NURSING PRACTICE II

NURSING PRACTICE II - CARE OF HEALTHY/AT RISK MOTHER & CHILD

INSTRUCTION:
1. Detach one (1) answer sheet from the last page of your Examinee ID/Answer Sheet Set.
2. Write the subject title “Nursing Practice II” on the box provided.
3. Shade set Box “A” on your answer sheet if your test booklet is set A; Set Box “B” if your test booklet is Set B.
4. Select the correct answer for each of the following questions. Mark only one answer for each item by shading
the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES
ALLOWED.

Situation 1: Nurse Kathy is caring for a postpartum patient. Routine postpartum care is rendered to the patient.

1. Which assessment finding would lead the nurse to suspect a postpartum hemorrhage? Blood loss of:
A. Less than 300 ml/24 hours
B. More than 400 ml/24 hours
C. Less than 200 ml/2 hours
D. More than 500 ml/ 24 hours

2. Which of the following is caused by the markedly distended uterus and intermittent uterine contraction within 2 to
3 days after birth?
A. Retained placenta
B. Uterine atony
C. Afterpains
D. Boggy uterus

3. The nurse prepares a care plan for the patient. Based on Ramona Mercer’s becoming a mother (BAM) theory,
which of the following statements fosters the process of becoming a mother?
A. The woman becomes comfortable with her identity as a married individual.
B. It encompasses the dynamic transformation and evolution of a woman’s person
C. A woman learns mothering behavior prior as early as a teenager
D. It accurately reflects the transitional process from being single to a married relationship

4. The mother asks why she has a gush of blood coming out from the vagina that occurs when she first arises from
bed. The nurse’s CORRECT response should be:
A. “Blood pools at the top of vagina and forms clots that are passed upon rising or sitting on the toilet.”
B. “Positioning causes blood to flow out when she stands”
C. “Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep.
D. “Normal physiologic occurrence that results as the body attempts to eliminate excess fluids.”

5. Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum.
Which PRIORITY nursing measures stimulate the sensation of voiding?
A. Encouraging her to void.
B. Running water in the sink or shower
C. Helping the mother into the shower
D. Providing cold tea or fluids of choice.

Situation 2: A postpartum mother newly delivered her baby per vagina. She keeps on asking the nurse when the basic
physiologic changes occur as her body returns to a pre pregnant state.

6. The nurse explains to the mother that the uterus will return to its pre pregnancy state in ____weeks:
A. Six
B. Three
C. Four
D. Five

7. In her capacity to teach, the nurse describes the changes of the uterus after childbirth to return to a nonpregnant
state as:
A. Catabolism
B. Subinvolution
C. Contraction of muscle fibers
D. Involution

Pre-Board I – Nursing Practice II – Set A/Page 1 of 12

8. Which of the following conditions does the nurse explains to the patient the contributory factor that slows uterine
involution?
A. Full bladder during labor
B. Difficult birth
C. Prolonged labor
D. Infection during pregnancy

9. The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?
A. Symphysis pubis
B. Midline
C. Umbilicus
D. Sides of the abdomen

10. The FIRST PRIORITY nursing intervention during the immediate postpartum period is focused on:
A. Monitoring urinary output
B. Taking the vital signs every 4 hours
C. Observing postpartum hemorrhage
D. Checking level of responsiveness

Situation 3: Evelyn a multigravida, in her 20th weeks of gestation visited the community clinic with complaints of
dizziness, vertigo, and heartburns. After the physical assessment, Nurse Harper finds the patient as malnourished.

11. Iron supplementation was prescribed because of her low hemoglobin level. Which statement if made by Evelyn
would indicate an understanding of health instructions?
A. “My body has all the iron it needs and I don't need to take supplements.”
B. “Meat does not provide iron and should be avoided.”
C. “The iron is best absorbed if taken on an empty stomach.”
D. “Iron supplements will give green color to my stool.

