn7s hospital and as accepted. Since her
assumption to o'ce, she has been signing
documents as master7s graduate a'!ing +8#, CA#.
to her name. the action of the chief nurse constitutes
A. Cisrepresentation
B. Calpractice
C. (ersoni*cation
D. Cisdemeanor
)). The charge nurse reported to the chief nurse that the
-emerol 5E cc vial inventory has been incorrect for
the last )9 hours. The most appropriate action of the
narcotic nurse is:
A. =og every inDection of -emerol
B. Ca$e fraction dosage li$e E.5 ml as 1 ml
C. -emerol inventory must be chec$ed every
endorsement by the narcotic nurse
D. 8evie endorsement of clients ho received
-emerol ithin the last )9 hours
)5. A sta3 nurse as found charting blood glucose result
ithout actually doing the procedure. /hat is the
appropriate initial action of the senior nurse"
A. /rite and submit an e!planation and
reprimand as necessary
B. Ko on leave ithout pay
C. /rite an incident report
D. 2!plain to the patient
)9. /hile ma$ing your (C shift endorsement, you sa
the nursing attendant receiving a pac$age from a
patient7s atcher. Mour appropriate action ould be
A. 8eprimand the nursing attendant right aay
B. 8emind the patient that gift giving to any
hospital sta3 is not alloed
C. 8evie ith the nursing attendant the
hospital policy
D. 2ndorse to the incoming shift for proper
action
)5. The 0ode of 2thics states that the nurse7s primary
commitment is to the client hether an individual of
family, group or community. /hich nursing activity
ould best demonstrate the ethical principle called
Dustice"
A. The nurse providing care on a +*rst come N
*rst served. basis
B. 8eferring the client for evaluation to the
social or$er on duty regarding her socio-
economic status
C. The client7s preference is least considered
D. The nurse7s providing care to ma!imi<e
health according to available resources
Situation ;: #urse 6ely is in charge of a client ho as
admitted for management of acute episode of cholecystitis.
);. #urse 6ely did her admission. She understands that
the pain is characteri<ed as
A. Tenderness that is generali<ed in the upper
epigastric area
B. (ain in the left upper 1uadrant radiating to
the left shoulder
C. Tenderness and rigidity at the left epigastric
area radiating to the bac$
D. Tenderness and rigidity at the upper right
abdomen radiating to the midsternal area
)?. To con*rm the diagnosis of cholecystitis, the
attending physician ordered a procedure that can
detect gallstones as small as 1 N ) cm and
inFammation. The nurse ould prepare the client for
hich speci*c diagnostic procedure"
A. 0holangiography
B. &ltrasonography
C. Kall bladder series
D. :ral cholecystogram
)@. The diagnosis as con*rmed as cholecystitis ith
gallstones. The doctor prepared the client for the
removal of the gallbladder. The client as$s the nurse
ho the procedure ill a3ect digestion. The nurse7s
most correct response ould be
A. 8emoval of the gallbladder ould
signi*cantly interfere only ith the digestion
of fatty foods.
B. 8emoval of the gallbladder does not usually
interfere ith digestion
C. The body ill adDust in due time
D. 8emoval of the gallbladder usually
interferes ith digestion but can be
remedied by dietary modi*cations
)A. 8evieing the laboratory *ndings of the client, the
nurse ould found hich *ndings are elevated"
1. /hite blood cell count
). Total serum bilirubin
5. Al$aline phosphate
9. 8ed blood cell count
5. 0holesterol
;. Serum amylase

A. 1, ), and 5
B. ), 5, and 9
0. 5, 5, and ;
-. 1, ), and ;
5E. A T-tube as inserted and the physician ordered,
+Conitor the amount, color, consistency and odor of
drainage.. /hich of the folloing procedures can the
nurse perform ithout the doctor7s order"
A. 0lamping
B. Aspirating
C. 4rrigating
D. 2mptying the drainage
Situation ?: Cary 8ose, 1; years old, is admitted to the
hospital for observation due to vague epigastric pain. The
doctor7s clinical impression is appendicitis.
51. Based on the initial manifestation on admission, the
nurse is loo$ing for positive manifestations of
appendicitis hich includes the folloing e!cept
A. Abdominal tenderness on palpation
B. =o grade fever
C. Thrombocytopenia
D. #ausea and vomiting
5). A positive sign of appendicitis is locali<ed and
rebound tenderness on palpation at hich 1uadrant
of the abdomen"
A. =eft upper 1uadrant
B. 8ight upper 1uadrant
C. =eft loer 1uadrant
D. 8ight loer 1uadrant
55. The client is scheduled to undergo appendectomy.
(reparation for appendectomy includes the folloing:
1. 4ntravenous infusion
). =a!ative
5. (ubic area shaving
9. 2nema
5. Shoer
;. (ain medication
A. ), 5, and 9
B. 1, 5, and 5
0. 1, ), and 5
-. 1, 5, and ;
59. The nurse monitors for signs of peritonitis, a potential
complication postoperatively. The manifestations
include the folloing e!cept
A. 6ever
B. Tachycardia
C. Abdominal tenderness
D. Soft abdomen
55. 4ntravenous therapy as prescribed. /hich of the
folloing is not an indication of the therapy"
A. To replace blood and Fuid loss
B. 6or antibiotic therapy
C. 6or parenteral nutrition
D. To promote renal function
Situation @: -rug administration is one of the collaborative
functions of the nurse that re1uire a ritten order of the
physician. To date, errors in medication continue to be a
problem in the health care setting across the globe.
5;. A nurse is obligated to carry out a physician7s order
e!cept
A. /hen the nurse is very busy
B. Believes an order to be inappropriate or
inaccurate
C. /hen the nurse does not understand the
order
D. /hen the client refuses
5?. /hen do you carry out the order of the physician"
A. /hen the consent has been signed by the
client or any appropriate person
B. /hen the physician has signed the order
C. As soon as the medicine or therapy is
available
D. /hen the guardian of the client is present
5@. A nurse encounters a client ho refuses to ta$e a
prescribed medication. /hat is the appropriate
action of the nurse"
A. Tell the client that he ill be subDected to
another mode of treatment li$e surgery
B. =et the client sign the aiver
C. 2!plore the possible reason hy the client
refuses the prescribed medication
D. 8efer the client to the attending physician
5A. 4n case of telephone orders, the concerned physician
needs to countersign the order ithin
A. The shift
B. As soon as possible
C. A time frame according to hospital policy
D. The day
9E. The nurse should ensure that all components of
medications are documented. 4dentify all these
components.
1. -osage, route and fre1uency
). #ame of client and medication
5. -ate and time the medication as ordered
9. -osage, route, fre1uency and strength
5. (hysician7s signature and specialty
;. (hysician7s signature and (80 license number
A. All e!cept 9 and 5
B. All e!cept 9 and ;
C. All e!cept 5 and ;
D. All e!cept 5 and 5
Situation A: #urse Cercy is assigned in the medical-surgical
unit and most of the clients assigned to her ere elderly
clients.
91. 6or a client complaining of mild musculos$eletal pain,
the nurse ill anticipate that the treatment for this
client7s level of discomfort ill include hich of the
folloing"
A. -ia<epam
B. Acetaminophen
C. Ceperidine G0l
D. 6entanyl
9). The nurse is to inDect >itamin B intramuscularly to
another elderly client. Before inDecting, the nurse
e!plained that the client may feel some discomfort.
This is an e!ample of
A. 8educing pain perception
B. Self-preservation
C. Anticipatory response
D. -istraction
95. Cr. Kome<, ?1 years old, has a history of chronic
bac$ pain. Ge thin$s that his family perceives him as
a +ea$ling. because he often as$s for pain
medication. /hich of the folloing is the most
therapeutic response of the nurse"
A. +4t seems that you are orried. /hich
matter to you more" /hat people ill say or
getting relief from your pain".
B. +Ta$ing pain medication as prescribed ill
help you become more active and your
family ill be happy to see you up and
about..
C. +0hronic pain is very di'cult to manage%
use pain medication because that is hat it
is for..
D. +-on7t you thin$ your family ants you to
be comfortable, and the only ay is to ta$e
your medicine".
