PREBOARDS 2
NURSING PRACTICE 2
Situation
Routine postpartum care is being performed by
Nurse Barbie in caring for a postpartum patient
who gave birth via normal spontaneous vaginal
delivery.
1. Blood loss of _________ would lead to
Nurse Barbie to suspect that the patient is
experiencing postpartum hemorrhage.
A. More than 300ml/24 hours
B. More than 400ml/ 24 hours
C. More than 500ml/ 24 hours
D. Less than 200ml/ 24 hours
R:
300-500mL = NSVD
500-1000mL = CS
2. This is a condition caused by a markedly
distended uterus and intermittent uterine
contractions within 2 to 3 days after birth?
A. Retained placenta = hemorrhage
B. Afterpains
C. Uterine atony
D. Boggy uterus
R: in some women, contraction of the uterus
after birth causes intermittent cramping
termed afterpains, similar to that
accompanying a menstrual period. Afterpains
tend to be noticed most by multiparas rather
than primiparas and by women who have
given birth to large babies or multiple births.
In these situations, the uterus must contract
more forcefully to regain its pre-pregnancy
size and has difficulty maintaining a steady
contracted state.
3. Nurse Barbie observes that her patient is
still adjusting to being a mother. In line with
Ramona Mercer’s Maternal Role Attainment
Theory, which statement best describes the
process of becoming a mother?
A. A woman learns mothering behavior as
early as a teenager.
B. The woman learns to become comfortable
with her role as a married individual.
C. It reflects the transitional process from
being single to raising a family.
D. It involves the dynamic transformation of a
women’s persona.
R: The primary concept of this theory is the
developmental and interactional process of
the mother, which occurs over a period of
time. In the process, the mother bonds with
the infant, acquires competence in general
caretaking tasks and then comes to express
joy and pleasure in her role as a mother.
4. The mother suddenly becomes worried
when a gush of blood comes out of her vagina
when she first arises from her bed. She asks
Nurse Barbie why this has occurred. Nurse
Barbie is correct when she says _________.
A. “Blood pools at the top of the uterus and
passes upon rising or sitting on the bed”
B. “This is due to the normal pooling of blood
in the vagina when the woman lies down to
rest or sleep.”
C. “Physical activity stimulates bleeding in the
vagina”
D. “This is a normal physiologic occurrence
where the body attempts to eliminate excess
fluids.”
5. The mother is currently having difficulty
with voiding due to her perineal edema. What
can Nurse Barbie do to stimulate the
sensation of voiding?
A. Reminding her to void every hour
B. Helping the mother into the shower.
C. Insertion of a catheter
D. Running water in the sink or shower.
R: Some women have too much perineal
edema to be able to void this early. A woman
with an episiotomy may be reluctant to void
because she knows that acid urine against her
sutures will sting. Assist by providing privacy
(but remain in proximity in case a woman
becomes dizzy if this is her first time out of
bed), running water at the sink, or offering the
woman a drink of water. These activities and
interventions help in stimulating urination
from the women. Inserting a catheter may
facilitate elimination of urine but it does not
stimulate the mother to void naturally.
Situation
A postpartum mother who underwent a
normal spontaneous vaginal delivery asks the
nurse when and how her body will return to
its prepregnancy state.
6. The uterus is known to return to its
prepregnancy state in ____.
A. 6 weeks
B. 6 days
C. 4 weeks
D. 35 days
R: involution is the process where a woman’s
uterus shrinks into its prepregnancy state and
takes around 6 weeks to complete. Although
the uterus will never completely return to its
prepregnancy state, its reduction in size is
dramatic. Immediately after birth, the uterus
weighs about 1000g. at the end of the first
week, it weighs 500g. by the time involution is
complete (6 weeks), it weighs approximately
50g, similar to its prepregnancy weight.
7. The nurse knows that the process where
the uterus changes after childbirth to return
to its previous, prepregnancy state is called
__________.
A. Involution
B. Evolution
C. Subinvolution
D. Inversion
8. Among the following factors experienced by
the patient during her pregnancy and
subsequent delivery, which would most likely
contribute to a slow uterine involution?
A. Full bladder during labor
B. Difficult Birth – uterine involution may be
delayed by a condition such as the birth of
multiple fetuses, hydramnios, exhaustion from
prolonged labor or a difficult birth, grand
multiparity, or physiologic effects of excessive
analgesis
C. Perineal Laceration
D. Gestational Hypertension
9. To assess the progression of involution, the
nurse plans to assess the uterine fundus of the
mother. Which part of the abdomen should
the nurse begin with her assessment?
A. Symphysis pubis
B. Umbilicus
C. 5 cm below the xiphoid process
D. 5 cm below the umbilicus
R: After the first hour after birth, the fundus
can be found at the umbilicus or slightly above
it and continues to decrease one
fingerbreadth or 2cm in size daily. Measuring
the distance of the fundus from under the
umbilicus helps to indicate progression of
involution.
10. The priority nursing intervention during
the immediate postpartum period is focused
on ____.
A. Monitoring for signs of infection
B. Watching out for postpartum hemorrhage
C. Taking the vital signs every 2 hours
D. Assessing level of consciousness
R: postpartum hemorrhages are one of the
primary causes of maternal mortality and is
considered the greater danger in the first 24
hours after birth because of the grossly
denuded and unprotected uterine area left
after the placenta detaches, making it
imperative for the nurse to watch out for this
complication.
Situation
Liza, a multigravida currently at 20th weeks of
gestation visited your clinic with complaints of
dizziness, vertigo, and heartburn. Upon
assessment, it was determined that she was
malnourished.
11. Liza, a multigravida currently at 20th
weeks of gestation visited your clinic with
complaints of dizziness, vertigo, and
heartburn. Upon assessment, it was
determined that she was malnourished.
A. “I don’t need to take these as our bodies
have iron stores.”
B. “Iron supplements may cause my stool to
become blackish green in color”
C. “The iron is best absorbed if taken on an
empty stomach.”
D. “Meat should be avoided as to ensure iron
is absorbed”
R: oral iron supplements turn stools black or
blackish green. Due to physiologic anemia,
iron supplements are commonly taken by
pregnant women to increase supply of
hemoglobin. Taking iron on an empty stomach
may aggravate nausea and vomiting in
pregnant women which is why it is
recommended to take it with food. Food rich
in iron include organ meats, eggs, and green
leafy vegetables which is why these are
recommended to pregnant women as well.
12. Liza was concerned with taking her iron
supplements as she has been taking vitamin C
regularly. What will be the most appropriate
response to this?
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A. “This is okay as long as you take the two
supplements 1 hour apart”
B. “Stop taking Vitamin C supplements”
C. “This is okay as absorption of iron is
enhanced with Vitamin C.”
D. “This is not okay as absorption of iron is
decreased by Vitamin C.”
R: iron absorption increases in an acid
environment, so eating iron-rich foods or
swallowing iron pills with ascorbic acid (found
in orange juice) may increase absorption.
