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Nurse Practice 1

University of Iloilo- College of Nursing


Refresher Drills

1. The most important nursing intervention to tubes, such as feeding tubes, I.V. lines, and
correct skin dryness is: urinary catheters
a. Avoid bathing the patient until the condition is b. Prevent a patient from falling out of bed or a
remedied, and notify the physician chair
b. Ask the physician to refer the patient to a c. Discourage a patient from attempting to
dermatologist, and suggest that the patient wear ambulate alone when he requires assistance for
home-laundered sleepwear his safety
c. Consult the dietitian about increasing the d. Prevent a patient from becoming confused or
patient’s fat intake, and take necessary disoriented
measures to prevent infection
d. Encourage the patient to increase his fluid 7. Which of the following is the nurse’s legal
intake, use nonirritating soap when bathing the responsibility when applying restraints?
patient, and apply lotion to the involved areas a. Document the patient’s behavior
b. Document the type of restraint used
2. When bathing a patient’s extremities, the c. Obtain a written order from the physician
nurse should use long, firm strokes from the except in an emergency, when the patient must
distal to the proximal areas. This technique: be protected from injury to himself or others
a. Provides an opportunity for skin assessment d. All of the above
b. Avoids undue strain on the nurse
c. Increases venous blood return 8. Kubler-Ross’s five successive stages of death
d. Causes vasoconstriction and increases and dying are:
circulation a. Anger, bargaining, denial, depression,
acceptance
3. Vivid dreaming occurs in which stage of b. Denial, anger, depression, bargaining,
sleep? acceptance
a. Stage I non-REM c. Denial, anger, bargaining, depression
b. Rapid eye movement (REM) stage acceptance
c. Stage II non-REM d. Bargaining, denial, anger, depression,
d. Delta stage acceptance

4. The natural sedative in meat and milk 9. A terminally ill patient usually experiences all
products (especially warm milk) that can help of the following feelings during the anger stage
induce sleep is: except:
a. Flurazepam a. Rage
b. Temazepam b. Envy
c. Tryptophan c. Numbness
d. Methotrimeprazine d. Resentment

5. Nursing interventions that can help the patient 10. Which is the correct procedure for collecting
to relax and sleep restfully include all of the a sputum specimen for culture and sensitivity
following except: testing?
a. Have the patient take a 30- to 60-minute nap a. Have the patient place the specimen in a
in the afternoon container and enclose the container in a plastic
b. Turn on the television in the patient’s room bag
c. Provide quiet music and interesting reading b. Have the patient expectorate the sputum
material while the nurse holds the container
d. Massage the patient’s back with long strokes c. Have the patient expectorate the sputum into
a sterile container
6. Restraints can be used for all of the following d. Offer the patient an antiseptic mouthwash just
purposes except to: before he expectorate the sputum
a. Prevent a confused patient from removing

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a. Any quadrant first
11. The best way to decrease the risk of b. The symptomatic quadrant first
transferring pathogens to a patient when c. The symptomatic quadrant last
removing contaminated gloves is to: d. The symptomatic quadrant either second or
a. Wash the gloves before removing them third
b. Gently pull on the fingers of the gloves when
removing them 17. The nurse is assessing a postoperative adult
c. Gently pull just below the cuff and invert the patient. Which of the following should the nurse
gloves when removing them document as subjective data?
d. Remove the gloves and then turn them inside a. Vital signs
out b. Laboratory test result
c. Patient’s description of pain
d. Electrocardiographic (ECG) waveforms

