1.

Nurse Suzie
Suzie is administe
administering
ring 12:00
12:00 PM medication
medication in War
Ward
d 4. Two
Two patients
patients have to
receive ano!in. What shou"d Nurse Suzie when one o# the c"ient does N$T have a
reada%"e identi#ication %and&

'. 's( the

the c"ient
c"ient i#
i# she is Mrs.
Mrs. Santos
Santos
). 's(
's( the
the c"ie
c"ient
nt his
his nam
namee
*. 's( the
the roommate
roommate i# i# the c"ient is Mrs.
Mrs. Santos
Santos
+. *ompare
*ompare the
the ,+ %and
%and with
with the
the %ed tag
tag
Answer: ). Ask the client his name

Rationale: The c"ient-s identit shou"d a"was %e #urther veri#ied % one other method/
such as stating the c"ient-s name/ or as(ing the c"ient to state his name

Book source: oundations o# )asic Nursing % ois White page 41

2. izette/
izette/ a head nurse
nurse in a surgica"
surgica" unit/
unit/ hears
hears one o# the
the sta##
sta## nurses
nurses sa she
she does not
touch an c"ient assigned to her un"ess she per#orms nursing procedures or conducts
phsica" assessment. To
To guide the sta## nurse in the use o# touch/ which o# the #o""owing
wou"d %e )ST response o# izette&

'. 3se touch

touch when
when the situati
situation
on ca""s
ca""s #or it5.
). 3Touch
3Touch serves
serves as a connection
connection %etween
%etween thethe nurse and
and the patient5.
patient5.
*. 3se
3se touch
touch with
with discr
discreti
etion5.
on5.
+. 3Touch
3Touch is used
used in phsic
phsica"a" assessme
assessment5.
nt5.

Answer: B. “Touch
“Touch serves as a connection between the nurse and the patient.”

Rationale: Therapeutic touch a""ows the nurse to com#ort patients on a caring "eve"/
connecting with them on a humanistic "eve" awa #rom the medica" proceures and
techni6ues that are o#ten e!perienced. ,n addition/ therapeutic touch a""ows the nurse
n urse to
communicate non7ver%a"" a variet o# #ee"ings to the patient/ inc"uding warmth/
reassurance and trust. Therapeutic touch can a"so %e used more #orma"" as a named
techni6ue/ such as massage or hea"ing touch/ to he"p the nurse in a variet o# phsica"/
emotiona" and spiritua" aids.

Book source: The ssentia" *oncepts o# Nursing: )ui"ding )"oc(s #or Practice % 8ohn
9. *utc"i##e/ ugh P. Mc;enna/ page 2<=

. >ou
>ou are as(ed to teach
teach the c"ient/
c"ient/ Mr. apuz/
apuz/ who has right
right sided
sided wea(ness the
the use o#
cane. Which o%servation wi"" indicate that Mr. apuz is using the cane proper"&

A. The cane and one foot foot or both

both feet are
are on the floor at all
all times
). e advances
advances thethe cane #o""owed
#o""owed % the "e#t
"e#t "eg
"eg
*. *"ient
*"ient (eeps the
the cane on the right
right side
side a"ong the wea( "eg
+. *"ient
*"ient "eans to the "e#t
"e#t side
side which
which is stronger
stronger
 'nswer:
9ationa"e:
)oo( source:

4. ?eorge/ a 4 ear o"d e!ecutive is schedu"ed #or cardiac %pass surger. Whi"e %eing
prepared #or the surger/ he sas to the nurse 3, am not going to have the surger. , ma
die %ecause o# the ris(.5 Which response % the nurse is most appropriate&

'. 3Without the surger ou wi"" most "i(e" die sooner.5
). There are a"was ris(s invo"ved with surger.5
*. 3There is a c"ient in the other room who had success#u" surger and ou can ta"( to
him.5
+. 3This must %e ver #rightening #or ou. Te"" me how ou #ee" a%out the surger.5

Answer: D. “This must be very frightening for you. Tell me how you feel about the
surgery.”

Rationale: The $9 environment can seem co"d/ star( and #rightening to the patient/ who
ma %e #ee"ing iso"ated and apprehensive. ,ntroducing ourse"#/ addressing the patient %
name #re6uent"/ veri#ing detai"s/ providing e!p"anations/ and encouraging an answering
6uestions provided sense o# pro#essiona"ism and #riend"iness that can he"p the patient #ee"
sa#e and secure. When discussing what the patient can e!pect surger/ the nurse uses
%asic communication s(i""s/ such as touch and ee contact/ to reduce an!iet. Te""ing the
patient who e"se wi"" %e present in the $9/ how "ong the procedure is e!pected to ta(e
and other detai"s he"ps the patient prepare #or the e!perience and gain sense o# contro".

Book source: )runner @ Suddarth-s Te!t%oo( o# Medica"7Surgica" Nursing 12th dition

% Suzanne *. Sme"tzer/ )renda ?. )are/ et.a" *opright 2010. Page 4AB

A. ' c"ient is ordered to ta(e asi!/ a diuretic/ to %e ta(en ora"" dai". Which o# the
#o""owing is an appropriate instruction % the nurse&

'. 9eport to the phsician the e##ects o# the medication on urination.

). Ta(e the medicine ear" in the morning
*. Ta(e a #u"" g"ass o# water with the medicine
+. Measure #re6uenc o# urination in 24 hours.

