Professional Documents
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Nursing-Practice I
Nursing-Practice I
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.
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:
5. The rationale for giving medications through the subcutaneous route is:
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
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. 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?
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:
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:
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a
client for discharge include all EXCEPT:
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:
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:
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?
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:
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:
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:
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:
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
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
44. The nurse applies dressing on the bleeding site. This intervention is done to:
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:
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.
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:
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 2 nd 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.
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:
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:
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. 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:
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
63. The most important nursing responsibility where ethical situations emerge in patient care is to:
64. You inform the patient about his rights which include the following EXCEPT:
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. 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:
70. Part of standards of care has to do with the use of restraints. Which of the following statements is
NOT true?
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:
72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
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:
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?
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:
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.
82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
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
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
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:
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:
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:
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:
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:
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