18. Which of the following planes divides the


12. After having an I.V. line in place for 72 body longitudinally into anterior and posterior
hours, a patient complains of tenderness, regions?
burning, and swelling. Assessment of the I.V. a. Frontal plane
site reveals that it is warm and erythematons. b. Sagittal plane
This usually indicates: c. Midsagittal plane
a. Infection d. Transverse plane
b. Infiltration
c. Phlebitis 19. A female patient with a terminal illness is in
d. Bleeding denial. Indicators of denial include:
a. Shock dismay
13. How should the nurse prepare an injection b. Numbness
for a patient who takes both regular and NPH c. Stoicism
insulin? d. Preparatory grief
a. Draw up the NPH insulin, then the regular
insulin, in the same syringe 20. The nurse in charge is transferring a patient
b. Draw up the regular insulin, then the NPH from the bed to a chair. Which action does the
insulin, in the same syringe nurse take during this patient transfer?
c. Use two separate syringe a. Position the head of the bed flat
d. Check with the physician b. Helps the patient dangle the legs
c. Stands behind the patient
14. A patient has just received 30 mg of codeine d. Places the chair facing away from the bed
by mouth for pain. Five minutes later he vomits.
What should the nurse do first? 21. She is the first one to coin the term
a. Call the physician “NURSING PROCESS” She introduced 3 steps
b. Remedicate the patient of nursing process which are Observation,
c. Observe the emesis Ministration and Validation.
d. Explain to the patient that she can do nothing A. Nightingale
to help him B. Johnson
C. Rogers
15. Nurse Brenda is teaching a patient about a D. Hall
newly prescribed drug. What could cause a
geriatric patient to have difficulty retaining 22. The American Nurses association
knowledge about prescribed medications? formulated an innovation of the Nursing process.
Today, how many distinct steps are there in the
a. Decreased plasma drug levels nursing process?
b. Sensory deficits A. APIE – 4
c. Lack of family support B. ADPIE – 5
d. History of Tourette syndrome C. ADOPIE – 6
D. ADOPIER – 7
16. When examining a patient with abdominal
pain the nurse in charge should assess: 23. They are the first one to suggest a 4 step

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nursing process which are : APIE , or This is what type of Nursing Diagnosis?
assessment, planning, implementation and A. Actual
evaluation. B. Probable
1. Yura C. Possible
2. Walsh D. Risk
3. Roy
4. Knowles 29. Nurse Angela diagnosed Mrs. Delgado, who
have undergone a BKA. Her diagnosis is SELF
A. 1,2 ESTEEM DISTURBANCE R/T CHANGE IN
B. 1,3 BODY IMAGE. Although the client has not yet
C. 3,4 seen her lost leg, Angela already anticipated the
D. 2,3 diagnosis. This is what type of Diagnosis?
A. Actual
24. Which characteristic of nursing process is B. Probable
responsible for proper utilization of human C. Possible
resources, time and cost resources? D. Risk
A. Organized and Systematic
B. Humanistic 30. Nurse Angela is about to make a diagnosis
C. Efficient but very unsure because the S/S the client is
D. Effective experiencing is not specific with her diagnosis of
POWERLESSNESS R/T DIFFICULTY
25. Which characteristic of nursing process ACCEPTING LOSS OF LOVED ONE. She then
addresses the INDIVIDUALIZED care a client focus on gathering data to refute or prove her
must receive? diagnosis but her plans and interventions are
A. Organized and Systematic already ongoing for the diagnosis. Which type of
B. Humanistic Diagnosis is this?
C. Efficient A. Actual
D. Effective B. Probable
C. Possible
26. A characteristic of the nursing process that is D. Risk
essential to promote client satisfaction and
progress. The care should also be relevant with 31. Nurse Angela knew that Stephen Lee Mu
the client’s needs. Chin, has just undergone an operation with an
A. Organized and Systematic incision near the diaphragm. She knew that this
B. Humanistic will contribute to some complications later on.
C. Efficient She then should develop what type of Nursing
D. Effective diagnosis?
A. Actual
27. Rhina, who has Menieres disease, said that B. Probable
her environment is moving. Which of the C. Possible
following is a valid assessment? D. Risk
1. Rhina is giving an objective data
2. Rhina is giving a subjective data 32. Which of the following Nursing diagnosis is
3. The source of the data is primary INCORRECT?
4. The source of the data is secondary A. Fluid volume deficit R/T Diarrhea
B. High risk for injury R/T Absence of side
A. 1,3 rails
B. 2,3 C. Possible ineffective coping R/T Loss of loved
C. 2.4 one
D. 1,4 D. Self-esteem disturbance R/T Effects of
surgical removal of the leg
28. Nurse Angela, observe Joel who is very
apprehensive over the impending operation. The 33. Among the following statements, which
client is experiencing dyspnea, diaphoresis and should be given the HIGHEST priority?
asks lots of questions. Angela made a diagnosis A. Client is in extreme pain
of ANXIETY R/T INTRUSIVE PROCEDURE. B. Client’s blood pressure is 60/40

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C. Client’s temperature is 40 deg. Centigrade 40. Which of the following is true about the
D. Client is cyanotic NURSING CARE PLAN?
A. It is nursing centered
34. Which of the following need is given a higher B. Rationales are supported by interventions
priority among others? C. Verbal
A. The client has attempted suicide and safety D. Atleast 2 goals are needed for every nursing
precaution is needed diagnosis
B. The client has disturbance in his body image
because of the recent operation SITUATION : Aling Brea, a 32 year old fish
C. The client is depressed because her vendor from Barangay Wisteria Lane came
boyfriend left her all alone to see you at the prenatal clinic. She brought
D. The client is thirsty and dehydrated with her all her three children. Maye, 1 year
and 6 months; Joy, 3 and Dan, 7 years old.
35. Which of the following is TRUE with regards She mentioned that she stopped taking oral
to Client Goals? contraceptives several months ago and now
A. They are specific, measurable, attainable and suspects she is pregnant. She cannot
time bounded remember her LMP.
B. They are general and broadly stated 41. Which of the following would be useful in
C. They should answer for WHO, WHAT calculating Aling Brea's EDC?
ACTIONS, WHAT CIRCUMSTANCES, HOW A. Appearance of linea negra
WELL and WHEN. B. First FHT by fetoscope
D. Example is : After discharge planning, Client C. Increase pulse rate
demonstrated the proper psychomotor skills for D. Presence of edema
insulin injection.
42. Which hormone is necessary for a positive
36. Which of the following is a NOT a correct pregnancy test?
statement of an Outcome criteria? A. Progesterone
A. Ambulates 30 feet with a cane before B. HCG
discharge C. Estrogen
B. Discusses fears and concerns regarding the D. Placental Lactogen
surgical procedure
C. Demonstrates proper coughing and breathing 43. With this pregnancy, Aling Brea is a
technique after a teaching session A. P3 G3
D. Reestablishes a normal pattern of B. Primigravida
elimination C. P3 G4
D. P0 G3
37. Which of the following is a OBJECTIVE
data? 44. In explaining the development of her baby,
A. Dizziness you identified in chronological order of growth of
B. Chest pain the fetus as it occurs in pregnancy as
C. Anxiety A. Ovum, embryo, zygote, fetus, infant
D. Blue nails B. Zygote, ovum, embryo, fetus, infant
C. Ovum, zygote, embryo, fetus, infant
38. A patient’s chart is what type of data source? D. Zygote, ovum, fetus, embryo, infant
A. Primary
B. Secondary 45. Aling Brea states she is happy to be
C. Tertiary pregnant. Which behavior is elicited by her
D. Can be A and B during your assessment that would lead you to
think she is stressed?
39. All of the following are characteristic of the A. She told you about her drunk husband
Nursing process except B. She states she has very meager income from
A. Dynamic selling
B. Cyclical C. She laughs at every advise you give even
C. Universal when it’s not funny
D. Intrapersonal D. She has difficulty following instructions

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46. When teaching Aling Brea about her C. Inches
pregnancy, you should include personal D. Fingerbreadths
common discomforts. Which of the following is
an indication for prompt professional 53. To determine fetal position using Leopold's
supervision? maneuvers, the first maneuver is to
A. Constipation and hemorrhoids A. Determine degree of cephalic flexion and
B. Backache engagement
C. Facial edema B. Determine part of fetus presenting into pelvis
D. frequent urination C. Locate the back,arms and legs
D. Determine what part of fetus is in the fundus
47. Which of the following statements would be
appropriate for you to include in Aling Brea's 54. Aling Brea has encouraged her husband to
prenatal teaching plan? attend prenatal classes with her. During the
A. Exercise is very tiresome, it should be prenatal class, the couple expressed fear of pain
avoided during labor and delivery. The use of touch and
B. Limit your food intake soothing voice often promotes comfort to the
C. Smoking has no harmful effect on the growth laboring patient. This physical intervention is
and development of fetus effective because
D. Avoid unnecessary fatigue, rest periods A. Pain perception is interrupted
should be included in your schedule B. Gate control fibers are open
C. It distracts the client away from the pain
48. The best advise you can give to Aling Brea D. Empathy is communicated by a caring person
regarding prevention of varicosities is
A. Raise the legs while in upright position and 55. Which of the following could be considered
put it against the wall several times a day as a positive sign of pregnancy ?
B. Lay flat for most hours of the day A. Amenorrhea, nausea, vomiting
C. Use garters with nylon stocking B. Frequency of urination
D. Wear support hose C. Braxton hicks contraction
D. Fetal outline by sonography
49. In a 32 day menstrual cycle, ovulation
usually occurs on the 56. Angela, at her first visit to the prenatal clinic,
A. 14th day after menstruation states that she has missed three menstrual
B. 18th day after menstruation periods, thinks she has twins because her
C. 20th day after menstruation abdomen is so large, but has started to have a
D. 24th day after menstruation brownish vaginal discharge. Her blood pressure
is elevated indicating that she may have
50. Placenta is the organ that provides gestational hypertension. The nurse is aware
exchange of nutrients and waste products that a further assessment is required because
between mother and fetus. This develops by she may have:
A. First month A. Renal failure
B. Third month B. Abruptio placenta
C. Fifth month C. Placenta previa
D. Seventh month D. H-mole

