NURSING PRACTICE IV

Situation 1: A patient has just arrived in the Oncology Unit selected by the group. Which of the following will the
from the PACU following a left modified radical mastectomy team leader do first?
because of inflammatory breast cancer (IBC). She has a
pressure dressing over the surgical site and two drains. A. Tell the group to state their objectives
Assessment shows her vital signs are stable, fully awake and B. Formulate a list of desired outcomes
claims that pain is under control. Fortune is the nurse C. Set a target
assigned to the patient. D. State actions to be done by each member of
the group
1. From the following data obtained from the chart,
which is not a risk factor which could have 8. The team leader organized the group. Which of the
predisposed the patient to breast cancer? following actions of the team leader reflect
organization? The team leader:
A. Age – 55 years old
B. Height – 5’2; Weight – 160 lbs.
A. Assigned tasks to each member
C. Menarche at age 13
B. Eliminated non-performing members of the
D. Mother died of colon cancer group
C. Checked the assignments of each member of the
2. Fortune read a literature which says that by the time group
IBC is diagnosed, 50%-75% have palpable auxiliary D. Determined which actions will be done first
lymph nodes, as many as 30% have gross distant
metastasis and as few as 30% of patients have an 9. Which of the following data will be most helpful to
underlying breast mass. Which of the following is the the group to ensure continuous process
appropriate interpretation of the research findings? improvement?