99. Cang (edring has chronic pain due to osteoarthritis
and has impaired speech. /hich of the folloing is
the most appropriate to determine his medication
needs for pain"
A. :bserve typical pain behavior through facial
e!pressions
B. As$ing the client to rate his pain on a scale
of E to 1E by riting on a magic slate
C. Cedicate the client ith analgesic as often
as ordered
D. 8ecord fre1uency of client7s complaint of
pain and administer medication accordingly
95. Aling Luana, ;?, diabetic, complained of elevated
blood glucose since she strained her bac$ a ee$
ago despite folloing her diet and drug prescription.
Mour best e!planation ould be
A. (hysiologic and psychologic stress can
elevate blood glucose level
B. 0lient is consuming more food as a coping
mechanism
C. 4t is a usual occurrence among the elderly
D. (arasympathetic stimulation from the
body7s normal response to pain
Situation 1E: 8esearch is essential to the development of any
profession. Through research, $noledge can be validated and
de*ned, and ne $noledge can be generated. A team of
researchers proposed a study on the individual e3ect of
preoperative teaching on the early ambulation of omen ho
have undergone abdominal hysterectomy. Target populations
are omen admitted on the same day for total abdominal
hysterectomy.
9;. /hich of the folloing is the most appropriate
method to use"
A. #on-e!perimental method
B. Oualitative method
C. Ouantitative method
D. 2!perimental method
9?. /hich of the folloing designs ould be most
appropriate to use in attempting to determine the
participants7 early ambulation after they ill be given
preoperative teachings"
A. Time series design
B. (retest N posttest control group design
C. Solomon four N group design
D. :ne shot case study
9@. 4n the proposed study, the researchers de*ned the
selected groups and as$ hat sample si<e should be
used. Since there are many 1uali*ers that to some
e!tent samples must be speci*c to the study, the
general rule in the sample si<e is to
A. -etermine the duration of the study
B. 0onsider the type of the study
C. 2stablish the number of variables
D. Ca$e the sample as large as possible
9A. The independent variable that is manipulated is
A. /omen
B. Abdominal hysterectomy
C. Gealth outcomes
D. (reoperative teachings
5E. 4n treating the data to be collected, the researcher
ill use hich of the folloing statistical tools"
A. (earson r coe'cient of correlation
B. /eighted mean
C. 0hi s1uare test
D. T-test
Situation 11: (ain brings client to the hospital more than any
other symptoms. #urses should therefore be s$illful to assess
pain and reduce discomfort both for the client and family.
51. Albert came to the hospital ith chest pain and fever.
After a thorough assessment by the doctor, he as
admitted for pericarditis management. The nurse
positions the client to reduce pain and discomfort.
-escribe this position.
A. (rone position ith one pillo to support the
head
B. (ut to pillos to elevate the head and one
pillo under the $nees
C. Sit the client upright and lean forard
D. Supine lying on either left or right side ith
one pillo to elevate the head
5). The nurse is aare that pericarditis pain varies from
mild to severe and is typically aggravated by
A. 0oughing, tal$ing and eating
B. 4nspiration, coughing, movement of the
upper body
C. Breathing, coughing and voiding
D. 0oughing, inspiration and movement of the
loer e!tremities
55. Albert7s mother as$s hy the client7s breathing is
shallo. The correct response of the nurse ould be
A. +The client is conserving his energy..
B. +That is good because the client is not
asting the much needed o!ygen..
C. +Ge is preventing unnecessary movement..
D. +8espiratory movement intensi*es
pericardial pain.
59. Albert is prescribed #SA4- every four hours to
relieve, fever, inFammation, and pericardial pain. To
ma!imi<e the e3ect of the drug, the nurse ould
administer it
A. /hen the client as$s for it
B. :n an empty stomach
C. 8ound the cloc$ on a consistent basis
D. /hen the client is aa$e only
55. The nurse ants to $no if the client is aare of the
side e3ects of #SA4-. /hat ould be the most
appropriate 1uestion of the nurse"
A. +Are you aare that you can be addicted to
the drug".
B. +Gave you ever vomited blood or noticed
very blac$ stools".
C. +Go familiar are you ith the drug".
D. +Gave you noticed something unusual ith
your urination".