51. In evaluating the weight gain of Aling Brea, 57. A client at 36 weeks’ gestation is schedule
you know the minimum weight gain during for a routine ultrasound prior to an
pregnancy is amniocentesis. After teaching the client about
A. 2 lbs/wk the purpose for the ultrasound, which of the
B. 5 lbs/wk following client statements would indicate to the
C. 7 lbs/wk nurse in charge that the client needs further
D. 10 lbs/wk instruction?
a. The ultrasound will help to locate the
52. The more accurate method of measuring placenta
fundal height is b. The ultrasound identifies blood flow through
A. Millimeter the umbilical cord
B. Centimeter c. The test will determine where to insert the

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needle
d. The ultrasound locates a pool of amniotic 63. In Leopold’s maneuver step # 3 you
fluid palpated a hard round movable mass at the
supra pubic area. The correct interpretation is
58. While the postpartum client is receiving that the mass palpated is:
herapin for thrombophlebitis, which of the A.The buttocks because the presentation is
following drugs would the nurse Mica expect to breech.
administer if the client develops complications B.The mass palpated is the head.
related to heparin therapy? C.The mass is the fetal back.
a. Calcium gluconate D.The mass palpated is the fetal small part
b. Protamine sulfate
c. Methylegonovine (Methergine) 64. The hormone responsible for a positive
d. Nitrofurantoin (macrodantin) pregnancy test is:
A.Estrogen
59. When caring for a 3-day-old neonate who is B.Progesterone
receiving phototherapy to treat jaundice, the C.Human Chorionic Gonadotropin
nurse in charge would expect to do which of the D.Follicle Stimulating hormone
following?
a. Turn the neonate every 6 hours 65. The hormone responsible for the maturation
b. Encourage the mother to discontinue breast- of the graafian follicle is:
feeding A.Follicle stimulating hormone
c. Notify the physician if the skin becomes B.Progesterone
bronze in color C.Estrogen
d. Check the vital signs every 2 to 4 hours D.Luteinizing hormone

60. A primigravida in active labor is about 9 days 66. The most common normal position of the
post-term. The client desires a bilateral fetus in utero is:
pudendal block anesthesia before delivery. After A.Transverse position
the nurse explains this type of anesthesia to the B.Vertical position
client, which of the following locations identified C.Oblique position
by the client as the area of relief would indicate D.None of the above
to the nurse that the teaching was effective?
a. Back 67. In the later part of the 3rd trimester, the
b. Abdomen mother may experience shortness of breath.
c. Fundus This complaint maybe explained as:
d. Perineum A.A normal occurrence in pregnancy because
the fetus is using more oxygen
61. You performed the leopold’s maneuver and B.The fundus of the uterus is high pushing the
found the following: breech presentation, fetal diaphragm upwards
back at the right side of the mother. Based on C.The woman is having allergic reaction to the
these findings, you can hear the fetal heart beat pregnancy and its hormones
(PMI) BEST in which location? D.The woman maybe experiencing complication
A.Left lower quadrant of pregnancy
B.Right lower quadrant
C.Left upper quadrant 68. Which of the following findings in a woman
D.Right upper quadrant would be consistent with a pregnancy of two
months duration?
62. In Leopold’s maneuver step #1, you A.Weight gain of 6-10 lbs. and presence of
palpated a soft broad mass that moves with the striae gravidarum
rest of the mass. The correct interpretation of B.Fullness of the breast and urinary frequency
this finding is: C.Braxton Hicks contractions and quickening
A.The mass palpated at the fundal part is the D.Increased respiratory rate and ballottement
head part.
B.The presentation is breech. 69. Which of the following is a positive sign of
C.The mass palpated is the back pregnancy?
D.The mass palpated is the buttocks. A.Fetal movement felt by mother