A. Auxiliary nodes were palpated on 20 out of A. Non-conformances to suctioning procedure

30 women positive for IBC B. Incidences of ventilator-associated pneumonia
B. Out of the 20 women who were positive for during the last month
IBC, only 5 have metastasis C. Experiences of nurses when managing care of
C. If there were 10 women diagnosed with IBC, intubated patients
3 have positive lymph nodes D. Documentation of observation of intubated
D. Breast mass was identified on 8 out of 30 patients
women positive for IBC
10. The group developed revisions to the existing
3. Fortune recognizes that adjuvant chemotherapy for procedure. Before the procedure could be
breast cancer may include any of the following implemented as a standard procedure, which of the
except following will be done first?
A. Monoclonal antibody
A. Gather relevant data
B. Proton inhibitors
B. Check if procedure is effective through feedback
C. Antibiotics C. Plan for the implementation of the procedure
D. Anti-estrogen D. Do the procedure on selected patients
4. Fortune understands that when the antineoplastic Situation 3: Luther, a 50-year-old construction worker
agent leaks through the peripheral vascular access sustained multiple injuries due to a motorcycle accident.
during chemotherapy, which of the following is
expected to be done first? 11. In the Emergency Department, the physician orderd
diagnostic tests, one of which is blood alcohol level.
A. Refer to the physician Which of the following is the purpose of this test?
B. Stop the chemotherapy infusion
C. Cleanse site with saline solution A. Determine level of alcohol dependence
D. Call another nurse to check the intravenous B. Discover injuries in the brain
site. C. Rule out alcoholism
D. Assessment of client’s level of consciousness
5. A clinical trial is currently undertaken to test
treatments for IBC. The research team leader wishes 12. Blood transfusion must be administered immediately
to include the patient as a participant in the study. As because of loss of blood volume due to trauma.
a patient advocate, which of the following will Luther’s blood type is O, as his nurse, you recognize
Fortune do first? which of the following statements is true?
A. Obtain informed consent from the patient
A. Type O blood has both types of antibodies
B. Explain to the patient the scope of the
clinical trial B. Persons with type O blood can also receive Type
A blood
C. Inquire from the team leader benefits for the
C. Type O blood has no antibodies
patient
D. Persons with Type O blood are also called
D. Read more related literature universal recipients
Situation 2: During a staff meeting at the Intensive care unit, 13. When assessing Luther for hypovolemic shock, which
the nurse manager reported a list of procedures that need to of the following data indicates that he is in the
be reviewed and updated. One of these procedures is the irreversible stage of shock?
precautionary measure related to ventilator-associated
pneumonia. A. Restless, anxious and confused
B. Anuria
6. While brainstorming, the group mentioned the use of
evidence-based techniques. Which of the following C. Skin moist, pale and moist
statements given by the members of the group D. Pulse rapid and weak
reflect evidence-based methods?
14. The physician ordered colloid solution such as
A. “Let us ask the opinion of experts.” Dextran 40. During the infusion, Luther complained
B. “The experiences of the nurses must be of dyspnea. Upon auscultation, you noted wheezes.
obtained.” Which of the following will you do first?
C. “Review of related literature will be very
A. Discontinue the infusion
helpful.”
B. Place Luther on a Fowler’s position
D. “We must agree on a common procedure.”
C. Decrease the infusion rate
7. The nurse manager assigned a group to develop a D. Call the attending physician
project intended to improve the existing procedure
related to the prevention of ventilator-associated 15. Luther’s central venous pressure is monitored every
pneumonia among ICU patients. A team leader was hour. When you measure the CVP using a water
 manometer, you are expected to observe which of
the following to ensure accuracy of CVP A. Intermittent fever for 4 days
measurement? B. Onset of fever was abrupt and remained
elevated for 4 days
A. Maintain the client on a Fowler’s position C. Abrupt onset of fever and sudden drop on the 4th
B. Use a one-way stopcock to regulate flow of IV day
fluids to the water manometer D. Gradual increase of body temperature and
C. Immobilize the client’s right arm sudden drop on the 4th day
D. Keep the zero point of the manometer in level
with the client’s right atrium 22. The nurse understands that the cycle of transmission
of dengue fever virus begins during which of the
Situation 4: You are caring for Warren, 58 years old, who is following?
diagnosed with laryngeal cancer.
A. Infected mosquito bites an uninfected human
16. Warren is scheduled for a total laryngectomy and B. Virus multiply in the midgut of the mosquito
radical neck dissection for cancer of the larynx. He C. Mosquito feeds on an infected human
asks you, “How will I talk after surgery?” As his D. Mosquito’s saliva is invaded by the virus during
nurse, your best response will be subsequent biting of infected human
A. “You will breathe through a permanent opening 23. The nurse noted that Aspirin and NSAID are
in your neck, but you will not be able to contraindicated for Bobby. Which of the following is
communicate orally.” the rationale behind this order?
B. “You won’t be able to talk right after the surgery,
but you will be able to speak again once the A. Patient may be allergic
tracheostomy tube is removed.” B. Drug contains anticoagulant properties
C. “You will have a permanent opening into your C. Due to stomach upset effects of the drug
neck, and you will need to have rehabilitation for
D. Drugs enhance production of maculopapular
some type of voice restoration.”
rashes
D. “You won’t be able to speak as you used to, but
there are artificial voice devices that will give 24. The condition of Bobby is closely watched for signs of
you the ability to speak normally.” hypovolemic shock. Which of the following should the
nurse report as early signs of hypovolemic shock?
17. Warren returns from surgery with a tracheostomy
tube after a total laryngectomy and radical neck 1. Lethargy
dissection. In caring for Warren during the first 24 2. Rapid pulse
hours after surgery, your priority nursing action is to 3. Clammy skin
4. Cyanosis
A. Avoid changing the tracheostomy ties 5. Restlessness
B. Monitor for bleeding around the stoma 6. Hematemesis
C. Assess airway patency and breath sounds A. 2, 3, 4 and 5
D. Clean the inner cannula every 8 hours B. 1, 2, 3 and 5
C. 1, 2, 5 and 6
18. After doing assessment, one of the nursing diagnosis D. 1, 3, 4 and 6
you identified is “Body image Disturbance related to
loss of control of personal care.” To evaluate 25. To prevent transmission of the virus to others, which
effectiveness of your interventions, the expected of the following is the most appropriate isolation
outcome for the problem that Warren should measure the nurse should implement in the care of
demonstrate is that he Bobby?
A. Screen the environment
A. Lets his wife provide hygiene and stoma care
B. Wears clothing that minimizes the disfigurement B. Blood and body secretion isolation
caused by the surgery C. Use gown, gloves and mask
C. Asks that only family members be allowed to D. Use strict universal isolation technique
visit
Situation 6: Agua Bendita, 35 years old, was admitted to the
D. Learns to remove and clean the laryngectomy
hospital because of near drowning. In the ICU where she was
tube independently
admitted for observation, her oxygen saturation dropped to
84% and subsequent blood gases showed PaO 2 of 55mmHg.
19. Warren is scheduled to start radiation therapy. You Diagnosis is probably Acute Respiratory Distress Syndrome
have just taught Warren all about radiation therapy. (ARDS). Endotracheal intubation and mechanical ventilation
Which of the following statements by Warren would were ordered.
indicate that your teaching has been effective?
26. The nurse is aware that in ARDS, the basic changes
A. “I can use lotions to moisturize the skin on my in the lungs result from the injury to the alveolar wall
throat.” and capillary membrane leading to the following
B. “I will need to buy water bottle to carry with pathological changes, except
me.”
C. “I need to use alcohol-based mouthwashes to A. Fluid and protein leaks into alveoli and
help clean oral ulcers.” interstitial tissue
D. “I may experience diarrhea, I may have diarrhea B. Damaged surfactant producing cells
until the radiation is complete.”
C. Increased surfactant production
20. After completing the discharge instructions for D. Increased alveolar capillary permeability
Warren, you determine that additional instruction is
needed when he says 27. Which of the following ventilator settings reflect the
amount of air delivered within each ventilator
A. “I can participate in most of my prior fitness breath?
activities except swimming.”
B. “I should wear a Medic Alert bracelet that A. Inspiration to expiration ratio
identifies me as a neck breather.” B. Pressure limit
C. “I must keep the stoma covered with a loose C. Tidal volume
sterile dressing at all times.” D. Oxygen concentration (FiO2)
D. “I need to eat nutritious meals even though I
can’t smell or taste very well.” 28. Which of the following will the nurse closely monitor
to ensure that the percentage of oxygen delivered
Situation 5: Bobby, 11 years old, was admitted because of with ventilator breaths is adequate?
hematuria. Diagnosis is Dengue fever.
A. Respiratory rate
21. Which of the following is the most likely description B. Central venous pressure
of Bobby’s fever prior to the onset of hematuria that
C. Pulse oximeter’s reading
supports the physician’s diagnosis of dengue fever?
D. Cardiac monitor
 A. Risk for injury related to increased intracranial
29. The nurse is expected to closely watch the client for pressure
complications related to mechanical ventilation. B. Disturbed sensory perception relation to central
Which of the following will the nurse do to assess nervous system impairment
subcutaneous emphysema? C. Risk for aspiration related to impaired motor
functions
A. Observe for signs of unequal chest expansion D. Ineffective airway clearance related to
B. Auscultate the lungs and observe for crackles depressed sensorium
C. Palpate neck for air bubble-popping sensation
D. Percuss for hyperresonant percussion tone 37. When interpreting the patient’s degree of depressed
coma, the pediatric Glasgow Coma Scale is used.
30. The nurse observed air leaks from the endotracheal Which of the following is not included in the three-
tube and decreased breath sounds. Which of the part assessment of the scale?
following will the nurse do first?
A. Motor responses
A. Report to the physician B. Response to auditory and verbal stimuli
B. Call the respiratory therapist C. Pupil size and reaction
C. Place patient on semi-fowlers position D. Eye opening
D. Reposition the endotracheal tube
38. When assessing the level of consciousness of the
Situation 7: You admitted Englebert, 70 years old, because of patient, which of the following should the nurse
pulmonary edema. He has a history of congestive heart consider most appropriate in eliciting a desired
failure, type 2 diabetes mellitus and hypertension. response?

31. Based on the history, you specifically noted that A. Environment should be quiet, well-lighted and
Englebert regularly took Lanoxin (Digoxin). Which of ventilated
the following is the specific action of this drug on the B. Keep equipment at the bedside
patient? C. Parent should be present
D. Have record readily available for accurate
A. Improves myocardial contractility, decreases the documentation.
heart rate, and reduces oxygen consumption
B. Causes vasoconstriction, increased resistance 39. During assessment, the nurse observes absence of
preload and dilation of the ventricles doll’s eye movement. Which of the following is the
C. Reduces peripheral vascular resistance and correct interpretation of this observation?
afterload, reducing myocardial workload
D. Interfered with the production of angiotensin II A. Ruptures aneurysm
resulting in improved cardiac output and B. Meningeal inflammation
reducing pulmonary congestion C. Brainstem injury
D. Subdural hematoma
32. Which of the following specific positions would be
most helpful for Englebert to facilitate and trap 40. Due to hypothalamic dysfunction, a syndrome of
excess fluids in the lower extremities? inappropriate antidiuretic hormone develops. Which
of the following manifestations should the nurse
A. Head bent forward on an overbed table watch closely?
supported with pillows
B. Upright sitting position with the legs dangling A. Increased urine output, decreased specific
C. Lateral position with the upper leg flexed and gravity, decreased serum sodium
lower leg extended B. Increased urine output, increased urine specific
D. Fowler’s position with the patient lying on the gravity, increased serum sodium
left side C. Decreased urine output, decreased urine specific
gravity, decreased serum sodium
33. Furosemide (Lasix) 20 mg was administered by IV D. Decreased urine output, increased urine specific
push at 10 am with urinary output from indwelling gravity, increased serum sodium
catheter at the level of 120 cc. At 10:15 AM, the
nurse observed that the urinary output did not Situation 9: Teddy, 8 years old, was playing in the garden
change. Which of the following will you check first? when all of a sudden he stopped playing and started
scratching his legs. Teddy’s mother washed his legs but Teddy
A. Foley cathter connecting tube for kinks complained of difficulty of breathing; was nauseated and had
B. Patient’s hypogastrium for urinary retention cold moist skin. In the emergency department, anaphylaxis
C. Intravenous site for swelling was suspected. Insect bites were noted on Teddy’s legs.
D. Foley catheter for leakage
41. The health team suspects that Teddy experienced a
34. While preparing the medication, you checked the sting at some previous time. Which of the following
medication which was dispensed by the pharmacist could be the rationale for the itchy skin?
with the written order of the physician. Which of the
following actions will you do first if you found out that A. Irritation caused by digestive substance released
instead of Regular insulin, the pharmacist dispensed by the insect
NPH insulin? B. Infiltration of inflammatory cells into the
epidermis
A. Validate the order with the physician C. Sensory nerve endings irritated by histamine
B. Document the error D. Accumulation of histamine at the insect bite
C. Ask the pharmacist to change the drug
D. Report the error to the unit manager 42. Which of the following drugs will the nurse expect
the physician to prescribe initially?
35. You administered morphine Sulfate 1 mg
intravenously as ordered. The following are the A. Corticosteroids
intended actions of this drug except B. Aminophylline
C. Epinephrine
A. Improved efficacy of breathing D. Dipenhydramine
B. Reduce preload
C. Decrease anxiety 43. The mother asked the nurse what could have caused
D. Relieve pain her son to experience difficulty of breathing. Which of
the following is the most appropriate response of the
Situation 8: Helen, a Pediatric Intensive Care Unit staff nurse, nurse?
is assigned to a 4-year-old female unconscious patient due to
an acute head injury sustained from a vehicular accident. A. “It was an early sympatetic response to the
insect bite.”
36. Helen identifies which of the following nursing B. “Chemical mediators due to hypersensitivity
diagnosis to be of highest priority? reactions caused by edema in the bronchioles.”
 C. “Histamine released due to allergic reaction Situation 11: It is important and necessary that the nurse is
caused narrowing of the airway.” well-educated about Severe Acute Respiratory Syndrome
D. “It was due to threatening laryngeal edema.” (SARS), an emerging global threat.

44. The mother claimed that this is the first time it 51. If you were a nurse who works in a health clinic, and
happened. Which of the following should be given you suspect that a patient has SARS, which of the
priority by the nurse? following will you do first?
A. Contact the hospital
A. Instruct the mother on emergency measures in B. Protect self by putting on an N95 disposable
care recurrence mask
B. Recommend desensitization C. Refer the patient to the physician for medical
C. Identification of allergens diagnosis
D. Identification of environmental hazards D. Have your patient put on surgical face mask

45. Since Teddy is allergic to insect venom, which of the 52. Which of the following confirms the diagnosis of
following is the most appropriate measure to ensure SARS?
that Teddy gets immediate treatment during
recurrence? A. Travel to an area with known SARS outbreak
B. Signs and symptoms
A. Have Teddy carry an emergency kit all the time C. History of contact with someone suspected of
SARS
B. Teach Teddy how to use an emergency kit
D. Presence of antibody to SARS
C. Use of a medical information such as bracelet or
necklace
D. Teach Teddy to get help when symptoms develop 53. The SARS virus is transmitted through

Situation 10: Radiation therapy is another modality of cancer A. Airborne droplets

management. With the emphasis on multi-disciplinary B. Contact with urine
management, you have important responsibilities when caring C. Mosquito bites
for patients receiving radiation therapy. D. Contaminated needle

46. Thrombocytopenia often results from bone marrow 54. If the nurse has an unprotected exposure to SARS
depression. As a nurse, you should observe for the during incubation, which of the following will be
following symptoms that include done?