13. Calcium supplements were also prescribed
to Liza to be taken during the 2nd and 3rd
trimesters. To help facilitate absorption of
calcium, which of the following should you
advise her to take with this?
A. Fat-soluble vitamins – ADEK : Vit. D for
absorption of calcium
B. Water-soluble vitamins
C. Iron
D. Milk
14. Liza asks you what the main source of
nutrition for her baby is. You answer correctly
by stating that it is the ______.
A. Amniotic Fluid
B. Placenta – nutrition & oxygen
C. Fetal Circulation
D. Small Intestines
15. You performed a health teaching session
for Liza to manage her heartburn. Which
statement by Liza indicates a need for further
teaching?
A. I will lie down after eating
B. I will drink milk between meals
C. I will eat small, frequent meals
D. I will avoid fatty or spicy foods
R: 1. SFF
2. sleep on left side w/ 2 pillows to elevate
torse
3. do not lie down immediately after eating;
try & wait at least 2 hours
4. avoid fatty and fried foods, coffee,
carbonated drinks, tomatoes, citrus juices
Situation
Nurse Young was recently transferred to the
pediatric ward and was assigned to give
medications for the shift
16. When giving medicine to pediatric
patients, dosage varies. Which of the following
should Nurse Alicia consider?
A. Height and weight
B. Size, surface area and age
C. Size and surface area – height & weight
D. Size, surface area, age and weight
R: the correct dosage of most drugs for
children is based on body surface area. To
calculate surface area, height and weight of
the child is determined. Size can be area,
volume, length, or height of the baby.
17.Before administering oral medications,
Nurse Young is being assessed by the head
nurse on her knowledge on administering
medications for pediatric patients. Which of
the following statements shows correct
understanding by Nurse Young?
A. Compared to an adult’s reaction, a child’s
reaction to the medication is more predictable
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
on top of their 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.
R: Factors related to growth and maturation
significantly after an individual’s capacity to
metabolize and excrete drugs. Immaturity or
defects in any of the important processes of
absorption, distribution, biotransformation or
excretion can significantly after the effects of
a drug. Therefore, there are several
considerations in administering medications
to children which makes medication error
greater for this population.
18. Nurse Young is to administer a medication
via IM injection to an 10-month-old baby.
What part should she use to reduce the risk of
nerve damage and vascular injury?
A. Gluteus maximus – sciatic nerve
B. Vastus lateralis
C. Deltoid muscle
D. Dorso-gluteal
19. Intramuscular injections have been known
to produce serious adverse effects according
to research. Nurse Young knows that the most
common complication that may arise from this
is ___________.
A. Infection
B. Paralysis
C. Hematoma
D. Muscle contracture
R: Repeated use of a single site has been
associated with fibrosis of the muscle with
subsequent muscle contracture which is the
most common complication. This is also due
to the insufficient muscle mass of pediatric
patients. Nerve damage is mostly involved
only in areas with large nerves like gluteal
muscle (near sciatic nerve).
20. Nurse Young is to administer the IM
medication to the 10-month-old baby. To
ensure that the ordered medication is given to
the right patient, what will Nurse Young do
first?
A. Check the patient's hospital bracelet. – 2nd
or for verification
B. Ask the parent/significant other to state
name of patient and birth date of patient.
C. Verify patient’s allergies with chart and with
patient.
D. Compare medication order to identification
bracelet.
Situation
Kim, a college student, was recently admitted
to the hospital due to having severe pre-
eclampsia. Despite her physician advising her
to rest, Kim insists on continuing her work
while admitted. She currently studies around
10 hours a day and is often visited by her
peers and relatives.
21. Nurse Dani is concerned about Kim’s
ability to comply with the doctor’s instruction
to rest. What appropriate action should she
take?
A. Ask her mother to explain to her why she
needs to rest.
B. Develop a routine with the patient to
balance her studies and her rest needs.
C. Tell her that she should prioritize her baby’s
health more than her studies
D. Ask her why she is not complying with the
prescription for bed rest.
R: It is important that in all interventions the
patient must always be involved in planning
and implementation. It must be individualized
to their needs. A routine balancing her
academic and physiologic needs is appropriate
for the patient. We cannot mandate the
individual to neglect certain priorities and
aspect of her life.
22. During the interview, Patient Kim becomes
irritated with the nurse, stating “I don’t want
to talk to you since you’re only a nurse. I’ll just
wait for the doctor. What would be Nurse
Dani’s best response?
A. "I do not like the way that you dismiss me."
B. “Noted. I should call your doctor.”
C. "So then you would prefer to speak with
your doctor?"
D. "Your doctor prescribed this for us to do
nursing care."
R: An example of statement of clarification
and restating, a therapeutic communication
strategy. This would help establish
understanding of the content of the patient’s
statement.
23. Due to the previous situation, Nurse Dani
is now experiencing a dilemma. This occurs
when _____.
A. There is a conflict between the nurse's
decision and that of their superior
B. Choices regarding patient care are unclear
C. There is a conflict of two or more ethical
principles
D. A decision must be made quickly under a
stressful situation
R: Although ethical reasoning is principle
based and has the client’s well-being at
center, being involved in ethical problems and
dilemmas is stressful for the nurse. The nurse
may feel torn between obligations to the
client, the family, and the employer. What is in
the client’s best interest may be contrary to
the nurse’s personal belief system. The
different ethical principles may also have
converging conflicts in a certain situation. This
conflict is referred to as moral distress and
dilemma and is considered a serious issue in
the workplace.
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24. Nurse Dani knows that regardless of what
just happened, she must still abide to the
ethical principle that states the nurse is
obligated to implement actions that will
provide care and benefit to the patient. What
specific principle is this?
A. Beneficence – doing good
B. Justice – resources; fairness
C. Nonmaleficence – do no harm
D. Veracity – telling the truth
25. In providing a safe environment for the
patient with preeclampsia, what can Nurse
Dani do?
A. Maintain fluid and sodium restrictions.
B. Encourage frequent visits from family and
friends for psychosocial support
C. Take the patient's vital signs every 4 hours.
D. Take off the room lights and draw the
window shades.
R:
D = Darken the room if possible because a
bright light can also trigger seizures. However,
the room should not be so dark that
caregivers need to use a flashlight to make
assessments. Shining a flashlight beam into a
woman’s eyes is the kind of sudden
stimulation to be avoided.
A - Stringent sodium restriction may activate
the renin-angiotensin-aldosterone system and
result in increased blood pressure,
compounding the problem
B – Visitors are usually restricted to support
people such as a husband, father of the child,
mother or older children because noise and
crowd can trigger seizures.
Situation
Head Nurse Kylie is currently facilitating a
training program for newly hired nurses at
Olympia Medical Center (OMC). A key part of
her training is giving scenarios for the nurses
to apply what was taught during the program.