12. Evelyn was given iron as a supplement vitamin to prevent maternal anemia. She asks if it will not be affected
because she is regularly taking vitamin C. Which of the following would be the BEST response of the nurse?
A. “Take two other vitamins separately.”
B. “Take the iron after a full meal.”
C. “Absorption of iron is enhanced with vit C.”
D. “Drink milk when taking the iron supplement.”

13. Evelyn was also advised to take calcium supplements on the 2nd 3rd trimester of pregnancy. Which of the
following would ENHANCE her intestinal absorption of calcium?
A. Fat-soluble vitamins
B. Proteins
C. Minerals
D. Water soluble vitamins

14. Nurse Harper observes Evelyn has a knowledge deficit regarding fetal nutrition. Nurse harper has to explain that
the MAIN SOURCE of nutrition for the baby is which of the following?
A. Amniotic fluid
B. Uterus
C. Placenta
D. Chorionic villi

15. Nurse Harper provides health instruction to the patient experiencing heartburn. Which statement by the patient
indicates a NEED for further instructions? I have to:
A. Drink milk between meals
B. Eat small frequent meals
C. Avoid fatty or spicy foods
D. Lie down after eating

Situation 4: The giving of medication to a pediatric patient is a serious responsibility of a nurse. Nurse Cory has just
been assigned to the pediatric wards.

16. When giving medicines to pediatric patients, dosage varies. Which of the following should nurse Imelda consider?
A. Height and surface area
B. Size, surface area & age
C. Size, & surface area, age, & height
D. Size, surface area

Pre-Board I – Nursing Practice II – Set A/Page 2 of 12

17. The head nurse checks Nurse Cory’s knowledge on administering oral medications to pediatric patients. Which of
the following statements below should she chosen as CORRECT?
A. A child’s reaction to a dose ordered by a physician is not less predictable than an adult's reaction.
B. When giving oral medication, the child as young as two years of age cannot be taught to swallow drugs.
C. The child should be told to place the tablet in the middle of his tongue and drink water to wash down the tablet.
D. The possibility of error is greater in the giving of medication to children than to adults.

18. In infants and toddlers, which part should nurse Cory often use for intramuscular injection to reduce the risk of
vascular and peripheral nerve injuries?
A. Gluteus maximus
B. Dorso-gluteal
C. Deltoid muscle
D. Vastus lateralis

19. Administering medication intramuscularly can produce a variety of serious adverse effect has been revealed in
comprehensive surveys of research reports. When asked by the head nurse what is the MOST common
complication that may arise, Nurse Cory should mention:
A. Abscess
B. Herve palsies and paralysis
C. Hematoma
D. Muscle contracture

20. Prior to administering the drugs ordered by the pediatrician, Nurse Cory needs to know if She is giving the ordered
medication to the right patient. The FIRST step is:
A. Check the patient’s hospital bracelet.
B. Ask the parent/ significant other to state name of patient and birth date of patient
C. Verify patient’s allergies with charts and with patients.
D. Compare medication order to identification bracelet.

Situation 5: Isabelle, a patient with severe preeclampsia, is admitted to the hospital. She is a student from one of the
local universities, she insists on continuing her studies while in the hospital despite being instructed to rest. The patient
studies approximately 10 hours a day and has numerous visits from fellow students, family, and friends.

21. Nurse Isabelle is concerned about the patient’s welfare and her ability to comply with the doctor’s instructions.
What should be the APPROPRIATE action?
A. Include a significant other in helping the patient understand the need for rest.
B. Instruct the patient that the baby’s health is more important than her studies at this time.
C. Develop a routine with the patient to balance her studies and her rest needs.
D. Ask her why she is not complying with the prescription for bed rest.

22. Patients Alaia, who seems to be irritated with the nurse, said, “I don’t want to talk to you because you’re only a
nurse. I will wait for my doctor.” Which of the following is an APPROPRIATE response by the nurse?
A. “I ‘m angry with the way you dismissed me.”
B. “So, then you would prefer to speak with your doctor?”
C. “I understand. I should call your doctor.”
D. “Your doctor prescribed this for us to do nursing care.”