A. Headache, dizziness, blurred vision A. Voluntary quarantine of 10 days

B. Severe sore throat, bacteremia, hepatomegaly B. Nurse is placed on vacation from work
C. Petechiae, ecchymosis, epistaxis C. Nurse will be given a high dose of gamma
D. Weakness, easy fatigability, pallor globulin
D. Administer vaccine to the nurse
47. When caring for a client who has thrombocytopenia,
which of the following intervention should you 55. After exposure to a patient with SARS, it is expected
include in the care plan? that SARS can develop in

A. Provide rest between activities A. 2-10 days

B. Place the patient on strict isolation precaution B. 6 weeks – 6 months
C. Inspect the patient’s skin for petechiae, bruising, C. 30 days
GI bleeding regularly D. 12-14 days
D. Administer antipyretics if the patient’s
temperature 38°C Situation 12: You are assigned at the medical ward caring for
clients with fluid and electrolyte imbalances. You know that
48. A patient is receiving external radiation therapy and you have very important collaboration responsibilities when
he complains of fatigue and malaise. Which of the you give your patients their medications to correct their
following nursing interventions would be most illness.
appropriate?
56. Samson is taking Hydrochlorothiazide, a potassium-
A. Refer the patient to the physician wasting diuretic, for treatment of hypertension. As a
B. Help the patient plan activities and rest periods nurse, you will teach him to report symptoms of
C. Reassure the patient that these feelings are adverse effects such as
normal
D. Tell the patient that sometimes these feelings A. Facial muscle spasms
can be psychogenic B. Frequent loose stools
C. Mood changes
49. External beam radiation is planned for a patient with D. Generalized weakness
endometrial cancer. You teach her that the important
measure to prevent complications from the effects of 57. Spironolactone (Aldactone), an aldosterone
radiation is to antagonist, is prescribed for Hermin as a diuretic.
Which statement made by Hermin indicated that the
A. Maintain a high-residue and high-fat diet teaching about his medication has been effective?
B. Perform perineal care with sitz bath and
meticulous cleaning A. “I can use a salt-substitute”
C. Test all stools for the presence of blood B. “I can have apple juice instead of orange juice.”
D. Inspect the mouth and throat daily for the C. “I can have low-fat cheese”
appearance of thrush D. “I will drink at least 6 glasses of water every
day.”
50. A post total hysterectomy bilateral salphyngo-
oophorectomy patient had chemotherapy and 58. Joseph has been receiving diuretic therapy and is
radiation therapy. The nurse oriented her on the admitted to the hospital with a serum potassium
rationale and the measures to be done to prevent level of 3.1 mEq/L. Of the following medications that
movement of the radioactive source which include he has been taking at home, which you be most
the following, except: concerned about?

A. Complete bed rest while source is implanted A. Oral digoxin (Lanoxin) 0.25 mg daily
B. Spinal anesthesia while source is implanted B. Lantus insulin 23 U subcutaneously every
C. Bowel cleansing prior to insertion of source evening
D. Placement of urinary Foley catheter while source C. Ibuprofen (Motrrin) 400 mg every 6 hours
is implanted D. Metoprolol (Lopressor) 12.5 mg orally daily

59. You administered 3% Saline to Wanda who has

hyponatremia. As her nurse, which one of your
 assessment findings will require your most rapid 67. Taking into consideration the incubation period,
response? which of the following data in Rolando’s health
history will you consider relevant?
A. Her blood pressure increased from 120/80 to
142/94 mmHg A. Positive for type 2 diabetes mellitus
B. There is sediment and blood in Wanda’s urine B. Immunization status unceratain; no booster dose
C. Wanda’s radial pulse is 105 beats per minute administered
D. There are crackles audible throughout her both C. Wound laceration sustained a week ago was
lung fields treated at home
D. Wound pain, unbearable and unrelieved by
60. When caring for Edna who has just been admitted analgesic
with septic chock, which of these assessment data
will be your greatest concern? 68. To decrease stimuli that cause spasms and seizures,
which of the following nursing interventions is least
A. Arterial oxygen saturation of 90% relevant for you to do?
B. BP of 88/56
C. Apical pulse of 110 beats per minute A. Maintain a quiet, well-ventilated and darkened
D. Urine output of 15 mL for 2 hours room
B. Administer sedatives as prescribed
Situation 13: Timothy, 56 years old, was admitted because of C. Monitor for hazards of immobility
aortic dissection type B. D. Perform physical care during time of maximal
sedation
61. The nurse recognizes which of the following as the
correct description of the patient’s diagnosis? 69. The priority nursing diagnosis for Rolando is “Risk for
ineffective airway clearance related to which of the
A. Tear in the intima of the aorta with hemorrhage following?
into the tunica media
B. Stretching of the walls of the aorta involving one A. Stiffness of the jaw
layer of the aorta B. Back muscle spasms
C. One-sided protrusions of one distinct area of the C. Seizures
aorta D. Infection
D. Pulsating hematoma on three layers of the aorta
70. During a seizure, which of the following are you
62. Of the following diagnostic tests prescribed by the expected to do first?
physician, which of the following will the nurse
expect to show precise measurement of the A. Monitor vital signs especially the respiratory rate
aneurysm? B. Provide a padded tongue blade in the patient’s
mouth
A. Angiography C. Provide mechanical ventilation
B. Chest X-ray D. Turn patient to his side
C. Transesophageal echocardiography
D. Abdominal ultrasonography Situation 15: In the medical unit, Connie was assigned to work
with Sandy, a staff nurse with 2 years experience
63. The physician initially treated Timothy with
Propanolol (Inderal). The nurse noted in her nursing 71. Which of the following reports of Connie will Sandy
care plan that this drug will attend to immediately?