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B.Enlargement of the uterus C.28-30 weeks
C.(+) pregnancy test D.38-40 weeks
D.(+) ultrasound
77. Which provision of our 1987 constitution
70. What event occurring in the second trimester guarantees the right of the unborn child to life
helps the expectant mother to accept the from conception is
pregnancy? A.Article II section 12
A.Lightening B.Article II section 15
B.Ballotment C.Article XIII section 11
C.Pseudocyesis D.Article XIII section 15
D.Quickening
78. In the Philippines, if a nurse performs
71. Shoes with low, broad heels, plus a good abortion on the mother who wants it done and
posture will prevent which prenatal discomfort? she gets paid for doing it, she will be held liable
A.Backache because
B.Vertigo A.Abortion is immoral and is prohibited by the
C.Leg cramps church
D.Nausea B.Abortion is both immoral and illegal in our
country
72. When a pregnant woman experiences leg C.Abortion is considered illegal because you got
cramps, the correct nursing intervention to paid for doing it
relieve the muscle cramps is: D.Abortion is illegal because majority in our
A.Allow the woman to exercise country are catholics and it is prohibited by the
B.Let the woman walk for a while church
C.Let the woman lie down and dorsiflex the foot
towards the knees 79. The preferred manner of delivering the baby
D.Ask the woman to raise her legs in a gravido-cardiac is vaginal delivery assisted
by forceps under epidural anesthesia. The main
73. From the 33rd week of gestation till full term, rationale for this is:
a healthy mother should have prenatal check up A.To allow atraumatic delivery of the baby
every: B.To allow a gradual shifting of the blood into
A.week the maternal circulation
B.2 weeks C.To make the delivery effort free and the
C.3 weeks mother does not need to push with contractions
D.4 weeks D.To prevent perineal laceration with the
expulsion of the fetal head
74. The expected weight gain in a normal
pregnancy during the 3rd trimester is 80. When giving narcotic analgesics to mother in
A.1 pound a week labor, the special consideration to follow is:
B.2 pounds a week A.The progress of labor is well established
C.10 lbs a month reaching the transitional stage
D.10 lbs total weight gain in the 3rd trimester B.Uterine contraction is progressing well and
delivery of the baby is imminent
75. Which of the following conditions will lead to C.Cervical dilatation has already reached at
a small-for-gestational age fetus due to less least 8 cm. and the station is at least (+)2
blood supply to the fetus? D.Uterine contractions are strong and the baby
will not be delivered yet within the next 3 hours.
A.Diabetes in the mother
B.Maternal cardiac condition SITUATION: Dervid, A registered nurse,
C.Premature labor witnessed an old woman hit by a motorcycle
D.Abruptio placenta while crossing a train railway. The old
woman fell at the railway. Dervid Rushed at
76. The lower limit of viability for infants in terms
the scene.
of age of gestation is:
81. As a registered nurse, Dervid knew that the
A.21-24 weeks
first thing that he will do at the scene is
B.25-27 weeks

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A. Stay with the person, encourage her to B. On his left hand, because of reciprocal
remain still and Immobilize the leg while waiting motion.
for the ambulance. C. On his right hand, to support the right leg.
B. Leave the person for a few moments to call D. On his right hand, because only his right leg
for help. is weak.
C. Reduce the fracture manually.
D. Move the person to a safer place. 87. You also told Mr. E.to hold the cane
A. 1 Inches in front of the foot.
82. Dervid suspects a hip fracture when he B. 3 Inches at the lateral side of the foot.
noticed that the old woman’s leg is C. 6 Inches at the lateral side of the foot.
A. Lengthened, Abducted and Internally D. 12 Inches at the lateral side of the foot.
Rotated.
B. Shortened, Abducted and Externally Rotated. 88. Mr. E. was discharged and 6 months later,
C. Shortened, Adducted and Internally Rotated. he came back to the emergency room of the
D. Shortened, Adducted and Externally Rotated. hospital because he suffered a mild stroke. The
right side of the brain was affected. At the
83. The old woman complains of pain. John rehabilitative phase of your nursing care, you
noticed that the knee is reddened, warm to observe Mr. E. use a cane and you intervene if
touch and swollen. These signs and symptoms you see him
are likely related to A. Moves the cane when the right leg is moved.
A. Infection B. Leans on the cane when the right leg swings
C. Thrombophlebitis through.
B. Inflammation C. keeps the cane 6 Inches out to the side of the
D. Degenerative disease right foot.
D. Holds the cane on the right side.
84. The old woman told Dervid that she has
osteoporosis; Dervid knew that all of the SITUATION: Alfred, a 40 year old
following factors would contribute to construction worker developed cough, night
osteoporosis except sweats and fever. He was brought to the
A. Hypothyroidism nursing unit for diagnostic studies. He told
B. End stage renal disease the nurse he did not receive a BCG vaccine
C. Cushing’s Disease during childhood
D. Taking Furosemide and Phenytoin. 89. The nurse performs a Mantoux Test. The
nurse knows that Mantoux Test is also known as
85. Martha, the old woman was now A. PPD
Immobilized and brought to the emergency B. PDP
room. The X-ray shows a fractured femur and C. PDD
pelvis. The ER Nurse would carefully monitor D. DPP
Martha for which of the following sign and
symptoms? 90. The nurse would inject the solution in what
A. Tachycardia and Hypotension route?
B. Fever and Bradycardia A. IM
C. Bradycardia and Hypertension B. IV
D. Fever and Hypertension C. ID
D. SC
SITUATION: Mr. E., An obese 50 year old C.I
of UI-PEN is admitted due to pain in his 91. The nurse notes that a positive result for
weight bearing joint. The diagnosis was Alfred is
Osteoarthritis. A. 5 mm wheal
86. As a nurse, you instructed Mr. E. how to use B. 5 mm Induration
a cane. Mr. E. has a weakness on his right leg C. 10 mm Wheal
due to self-immobilization and guarding. You D. 10 mm Induration
plan to teach Mr. E.to hold the cane
A. On his left hand, because his right side is 92. The nurse told Alfred to come back after
weak. A. a week
B. 48 hours

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C. 1 day D. 5 months
D. 4 days
97. Which of the following drugs is UNLIKELY
93. Mang Alfred returns after the Mantoux Test. given to Mang Alfred during the maintenance
The test result read POSITIVE. What should be phase?
the nurse’s next action? A. Rifampicin
A. Call the Physician B. Isoniazid
B. Notify the radiology dept. for CXR evaluation C. Ethambutol
C. Isolate the patient D. Pyridoxine
D. Order for a sputum exam
98. According to the DOH, the most hazardous
94. Why is Mantoux test not routinely done in period for development of clinical disease is
the Philippines? during the first
A. It requires a highly skilled nurse to perform a A. 6-12 months after
Mantoux test B. 3-6 months after
B. The sputum culture is the gold standard of C. 1-2 months after
PTB Diagnosis and it will definitively determine D. 2-4 weeks after
the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific 99. This is the name of the program of the DOH
microorganism responsible for the lesions to control TB in the country
D. Almost all Filipinos will test positive for A. DOTS
Mantoux Test B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
95. Mang Alfred is now a new TB patient with an D. Expanded Program for Immunization
active disease. What is his category according
to the DOH? 100. Susceptibility for the disease [ TB ] is
A. I increased markedly in those with the following
B. II condition except
C. III A. 23 Year old athlete with diabetes insipidus
D. IV B. 23 Year old athlete taking long term
Decadron therapy and anabolic steroids
96. How long is the duration of the maintenance C. 23 Year old athlete taking illegal drugs and
phase of his treatment? abusing substances
A. 2 months D. Undernourished and Underweight individual
B. 3 months who undergone gastrectomy
C. 4 months

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