23. Nurse Alaia is now in a dilemma. This occurs when:

A. There is a conflict between the nurse’s decision and that of his/her superior
B. Choices are unclear
C. There is a conflict of two or more ethical principles
D. A decision had to be made quickly under a stressful situation

24. Which of the ethical principles stipulates that the nurse is responsible for providing all patients with care, attention
and information?
A. Beneficence
B. Advocacy
C. Nonmaleficence
D. Veracity

25. Which action by the nurse provides a safe environment for a preeclamptic patient?
A. Maintain fluid and sodium restrictions.
B. Take off the room lights and draw the windows shades.
C. Encourage visits from family and friends for psychosocial support
D. Take the patient’s vital signs every 4 hours

Pre-Board I – Nursing Practice II – Set A/Page 3 of 12

Situation 6: Part II of the training is the giving of the hypothetical situation for application of what was taken during
the didactic. A group was given a scenario of a pregnant woman in the OB ward.

26. The scenario states that the nurse is discussing the nursing process with a newly hired nurse. Which of the following
describes the planning phase of the nursing process?
A. Identify the nursing process?
B. Gather information if the patient’s problem has been resolved in the evaluation phase
C. Review the patient’s history during the assessment
D. Prioritize patient problems.

27. Nurse Jezyl one the group leaders reviewed the steps of the nursing process with the group. Which of the following
data should the nurse identify as objective data? Select all that apply.
I. Respiratory rate is 22/min
II. Feels pain after a 10-minute walk
III. Pain is rated as 3 on a scale of 10
IV. Akin is pinkish in color, warm and dry.
A. II and III
B. I and IV
C. III and IV
D. I and II

28. On the second day, the patient delivered an alive baby girl. She complains of leg pain. The nurse took hold of the
patient’s chart. Ponstan 500 mg every hour PRN for pain was ordered and was given. After 40 minutes, the patient
was relieved. What step of the nursing process should the nurse have conducted?
A. Assessment
B. Planning
C. Evaluation
D. Intervention

29. According to the nursing process, which of the following actions the nurse takes if the pain does not satisfactorily
relieve?
A. Wait for more time for the pain reliever to take effect
B. Collect additional data as to why the patient has not been relieved of pain.
C. Teach the patient relaxation breathing techniques.
D. Refer to an attending physician.

30. The nurse trainor discusses the elements of documentation. Which of the following refers to being comprehensive
and timely?
A. Complete and current
B. Accurate and concise
C. Organized
D. Factual

Situation 7: Patient Ellie, a 28-year-old primigravida, is admitted to a birthing center, She has been in labor with an
interval of 5 minutes apart for 10 hours now. Hypotonic contractions are observed by nurse Nora. She feels more pain
in her back than in her abdomen, sonogram shows her fetus is “borderline” large for gestation and in occipitor -
posterior position.

31. Nurse Nora observes that the Ellie’s uterine contractions are irregular in frequency and short in duration. Ellie
screams in pain during contractions. Which of the following actions is considered BEST for the nurse to perform?
A. Try to divert attention from pain
B. Administer pain reliever as ordered
C. Stay with the patient and offer her a back rub
D. Document and report frequency and duration of contractions

32. The physician is considering augmenting her labor with oxytocin. What would make nurse Nora questions the use
of oxytocin for patient Ellise?
A. She had an amniocentesis performed during pregnancy
B. Her fetus is large for gestational age by a sonogram
C. Her membrane ruptured after only 1 hour of labor
D. Her blood pressure is slightly elevated above normal

Pre-Board I – Nursing Practice II – Set A/Page 4 of 12

33. Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing
the frequency of her contractions after she receives oxytocin. What would be the nurse’s FIRST action?
A. Give an emergency bolus of oxytocin to relaxed the uterus
B. Discontinue the administration of the oxytocin infusion
C. Increase the rate of client’s IV infusion
D. Ask client to turn to her left side and breaths deeply

