Name:___________________________________________________________Date:________

I. Multiple choice. No ERASURES and SUPERIMPOSITIONS!

Situation: Nursing as an profession, continuously struggle for autonomy in response to societal needs. Events in the past have greatly influenced our nursing practice today.

1. Which of the ff is true about Florence Nightingale?a. She is the mother of modern American nursing.b. She nurses wounded soldiers during the civil warc. She established the first nursing school in Germanyd. She is the first nursing theorist

2. She is considered as the patroness of nursing

a. Catherine of Siennab. Elizabeth Seatonc. Elizabeth of Hungaryd. Florence Nightingale

3. The code of Hammurabia. Lists the functions of the nurseb. Describes the qualities of a nursec. Lists the rights of the clientsd. Is a law that requires all Hebrews to undergo circumcision

4. She is considered as the “Florence Nightingale of Iloilo”a. Loreto Tupasb. Sor Ricarda Mendozac. Anastacia Tupasd. Socorro Diaz

5. Which of the ff developments occurred during the apprentice period?a. “spirit of nursing”b. Informal education in nursingc. Standardization of nursing curriculumd. CHN as specialized field

Situation: A nursing theory is a system of ideas that explains a certain phenomena in nursing. It may be utilized by a nurse in the practice of her profession.

6. Which of the ff theories consider and utilize nature and environment in the healing process?a. Orlandob. Nightingalec. Rogersd. King

7. Which of the ff is recognized for developing the concept of high level wellness?a. Ericksonb. Maslowc. Peplaud. Dunn

8. Who is the first nursing theorist?`a. Abdellah b. Nightingalec. Oremd. Maslow

9. Nursing theories should include descriptions of the four concepts such as:a. Person, environment, health, nursingb. Nursing, environment, health, illness

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c. Person, society, illness, healthd. Society, nursing, health, illness

10. She conceptualized the framework for psychiatric nursing, wherein a nurse must established a therapeutic relationship with the client.

a. Peplaub. Leningerc. Halld. Neuman

Situation: Nurses assume a number of roles when the provide care to the individual, family or community.

11. Misconceptions, superstitious beliefs of a client can be best corrected if a nurse will act as a:a. Communicatorb. Teacherc. Counselord. Leader

12. When a nurse assists the client in meeting his hygienic needs, the nurse portrays what role?a. Managerb. Client advocatec. Caregiverd. Leader

13. Before Lira undergoes an operation, the nurse checked whether Lira understood what is to be done to her. With this regard the nurse acts as a:

a. Client’s advocateb. Managerc. Caregiverd. Teacher

14. You demonstrate a client advocate role to a client for operation when you:a. Check her v/s and carries out pre-op orders.b. Arrange services for clientsc. Check if the client knows what is to be done to her.d. Question the order of the doctor

Situation: Health is changing, evolving concept that is basic to nursing. There is knowledge on how to attain a certain level of health. But, health itself cannot be measured.

15. The actions people take understand their health state, maintain their health or prevent illness and injury are called:

a. Health statusb. Health beliefsc. Health behaviorsd. Health values

16. The health illness continuum concept views health as:a. Spectrum that ranges from extreme state if ill health to peak wellnessb. Adjustment to changes of the external and internal body environmentsc. Health illness curve is subject to biorhythmic influencesd. Hierarchy based upon satisfying the needs at the lowest end of the continuum first

17. A single mother of three school age children is concerned about maintaining her present health status. Although she knows that she should exercise regularly, her job and the classes she is taking at the local community college require all her spare time. Where is the client at the Dunn’s health grid?

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a. High level wellness in a favorable environmentb. Emergent high level wellness in unfavorable environmentc. Protected poor health in a favorable environmentd. Poor health in an unfavorable environment

18. Mira was not able to attend to the taping of her movie because of abdominal pain. Mira is said to be on what stage of illness behavior?

a. Symptom experienceb. Assumption of sick rolec. Medical care contactd. Dependent client role

19. Which of the ff activities is considered a promotive nursing action?a. Environmental sanitation to decrease the incidence of dengueb. Adequate nutrition to attain normal growth c. Finding cases of clients suffering from HIVd. Administration of antibiotics as ordered so infection will not set in

20. Health beliefs are affected by certain internal and external variables. What is the best definition of health belief?

a. Actions taken by an individual related to healthb. Concepts related healthc. Health practices as a persond. Health habits

Situation: The nursing process is systemic, scientific method of providing care. Its components follow a logical sequence.