She gave the group a situation: Patient Rosita
is a pregnant woman admitted in the OB
Ward.
26. In caring for patient Rosita, Head Nurse
Kylie is discussing with Nurse Josie, a newly
hired nurse, on how to utilize the nursing
process for the pregnant patient. Nurse Josie
is correct when she mentions the planning
phase includes:
A. Reviewing the history of the patient during
assessment
B. Prioritizing the patient’s problems
C. Identifying the nursing diagnoses
D. Collecting information of the patient’s
problem has been resolved in the evaluation
phase
R: In the process of developing client care
plans, the nurse engages in the ff. activities:
• Setting priorities
• Establishing client goals/desired
outcomes
• Selecting nursing interventions and
activities
• Writing individualized nursing
interventions on care plans
27. Nurse Thea, one of the assigned group
leaders during the training, is reviewing the
steps of the nursing process with the group.
Nurse Thea identifies which of the following
is/are 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. Skin is pinkish in color, warm, and dry.
A. II and III
B. I and IV
C. III and IV
D. I and II
28. The very next day, Patient Rosita delivered
an alive baby girl. After delivery, she
complained of leg pains. Nurse Josie took hold
of Patient Rosita’s chart. In the chart, an order
was provided to give PONSTAN 500 mg every
4 hours PRN for pain. After 40 minutes, the
patient felt relieved. Nurse Josie should have
conducted what step of nursing process?
A. Assessment
B. Planning
C. Evaluation
D. Intervention
29. If Patient Rosita’s pain was not
satisfactorily relieved after administration of
the medication, Nurse Josie should perform
which of the following actions upholding the
nursing process?
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 attending physician.
R: Despite pain being subjective, it must not
be ignored and neglected. If the pain relievers
are not working, there must be some
problem. Before referring to the doctor,
additional assessment must be taken for
possible cause of the unsuccessful relief of the
pain.
30. Head Nurse Kylie discusses in the training
the different elements of documentation. In
order for the document to be comprehensive
and timely, it must be:
A. Complete and current
B. Accurate and concise
C. Organized
D. Factual
R: Same meanings, different terms. Document
events in the order in which they occur; for
example, record assessments, then the
nursing interventions, and then the client’s
responses. Update or delete problems as
needed. Not all data that a nurse obtains
about a client can be recorded. However, the
information that is recorded needs to be
complete and helpful to the client and health
care professionals.
Situation
Mommy Oni is a 28-year-old primigravida that
is admitted to Solaris Birthing Center. She
confirms to have been in labor for the past 10
hours, having contractions 5 minutes apart.
With astute observation from Nurse Karen,
she deduced that the patient is having
hypotonic contractions. Mommy Oni also
complains of more pain in her back than in her
abdomen. Sonogram was performed which
showed her fetus to be “borderline” large for
gestation and in occipito-posterior position.
31. Nurse Karen notices that Mommy Oni’s
uterine contractions are short in duration and
irregular in frequency. During contractions,
Mommy Oni is screaming with pain. Nurse
Karen knows that the BEST nursing action to
perform is?
A. Try to divert attention from pain.
B. Administer pain reliever as ordered.
C. Stay with the patient and offer her a back
rub. – remember that pain is an exhausting
phenomenon. Encourage the use of
nonpharmacologic comfort measure such as
breathing with the woman, giving back rubs,
changing sheets, using cool washcloths and so
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PREBOARDS 2
NURSING PRACTICE 2
forth. Complementary therapies such as
aromatherapy or music are also helpful.
D. Document and report frequency and
duration of contractions.
R: With hypotonic uterine contractions, the
number of contractions is unusually low or
infrequent (not more two or three occurring
in a 10 min period). They may occur after the
administration of analgesia, especially if the
cervix is not dilated to 3 to 4cm or if bowel or
bladder distention prevents descent or firm
engagement. This can increase chances of
post partum bleeding and inadequate
oxygenation of fetus. Therefore, it is
important to assess if the labor of the mother
is progressing.
32. Mommy Oni’s physician is considering
augmenting her labor with the use of oxytocin.
Nurse Karen would question the use of
Oxytocin for Mommy Oni if?
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
R: Oxytocin can cause a biphasic effect on the
blood pressure. It can cause severe
hypertension and going to severe
hypotension. Any irregularities in the blood
pressure can merit questioning of the use of
oxytocin. The use of oxytocin helps in the
delivery of large for gestational age babies
since it can cause hypotonic labor. Aside from
that, the rupture of membranes needs faster
delivery since prolonged labor can cause
infection; therefore, requiring augmentation is
possible.
33. Nurse Karen observes that Mommy Oni’s
contractions are 70 seconds long and
occurring every 90 seconds when assessing
the frequency of her contractions after
oxytocin was administered. Nurse Karen’s first
action should be which of the following?
A. Give an emergency bolus of oxytocin to
relax 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 take
breaths deeply.
R: Contractions should occur:
• No more often than every 2 mins
• Should not be stronger than
50mmHg pressure
• Should last no longer than 70 sec
• If the contractions become more
frequent or longer in duration that
the safe limits, IV infusion of
oxytocin should be STOPPED
IMMEDIATELY and seek help
immediately
34. As Nurse Karen monitors Mommy Oni, she often responsive to people they know and
should know which finding shows an adequate familiar with.
pattern of uterine contraction? 37. Leaving the child alone Seeking the help of
A. Three to 5 contractions in a 10-minute the mother in giving the oral drug. Mixing the
period, with resultant cervical dilatation – in a drug with milk to cover up the unfavorable
normal labor, one contraction every 2 – 3 taste. Getting angry with the mother and the
mins or less than 5 contractions in a 10 min child.
period is ideal. A uterus must rest between A. has separation anxiety.
contractions, having sufficient uterine resting B. internalizes the attitudes of others.
tone (soft to the touch) and uterine resting C. utilizes magical thinking.
time (about one minute). D. is negativistic in all matters.
B. Four contractions every 5 minutes, without
resultant cervical dilatation
C. One contraction every 10 minutes, without
resultant cervical dilatation
D. One contraction per minute, with resultant
cervical dilatation
35. Nurse Karen is an effective nurse when she
knows which of the nursing measures should
she LEAST consider doing to Mommy Oni
having oxytocin drip?
38. Nurse Ria knows that in giving Trixie
A. Know how to recognize potential adverse
oxygen effectively, the best way to administer
reactions.
it is through the use of _______.
B. Administer oxytocin drug with caution
A. hood
C. Monitor patient closely when infusing
B. face Mask
oxytocin
C. Incentive Spirometer
D. Inform patient about potential
D. nasal catheters
complication.
R: Oxygen hood is a high-flow device (4-
R: Oxytocin is a drug that can cause adverse
6L/min) and leads to a lot of wastage, whereas
effects to a laboring woman. It is important to
nasal prongs/catheters are low-flow devices
monitor the patient and her baby cautiously
requiring a low flow rate for infants. This tube
for any adverse reactions. Although it is also
has soft prongs that gently fit into the baby’s
important to inform the patient regarding the
nose. Face-mask, head boxed, incubators and
drug, it would be the least priority to do since
tents are not recommended because they
it can increase the anxiety of the patient while
waste oxygen and are potentially harmful. The
in labor.
recommended methods for neonates, infants
Situation
and children are nasal prongs, nasal catheters
Madam Irene’s daughter, one-year-old Trixie,
and nasopharyngeal catheters. A nasal
is admitted at Sta. Teresa Medical Center due
catheter is a thin, flexible tube that is passed
to Pneumonia. Upon admission, she was given
into the nose and ends with its tip in the nasal
IV antibiotics, decongestant, antipyretic, and
cavity.
vitamins. She was also subjected to oxygen
39. With Trixie being given IV Antibiotic
therapy.
therapy, Nurse Ria should give the MOST
36. As Nurse Ria gives Trixie her oral
common gauge used for IV cannula for her age
medication, she immediately refuses, making
which is gauge ____.
Nurse Ria worried. Nurse Ria will handle the
A. 20
situation by:
B. 24
A. Leaving the child alone
C. 22
B. Seeking the help of the mother in giving the
D. 18
oral drug.
C. Mixing the drug with milk to cover up the
40. Nurse Ria is monitoring Trixie for
unfavorable taste.
improvement of her condition. An
D. Getting angry with the mother and the
IMPORTANT evaluation parameter that she
child.
should watch out is ____.
R: Attachment to their parents is increasingly
A. Absence of fever.
evident during the second half of the first
B. Absence of chest indrawing.
year. At approximately 6-12 months of age,
C. Respiratory rate of 45 beats per minute,
infants show a distinct preference for the
D. Respiratory rate of 55 beats/ minute.
mother. They follow her more, cry when she
R: Pneumonia is often characterized by high-
leave, enjoy playing with her more, and feel
grade fever. Being afebrile is a sign that the
most secure in her arms. About 1 month after
infection is already resolving. It is also
showing attachment to the mother, many
characterized by tachypneic patients. The 45
infants begin attaching to other members of
& 55 bpm of RR are still fast for a 1 y/o infant.
the family, most often the father. They are
Situation
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Patient Boa Hancock is a postpartum patient
admitted at Marineford General Hospital
where she delivered a stillborn. She is hooked
to an intravenous fluid (IVF) and is currently
being monitored postpartum. She tells her
nurse, Nurse Luffy, that she wants to leave the
hospital. However, she doesn’t have an order
from Dr. Chopper to be discharged from the
hospital.
41. Given that Nurse Luffy is aware of the
ethico-legal concerns regarding Boa Hancock’s
request, he has to avoid liabilities. Which of
the following actions is APPROPRIATE for
Nurse Luffy to do?
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.
R: Every hospital has their own policy
regarding discharge against medical device. It
would be most appropriate to relay the plan
of the patient to the nurse supervisor of the
charge nurse so they can be able to activate
the process based on hospital policies. The
process could include residents and attending
explanation of hospitalization necessity,
signing of consents, discharge instructions,
notification of billing and other steps.
42. With Patient Boa Hancock being on
postpartum, Nurse Luffy reminds her on the
importance and need of early ambulation. As
per Nurse Luffy’s instruction, which of the
following is INCORRECT in doing ambulation?
A. Assist the patient from sitting to standing
position.
B. Raise the head of the bed slowly to achieve
sitting position of the patient.
C. Allow the patient to rise from the bed to a
standing position unassisted.
D. Assist patient to rise from lying to sitting
position.
R: Gradual ambulation is important for any
patient coming from a procedure like delivery
of a baby. This is to prevent orthostatic
hypotension and eventual fall incidents.
Leaving the patient unassisted especially when
standing can cause accidents like fall.
43. As Nurse Luffy is waiting for an update
from Nurse Rayleigh, his supervisor, regarding
Boa Hancock’s request to go home, he
proceeds to check his patient. As he entered
the room, he discovers that the basket
containing wastes caught on fire. In response
to the emergency, Nurse Luffy calmly recalled
that the correct steps to do in this situation is:
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 and IV
C. I, II and IV
D. II, IV and I
44. After Nurse Luffy put out the fire, he
noticed that Boa Hancock has absconded.
What is the ethico-legal responsibility of Nurse
Luffy?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Justice
R: The ethico-legal responsibility of the nurse
is to prevent the patient from getting harmed.
Tha patient is still at their recovery phase
which means they are not yet stable to leave
the hospital especially without any
instructions. Aside from that, the facility just
recovered from a fire. Hazards can still harm
the patient. It is important for the nurse and
the team to find the patient.
45. Nurse Rayleigh told Nurse Luffy that
absconding is inevitable in any health care
facility. If the patient suddenly absconded,
Nurse Luffy should IMMEDIATELY inform
which of the following?
A. Attending physician
B. Security guard on duty
C. Resident on duty
D. Nursing staff
R: Absconding patient = a patient who has
been absent from a clinical area without
having notified staff of the intention to leave.
Failed to return to the clinical area at the
agreed time ex. After attending activity
outside the clinical area, including playrooms
for children.
Situation
Patient Anya Forger is a 5-year-old child
currently admitted at the pediatric ward of
Ostania Medical Memorial Center (OMMC).
She was admitted due to having severe
otalgia, irritability, and fever. Yor Forger, her
mother, informed Nurse Fiona that Patient
Anya developed Upper Respiratory Infection
three weeks prior to admission. The admitting
diagnosis of Patient Anya is Acute Otitis Media
(AOM).
46. Nurse Fiona performs her initial
assessment on Anya. She notices that Patient
Anya keeps crying and constantly pulling her
right ear. Being Patient Anya’s nurse, she
knows that the MOST APPROPRIATE action to
do is:
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.
R: Ear pulling or tugging accompanied by
crying is an indication of pain from a child with
acute otitis media. This warrants appropriate
pain management such acetaminophen,
ibuprofen or topical pain relief drops. With
that, it must be referred to the physician.
Consistent severe pain can also warrant
possible myringotomy procedure to relieve
the pressure. These therapeutic management
and plan can be ordered by the attending
physician.
47. Patient Anya’s physician gives a doctor’s
order to administer Ofloxacin eardrop on
Patient Anya. As Nurse Fiona prepares to
administer the 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
R: Hold the bottle in your hands for 1 to 2
mins to warm up the solution before putting it
in your ear. Otherwise, putting cold solution in
your ear could cause you to become dizzy.
48. Nurse Fiona washed her hands and gently
started cleaning any discharges that can be
removed easily from the outer ear. As Nurse
Fiona positions Patient Anya, she vividly
remembers that the next step in the
procedure is to:
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.