Situation 1): #urse 0arla admitted Garry for management of
acromegaly.
5;. The nurse is aare that acromegaly is a condition
hen groth hormone occurs in e!cess in adulthood
or after epiphyses of the long bones have fused. The
folloing are the typical features of the disorder
e!cept
A. The soft tissues continues to gro
B. Gands and feet are enlarged
C. The client gros taller
D. Broad and bulbous nose
5?. The client as prescribed :creotide acetate
ISandostatinJ. #urse 0arla ould monitor for hich of
the folloing side e3ects"
A. Abdominal pain
B. -ysuria
C. Gypotension
D. 0onstipation
5@. 6or e3ective dosing, :creotide acetate must be
administered by hich appropriate route, three times
ee$ly"
A. 4ntravenously
B. 4ntramuscularly
C. :rally
D. Subcutaneously
5A. (riority discharge plans should include hich of the
folloing"
1. 6asting blood sugar monitoring
). Bone assessment
5. 4nta$e and output
9. &rine output
A. ) and 5
B. 1, ), and 5
0. All e!cept 1
-. 1 and )
;E. Acromegaly often develops insidiously that nurses
should understand that the client ith this disorder
ould see$ medical care because of
A. Alteration in fat and carbohydrate
metabolism
B. 0hanges in blood sugar level
C. 0hanges in appearance
D. Alteration in their voice
Situation 15: (art of your duty hile on (C shift at the medical
ard is to give health instructions to clients and signi*cant
others especially during visiting hours.
;1. A client ith gout as$s the nurse hat food must be
avoided so that the family can provide support.
/hich food has the highest in purine content and
must be e!cluded from the dietary plan"
A. 0hic$en
B. 0arrots
C. 0hocolate
D. =iver
;). A 5E-year-old client had cholesterol blood test before
admission to the hospital. The nurse in charge ould
teach the family and signi*cant others that the client
should e!ercise to help $eep the total cholesterol to a
desired level of
A. 19E mgBdl
B. )EE mgBdl
C. )5E mgBdl
D. 5EE mgBdl
;5. A hypertensive client is ta$ing herbal supplement for
his hypertension. Ge as prescribed antihypertensive
medication. The client ants to continue ta$ing his
herbal medication to loer his blood pressure. The
nurse7s most appropriate action is to
A. Advise the client to discuss this concern
ith the attending physician
B. Tell the client that herbal supplements have
no proven therapeutic e3ects
C. Tell the client that herbal and the prescribed
medications are not compatible
D. 4nstruct the client to have a more fre1uent
B( chec$ing
;9. The client as placed on a lo sodium diet. The ife
as$s the nurse hich foods to include in the client7s
diet hile at home. The nurse should instruct to
include hich of these"
A. 0anned foods
B. (reserved foods
C. 6ruits and vegetables
D. Salt ater *sh
;5. /hile the nurse as chec$ing the B( of the client,
the ife as intently observing the nurse. The ife
as$s the nurse ho to ensure accurate measurement
of B( reading. 4dentify all the nurse mentioned that
ill ensure accurate B( reading.
1. Ta$ing the B( 15 minutes after inta$e of
antihypertensive drug
). Ceasuring the B( after the client has
been seated for 5 minutes
5. Seating the client ith arm bared
supported and at the heart level
9. &sing the cu3 ith rubber bladder that
encircles at least @EH of the arm
5. Kauges of B( apparatus should be
calibrated every @ hours
;. The client should rest 1uietly for 5
minutes before reading and can tal$ hile
B( is being chec$ed
A. 1, ), 5, and 9
B. 5, 9, 5, and ;
0. ), 5, 9, and 5
-. ), 9, 5, and 5
Situation 19: Carina, a nely hired sta3 nurse in the medical
surgical unit as assigned to or$ ith a senior nurse. A
female client as admitted ith a diagnosis of diabetic foot,
gangrene left toe, type ) diabetes.