34. Nurse Nora monitors the patient's knowledge that which findings indicate an adequate contraction pattern?
A. Three to 5 contractions in a 10 minutes period, with resultant cervical dilatation
B. Four contractions every 5 minutes, without resultant cervical dilatation
C. Once contraction every 10 minutes, without resultant cervical dilatation
D. One contraction per minute, with resultant cervical dilatation

35. Which of the following nursing measures would the nurse LEAST CONSIDERS to patient Ellie with oxytocin
drip?
A. Know how to recognize potential adverse reactions.
B. Administer oxytocin drug with caution
C. Monitor patient closely when infusing oxytocin
D. Inform patients about potential complications.

Situation 8: Miriam at one years of age, is admitted due to pneumonia. She has IV antibiotics, antipyretic, decongestant
and vitamins as medications. She also is under oxygen therapy.

36. Nurse Messy has been worried about Miriam’s refusal to take oral drugs. How will she handle the situation?
A. Leave the child alone
B. Seek the help of the mother in giving the oral drug.
C. Mix the drug with milk to cover up the unfavorable taste.
D. Get angry with the mother and the child.

37. As a one-year child, nurse Messy understands the reason(s) why Miriam continuously refuses to take her drugs. It
is because it is normal for her age to:
A. Have separation anxiety
B. Internalize the attitudes of others
C. Utilize magical thinking
D. Be negativity in all matters

38. The BEST way to administer oxygen on Miriam is by:

A. Hood
B. Face mask
C. Incentive spirometer
D. Nasal catheter

39. For the IV antibiotic therapy of Miriam, the MOST common gauge used for IV cannula is Gauge:
A. 20
B. 24
C. 22
D. 18

40. What IMPORTANT evaluation parameter should nurse Messy observe that would show improvement in Miriam’s
condition?
A. Absence of fever
B. Absence of chest indrawing
C. Respiratory rate of 45 beats per minute
D. Respiratory rate of 55 beats per minute

Situation 9: Ashley a postpartum patient, who has delivered a stillborn wants to leave the hospital without a physician’s
order. The patient is still hooked to an intravenous fluid (IVF) and is on closed post-partum monitoring.

41. To avoid liability, which of the following is an APPROPRIATE action by nurse Valerie?
A. Notify nursing supervisor of the patient's plans to leave
B. Arrange medication prescriptions at the patient’s preferred pharmacy.
C. Notify directly the attending obstetrician
D. Ask the patient about transportation plans from the hospital

Pre-Board I – Nursing Practice II – Set A/Page 5 of 12

42. Nurse Valerie informs Ashley of the need for early ambulation. Which of the nurse’s instructions on ambulation
is INCORRECT?
A. Assist the patient from sitting to standing position
B. Raise the head of the bed slowly to achieve the sitting position of the patient.
C. Allow the patient to rise from the bed to a standing position unassisted.
D. Assist patients to rise from lying to sitting position.

43. While waiting for feedback from the nurse supervisor regarding the patient’s desire to go, home, nurse Valerie
opted to check on the patient. Upon entering the room, she discovers that the waste basket is on fire. Sequence the
nurse’s actions below.
I. rescue the patient
II. Activate the fire alarm
III. Close the door to confine the fire.
IV. Put off the fire with fire extinguisher

A. IV, II, and I

B. I, II, III, IV
C. I, II, and, IV
D. II, IV, and I

44. After the fire was put off, the patient was found to have absconded. What is the ethico-legal responsibility of the
attending nurse?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Justice

45. Absconding is inevitable in any health care facility WHO will be informed IMMEDIATELY if the patient found
out absconded?
A. Attending physician
B. Security guard on duty
C. Resident on duty
D. Nursing staff

Situation 10: Catherine, 5 years of age, is admitted to the pediatric ward due to severe otalgia, fever and irritability.
The mother informed nurse Selma that the patient had upper respiratory infection three weeks prior to admission. The
admission diagnosis is acute otitis media (AOM).