21. What is the goal of the nursing process?a. Help nurses in the delivery of careb. Give a quality , comprehensive client carec. Modify the client’s plan of cared. Identify client’s problem

22. Which of the ff steps in the nursing process serve as framework in identifying client’s problem?

a. Evaluationb. Nursing diagnosisc. Assessmentd. Planning

23. It is statement of the health response of a client to his/her pathological condition. What is this statement called?

a. Nursing diagnosisb. Medical diagnosisc. Diagnosisd. Collaborative diagnosis

24. What type of nursing diagnosis needs further gathering of evidences to support the problem?

a. Actual diagnosisb. Wellness diagnosisc. Risk nursing diagnosisd. Possible nursing diagnosis

25. What is the primary purpose of time-lapsed assessment?a. To identify the client’s problemb. To establish a data basec. To compare client’s present from previous health statusd. To identify ongoing problems

26. When the nurse monitors the BP of a client after admission, the nurse is on what stage of the nursing process?

a. Assessmentb. Implementation

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c. Planningd. Evaluation

27. During the implementation process, the nurse needs to possess various skills. If she is going to suction a neonate, which of the ff skills will mostly be utilized by the nurse?

a. Cognitiveb. Interpersonalc. Psychomotord. Communication

28. 28. A client comes to the clinic for comprehensive health assessment. Upon obtaining the client’s biographic data, which of the ff questions would be best to begin history taking?

a. “What brings you to the clinic today?b. ”Would you describe your health as good?”c. “Are you healthy?”d. “Describe your health, now and in the past”

29. In formulating learning goals, which of the ff does not illustrate an important factor to be considered at this stage of the teaching process?

a. Involvement of clients and their families in the development of goalsb. Inclusion of teaching methods appropriate to client’s learning styles c. Consideration of the primary learning domains in which to focus teachingd. Use of behavioral objectives in formulating goals

30. Making judgments and conclusions about the meaning of the data you have collected in your assessment of Alfred is:

a. Analysis of datab. Verifying datac. Organizing datad. Interpretation of data

31. Which of the ff techniques can be most helpful in identifying the degree of distress and discomfort of a newly admitted client?

a. Review of nurses notesb. Performing physical examinationc. Active listening on what the clients saysd. Observation of client’s behavior

32. Your admission data will include social data about your client. These are examples of social data EXCEPT:

a. Client’s lifestyleb. Perception of illnessc. Religious practicesd. Family home situation

33. The nurse should take the initiative in setting priorities when a. In an emergency situationb. The client is illiteratec. The client is uncooperatived. There are differences in cultures

Situation: Amihan, 25y/o, was brought to the hospital because of convulsion, high fever and diarrhea. Stat and PRN drug were administered.

34. What is the most appropriate method of temperature taking will the nurse use?a. Per Oralb. Per Axillac. Per Rectald. None of the above

35. How many degrees centigrade is the normal body temperature If taken by such method (refer to above question)?

a. 37b. 37.5

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c. 37.8d. 36.5

36. If the fever of Amihan fluctuates from 38 to 40.5 degrees centigrade, she is said to have what type of fever?

a. Intermittentb. Remittentc. Constantd. Relapsing

37. Amihan’s BP is 140/80. 60 mmHg is known as:a. Systolicb. Diastolicc. Pulse pressured. Pulse deficit

38. During TSB, fever goes down through the process of :a. Convectionb. Conductionc. Radiationd. Evaporation

39. An important nursing measure that should be carried about 30 minutes after completing TSB is to:

a. Give aspirinb. Offer fluids rich in Vit. Cc. Obtain vital signsd. Provide thick blanket

40. A few minutes after the nursing measures, Amihan’s fever goes down gradually. This method of fever abatement is known as:

a. Crisisb. Lysisc. Acuted. Chronic

SITUATION: All living things need oxygen. Alterations in the respiratory and cardiovascular system will affect the individuals level of oxygenation.