A. Increase contractility of the heart A. A 65-year-old unconscious due to be turned to

B. Enhance electrical conduction of the heart prevent bed sores
C. Decrease release of epinephrine B. A 55-year-old diabetic, first day post-operative
D. Reduce heart rate for below-the-knee amputation, complains of
severe pain
64. Based on an understanding of Heparin therapy, the C. A 75-year-old with hepatic encephalopathy,
nurse administers it to Timothy who has undergone intravenous infusion due in 4 hours consumed
repair of aneurysm fro which of the following D. A 45-year-old scheduled for partial
reasons? thyroidectomy wishes to go home

A. To prevent recurrence of aneurysm 72. Connie observes Sandy perform peripheral catheter
B. To control hemorrhage insertion for intravenous infusion. The patient
C. To maintain arterial pressure insisted to sit on the edge of the bed. After a second
D. To prevent clot formation unsuccessful attempt on cannulation, the patient
suddenly became anxious, diaphoretic, nauseated
65. To counteract reactions to overdosage of intravenous and dizzy. Which of the following will Sandy do first?
infusion of Heparin, which of the following drugs will
the nurse expect the physician to prescribe? A. Place the patient on a supine position
B. Instruct Connie to call the physician
A. Protamine sulfate C. Check vital signs
B. Epinephrine D. Discontinue the IV fluids
C. Vitamin K
D. Atropine Sulfate 73. Sandy explained to Connie that the patient
experiences a vasovagal reaction. Which of the
Situation 14: You are caring for Rolando, 58 years old, who following vital signs will the nurse expect?
was admitted because of difficulty of swallowing and stiffening
of the neck. He has a history of a wound laceration on his A. Normal blood pressure and increased pulse
right hand sustained while gardening. The physician suspects B. Decreased blood pressure and decreased cardiac
tetanus infection. rate
C. Increased blood pressure and tachycardia
66. While you were preparing to administer oxygen D. Normal pulse and increased blood pressure
inhalation, Rolando had seizures assumed an
opisthotonic position. Which of the following correctly 74. One of Connie’s patients is Greg who just had
describes this position? bronchoscopy. Sandy asked Connie what she should
be alert for in observing Greg?
A. Head retracted, back arched, and feet extended
B. Neck, hip, knee and feet plantar flexed A. Sore throat and hoarseness
C. Head flexed forward, jaw clenched, arms B. Blood tinged sputum and coughing
pronated and feet plantar flexed. C. Nausea and vomiting
D. Head hyperextended hip flexed, and feet D. Shortness of breath and laryngeal stridor
extended
 75. At the end of the shift, Sandy told Connie to do self-
evaluation of competencies developed during the
week. Which of the following indicators will Connie
consider as an improvement of her ability to respond
to the urgency of her patient’s conditions?
A. Able to identify adverse reactions of drugs
B. Responds to inquiries promptly
C. Recognize abnormal laboratory results
D. Administer medications on time
Situation 16: Nurse have crucial legal responsibilities in the
exercise of her profession
76. Mary Jane, a 3rd year nursing student assigned to the
surgical unit asks your permission to photocopy the
surgical record from a patient’s chart for an
assignment that she must write. Which of the
following is your appropriate nursing action?
A. Allow Mary Jane to photocopy the pages without
the client’s name
B. Photocopy the pages for Mary Jane
C. Ask the physician for permission to photocopy
the pages
D. Allow Mary Jane to write down pertinent
information but not identifying
77. You are caring for Felisa who has dementia and is
soiled with feces but you failed to clean and bathe
her because it is endorsement time already. You
endorse her to the next shift nurse. The nurse reports
that you are guilty of
A. Malpractice
B. Nonmaleficence
C. Assault
D. Negligence
78. You are invited to talk to new graduate nurses about
negligence. Which of the following situations is a
priority for you to include as an example of
negligence?
A. Talking about client outside of the health care
facility
B. Not allowing a family member to awaken an
adult client who is sleeping
C. Not giving a prescribed medication to an older
patient
D. Not turning off the oxygen at the bedside when a
client wants to smoke in bed
79. You call the physician of your patient Erlinda, 76
years old, to report a change in her condition and to
request orders for a pain medication. The physician is
unable to take the call and the message is left with
the office secretary who repeats a verbal order from
the physician. Which of the following is your most
appropriate nursing action?
A. Refuse to accept the order from the office
secretary and call back later
B. Accept the order form the office secretary and
document it appropriately
C. Accept the order as it comes from the physician
as interpreted by the office secretary
D. Insist on speaking to the physician personally
80. You observe bruises and skin tears on Agatha, an 80-
year-old client. She does not make eye contact and
appears fearful. Which of the following is your priority
nursing action?
A. Ask the client about the bruises and skin tears
B. Ask the family members what has happened
C. Document your findings
D. Call the physician
Situation 17: You are assigned in the Pediatric ICU and your
critical decisions and proper documentation are important.
You are caring for Charlie, 5 years old, who was admitted
following a vehicular accident. Clinical data obtained were; BP
80/58 mmHg, heart rate 120, respirations 32, peripheral pulse
slightly diminished, hematocrit 30%, pulse oximeter 94%,
serum electrolytes normal. CT scan is positive for abnormal
bleeding. Weight 20 kg.
81. Based on the above data, which of the following
nursing diagnosis would you select as being
appropriate in Charlie’s care?
A. Fluid volume deficit
B. Ineffective airway clearance
C. Impaired gas exchange
D. Altered cardiac output: decreased
Answer: A
82. Charlie is placed on a cardiac monitor and a urinary
catheter is inserted. One peripheral IV line in the left
arm is infiltrated and discontinued. An indirect BP
reading is 70/40 mmHg and a heart rate of 140 is
noted. Which of the following orders should be
initiated first?
A. IV access
B. Serum hematocrit and hemoglobin
C. Arterial line set-up
D. Dopamine continuous infusion
83. What parenteral solution would you anticipate to
prepare for Charlie’s volume replacement?
A. 5% Dextrose in 0.25% normal saline
B. 25% albumin
C. 0.9% Normal Saline
D. 5% Dextrose in water
84. Charlie’s mother verbalizes her concerns regarding
Charlie’s condition. She informs you that Charlie is
their only child and that her husband is working
overseas. What would be your best response?
A. Hold her hand, and have an eye contact with her
and reassure her that you are doing your best.
B. Ask one of your con-staff to assist Charlie’s
mother
C. Tell her you understand how she feels but your
priority is to take care of Charlie
D. Tell her to pray and leave everything to God
85. Charlie’s condition worsens. He develops respiratory
arrest. What nursing intervention should you perform
first?
A. Assemble intubation kit
B. Administer oxygen
C. Do chest compression
D. Ventilate with a bag-valve mask device
Situation 18: Kevin, 22 years old, swerved his car and hit a
tree head-on when he avoided a dog crossing the street. Kevil
loss consciousness, sustained several cuts on his forehead
and was bleeding from his nose and mouth. He was diagnosed
in the Emergency Department with Traumatic Brain Injury
(TBI)
86. Since volume resuscitation was necessary for Kevin,
intravenous 0.9% normal saline solution was started.
The nurse who admitted the patient understands that
the intravenous solution was considered by the
physician because it
A. Will reduce intracranial pressure
B. Will easily maintain hydration
C. Will promote fluid shift into the vascular space
D. Won’t aggravate cerebral edema
87. To determine level of consciousness, the Glasgow
Coma Scale (GCS) is used. Which of the following is a
correct interpretation of the nurse of the GCS score
of Kevin?
A. The higher the score, the higher is the
probability of permanent damage
B. The lower the score is, the lower is the
probability of delayed recovery
C. The higher the score, the greater is the
impairment in the brain
D. The lower the score, the more serious is the
brain injury
88. The nurse maintains the body temperature of Kevin
within normal limits. This intervention is significant in
preventing which of the following?
A. Cerebral ischemia
 B. Infection
C. Seizures A. Ineffective peripheral tissue perfusion related to
D. Dehydration fluid volume deficit
B. Fluid volume deficit related to abnormal loss and
89. When intracranial pressure increases, which of the decrease intake
following nursing diagnosis is appropriate? C. Activity intolerance related to malaise
D. Impaired skin integrity related to frequent
A. Risk for ineffective breathing pattern diarrhea
B. Disturbed sensory perception
C. Risk for cardiac dysfunction 97. The following management goals for Lilette are most
D. Ineffective airway clearance important for you to include in your plan except