46. Nurse Selma conducts her INITIAL assessment on Catherine. The patient keeps on crying and constantly pulls her
right ear. What is her MOST APPROPRIATE action?
A. Request parent to carry the child
B. Take Catherine’s vital signs
C. Refer to the attending physician.
D. Assess the description and frequency of pain

47. Nurse Selma is preparing to administer Ofloxacin ear drop on Catherine per doctor’s order. She needs to hold the
bottle with her hands to warm up the solution to prevent dizziness for:
A. 5-6 minutes
B. 1 to 2 minutes
C. 3-4 minutes
D. 6-7 minutes

48. After washing her hands and gently cleaning any discharge that can be removed easily from the outer ear, Nurse
Selma positions the child. Which of the following steps follows?
A. Gently press the tragus of the ear four times in a pumping motion
B. Gently pull the outer ear
C. Drop the medicine into the ear canal.
D. Keep the ear up for five minutes.

49. Based on her knowledge on otitis media, Nurse Selma recalls that children are predisposed to AOM due to the
following risk factors, EXCEPT:
A. Absence of breastfeeding
B. Swimming
C. Exposure to cigarette smoke
D. Poor hygiene

Pre-Board I – Nursing Practice II – Set A/Page 6 of 12

50. To promote drainage and reduce pressure from fluid, nurse Selma’s nursing intervention is to have the child assume
any of the following positions, EXCEPT:
A. Tilt head to side if sitting up.
B. Lie on the affected are
C. Put the pillows behind the head
D. Lie on the non-affected ear

Situation 11: Nurse Ester is rotated to the Pediatrics Ward. As such, she needs to review the principles and concept of
human growth and development to better appreciate her role as a professional nurse.

51. Being assigned to care for pediatric patients, nurse Ester should remember which of the following statements?
A. Toddler period ranges from 12 to 36 months
B. An infant’s tongue is smaller than the adult
C. Early childhood period ranges from 3 to 7 years.
D. Breast milk provides complete infant nutrition
52. While nurse Easter was taking the temperature of Baby Chooka, the mother asked nurse Ester when growth and
development become more rapid. Her answer should be, during at ______ months of life?
A. Ten
B. Nine
C. Twelve
D. Eleven

53. It is vital for nurse Ester to give concrete examples of activities to stimulate gross and fine motor development.
Examples are, which of the following /
1. push/pull
2. Use of scissors and pencil appropriately
3. Poking straws into holes
4. Stand on tiptoes if shown first
A. 1 & 2
B. 2 & 3
C. 3 & 4
D. 1,2,3 &4
54. According to the world health organization (WHO), suicide has become a global phenomenon. When taking care
of emotionally disturbed adolescent patient’s, Nurse Ester should be alerted with warning signs which often occur
for at least one month before a suicide attempt, EXCEPT:
A. Increase in initiative
B. Verbalization of suicidal thoughts
C. Crying
D. Sleep disturbances

55. During one of the nursing rounds, the pediatric ward headnurse asked nurse Ester the inclusive ages considered as
the transition from childhood to adulthood but sometimes extending until college graduation. Her CORRECT
answer should be:
A. 15 to 18
B. 12 to 16
C. 11 to 18
D. 12 to 18

Situation 12: In a birthing station, five postpartum mothers delivered 2 hours, 4 hours, and 6 hours ago, respectively.
All of them are multigravida patients. Adalynn, the nurse educator opted to conduct health education on a postpartum
hemorrhage.
56. Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage
is:
A. Increasing pulse and decreasing blood pressure
B. Altered mental status and level of consciousness
C. Dizziness and increasing respiratory rate
D. Cool, clammy skin, and pale mucous membranes

57. The nurse educator Adalynn reviewed the risk factors for postpartum hemorrhage for the mothers. Which of the
following factors is NOT included?
A. Ruptured uterus
B. Uterine atony
C. Overdistended uterus
D. Retroversion of the uterus
Pre-Board I – Nursing Practice II – Set A/Page 7 of 12
58. During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in
line with the umbilicus?
A. Immediately after the delivery
B. 4 days after the delivery
C. When the client’s bladder is full
D. The day after the delivery