41. The nurse palpated the clients back to assess the lung sounds. Which of the following will reveal a normal lung sounds?

a. presence of vesicular soundsb. absence of vesicular soundsc. presence of tactile fremitusd. absence of tactile fremitus

42. Purse lip breathing exercises was advised. What is the effect of this action to the clients respiratory system?

a. prevents air trappingb. maintains a patent airwayc. liquefies secretionsd. promotes ciliary function

43. Immobilize clients should be turned to sides every 1 to 2 hours to:1. clear the clients air passages of secretions2. prevent stasis of lung secretions3. promote lung expansion

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4. liquefy secretionsa. 1,2b. 1,4c. 2,3d. 3,4

44. The process by which gases are exchange from the lungs into the atmosphere and vice versa is known as:

a. Diffusionb. Perfusionc. Ventilationd. Osmosis

45. Which of the following term is defined as the ability of the lungs to expand?a. Lung atelectasisb. Lung compliancec. Inspirationd. Ventilation

46. The most comfortable position for a client to assume during asthmatic attack is:a. sittingb. fowlersc. orthopnicd. supine with 2 pillows

47. Danya’s respiratory pattern was described by the nurse Kussmaul. This means that Danaya’s character of breathing is:

a. Rapid, shallowb. Slow, shallowc. Rapid, deepd. Slow, deep

SITUATION: Utilizing the concept of Nutrition helps the nurse to become an effective health educator.

48. The nurse discusses the need for a diet rich in calcium. Which of the following foods are the best sources of calcium?

a. Meat, poultryb. Orange, grapefruitc. Potatoes, carrotsd. Cheddar cheese, sardines

49. Cooking vegetables quickly under low fire and with the least amount of water possible in a covered container help avoid destroying what vitamin?

a. Vitamin Cb. Vitamin Dc. Vitamin A d. Vitamin K

50. Alena tells the nurse that her 3 year-old son, Kalil does not like and will not drink milk. Which of the following foods is an alternative source of essential amino acids?

a. Beansb. Gelatinc. Fresh fruitsd. Fresh eggs

51. The nurse is correct when teaches that the vitamin is important for the proper absorption and utilization of calcium in the body is:

a. Vitamin Ab. Vitamin Bc. Vitamin C

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d. Vitamin D

52. Which of the following foods is considered food of high biological?a. Beans b. Carrotsc. Fishd. Broccoli

53. Pirena asks the nurse if her 12 year-old son, with a height of 1.2 meters and a weight of 50 kgs, has a normal height? Based on his BMI, in which of the following categories does the child belongs?

a. Underweightb. Overweightc. Normal weightd. Obese

SITUATION: Adequate elimination is one of the physiologic needs of man. A nurse must always include patterns of bowel and bladder elimination in her assessment when admitting a client.

54. What is the position of a client during abdominal palpation?a. Lateralb. Supinec. Dorsal recumbentd. Knee chest

55. During your assessment, you noticed that there is hypertympanism when you percussed your clients abdomen. Your client should be suffering from what bowel problem?

a. Constipationb. Fecal impactionc. Flatulenced. Diarrhea

56. Which of the following fecal characteristics is considered normal?a. It has bacteria and bile ligaments.b. It contains fat and undigested food.c. It is dry and hard.d. It is clay colored and has pungent odor.