;;. 6rom the nursing history obtained from the client,
hich information is most li$ely related to the
development of gangrene on the client7s left toe"
A. (referred open toed sandals to closed
leather shoes
B. Type ) diabetic diagnosed 15 years ago
C. 6ather had type ) diabetes% post-above-
$nee amputation right leg
D. Accidental cut in big toe hile cutting toe
nails
;?. The physician ordered bilateral loer e!tremities
-oppler ultrasound. /hich of the folloing is the
physician interested to *nd out through this
diagnostic test"
A. -istal paresthesias
B. :!ygenation of the tissues in the loer
e!tremities
C. :cclusion of large vessels and arterioles
D. 4solated peripheral neuropathies
;@. The senior as$ed Carina to list nursing interventions
for the nursing diagnosis +4ne3ective tissue
perfusion: peripheral.. 6rom the folloing list, hich
intervention ill the senior nurse consider to be
contraindicated"
A. 8egular passive and active e!ercises of all
e!tremities
B. ,eep e!tremities arm using a foot cradle
C. 2ncourage fre1uent changes in position
D. Caintain both e!tremities in a dependent
position
;A. /hen Carina chec$ed the capillary blood glucose of
the client at ; (C before meals as instructed by the
senior nurse, the result shoed ;5 mgBdl. /hich of
the folloing ill Carina do *rst"
A. Kive Duice as prescribed in the insulin scale
pre-meals
B. 8echec$ 0BK
C. 0hec$ the physician7s order in case 0BK is
belo ?E mgBdl
D. =oo$ for the senior nurse and report
?E. The senior nurse observes that Carina occasionally
does not follo agreed upon interventions. The
senior nurse reports that Carina should improve in
hich of the folloing"
A. 4dentifying on learning needs
B. Attitute toard criticism
C. 0ompliance to standards
D. -emonstration of proper decorum
Situation 15: A 59-year-old female client ith Krave7s disease
as admitted for treatment. The physician prescribed
(ropylthiouracil to treat the disorder.
?1. Before the nurse administers the medication, hich
of the folloing is most relevant for the nurse to as$"
A. +-o you e!perience gastric discomforts".
B. +/hen as the last time you tool alcohol".
C. +/hen as your last menstruation".
D. +-o you prefer a li1uid form of medication".
?). The client is to have surgery in 1E days. =ugol7s
solution 9 gtts po as prescribed in 1E days. The
client as$ed the nurse for the purpose of the drug.
/hich response of the nurse is correct"
A. 4t decreases the ris$ of bleeding
B. 4t eliminates the needs to ta$e hormone
replacement
C. 4t stabili<es your immune system to
ithstand surgery
D. 4t decreases the ris$ for thyroid crisis
?5. /hen the client returns to the unit after surgery,
hich techni1ue is most appropriate to monitor
bleeding from the incision"
A. /eigh all gau<e dressing before and after
changing ound dressings
B. Assess for dampness at the bac$ of the
client7s nec$
C. (ass a Fashlight across the incision ound
on top of the dressings
D. 8emove the dressings to directly inspect the
incision ound
?9. /hich of the folloing assessment *ndings hen
observed in a post-thyroidectomy client is indicative
of a thyroid crisis"
A. 6alling blood pressure
B. 8egular and noisy respiration
C. Gigh fever
D. Spasm in the hand
?5. At the start of thyroid replacement post-total
thyroidectomy, the nurse must monitor for side
e3ects. /hich side e3ects ould the nurse e!pect to
assess"
1. Gypertension
). Tremors
5. Girsutism
9. 4nsomnia
5. Tachycardia
;. Gyperglycemia
A. 5, 9, 5, and ;
B. 1, ), 5, and ;
0. 1, 5, 9, and 5
-. 1, ), 9, and 5
Situation 1;: The illingness of nurses to accept a set of
professional and ethical principles and apply it in their daily
a3airs is the hallmar$ of a true professional.
?;. A client is being positioned for radical vulvectomy
and a couple of clinical cler$s anted to come in to
atch the surgery. The circulating nurse advise them
to enter the :8 suite later. 6oremost, this decision of
the nurse is directed toards
A. 8especting the client7s rights
B. (reventing infection
C. Cinimi<ing a crod in the room
D. (reserving privacy
??. #urse ,ristine is to inDect -emerol ?5 mg to a post-
T&8( Itransurethral resection of the prostateJ client
ho is in pain. /hen she chec$ed the narcotic
cabinet, she found out a vial that is almost empty.
She as able to aspirate ;E mg only. #urse ,ristine
decided to inDect it instead of ma$ing the client ait
until the ne!t -emerol vial is available. The action of
the nurse violates hich of the folloing ethical
principles"
A. Lustice
B. Bene*cence
C. Truth
D. Autonomy
?@. #urse #ora is assigned on (C shift for the month of
Lune. She re1uested the head nurse if she can be on
night or morning instead to be able to tutor her )
sons in the elementary. The head nurse emphasi<ed
that it is her turn to go on (C duty. The action of the
head nurse e!empli*es hich of the folloing"
A. Authority
B. 6idelity
C. Autonomy
D. Lustice
?A. A scrub nurse is assisting an emergency 0esarian
section on a 5A-year-old laundry oman. Before
closing the peritoneum, the surgeon as$s, +Go old
is the client". Golding the fallopian tube, the surgeon
as$s for a hemostat. The scrub nurse sensing that
the surgeon is about to ligate the tube said, +-octor
there is no signed consent for tubal ligation.. The
nurse Dust demonstrated hich of the folloing"
A. 4nsubordination
B. Abandonment of duty
C. Advocacy
D. Calpractice
@E. An o'cer-in-charge signs a document for the chief
nurse ho ent on leave. The :40 signs her full
name over the name of the chief nurse. The proper
ay to sign for the chief nurse ho is on leave is
A. Sign your name over the printed name of
the chief nurse
B. /rite +for. before the title of the chief nurse
then sign your name above it
C. 2rase the name of the chief nurse and rite
your name then sign
D. Sign on a separate line as :40
Situation 1?: Sponge count should be performed by to
members of the surgical team in any surgical procedure here
there is a possibility that the sponge can be retained.
@1. The scrub and circulating nurse should perform
sponge count during hich phases of an abdominal
hysterectomy procedure"
1. Before the procedure
). Before closing the endometrium
5. Before closing the peritoneum
9. At the s$in closure
5. /hen the scrub nurse goes for a lunch
brea$
A. All e!cept 5
B. All e!cept 1
0. 5 and 9 only
-. All e!cept )
@). The :8 nurse $nos that the correct ay to count
sponge is
A. Scrub nurse counts singly folloed by the
circulating nurse
B. Scrub and circulating nurse count by pac$s
of tens
C. Scrub nurse and circulating nurse count
audibly by pac$s of *fties
D. Scrub nurse and circulating nurse count
singly, audibly and concurrently
@5. The scrub nurse and circulating nurse also counted
the sharps and miscellaneous items li$e instruments
before the procedure. 0ontinuous accounting for
these items can primarily
A. 2!pedite the procedure thus shortening the
surgical time
B. 4mprove hospital miscellaneous revenue
C. Cinimi<e inDuries andBor liabilities to sterile
surgical team
D. Shorten surgical cases turnover by 15 N 5E
minutes
@9. The circulating nurse ill document +surgical count.
in hich of the folloing"
A. :bservation notes
B. 4ntraoperative record
C. #urse7s notes
D. 0hec$list
@5. /hen the surgeon as$ed for suture to close the
abdomen, sponge count has not been completed.
/hich of the folloing is the appropriate action of the
scrub nurse"
A. 8e1uests the surgeon to rechec$ the
abdomen for sponges, if any
B. 0ontinues to count the sponges
C. Gands obligingly the suture for closure to
the surgeon
D. 4nforms the surgeon that sponge count has
not been completed
Situation 1@: The continuum of care is facilitated by e3ective
communication among the members of the health care team.
This activity is facilitated by documenting reports.
@;. The change of shift report of nurses describes the
folloing e!cept
A. (riority clients and impending needs
B. 0lient health status
C. #urses priority needs
D. 0lient special needs
@?. /hen the sta3 nurse on duty encounters a problem
that cannot be solved using nursing $noledge, s$ills
and available resources, it is best for the nurse to
consult the
A. #urse supervisor
B. Cedical director
C. Gead nurse
D. 0hief nurse
@@. /hen the nurse ensures that the client has plan for
continuous care after leaving the health care facility
and assists from the transition from one environment
to another, she is doing a
A. -ischarge plan
B. Admission plan
C. 8eferral
D. #ursing care plan
Answer: A
Rationale: Discharge planning is the process of preparing a client
to leave one level of care for another within or outside the current
health care agency. Usually, discharge planning refers to the client
leaving the hospital for home. However, discharges occur among
many other settings. Within a facility it can occur from one unit to
another.
Reference: - p. !, "o#ier et al, $%%&
@A. A nurse has to attend a committee meeting for to
hours. She delegates her or$ to another nurse.
/hat primary consideration should be observed"
A. Availability of resources
B. Time needed to perform delegated function
C. /illingness to assist
D. 0ompetency to perform the given function
AE. /hen a telephone order is made, it should be
documented by the nurse ho is receiving the order.
The folloing should be included in the order to be
e!ecuted e!cept
A. Time the call as made and its duration
B. /ho made the call and ho received the
order
C. /hat information as given and for hom
as the order
D. /hen the order as made and ho made
the order
Situation 1A: #urse Abe receives a subpoena as a itness in a
court case.
A1. /hich of the folloing best describes the
responsibility of the nurse as a itness in a case of
court"
A. (rotect the patient
B. State the truth
C. 0ollaborate ith the primary physician
D. 8elate a dramatic e!perience
A). /hich doctrine is invo$ed if an abdominal P-ray of a
postoperative patient shos a forcep inside the
abdomen"
A. 6orce maDeure
B. Borroed servant doctrine
C. 8es ipsa lo1uitor
D. -octrine of captain of the ship
A5. /hen the nurse is called to itness and as told to
bring the patient7s chart, hat is needed to legally
summon the client7s chart in court"
A. 8e1uest order
B. #otari<ed letter from the complainant
C. (ermission from the client
D. Subpoena from the Dudge
A9. /hen #urse Abe presents the patient7s chart as
evidence of a case, this is called aBan
A. -uces tecum
B. Appendices
C. 2!hibit
D. -ocumentation
A5. /hen a case is already *led in court, it is a court rule
not to discuss the matter outside the court. This is
A. Calpractice
B. Cotu proprio
C. SubDudice
D. Sine-1ua-non
Situation )E: A nursing student as assigned to ta$e care of a
client ith polycythemia vera.
A;. Mou planned the nursing care of the client together
ith the nursing student. Mou as$ed the nursing
student to enumerate the clinical manifestations of a
client ith polycythemia vera. Mou e!pect the nursing
student to enumerate the folloing manifestations
e!cept
A. Kenerali<ed pruritus
B. Gepatomegaly
C. Splenomegaly
D. 8uddy comple!ion
A?. The nursing student revies the laboratory *ndings
and *nds hich blood results are elevated"
A. 8B0, /B0, and platelets
B. /B0, platelet, and cholesterol
C. Bilirubin, 8B0, and platelet
D. B(, /B0, and hematocrit
A@. (hlebotomy as ordered as part of the therapy. Mou
instructed the client and emphasi<ed that the
procedure can be repeated. The client in1uired,
+/hat is the primary aim of the procedure". Mour
appropriate response is
A. +4t removes the e!cess blood and donate to
patients of the same blood type..
B. +4t prevents headache and di<<iness..
C. +4t $eeps the B( reading ithin normal
range..
D. +4t $eeps the hematocrit ithin normal
range..
AA. The companion as$s hy the client as advised to
avoid iron supplements or vitamins. The correct
response of the nurse ould be
A. +These supplements enhance the
production of 8B0..
B. +The vitamins and iron can suppress bone
marro function..
C. +Actually the patient does not need these
supplements..
D. +4t is best that the client gets these
supplements from natural sources..
1EE.The client complained of generali<ed pruritus. The
folloing are appropriate nursing interventions
e!cept
A. Administer routine antihistamine Qround the
cloc$
B. 8egulate the temperature to )5 degrees
centigrade or loer
C. Bathe in tepid or cool ater folloed by
cocoa-based lotion application
D. /ear light material loose-*tting camisa