59. A postpartum patient asks nurse Adalynn when she may safely resume sexual activity. Which of the following
information should the nurse tell the patient on resumption of sexual Activity?
A. In 2 to 4 weeks
B. At any time
C. After the 6-weeks physician check-up
D. When her normal menstrual period has resumed

60. Nurse Adalynn discusses the possibilities of future postpartum hemorrhage with the patients. Which of the
following increases the absorption of vitamin K?
A. Proteins
B. Carbohydrates
C. Mineral
D. Fats

Situation 13: During the nurse’s rounds, the head nurse noticed that the intake & output sheets have not been filled up.

61. Based on the findings, what should the head nurse do?
A. Ask the staff nurses the reasons for the failure to properly fill up the intake & output flow sheet.
B. Give the staff nurses first warning
C. Conduct a need assessment
D. Review the orientation program

62. The head nurse decided to coach her staff nurses. One of the questions she raised was what fluids should be
excluded in the I & O flow sheet. The CORRECT response should be, Which of the following?
A. Intravenous fluids
B. Gelatin
C. Solid foods
D. Beverages

63. The head nurse emphasized to the staff nurses what NOT to be included under the output list. the answer should
be, which of the following?
A. Drainage from tubes
B. solid/hard faces
C. Urine
D. Vomitus

64. The BEST time to record the intake & output is:
A. During endorsement
B. After endorsement
C. Right before endorsement
D. Anytime before duty

65. A patient’s I & O is vital for patients with chronic heart failure. The MAIN purpose of recording accurately the I
& O of such patient is to:
A. Determine if client is improving or not
B. Find out if there is still water retention in the interstitial cells
C. Detect cardiac overload
D. Determine weight gain/loss

Situation 14: The group of nurses assigned in the delivery room is interested in conducting a study on the experiences
of pregnant women in labor. They are thinking of qualitative research.

66. In the presentation of results of qualitative research, the nurse researcher uses as a reference in the write-up the
____ person:
A. First
B. Second
C. Fourth
D. Third
Pre-Board I – Nursing Practice II – Set A/Page 8 of 12
67. Nursing as a human science, deals with the critical and fundamental differences in attitude Towards their respective
phenomena. Which of the following is an aim of human science?
A. Construct prediction
B. Seeks causal explanation
C. Set control.
D. Makes meaningful interpretation.

68. The group was observant as to the activities taking place in the delivery room. One of the Activities involve social
processes, which can be better explored. Which of the following qualitative research method should be used?
A. Grounded theory
B. Historical research
C. Descriptive phenomenology
D. Case study

69. After the data analysis of their study, experiences of pregnant woman in labor, they returned to the participants to
determine the accuracy of the emerged themes. Which criteria of Trustworthiness is the group doing?
A. Confirmability
B. Credibility
C. Transferability
D. Dependability

70. The group used an audio recorder to capture what transpired during the interview. After the transcription, which
of the following action is APPROPRIATE for the group to do with the Audiotape?
A. Keep audiotape in a vault and dispose it a year after.
B. Submit the audiotape to their research adviser
C. Throw it in the trash bin immediately after it was used.
D. Post the recording on their university research website for others to listen.

Situation 15: Marie, OB-GYN head nurse, conducted an in service program on staff development.

71. Head nurse Marie, discussed that the MOST frequently neglected area in management is:
A. Managerial knowledge
B. Professional development
C. Clinical skills
D. Successful communication

72. A critical component of the supervisory process is delegation. Which of the following is the MOST empowering
to staff?
A. Effective delegation does not require nurses to know the abilities and weaknesses of staff.
B. Delegation frees the manager to do other tasks while empowering staff
C. Delegation fosters the responsibility of staff while increasing professional growth.
D. Delegations start at top management down to subordinates.

73. Head nurse Marie discussed negotiation. The focus of negotiation is to create a:
A. Soothing situation
B. Third-party consultation
C. Trade-off
D. Win-win situation

74. Supervision occurs after delegation. What is the PRIMARY purpose of supervision?
A. Influences the organization’s approach in recruitment, promotion and personnel evaluation.
B. Improves staff compliance with policy and procedure
C. Assigns appropriate work tasks to the best qualified individual.
D. Enhance the delivery of quality nursing care.

75. Delegation involves the transfer of care to an individual. What is the BEST criterion when delegating staff?
A. Responsibility
B. Adaptability
C. Flexibility
D. Competence

Pre-Board I – Nursing Practice II – Set A/Page 9 of 12

Situation 16: Therapeutic communication promotes understanding between the sender and receiver. Nurse Gary should
be absent with the common effective and achievable.

76. When a patient says, “I am not sure if I should undergo colonoscopy or not as I am Scared.” Which of the following
is the MOST appropriate communication technique that Nurse Gary use?
A. Touch
B. Clarifying
C. Restating
D. Silence

77. When a patient says, “whenever I see my husband visit me, I feel depressed”. Nurse Gary says, “Your husband
depresses you?” the therapeutic communication is which of the following?
A. Restatement
B. Focusing
C. Focusing
D. Seeking clarification

78. When a Nurse Gary says to the patient, “Tell me more about your experience when you have the colonoscopy.”
Which of the following therapeutic techniques is Nurse Gary using?
A. Focusing
B. Clarifying
C. Encouraging elaboration
D. Restating

79. When nurse Gary says, “tell me more about the experience. I wish to hear about.” Which of the following
therapeutic communication techniques is nurse Gary using?
A. Restating
B. Seeking clarification
C. Open-ended questions
D. Summarizing

80. When Nurse Gary tells the patient, “You will be wheeled in to the OR and will be hooked to an IVF where the
anesthesia will be given intravenously. “Which of the following therapeutic communication techniques is nurse
Gary using?
A. Clarification
B. Summarizing
C. Giving information
D. Reflection

Situation 17: A pediatric patient, 12 years old, is admitted to the private room with a tracheostomy tube.

81. Since the staff nurse assigned to the patient does not have any experience in caring for a patient with tracheostomy
tube, who among the following should NOT do the care?
A. Medical resident
B. Medical intern
C. Charge nurse
D. Mother of child with care of tracheostomy tube experience

82. The otolaryngologist arrives to change the tracheostomy tube. Which of the following should the nurse collaborate
with for the appropriate equipment/supplies needed in changing the tracheostomy tube?
A. Emergency department
B. Central supply unit
C. Anesthesia department
D. Operating room department

83. To assure that nurse Mica will learn the proper way of caring for patients with tracheostomy tube, the head nurse
should collaborate with, who among the following personnel for the training?
A. Asst. chief nurse for clinical
B. Chief of unit
C. Asst. chief nurse for education training
D. Chief of clinics

Pre-Board I – Nursing Practice II – Set A/Page 10 of 12

84. The otolaryngologist ordered a change of the tracheostomy tube ties? who among the following should the doctor
collaborate with?
A. Medical intern
B. Medical resident
C. Nursing aids
D. Staff nurse

85. The skills of suctioning using a single use catheter for tracheostomy is more safely performed with which of the
number of assistants?
A. Four
B. Two
C. Three
D. One

Situation 18: Josephine, a multiparous patient is admitted due to labor pains which started an hour ago. During the
vaginal examination, the nurse noted the complete dilatation of the cervix and effacement is 100 percent. The patient
is in true labor pains.