Answer: B. Take the medicine early in the morning.

Rationale: when nursing care invo"ves diuretic therap/ the nurse needs to administer the
medication and monitor the patient-s response care#u"". 'dminister the diuretic at a time
conducive to patient-s "i#est"eC #or e!amp"e/ ear" in the da to avoid nocturia
 Book source: *hart 072 Pharmaco"og: 'dministering/ Monitoring +iuretic Therap
)runner @ Suddarth-s Te!t%oo( o# Medica"7Surgica" Nursing 12th dition % Suzanne *.
Sme"tzer/ )renda ?. )are/ et.a" *opright 2010. Page =2

D. Nurse ?"enda gets a ca"" #rom the neigh%our who te""s her that his  ears o"d daughter
has %een vomiting and has #ever and as(s #or advice. Which o# the #o""owing is the most
appropriate action o# the nurse&

'. $%serve the chi"d #or an hour. ,# the chi"d does not improve/ re#er to the phsician in
the neigh%ourhood.
B. Recommend to bring the child immediately to the hospital.
*. 'ssess the chi"d/ recommend o%servation and administer acetaminophen. ,#
smptoms continue/ %ring to the hospita".
+. Te"" the neigh%our to o%serve the chi"d and give p"ent o# #"uids. ,# the chi"d does not
improve/ %ring the chi"d to the hospita".

'nswer:
9ationa"e:
)oo( source:

B. Wi"#red/ 0 ears o"d ma"e/ was %rought to the hospita" due to inEuries sustained #rom a
vehicu"ar accident. Whi"e %eing transported to the F7ra de partment/ he straps
accidenta"" %ro(e and the c"ient #e"" to the #"oor hitting to his head. ,n this situation/ the
nurse is:

'. Not responsi%"e %ecause o# the doctrine o# respondent superior

). ree #rom an neg"igence that caused harm to the patient
*. ia%"e a"ong with the emp"oer #or the use o# a de#ective e6uipment that harms the
c"ient
+. Tota"" responsi%"e #or the neg"igence

Answer: C. iable along with the employer for the use of a defective e!uipment that
harms the client

Rationale: To esta%"ish "ega" "ia%i"it #or ma"practice Gpro#essiona" neg"igenceH/ the

inEured c"ient Gp"ainti##H must prove the #o""owing 4 e"ements:
a. +ut o# care was owed to the inEured part.
%. There was %reach o# that dut
c. The %reach o# the dut caused the inEur GcausationH.
d. 'ctua" harm or damages were su##ered % the p"ainti##.

*ritica" in determining "ia%i"it #or ma"practice is the de#inition o# the dut o# care owed
% the nursing pro#essiona" to the c"ient. The standard o# care/ the minimum re6uirements
that de#ine an accepta%"e "eve" o# care/ 3is the average degree o# s(i""/ care and di"igence
e!ercised % mem%ers o# the same pro#ession under the same or simi"ar circumstances.5
G'i(en 2004/ page <H
 Book source: eadership and Nursing *are Management ) +iane u%er page <=

=. Whi"e going on evening round/ Nurse dna saw Mrs. Pascua" meditating and a#terwards
started singing praer#u" hmns. What is the )ST response o# dna&

'. ,gnore the incidence

). 9eport the incidence to the head nurse
C. Respect the client’s action as this provides structure and support to the client
+. *a"" her attention so she can go to s"eep

'nswer:
9ationa"e:
)oo( source:

<. ' c"ient as(s #or advice on "ow cho"estero" #ood. >ou advise the c"ient to eat the
#o""owing:

'. *hic(en "iver/ cow "iver/ eggs

B. ean beef and pork! egg white! fish
*. )a"ut/ sa"ted eggs/ duc( and chic(en egg
+. Por( "iempo/ cow %rain/ "ungs and (idne

'nswer:
9ationa"e:
)oo( source:

10. The code o# ethics #or nurses has an interpretative statement that provides:

'. continuit o# care #or the improvement o# the c"ient

). guide #or carring out nursing responsi%i"ities that provide 6ua"it care and #or the
ethica" o%"igation o# the pro#ession
*. standards o# care in carring out nursing responsi%i"ities
+. identica" care to a"" c"ients in an setting

Answer: B. guide for carrying out nursing responsibilities that provide !uality care and
for the ethical obligation of the profession

Rationale: *ode o# ethics is a #orma" statement o# a group-s idea"s and va"ues. ,t is a set
o# ethica" princip"es that GaH is shared % mem%ers o# the group/ G%H re#"ects their mora"
Eudgments over time/ and GcH serves as a standard #or their pro#essiona" action.

Book source: ;ozier and r%-s undamenta"s in Nursing/ =th dition page =A

11. Which o# the #o""owing situation wou"d possi%" cause a nurse to %e sued due to
neg"igence&
 Answer: A. $&'$% drops
Rationale: G1000mLhrHG10drops per minuteH
GD0 minutesHG12 hoursH
Book source: ocus on Nursing Pharmaco"og % 'm M. ;arch Ath dition page A=

20. The phsician ordered Nem%uta" Na gr FF. The %ott"e contains 100mgLcapsu"e. ow
man capsu"e wi"" %e administered to the c"ient&

'. 1 capsu"e C. ' capsule

B. 1 K capsu"e +. K capsu"e

'nswer:
9ationa"e:
)oo( source: