REFRESHER COURSE: PREBOARD EXAMINATION

Nursing Practice I: Basic Foundation of Nursing and

Professional Practice
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE I” on the box provided.
Situation: Nursing is a profession. Miss Perez is a newly
appointed nurse in a hospital in Manila. Born May 1993, her
Knowledge of nursing profession development is
Required in order to project the profession in a way that it
uplifts the standard of nursing.
1. Miss Perez defined nursing as the following except: 6. Jenny plans to resign from her job as a staff nurse. She
A. Assisting individual, family, and community in attaining must give an advance notice of:
health A. 15 days C. 45 days
B. Assisting in basic health needs B. 30 days D. 60 days
C. Establishing nursing diagnosis and implementing nursing
care 7. If a nurse filed a sick leave and plans to return to work
D. Diagnosing, treating, prescribing medication and doing after, she must show her:
minor surgery A. Back to work certificate
B. Fit to work certificate
2. PNA was established: C. Death certificate
1. In 1922 D. Medical certificate
2. In 1926
3. With Mrs. Rosario Delgado as the first president 8. A certificate that will show that a nurse met the requirement
4. With Mrs. Anastacia Tupas as the first president set by the Philippine Government to practice the profession is:
A. 1 and 3 C. 2 and 3 A. Diploma
B. 1 and 4 D. 2 and 4 B. Certificate of passing
C. Nursing License
3. As a national nurses’ association, PNA is characterized by D. Board certificate/CoR
the following, except:
A. Both a professional body and labor union 9. Nurses in the Philippine Government also felt the need to
B. Affiliated with the International Council of Nurses organize themselves, this led to the creation of:
C. Advocating improved work and life condition of nurses A. National League of Government Nurses
D. Accrediting body for continuing education program B. National League of Filipino Government Nurses
C. National League of Philippine Government Nurses
4. CPE units per year are needed for license renewal. The D. Philippine Government Nurses Association
number of CPE units in 3 years should be:
A. 20 units 10. The founder of NLPGN, during her lifetime, exemplified
B. 30 units professional dignity, high level of intelligence and leadership
C. 60 units ability, as well as moral integrity. She was a good model, who,
D. 100 units like Florence Nightingale, initiated reforms and worked for the
improvement of the nursing profession and health care in the
5. To manifest that you want to quit from your job and Philippines. The name of the NLPGN Recognition award was
discontinue the services you render after the completion of a also named after her.
contract, you will file a/an: A. Anastacia Giron Tupas C. Betty Meritt
A. Certificate of resignation B. Francisca Delgado D. Annie Sand
B. Honorable dismissal
C. Certificate of termination
D. Resignation letter

D. Massage the skin gently to stimulate oil production from the

Situation: Anicieto is an elderly client who is immobile and sebaceous glands
sedentary.
12. Which of the following is a frequently used dressing for
11. Anicieto is frequently complaining of dry skin. Which of the pressure sores?
following is the best way to prevent dry skin? A. Transparent C. Wet to moist
A. Wash the skin with mild soap and water B. Wet to dry D. Hydrogel
B. Avoid exposure to cold or low humidity
C. Apply lotion or skin moisturizer 13. Heat is an old remedy for aches and pain. People equate
heat with comfort and relief because:
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 A. It is safer than cold application D. Gingko biloba has an effect on enhancing memory and
B. It causes a local anesthetic effect retention of 4th year high school students
C. It promotes blood circulation and tissue oxygenation
through vasodilation 22. Which of the following best represents the alternative
D. Slows bacterial growth hypothesis (Ha) for this study?
A. Gingko biloba has no effect on enhancing memory and
14. Heat and cold application should not exceed: retention
A. 10 minutes C. 30 minutes B. Gingko biloba has an effect on enhancing memory and
B. 15 minutes D. 1 hour retention
C. Gingko biloba has no effect on enhancing memory and
15. A client with deep wounds underwent Hydrocolloid retention of 4th year high school students
dressing. Which of the following is true with regards to this D. Gingko biloba has an effect on enhancing memory and
dressing? retention of 4th year high school students
A. They provide good wound visibility
B. They could last indefinitely until the wound heals 23. Which of the following is the average P value as threshold
C. They can be molded to uneven skin surfaces thus best used to determine the plausibility of the null hypothesis?
in pressure ulcers A. P=0.05 C. P=0.001
D. The client could not shower or bath with such dressing B. P=0.01 D. P=0.5

Situation: You are a nurse conducting a statistical analysis in 24. If the study is statistically highly significant, it would reflect
your research entitled “The Effect of Gingko Biloba in a p value of?
Enhancing Memory and Retention Among 4th Year High School A. p=0.05 C. p=0.001
Students.” B. p=0.01 D. p=0.5

16. What is the independent variable? 25. Supposed that your alternative hypothesis has a 1 in a
A. The effect of gingko biloba hundred chance of accepting the null hypothesis, has a 99%
B. Memory and retention chance of being correct, and has a 1 in a hundred chance that
C. Gingko biloba the null hypothesis is true. Your P value will be?
D. Enhancing memory and retention A. P=0.99 C. P=0.001
B. P=0.01 D. P=0.5
17. What is the dependent variable?
A. The effect of gingko biloba Situation: Survey and Statistics are important parts of research
B. Memory and retention that is necessary to explain the characteristics of the
C. Gingko biloba population.
D. Enhancing memory and retention
26. All but one of the following is not a measure of central
18. The research design best used in this research is: tendency.
A. Experimental A. Mode C. Standard deviation
B. Non-experimental B. Variable D. Range
C. Descriptive
D. Qualitative 27. It reflects the most frequent value that appears in the set
data.
19. The hypothesis developed was: Gingko biloba improves A. Mean C. Median
memory and retention. This is an example of: B. Mode D. Ratio
A. Simple, directional
B. Simple, non-directional 28. In the values: 87, 85, 88, 92, 90, the mean is:
C. Complex, directional A. 88.2 C. 87
D. Complex, non-directional B. 88.4 D. 90

20. Gingko biloba has an effect on memory and retention best 29. In the values: 80, 80, 80, 82, 82, 90, 90, 100, the mode is:
describes which type of hypothesis? A. 80 C. 90
A. Simple, directional B. 82 D. 85.5
B. Simple, non-directional
C. Complex, directional 30. In the values: 80, 80, 10, 10, 25, 65, 100, 200, the median
D. Complex, non-directional is:
A. 71.25 C. 10 and 25
21. Which of the following is the best null hypothesis (H 0) for B. 22.5 D. 72.5
this study?
A. Gingko biloba has no effect on enhancing memory and
retention
B. Gingko biloba has an effect on enhancing memory and
retention
C. Gingko biloba has no effect on enhancing memory and
retention of 4th year high school students
Situation: As a peri-operative nurse, you are aware of the
correct processing methods for preparing disinfection.
32. Before you use an instrument disinfectant, it is essential
31. As an OR nurse, what is your foremost consideration for that you:
selecting chemical agents for disinfection? A. Rinse with tap water followed by alcohol
A. Material compatibility and efficiency B. Wrap the instrument with sterile cloth
B. Odor and availability C. Dry the instrument thoroughly
C. Cost and duration of disinfectant process D. Rinse with sterile water
D. Duration of disinfectant and efficiency

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 33. You have a critical heat labile instrument to sterilize and 41. Which leadership style best empower the staff towards
are considering using high level disinfectant. What should you excellence?
do? A. Autocratic C. Democratic
A. Cover the soaking vessel to contain the vapor B. Situational D. Laissez faire
B. Double the amount of high level disinfectant
C. Test the potency of the high level disinfectant 42. As nurse manager, Jillian enjoys her staff of talented and
D. Prolong the exposure time according to manufacturer’s well-motivated individuals. She knew the leadership style to
direction suit the needs of this kind of people is called:
A. Autocratic C. Democratic
34. To achieve sterilization using disinfectant, which of the B. Participative D. Laissez faire
following is used?
A. Low level disinfectant immersion for 24 hours 43. A fire has broken in Jillian’s unit. The best leadership style
B. Intermediate level disinfectant immersion for 12 hours suited in cases of emergencies like this is:
C. High level disinfectant immersion for 1 hour A. Autocratic C. Democratic
D. High level disinfectant immersion for 10 hours B. Participative D. Laissez faire

35. Bronchoscope, thermometer, endoscope, ET tube,
cystoscope, are all best sterilized using which of the following?
A. Autoclaving at 1210C in 15 minutes
B. Flash sterilizer at 1320C in 3 minutes
C. Ethylene oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 30 minutes
Situation: Health promotion is the priority nursing
responsibility. The nurse should be able to promote the client’s
well-being and identify ways on improving the client’s quality
of life.
36. The nurse is caring for a 16-year old female client who isn’t
sexually active. The client asks if she needs a Papanicolau test.
The nurse should reply:
A. Yes, she should have a Pap smear after the onset of
menstruation
B. No, because she isn’t sexually active
C. Yes, because she’s 16 years old
D. No, because she is not yet 21 years old
37. The nurse is assessing a client who complains of abdominal
pain, nausea, and diarrhea. When examining the client’s
abdomen, which sequence should the nurse use?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, auscultation, percussion, inspection
38. The nurse is speaking to a group of women about early
detection of breast cancer. The average age of women in the
group is 45. Following the Philippine Cancer Society guidelines,
the nurse should recommend that the women should:
A. Perform a breast self-examination annually
B. Have a mammogram annually
C. Have a hormonal receptor assay annually
D. Have a physician conduct a clinical examination every 2
years
44. Mrs. Vergara is thinking of introducing the Primary Nursing
Model Approach. You understand that in this nursing model:
A. The nurse manager assigns tasks to the staff members
B. Critical paths are used in providing nursing care
C. A simple registered nurse is responsible for planning and
providing individualized nursing care
D. Nursing staff are led by an RN leader in providing care to a
group of clients
45. Evaluation as administrative process is best described as:
A. Obtaining commitment of members to do better
B. Follow-up activities that have been stated
C. A continuing process of seeing that performance meet goals
and targets
D. Informing personnel how well and how much improvement
has been made
Situation: Mr. Delos Reyes, 70 years old, was suddenly rushed
to the hospital because of severe chest pain. On admission, he
was diagnosed to have an acute myocardial infarction and was
placed in the ICU.
46. While he is in the ICU, he executes a document that lists
the medical treatments he chooses to refuse in case his
condition becomes severe to a point that he will be unable to
make decisions for himself. The document is:
A. Living will C. Last will and testament
B. Power of attorney D. Informed consent
47. After one day, the patient’s condition worsened and he felt
hopeless. He requested the nurse to remove the oxygen. The
nurse should:
A. Follow the patient because it is his right to die gracefully
B. Refuse the patient since euthanasia is not accepted in the
Philippines
C. Follow the patient as it is his right to determine the medical
regimen he needs
D. Refuse the patient and encourage him to verbalize his
feelings

39. The school nurse is planning a program for a group of 48. Euthanasia is an ethical dilemma which confronts nurses in
teenagers on skin cancer prevention. Which of the following the ICU because:
instruction should the nurse emphasize on her talk? A. Decisions has to be made quickly, often under stressful
A. Stay out of the sun between 1 pm and 3 pm situations
B. Tanning booth is a safe alternative for those who wish to B. Decisions has to be made based on societal norms
tan C. The choices involved do not appear to be clearly right or
C. Sun exposure is safe, provided the client wears a protective wrong
clothing D. A client’s legal rights co-exist with the nurse’s professional
D. Examine skin once per month, looking for suspicious lesions obligation
or changes in moles 49. The personal conviction that euthanasia is absolutely
wrong in any situation is:
40. An employer establishes a physical exercise area in the A. Personal value
workplace, and encourages all employees to use it. This is an B. Legal obligation
example of which level of prevention? C. Ethical issue
A. Primary prevention C. Tertiary prevention D. Immoral belief
B. Secondary prevention D. Passive prevention
50. Mr. Delos Reyes felt better after 3 days but recognized the
Situation: Mrs. Vergara is now the chief nurse of a hospital in severity of his illness. He executed a document authorizing his
Manila. She is clinically reviewing different management styles wife to transact any form of business in his behalf in addition
and theories that will best help her in running the nursing to all decisions relative to his confinement. This document is
services in the hospital. referred to as:
A. Power of attorney C. Medical record
B. Informed consent D. Living will
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Situation: Nursing as a profession. The nurse should have a
background on the theories and foundation of nursing as it has
influenced what nursing is today.