86. Which of the following problems with labor and delivery is completed in less than 3 hours?
A. Precipitous
B. Preterm
C. Induced
D. Prolonged

87. Patient Josephine was referred to the physician, routine blood examinations were taken. After reviewing the serum
electrolyte levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse
prepare?
A. 5 percent dextrose in water
B. 0.45 percent sodium chloride solution
C. 10 percent dextrose in water
D. 3 percent sodium chloride solution

88. The patient during labor would anticipate some emotional support. Which of the following nursing interventions
should nurse Sarah provide to keep the patient calm?
A. Giving praise for her the sense of satisfaction regarding quick labor
B. Support in maintaining a sense of control.
C. Explanation of the effect of labor on the newborn
D. Allowing the patient to express pain and anxiety.

89. Patient Josephine asks why her labor is much shorter compared to previous deliveries. Which of the following is
the BEST RESPONSE?
A. Onset of contraction was gradual
B. Multigravida patient has shorter labor
C. Cervical lengthening was longer.
D. Induction of labor was done.

90. Nurse Sarah reads the physician’s prescription to administer methylergonovine maleate (methergine)
intramuscularly after delivery. The rationale for giving this medication is which of the following?
A. Reduces the amount of lochia drainage.
B. Prevents postpartum hemorrhage
C. Decreases uterine contractions.
D. Maintains normal blood pressure.

Situation 19: Jose, 10 years old, has bronchitis. He needs oxygenation 4l/min per doctor’s order.

91. The first standard steps in oxygen therapy that the nurse should do is, which of the following?
A. Prepare the patient for the oxygen treatment.
B. Check the chart for ordered flow rate and oxygen delivery method.
C. Gather all the equipment and supplies.
D. Assess the patient's condition.

92. In planning for Jose’s oxygen therapy, the nurse shall consider which of the following, EXCEPT:
A. Need for a humidifier
B. Length of tubing
C. Determine the age of Jose.
D. Manner of administering oxygen, continuous or intermittent:
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93. The PRIORITY nursing action of the nurse for Jose due for oxygen therapy is:
A. Attach the humidifier and connect tubing to the oxygen delivery device.
B. Connect the flow meter to the pipe in the oxygen outlet.
C. Turn on the oxygen
D. Check the flow

94. What PRIORITY precautionary measure should be done by the nurse during the oxygen therapy?
A. Limit visitors.
B. Attach “No Smoking” signage
C. Check humidifier’s water regularly
D. Connect belt to oxygen tank

95. One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse’s INITIAL
intervention?
A. Give PRN medication.
B. Refer patients to the physician.
C. Assess the patency of the tubing
D. Reassess the patient.

Situation 20: Head nurse Wilma has been encountering errors in documentation and records management based on
her review of the nurses’ notes in the patients’ charts. To solve the issue, she decided to conduct a lecture on proper
nursing documentation and management of records.

96. At the start of her lecture, head nurse Wilma asked the purpose of the nursing process. Which of the following
purposes is the CORRECT answer?
A. Reduce the number of forms of the chart
B. List the patients’ health problems
C. Record the patient’s progress
D. Provide confidentiality of the chart

97. One of the staff nurses was asked about the principles to be observed when charting Patient’s progress accurately.
Which of the following principles would be the CORRECT Answer?
A. Statements are qualified by the use of “seems” and “appears”
B. Assumptions and conclusions are reported
C. Specific and definite words or phrases are used.
D. General statements and measurements are used.

98. Which of the following is NOT a characteristic of charting?

A. Complete
B. Subjective
C. Objective
D. Accurate

99. During nursing endorsements, the Kardex is used. Which of the following statements is NOT correct it is:
A. Kept up to date
B. A quick reference for current information about the client.
C. Consists of folded card for each patient
D. Part of the medical record.

100. A sample of an error in charting was shown by head nurse Wilma. Which of the following is the CORRECT
solution to remedy the error?
A. Recopy the sheet and destroy the original sheet
B. Use a single line to cross out the error, the write the date, time and sign the correction made
C. Use correction fluid to erase the error
D. Use eraser to remove the wrong entry

Warning: Failure to submit your Test Questionnaire (Complete) set will cause the cancellation of your Test
Results for the subject.

Pre-Board I – Nursing Practice II – Set A/Page 12 of 12