R: Straighten the auditory canal. Pull the pinna
upward and backward for clients over 3 years
of age. The auditory canal is straightened so
that the solution can flow the entire length of
the canal. This is before giving the medication.
49. Based on her previous knowledge on otitis
media, Nurse Selma remembers that children
like Patient Anya are predisposed to Acute
otitis media due to the following risk factors,
EXCEPT _____.
A. absence of breastfeeding
B. Swimming – otitis externa
C. exposure to cigarette smoke
D. poor hygiene
R: Predisposing factors include URIs, allergies,
down syndrome, cleft palate, daycare
attendance, exposure to secondhand smoke
and bottle propping during feeding. Infants
fed breast milk have a lower incidence of OM
than formula-fed infants. Breastfeeding may
protect infants against respiratory viruses and
allergy because it contains secretory
immunoglobulin A, which limits the exposure
of the eustachian tube and middle ear mucosa
to microbial pathogens and foreign proteins.
50. Nurse Fiona’s nursing interventions to
promote drainage and reduce pressure from
fluid from is to have Patient Anya assume any
of the following positions, EXCEPT?
A. tilt head to side if sitting up
B. lie on the affected area
C. put the pillows behind the head
D. lie on the non-affected ear
R: All of the choices promote drainage on the
affected ear. Lying on the non-affected ear
does not promote drainage on the other side.
Situation
GARCIA, GENEVA JANE C.
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PREBOARDS 2
NURSING PRACTICE 2
Nurse May is a nurse that is currently rotated
in the Pediatrics Ward of Kawayan Medical
Center. To better appreciate her role as a
professional nurse in the area, she needs to
review the principles and concepts of human
growth development.
51. As she was assigned to provide care to
pediatric patients, Nurse May should recall
which of the following correct information?
A. Toddler period ranges from 12 to 36
months.
B. An infant's tongue is smaller than the adult
– the young child’s tongue is relatively larger
in the oropharynx than the adult’s
C. Early childhood period ranges from 3 to 7
years – early childhood: 1 to 6 y/o
Middle childhood: 6-11 y/o
Late childhood: 11-19 y/o
D. Breast milk provides complete infant
nutrition – exclusive only up to 6 months
52. Nurse May is checking Baby Janjan’s
temperature when her mother asks about
what age does growth and development
become more rapid. Nurse May knows that
rapid growth and development occurs during
which time?
A. Ten
B. Nine
C. Twelve
D. Eleven
R: An average weight for a 6 month old child is
7.3kg (16 pounds). Weight gain slows during
the second 6 months. By 1 year of age, the
infant’s birth weight has tripled, for an
average weight of 9.75kg(21.5 pounds).
Height increases by 2.5cm (1 inch) a month
during the first 6 months of life and also slows
during the second 6 months.
53. The mother of Baby Janjan further asked
Nurse May how to determine if her baby is at
the right age of her development. Nurse May
explained that one of the key determinants of
the baby’s development is her gross and fine
motor development. She emphasized further
that there are actions that can stimulate and
growth and fine motor movement, such as
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 and 2
B. 2 and 3
C. 3 and 4
D. 1, 2, 3 and 4
54. According to the World Health
Organization (WHO), suicide has become a
global phenomenon. As a pediatric nurse that
deals with different children from toddler to
adolescent, Nurse May is bound to take care
of adolescents who are emotionally disturbed.
As such, it is vital for Nurse May to have prior
knowledge of warning signs of suicide which
occur for at least a month before an attempt.
Which of the following warning signs should
NOT alert Nurse May?
A. increase in initiative
B. verbalization of suicidal thoughts.
C. Crying
D. Sleep disturbances
55. Head Nurse Jona regularly performs
rounds in the Pediatric Ward. In one of her
nursing rounds, she asked Nurse Ester about
the age inclusivity where a person transitions
from childhood to adulthood or graduation.
Nurse Ester knows that the CORRECT age
range is from ________.
A. 15 to 18
B. 12 to 16
C. 11 to 18
D. 13 to 18
Situation
Nurse Elle is working in the Birthing station of
Maayo General Hospital, where five
postpartum mothers delivered 2 hours, 4
hours, and 6 hours ago, respectively. Upon
their obstetric history, she discovered that all
of them have had past pregnancies. Nurse
Elle, being a nurse educator, opted to conduct
health education about postpartum
hemorrhage which would deem vital to all
postpartum mothers present.
56. Nurse Elle explains to the mothers about
early indications for hypovolemia caused by
postpartum hemorrhage. She is CORRECT
when she states that early signs and
symptoms that can be observed 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
R: Excessive blood loss can cause several
complications like increased heart rate, rapid
breathing and decreased blood flow. These
symptoms can restrict blood flow to your liver,
brain, heart or kidneys and lead to shock. Also,
the key term used in the question is “EARLY”
signs.
57. Nurse Elle further discussed with the
mothers that there are risk factors that can
lead to postpartum hemorrhage. Nurse Elle
correctly explains that the following are risk
factors EXCEPT:
A. ruptured uterus
B. uterine atony
C. overdistended uterus – adolescents = not
contract easily
D. retroversion of the uterus – uterine
deviation = fertility
R: Uterine atony, laceration of the cervix or
vagina, hematoma development in the cervix,
perineum or labia, retained placental
fragments are the causes of postpartum
hemorrhage.
58. Nurse Elle reviews the normal postpartum
course and expects to note sexual activity
during:
A. After weeks from the delivery
B. 4 days after the delivery
C. When the client's bladder is full
D. The day after the delivery
R: Couples can begin intercourse as early as 4
weeks after giving birth, if desire and comfort
allow. This is the best answer since it does not
mention anytime timeframe. There is no
specific answer in this question, but it will be
specific in the next question.
59. During the health education session, one
mother asked Nurse Elle if sexual activity will
return if no complications develop. Nurse Elle
explains that through a normal postpartum
course, they would expect the return of sexual
activity during what time?
A. In 4 to 6 weeks
B. At any time
C. After the 6-week physician check-up
D. When her normal menstrual period has
resumed
60. Nurse Elle instructs the postpartum
mothers that there may be possibilities of
them experiencing postpartum hemorrhage in
the future. Nurse Elle emphasizes that proper
nutrition and diet may prevent or lessen the
occurrence of hemorrhage. An example would
be the inclusion of Vitamin K intake to lessen
the bleeding itself. Nurse Elle knows that the
patient should take Vitamin K with _______
for easier absorption.
A. Proteins
B. Carbohydrates
C. Minerals
D. Fats - ADEK
Situation
Nurse Sherry is the head nurse of the OB/GYN
ward of Marianas General Hospital. In one of
her nursing rounds, she noticed that there is a
lack of data filled up in the Intake & Output
sheets of various patients of the ward.
61. Based on the discovered findings, what
would be the most appropriate action for
Head Nurse Sherry to do?
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PREBOARDS 2
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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 needs assessment.
D. Review the Orientation Program.
R: The Head nurse wants to determine the
factors that may have affected the nurse to
not be able to fill the date of the I&O.
62. With the presenting issue in the ward,
Head Nurse Sherry decided to coach her staff
nurses. One of the questions she asked was
what fluids should not be included in
documenting the Intake/Output flowsheet.
The staff nurse is correct if she said:
A. Intravenous Fluids
B. Gelatin
C. Solid Foods
D. Beverages
R: Solid foods are not part of the intake that
will be written in the intake and output of
patient. Input list include: ice chips, foods that
are liquid at room temp, tube feeding,
parenteral fluids, IV medications,
catheter/tube irrigants.
63. Head Nurse Sherry also emphasized to the
staff nurses that which of the following should
be EXCLUDED in documenting the Output list?
A. Drainage from tubes
B. Solid/hard feces
C. Urine
D. Vomitus
R: Urinary output, vomitus, liquid feces, tube
drainage and wound & fistula drainage
64. Another question asked by Head Nurse
Sherry is about the time to record the Intake
and Output. The staff nurse is correct when
she said that the BEST TIME to record the
intake and output is:
A. During endorsement
B. After endorsement
C. Right before endorsement
D. Any time before duty
R: Fluid I&O measurements are totaled at the
end of the shift (every 8 to 12 hours), and the
totals are recorded in a client’s chart. In
intensive care areas, nurses may record I&O
hourly. Usually, the staff on the night shift
totals the amounts of I&O recorded for each
shift and records the 24 hour total.
65. Mommy Mathilda, a pregnant patient in
the ward, is also diagnosed with Chronic Heart
Failure. In patients with chronic heart failure,
monitoring intake and output is considered
vital. The MAIN purpose of recording accurate
data on intake and output of these patients 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
R: HYPOVOLEMIC SHOCK FROM INTERNAL
HEMORRHAGE OR THIRD-SPACE LOSSES,
when extracellular fluid is shifted from the
vascular compartment to the interstitial space
or compartment.
When there is fluid shifting due to third-
spacing, the fluid remains in the body but is
essentially unavailable for use, causing
isotonic fluid volume deficit
Situation
Nurse Melanie and her fellow staff nurses
assigned in the delivery room of Pandacan
Medical Center, is interested in conducting a
research study on the experiences of pregnant
women in labor. They are planning on making
it qualitative research to yield accurate results,
with Nurse Melanie as the lead researcher.
66. In the presentation of results and
discussion portion of the qualitative study,
Nurse Melanie should use as a reference in
the write-up the ______ person.
A. First
B. Second
C. Fourth
D. Third
R: Third – less subjectivity – it removes direct
reference to the researcher. In many reports
of qualitative research, scholars prefer to use
the first-person in their writing, as this
matched the intention of giving voice to their
participants’ perspectives. Indeed, style guides
published by specific associations provide
guidance on this issue.
67. Nursing is always regarded as both an art
and a science. In the field of human science,
nursing deals with the critical and
fundamental differences in attitude towards
their respective phenomena. Which of the
following is an aim of human sciences?
A. Construct prediction - QUANTI
B. Seek causal explanation – EXPERIMENTAL
QUANTI
C. Sets control – MCRV QUANTI
D. makes meaningful interpretation -
PHENOMENOLOGICAL
68. Nurse Melanie’s research group is
observing the activities occurring in the
delivery room. One of the activities happening
involves social processes, which can be further
explored. To explore this, which of the
following qualitative research method should
be used?
A. Grounded theory – processes; social
structures; social interaction
B. Historical research – anything from the
past, issues, describe the issue in the past
C. Descriptive Phenomenology – experience;
lived experience; meaning; essence
D. Case study – in depth or in-detail study of
persons or entities
69. After the research group is done analyzing
the data of their study about experiences of
pregnant women in labor, they proceed to
return to the participants in order to
determine the accuracy of the emerged
themes. The research group is doing which
criteria of trustworthiness?
A. Confirmability - objectivity
B. Credibility – confidence in the truth of data,
accurate
C. Transferability – in quanti: generalizability
D. Dependability – immerges in report, feeling
tone of participants
70. While conducting the interview as their
method of data collection in the study, the
research group utilized audio recording
devices to capture what transpired in the
interview session. After transcribing the data,
the research group is aware that the
APPROPRIATE action to do with the audio tape
is:
A. Keep the audiotape in a vault and dispose
of 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.
R: Some important ethical concerns that
should be taken into account while carrying
out qualitative research are: anonymity,
confidentiality and informed consent. You
must ensure that personal data are kept
secure and are not disclosed to unauthorized
persons. You should use a locked storage
container such as a filing cabinet in a locked
office for paper-based personal data; for
digital data, password-protected or
preferably, encrypted storage
Situation
Nurse Christine is the head nurse of the
OB/GYN area at Santa Monica General
Hospital. To increase better performance in
the area, she conducted an in-service program
on staff development.
71. Head Nurse Christine discussed with the
nurses in the area that the MOST frequently
neglected area in management is
__________.
A. Managerial knowledge
B. Professional development
C. Clinical skills
D. Successful communication – break in chain
of communication
72. Being the head nurse in the area, Nurse
Christine knows that a vital component in the
process of supervising is delegation of tasks.
She knows that the delegation is MOST
empowering to the staff because:
A. Effective delegation does not require nurses
to know the abilities and weaknesses of their
staff
B. Delegation frees the manager to do other
task while empowering staff.
C. Delegation fosters the responsibility of staff
while increasing professional growth.
D. Delegation starts at top management down
to subordinates
R: Supervision is defined as “provision of
guidance and direction, evaluation and follow-
up by the licensed nurse for the
accomplishment of a nursing task delegated to
GARCIA, GENEVA JANE C.
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PREBOARDS 2
NURSING PRACTICE 2
UAP”. Onsite supervision becomes a strong
tool for gathering information for personnel
evaluation or corrective action. Also, personal
contact through supervision gives the
delegate an opportunity to ask questions and
learn skills.
73. During the in-service program, Head
Nurse Christine discussed one of the common
conflict resolution methods which is
negotiation. She asked one staff what the
focus of negotiation is. The staff answered
correctly if she said negotiation creates a
________.
A. Soothing situation
B. Third party consultation
C. Trade-off
D. Win-win situation – negotiations focuses on
understanding who the perceived winners and
losers are; the best negotiations result in win-
win solutions. Negotiations, especially
collaborative negotiations, assumes that
people have both diverse and common
interests and that the negotiation can result in
both parties gaining something, creating a
win-win solution. trade-off supports a cause of
person in exchange for the goal at hand.
74. Head Nurse Christine emphasized that
after delegation of duty comes supervision.
She stated that the PRIMARY purpose of
supervision is it:
A. Influences the organization’s approach in
recruitment, promotion and personnel
evaluation.
B. Improves staff compliance with policy and
procedures.
C. Assigns appropriate work tasks to the best-
qualified
D. Enhances the delivery of quality nursing
care.
R: NCSBN (2021) defined supervision as
“provision of guidance or oversight by a
qualified nurse for the accomplishment of a
nursing task or activity with initial direction of
the task or activity and periodic inspection of
the actual act of accomplishing the task or
activity.” Onsite supervision becomes a strong
tool for gathering information for personnel
evaluation or corrective action. Also, personal
contact through supervision gives the
delegate an opportunity to ask questions and
learn skills.
75. Head Nurse Christine reinforced that
Delegation involves transferring of nursing
care to an individual. She stated that when
delegating care to the staff, there are various
criteria to observe. What is considered the
BEST criterion when delegating staff?
A. Responsibility
B. Adaptability
C. Flexibility
D. Competence
R: Delegation as “transferring to a competent
individual, the authority to perform as
selected nursing task in a selected situation.”
The amount of supervision depends upon the
competency of the delegate for nursing care
or other duties. The key to delegation is to
understand how your BON defines nursing
practice and the skills required by UAP that
define competence. Responsibility is a part of
licensed position and cannot be used as
criteria for delegation.
Situation
Therapeutic Communication is an important
aspect in providing better rapport as it
promotes understanding between the sender
and receiver. Nurse Dan, a staff nurse in the
Medical-Surgical ward of Taginting Medical
Center, should be abreast with common
therapeutic communication techniques if he
wants to have an effective and achievable
nursing care.
76. Karylle, a patient with gastrointestinal
problems explicitly says, “I am not sure if I
should undergo colonoscopy or not as I am
scared.” To give a proper response, which of
the following therapeutic communication
technique is the MOST appropriate for Nurse
Dan to use?
A. Touch
B. Clarifying
C. Restating
D. Silence
R: The nurse repeats what the client has said
in approximately or nearly the same words the
client has used. This restatement lets the
client know that he or she communicated the
idea effectively. This encourages the client to
continue. Or if the client has been
misunderstood, he or she can clarify his or her
thoughts.
77. When Karylle said, "Whenever I see my
husband visit me, I feel depressed,” Nurse Dan
replied, “Your husband depresses you?” Nurse
Dan responded with which therapeutic
communication technique?
A. Restatement
B. Focusing
C. Focusing
D. Seeking clarification
R: The nurse restated the patient’s statement.
Repeating the main idea of what the client has
said let’s the client know whether an
expressed statement has been understood
and gives him or her the chance to continue or
to clarify if necessary.
78. As Nurse Dan continued to converse with
Patient Karylle, he said, “Tell me more about
your experience when you had the
colonoscopy” Which therapeutic
communication technique is Nurse Dan
utilizing?
A. Focusing
B. Clarifying
C. Encouraging elaboration
D. Restating
R: Encouraging elaboration (FACILITATION):
technique that assists patients to more
completely describe problems. These
responses encourage patients to say more and
continue the conversation. They show
patients that the nurse is interested.
79. When Nurse Dan says, “Tell me more
about about your experience. I wish to hear
about…” He is displaying which therapeutic
communication technique?
A. Restating
B. Seeking clarification
C. Open-ended questions
D. Summarizing
R: The best answer is FOCUSING. The nurse
should seek clarification throughout
interactions with clients. Doing so can help the
nurse to avoid making assumptions that
understanding has occurred when it has not. It
helps the client to articulate thoughts, feelings
and ideas more clearly.
80. Nurse Dan 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." The therapeutic
communication technique that Nurse Dan
used is ____________.
A. Clarification
B. Summarizing
C. Giving information
D. Reflection
R: Informing the client of facts increases his or
her knowledge about a topic or lets the client
know what to expect. The nurse is functioning
as a resource person. Giving information also
builds trust with the client. Giving information
is making available the facts that the client
needs.
Situation
Patient Sheena is a 12-year-old pediatric
patient admitted at Calantag Hospital Private
Room, where she was equipped with a
tracheostomy tube. Nurse Kenny is the person
assigned to care of Sheena.
81. Nurse Kenny is a newly registered nurse,
so he does not have the experience and skill
caring for Patient Sheena who has a
tracheostomy tube. As an inexperienced
nurse, he can ask for anyone of the following
to perform the care, EXCEPT:
A. Medical Resident
B. Medical Intern
C. Charge Nurse
D. Mother of child with care of tracheostomy
tube experience
R: Sunctioning a tracheostomy or
endotracheal tube is a sterile, invasive
technique requiring application of scientific
knowledge and problem solving. This skill is
performed by a nurse or respiratory therapist
and is not delegated to UAP. Furthermore,
when allowing the mother is performing the
tracheostomy care the NURSE should always
assess the competency of the mother.
82. Dr. Dizon, the otolaryngologist, arrived at
the room to perform the changing of
tracheostomy tube. He asked Nurse Kenny to
prepare for the appropriate equipment and
supplies needed for the procedure. Nurse
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PREBOARDS 2
NURSING PRACTICE 2
Kenny is aware that the CORRECT department
to collaborate with is:
A. Emergency Department
B. Central Supply Unit
C. Anesthesia Department
D. Operating Room Department
83. Nurse Kenny informed his head nurse,
Jane, that he still does not have the skill and
experience to perform this procedure. To
assure that Nurse Kenny learns the proper
way of caring for patients with tracheostomy
tube, Head Nurse Jane knows to collaborate
with who among the following personnel?
A. Asst. Chief Nurse for Clinical
B. Chief of Unit
C. Asst. Chief Nurse to Education & Training
D. Chief of Clinics
84. Dr. Dizon ordered a change of the
tracheostomy tube ties for Patient Sheena.
Among the following, which should Dr. Dizon
collaborate with in performing this task?
A. Medical Intern
B. Medical Resident
C. Nursing Aide
D. Staff Nurse – the nurse provides
tracheostomy care for the client with a new or
recent tracheostomy to maintain patency of
the tube and reduce the risk of infection.
85. Dr. Dizon is going to perform suctioning
on patient Sheena using a single-used catheter
for tracheostomy. To perform the skill of
suctioning using a single-used catheter for
tracheostomy safely, he needs how many
assistants?
A. Four
B. Two
C. Three
D. One – if the client does not have copious
secretions, hyperventilate the lungs with a
resuscitation bag before sunctioning. Summon
an assistant, if one is available for this step.
Using your nondominant hand, turn on the
oxygen to 12 to 15L/min. if the client is
receiving oxygen, disconnect the oxygen
source from the tracheostomy tube using your
nondominant hand. Attach the resuscitator to
the tracheostomy or ETT. Compress the Ambu
bag 3-5 times, as the client inhales. This is best
done by a second person who can use both
hands to compress the bag. In infants and
children. An assistant should always be
present while tracheostomy care if performed.
Situation
Madellaine, a multipara patient is admitted at
Nicanor Buenavente General Hospital due to
having labor pain that started an hour ago.
Upon performing the vaginal examination,
Nurse Patricia noted that the cervix is
completely dilated and 100% effaced. With
this assessment, Patient Madellaine is
experiencing true labor pains.
86. During the shift, Nurse Patricia is keeping
watch of Patient Madellaine’s labor. She is
aware that one of the problems that can occur
with labor is that the labor and delivery can be
completed in less than 3 hours. This is usually
termed as ________ labor.
A. Precipitous – precipitous or precipitate
labor occurs when uterine contractions are so
strong that a woman gives birth only a few,
rapidly occurring contractions. It is often
defined as a labor that is completed in fewer
than 3 hours. Preterm labor occurs before 36
weeks if gestation. Induced labor occurs with
administration of oxytocin.
B. Preterm
C. Induced
D. Prolonged
87. Patient Madellaine is referred to the
physician, Dr. Matthew. Upon doctor’s
recommendation, routine blood examinations
were taken. After reviewing the serum
electrolyte levels, Dr. Matthew ordered IV
infusion of Isotonic fluid as prescribed. With
Nurse Patricia’s knowledge on IV fluids, which
IV solution should she prepare?
A. 5 percent dextrose in water - isotonic
B. 0.45 percent sodium chloride solution -
hypotonic
C. 10 percent dextrose in water - hypertonic
D. 3 percent sodium chloride solution -
hypertonic
88. Patient Madellaine, having been in labor,
would anticipate some emotional support. To
keep Patient Madellaine calm during labor,
Nurse Patricia should perform which of the
following nursing intervention?
A. Giving praise for her the sense of
satisfaction regarding quick labor.
B. Support in maintaining a sense of alcohol
C. Explanation of the effect of labor on the
newborn.
D. Allowing the patient to express pain and
anxiety.
R: It is important to help relieve strong
emotions capable of amplifying pain (ex.
Anxiety, anger & fear). When clients have no
opportunity to talk about their pain and
associated fears, their perceptions and
reactions to the pain can be intensified.
Situation
Jonah, a multiparous patient experiencing true
labor pains, is noted to have complete
dilatation of the cervix and effacement of 100
percent.
89. A nursing student asks the nurse why
Patient Jonah’s labor now is much shorter
compared to her 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.
R: In multiparas, dilatation may proceed
before effacement is complete. effacement
must occur at the end of dilatation, however,
before the fetus can be safely pushed through
the cervical canal.
90. Methylergonovine maleate (Methergin) is
prescribed by the physician and was
administered intramuscularly after delivery.
What is the primary action of this medication?
A. Reduces the amount of lochia drainage.
B. Prevents postpartum hemorrhage – this
medication is used after childbirth to help stop
bleeding from the uterus. Methylergonovine
belongs to a class of drugs known as ergot
alkaloids. It works by increasing the rate and
strength of contractions and the stiffness of
the uterus muscles. These effects help to
decrease bleeding.
C. Decreases uterine contractions.
D. Maintains normal blood pressure.
R: Medication to prevent post-partum
hemorrhage:
• Oxytocin
• Methergine
• prostaglandins
Situation
A doctor ordered oxygenation of 4 liters per
minute for Joseph, a 10-year-old child with
bronchitis.
91. What is the first standard step in oxygen
therapy?
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 patient's condition.
R: before administering oxygen, check:
• the order for oxygen, including the
administering device and the liter
flow rate (L/min) or the % of
oxygen
• the levels of oxygen (PaO2) and
carbon dioxide (PaCO2) in the
client’s arterial blood (Pao is
normally 80 to 100mmHg; PaCO2 is
normally 35 to 45mmHg
• whether the client has COPD
Note: if the client has not had arterial
blood gases ordered, oxygen saturation
should be checked using a noninvasive
oximeter.
92. All of the following needs to be considered
when administering oxygen therapy, EXCEPT
_____.
A. need for a humidifier.
B. length of tubing.
C. determine the age of Joseph.
D. manner of administering oxygen,
continuous or intermittent.
R: Humidifiers are devices that add water
vapor to inspired air. Developmental factors
have important influences on respiratory
function. Oxygen therapy is prescribed by the
primary care provider, who specifies the
concentration, method of delivery and
depending on the method, liter flow per
minute (L/min).
93. The nurse knows that the PRIORITY
nursing action when administering oxygen
therapy is to ______.
GARCIA, GENEVA JANE C.
9
PREBOARDS 2
NURSING PRACTICE 2
A. attach the humidifier and connect tubing to
the oxygen delivery device.
B. connect the flow meter to the pipe in
oxygen outlet
C. turn on the oxygen
D. check the flow.
R: It is important for nurse to also
assess/check the equipment used for nursing
interventions. To ensure that oxygen is
delivered to the patient it must be turned on.
94. Which precautionary measure done by the
nurse is PRIORITY during oxygen therapy?
A. Limit visitors.
B. Attach "No Smoking" signage
C. Check humidifier's water regularly
D. Connect belt to oxygen tank.
R: Place cautionary signs reading “No
Smoking: Oxygen in Use” on the client’s door
at the foot or head of the head and on the
oxygen equipment.
95. Joseph, while on continuous oxygen
therapy, still complains of having difficulty
breathing. The nurse's INITIAL intervention is
to ______.
A. Give PRN medication.
B. Refer patient to the physician
C. Assess the patency of the tubing.
D. Re-assess the patient.
R: It is important for nurse to also ensure the
patency of the tubings in order to accurately
deliver the oxygen needed to relieve the
patient’s dyspnea.
Situation
Due to an increasing number of errors in
regard to documentation and record
management, Head nurse Levi is conducting a
lecture on proper nursing documentation and
management of records in her ward.
96. Due to an increasing number of errors in
regard to documentation and record
management, Head nurse Levi is conducting a
lecture on proper nursing documentation and
management of records in her ward.
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. When charting patient's progress
accurately, which of the following principles
should be followed?
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 measurement are
used.
R: Notations on records must be accurate and
correct. Accurate notations consist of facts or
observations rather than opinions or
interpretations.
98. All of the following are characteristics of a
chart, EXCEPT?
A. Complete
B. Subjective
C. Objective
D. Accurate
R: Characteristics of charting:
• objective
• complete
• accurate
• appropriate
• sequence
• timeliness
• legible
• permanent
99. Kardex is used during nursing
endorsements. Which of the following is NOT
true about Kardex?
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.
R: The Kardex may or may not become a part
of the client’s permanent record. In some
organizations it is a temporary worksheet
written in pencil for ease in recording
frequent changes in details of a client’s care.
Accurate notations consist of facts or
observations rather than opinions or
interpretations.
100. When an error is made during charting,
what should the nurse do?
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
R: when a recording mistake is made,
draw a single line through it to identify it
as erroneous with your initials or name
above or near the line (depending on
agency policy). Do not erase, blot out, or
use correction fluid. The original entry
must remain visible.
GARCIA, GENEVA JANE C.
10