51. Nursing is the protection and optimization of health and
abilities, prevention of illness and injury, alleviation of suffering
through the diagnosis and treatment of human response and
advocacy in the care of the individuals, families, communities
and the population. This is the most accepted definition of
nursing as defined by:
A. PNA C. Florence Nightingale
B. ANA D. Virginia Henderson
52. Advancement in nursing leads to the development of the
expanded career roles. Which of the following is not an
expanded career role for nurses?
A. Nurse practitioner C. Nurse researcher
B. Clinical nurse specialist D. Nurse anesthesiologist
53. The board of nursing regulated the nursing profession in
the Philippines and is responsible for the maintenance of the
quality of nursing in the country. Powers and duties of the
board of nursing are the following, except:
A. Issue, suspend, revoke certificates or registration
B. Issue subpoena, decus tecum, ad testificandum
C. Open and close college of nursing
D. Supervise and regulate the practice of nursing
54. A nursing student or a beginning staff nurse who has not
yet experienced enough real situations to make judgments
about them is in what stage of nursing expertise?
A. Novice C. Advanced beginner
B. Newbie D. Competent
55. Benner’s “proficient” nurse level is different from the other
levels in nursing expertise in the context of having:
A. The ability to organize and plan activities
B. Attained an advanced level of education
C. A holistic understanding and perception of the client
D. Intuitive and analytic ability in new situations
Situation: The nurse has been asked to administer an injection.
56. The nurse prepares an IM injection for an adult client using
the Z track technique. 4 mL of medication is to be
administered to the client. Which of the following sites will you
choose?
A. Deltoid C. Ventrogluteal
B. Rectus femoris D. Vastus lateralis
57. In infants 1 year and below, which of the following is the
site of choice for intramuscular injection?
A. Deltoid C. Ventrogluteal
B. Rectus femoris D. Vastus lateralis
58. Mrs. Morales is obese. When administering subcutaneous
injection to an obese patient, it is best for the nurse to:
A. Inject needle at 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 via Z track
D. Spread skin or pinch at the injection site and inject needle
at a 45-90 degree angle
59. 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 to 27
C. Syringe 2 mL and needle gauge 22
D. Syringe 1-3 mL and needle gauge 25 to 27
60. The rationale for giving medications through the
subcutaneous route is:
A. There are many alternative sites for subcutaneous injection
B. Absorption time of medication is slower
C. There are less pain receptors in the area
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D. The medication can be injected while the client is in any
position
Situation: A client was rushed to the Emergency Room and you
are his attending nurse. You are assessing the vital signs.
61. After a few hours in the emergency room, the client is
admitted to the ward with an order of hourly monitoring of BP.
The nurse finds that the cuff is too narrow and this will cause
the BP 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
62. You attached a pulse oximeter to the client. You know that
the purpose of this is to:
A. Determine if the client’s hemoglobin level is low and if he
needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s antihypertensive
medications
D. Detect oxygen saturation of arterial blood before symptoms
of hypoxemia develops
63. Through the client’s health history, you found out that the
patient smokes and drinks coffee. When taking the BP of a
client who recently smoked or drank coffee, how long should
the nurse wait before taking the client’s BP for accurate
reading?
A. 5 minutes C. 30 minutes
B. 15 minutes D. 1 hour
64. While the pulse oximeter is on the client’s fingertip, you
notice that the sunlight is shining on the area where the
oximeter is. Your action will be to:
A. Turn on and set the alarm of the oximeter
B. Do nothing since there are no identified problems
C. Cover the fingertip sensor with a towel or bed sheet
D. Change the location of the sensor every four hours
65. You are to assess the temperature of the client the next
morning and found out that he ate ice cream. How many
minutes should you wait before assessing the client’s oral
temperature?
A. 10 minutes C. 20 minutes
B. 15 minutes D. 30 minutes
Situation: Oral care is an important part of hygienic practices
and promoting client comfort.
66. When performing oral care to an unconscious client, which
of the following is a special consideration to prevent aspiration
of fluids into the lungs?
A. Put the client on side-lying position with head of bed
lowered
B. Keep the patient dry by placing a towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly
progression
67. A possible problem while providing oral care to
unconscious clients is the risk of fluid aspiration to the lungs.
This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked in
mouthwash to avoid rinsing the buccal cavity
B. Swabbing the inside of the cheeks and lips, tongue, and
gums with dry cotton swabs
C. Use finger wrapped with wet cotton washcloth to rub inside
the cheeks, tongue, lips and gums
D. Suctioning as needed while cleaning the buccal cavity
68. Your client has difficulty of breathing and is mouth
breathing most of the time. This causes dryness of the mouth
with unpleasant odor. Oral hygiene is recommended for the
client and in addition, you will keep the mouth moistened by
using:
A. Salt solution C. Petroleum jelly
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 B. Water D. Mentholated ointment
69. A nurse is observed taking all of the following actions when
suctioning a patient who has a newly placed tracheostomy
tube. Which of the following actions require intervention?
A. Applying suction for less than 15 seconds at one time
B. Administering 100% oxygen prior to starting suctioning
C. Utilizing negative pressure of 120 mmHg during suctioning
D. Deflating tracheostomy cuff for three minutes before
initiating suction
70. The major difference between an antiseptic and a
disinfectant is that an antiseptic:
A. Destroys pathogenic and non-pathogenic microorganisms
B. Inhibits microbial growth on skin
C. Has a shorter duration of effectiveness
D. Destroys pathogens
Situation: Ensuring safety before, during, and after a
diagnostic procedure is an important responsibility of the
nurse.
71. To help Paul better tolerate the bronchoscope, you should
instruct him to practice which of the following prior to the
procedure?
A. Clenching the fist every 2 minutes
B. Breathing in and out through the nose with his mouth open
C. Tensing the shoulder muscles while lying on his back
D. Holding his breath periodically for 30 seconds
72. Thoracentesis may be performed for cytologic studies of
the pleural fluid. As a nurse, your most important function
during the procedure is to:
A. Keep the sterile equipment from contamination
B. Assist the physician
C. Open and close the three-way stopcock
D. Observe the patient’s vital signs
73. How will you prevent ascending infection to Arra who has
an indwelling catheter?
A. See to it that the drainage tubing touches the level of the
urine
B. Change the catheter every 8 hours
C. See to it that urine is draining freely
D. Clean catheter is used since urethral meatus is not a sterile
area
74. A patient’s blood test results reveal a hematocrit level of 66
mg/dL. The nurse should give priority to which nursing
diagnosis?
A. Ineffective breathing pattern
B. Activity intolerance
C. Hyperthermia
D. Dysreflexia
75. A client’s admission urinalysis shows the specific gravity
value of 1.039. Which of the following assessment data would
the nurse expect to find when assessing the client?
A. Moist mucous membranes
B. Urinary frequency
C. Poor skin turgor
D. Increased blood pressure
Situation: The staff nurse supervisor requests all the staff
nurses to brainstorm and learn ways to provide health
teachings to clients. She wants to ensure that there are nurses
available to do daily health education classes.
76. When Lanie, a nurse, delegates aspects of client care to
the nurse aide who is an unlicensed staff, Lanie:
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 nor evaluate the nurse aide
D. Must know how to perform the delegated task
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77. Which of the following is not a legally binding document
but is very important in the care of all patients in any health
care setting?
A. Bill of rights as provided in the Philippine constitution
B. Scope of nursing practice as defined by RA 9173
C. Board of nursing resolution adopting the code of ethics
D. Patient’s bill of rights
78. Bettina gave the wrong medication to a client. Another
nurse employed by the same hospital as a risk manager will
expect to receive which of the following communication?
A. Incident report C. Nursing kardex
B. Oral report D. Complaint report
79. Performing a procedure on a client in the absence of an
informed consent can lead to which of the following charges?
A. Fraud C. Harassment
B. Assault and battery D. Breach of confidentiality
80. Delegation is the process of assigning tasks that can be
performed by a subordinate. The RN should always be
accountable and should not lose his accountability. Which of
the following is a role included in delegation?
A. The RN must supervise all delegated tasks
B. After a task has been delegated, it is no longer a
responsibility of the RN
C. The RN is responsible and accountable for the delegated
task in adjunct with the delegate
D. Follow up on a delegated task is necessary only if the
assistive personnel is not trustworthy
Situation: Health care delivery system affects the health status
of every Filipino. As a nurse, knowledge of this system is
expected to ensure quality of life.
81. Which of the following exemplifies the preventive and
promotive programs in the hospital?
A. Hospital as a center to prevent and control infection
B. Program for smokers
C. Program for alcoholics and drug addicts
D. Personal wellness center
82. Which makes nursing dynamic?
A. Every patient is a unique physical, emotional, social, and
spiritual being
B. The patient participates in the overall nursing care plan
C. Nursing practice is expanding in the light of modern
development that takes place
D. The health status of the patient is constantly changing and
the nurse must be cognizant and responsive to these changes
83. During the evaluation phase for a client, the nurse should
focus on:
A. All findings of physical and psychosocial stressors of the
client and his family
B. The client’s status, progress towards goal achievement, and
ongoing re-evaluation
C. Setting short and long-term goals to ensure continuity of
care from hospital to home
D. Select interventions that are measurable and achievable
within selected timeframes
84. An adult comes to the clinic because of productive cough.
She smokes two packs of cigarette a day and has a family
history of lung cancer and emphysema. Using the principle of
heath promotion, the nurse would interpret the client’s
behavior as:
A. Using denial to deal with being at high risk for lung cancer
B. Not assuming self-responsibility for her health
C. Exhibiting a Laissez faire attitude toward smoking and her
risk for cancer
D. Demonstrating passive suicidal tendencies
85. To set the stage for a successful rehabilitation experience,
the rehabilitation nurse helps the client and her family
conceptualize their definition of:
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 A. Wellness
B. Quality of life
C. Independence
D. Active participation
Situation: The use of massage and meditation to help decrease
stress and pain have been strongly recommended based on
documented testimonials.
86. Georgia wants to perform a study on this topic entitled:
“Effects of massage and meditation on stress and pain.” The
type of research that best suit this topic is:
A. Applied research C. Basic research
B. Qualitative research D. Quantitative research
87. The type of research that does not manipulate the
independent variable is:
A. Experimental design
B. Quasi-experimental design
C. Non-experimental design
D. Quantitative design
88. 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
89. Georgia does review of related literature for the purpose
of:
A. Determining statistical treatment of data research
B. Gathering data about what is already known or unknown
about the problem
C. Identifying if the problem can be replicated
D. Answering the research question
90. Clients’ rights should be protected when doing research
using human subjects. Georgia identifies the rights as follows
except:
A. Right to self-determination C. Right to privacy
B. Right to compensation D. Right not to be harmed
Situation: Ben 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 Jenny’s
care plan is to loosen and remove secretions in the airway.
91. Jenny listens to Ben’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 Jenny does percussion would be:
A. Client lying on his back and 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 the flat on his abdomen
D. Client lying on his right the left side on Trendelenburg
position
92. When documenting outcome of Ben’s treatment, Jenny
should include the following on her recording except:
A. Color, amount, and consistency of sputum
B. Character of breath sounds and respiratory rate before and
after the procedure
C. Amount of fluid intake of client before and after the
procedure
D. Significant changes in vital signs
93. When assessing Ben for chest percussion or chest
vibration, and postural drainage, Jenny 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
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D. Doctor’s order regarding position restrictions and client’s
tolerance for lying flat
94. Jenny prepares Ben 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 able to tolerate sitting and lying position
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
95. 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 secretions 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: Mrs. Silva, 50 years old, asks about possible
problems regarding her elimination now that she is in the
menopausal stage.
96. Instruction on health promotion regarding urinary
elimination is important. Which would you include?
A. Hold urine as long as she can before emptying her bladder
to strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink
pineapple juice
C. After urination, wipe from anal area towards the pubis
D. Tell client to empty the bladder eat each voiding
97. Mrs. Silva talks about her 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 action
would be to:
A. Tell client to drink less fluid to avoid incontinence
B. Instruct client to start wearing thin adult diapers
C. Ask the client to bring an extra underwear “just in case”
D. Teach client pelvic exercises to strengthen perineal muscles
98. Mrs. Silva 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, rinsing, and drying of skin area that gets
her wet with urine
D. Making sure that the linen are smooth and dry at all times
99. Which of the following is the priority nursing action when a
urinary catheter has been inserted in a female client with no
urine return?
A. Insert the catheter another four inches
B. Secure the catheter tubing to the inside of the thigh
C. Encourage the client to increase fluid intake
D. Leave the catheter in the vagina and insert another catheter
100. Which of the following is the most appropriate nursing
action when the nurse has inserted a urinary catheter in a
male client but there is no return of urine?
A. Advance the catheter further
B. Remove catheter
C. Tape the catheter in place and encourage fluids
D. Report signs of urinary infection
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