90. Which of the following interventions can the nurse A. Adequate rehydration and fluid maintenance
include in the plan of care for Kevin to control B. Nothing per orem at all times
intracranial pressure? C. Continue assessment of fluid and electrolyte
1. Maintain his head and neck in neutral alignment imbalance
2. Initiate measures to enhance valsalva maneuver D. Reintroduction of adequate diet
3. Administer Oxygen to maintain PaO2 >90 mmHg
4. Elevate head of the bed as prescribed 98. To ensure adequate fluid and electrolyte pelacement,
the doctor ordered 500 ml of balanced electrolyte
A. 1 and2 solution for 10 hours. The IV set delivers 60 gtt/min
B. All except 2 to administer the 500 ml IV solution, you should set
C. 3 and 4 the IV drip rate at
D. All of the above
A. 35 gtt/min
Situation 19: You are caring for Angelo, 68 years old, who was B. 62 gtt/min
diagnosed with acute heart failure. Angelo has a history of C. 50 gtt/min
acute myocardial infarction and underwent coronary artery D. 41 gtt/min
bypass surgery. He is complaining of severe shortness of
breath and hemoptysis. 99. Which of the following findings would best indicate
that Lilette’s hydration level has improved?
91. You recognize that pulmonary edema may develop
because of which of the following?
A. No further weight loss
A. Low plasma protein levels decreasing plasma B. Lower hematocrit
oncotic pressure C. Lower creatinine
B. Increase capillary permeability due to lung D. Lower WBC
inflammation
100.Lilette cries whenever her Mommy and Grandma
C. Increased hydrostatic pressure in the pulmonary
leave her. Which of the following interventions can
capillaries
reduce her anxiety?
D. Increased surface tension in the alveoli
A. Have the same nurse care for her
92. Which of the following assessment findings would
B. Provide her with some new toys and bring her
you consider as priority for immediate nursing
favorite toys
intervention?
C. Restrict visiting hours to decrease her crying
A. Hemoptysis D. Encourage her playmates to visit her
B. BP 95/72, skin cool, and diaphoretic
C. Significant jugular vein distention
D. Severe orthopnea

93. Cardiac assessment reveals apical pulse is lateral to

midclavicular line. You understand that this finding
means

A. Mitral valve regurgitation

B. The heart is enlarged
C. That cardiac output is adequate]
D. Dilated heart

94. You observed for fibrillation on the cardiac monitor.

Which of the following ECG characteristics did you
observe on the cardiac monitor?

A. “sawtooth” appearance of P waves

B. P waves observed before, during, and after QRS
complex
C. P wave hidden in the QRS complex
D. P waves unidentifiable

95. The physician prescribed Furosemide to be

administered intravenously. Which of the following
nursing orders is least appropriate to ensure that
adverse effects of the drug are closely monitored on
Angelo?

A. Report significant weight changes

B. Monitor laboratory results on electrolytes
C. Measure hourly urine output
D. Integrate foods rich in potassium in the diet

Situation 20: Lilette, 4-year-old girl with a recent history of

nausea, vomiting and diarrhea is admitted to the Pediatric
Unit with a diagnosis of acute gastroenteritis. Your significant
physical examination includes dry skin with turgor, sunken
soft eyeballs, parched lips, abdominal distention. She has
tachycardia and fever (38C)

96. Based on your assessment findings, which of the

following is your nursing diagnosis?