57. Which of the following sites is best used for bowel sound auscultation/a. Right upper quadrantb. Left upper quadrantc. Right lower quadrantd. Left lower quadrant

58. A mother told the nurse that her 13-year-old son strains everytime he defecates. Which of the following actions is more appropriate to the child?

a. Decrease his level of activityb. Serve food neither too hot nor too coldc. Modify his lifestyled. Include dark green leafy vegetables in his diet

59. What is the minimum safe range for the hourly urinary output from the indwelling catheter?a. 20-30ccb. 90-120ccc. 60-90ccd. 30-60cc

60. The mechanism that start the act of urination is:a. feeling of voidingb. volume of urine in the bladderc. parasympathetic responsesd. relaxation of urinary sphincter

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61. If Benedict’s test is used to determine presence of glucose in the urine, how will you test if the solution is free from impurities?

a. Add 5-10gtts of urine and note for changes in color.b. Heat the solution and note for color changes.c. Add a few drops of alcohol and note for changes in color.d. Heat the solution and note for cloudiness.

62. The best urine specimen for determining glucose in the urine is:a. second voided urineb. 24 hour urine collectionc. Early morning urined. Midstream urine

63. Which of the following urine specific gravity values will indicate that there is dehydration?a. 1.010b. 1.005c. 1.024d. 1.035

SITUATION: Sleep is a state of conciousness but the persons awareness and response to the environment is decreased.

64. Sleep is important because of which of the follwing reason?1. It provides relaxation2. To conserve energy3. For protein synthesis and cell division4. For growth

a. 1,2,3b. 1,2,4c. 2,3,4d. All

65. A theory which states that sleep occurs due to the interrelationship between two cerebral mechanisms that controls sleep and wakefulness.

a. RASb. BSRc. Actived. Passive

66. Slow-wave sleep occurs during what phases of sleep?1. Stage I2. Stage II3. Stage III4. Stage IV

a. 1,2,3b. 1,2,4c. 2,3,4d. All

67. In what stage of sleep does brain tissue and cognitive restoration occur?a. NREMb. Stage IIIc. REMd. Delta sleep

68. Which of the following manifestations occur when an individual is deprived of sleep?1. clumsiness2. decrease alertness3. irritable4. pain sensitive

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a. 1,2,3b. 1,3,4c. 2,3,4d. All

69. Which of the following factors affect sleep?1. lifestyle2. age3. drugs4. caloric intake

a. 1,2,3b. 1,3,4c. 2,3,4d. All

70. Which among the following age group needs 16-20 hours of sleep?a. Infantb. Toddlerc. Preschoolerd. Adolescent

SITUATION: You were assigned in a neurological unit. Your client, Mrs. Imang, is unconscious and right-side paralysis. After five days, you noted reddening of skin over her sacral area.

71. Which of the ff is the first subjective manifestation of decubitus ulcer?a. Papular rashb. Tenderness c. Reddened skind. Skin abrasions

72. The best nursing measure to prevent bedsore formation isa. Increase client’s intake of fluidb. Turn client side to side every 1-2 hoursc. Keep client dry and comfortabled. Provide adequate nutrition

73. Which of the ff techniques in moving the client will most likely cause decibitus ulcer formation?

a. Sliding client on a sheet to move him up on bedb. Moving client to a chair with supportc. Lifting client from bed to stretcherd. Turning client to her side with a draw sheet

74. In transferring c client from the bed to a stretcher, what is the best position of the stretcher to the bed of the client?

a. Perpendicular b. Parallel c. At 90 degreesd. None of the above

75. In turning a client to her side using a logroll, which of the following actions are correct?1. Place a pillow between the legs2. One nurse counts counts 1,2,3 then turn client to her side3. Client’s arms are crossed over her chest4. Pull the client to one side of the bed before turning her to side

a. 1,2,3b. 1,3,4c. 2,3,4d. All

76. Which of the ff basic elements are involved in body movement?a. Posture, balance and coordinated body movementsb. Range of action movement and exercisec. Exercise, nutrition and postured. Activities of daily living and exercise

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77. Body mechanics is of value to the nurse as it:a. Decrease risk for injuryb. Promote active exercisec. Reduce extra body fats d. Increase energy conservation

Situation: Drug administration is one of the most common errors committed by the nurse. Prudence, possession of adequate knowledge and sound judgment are important when administering drug to a client.

78. The doctor ordered for MgSO4 5 gram to be injected on each buttock? How may cc will you inject on each buttock if the stock dose is 250 mg/cc in a 10 cc ampule?

a. 10cc b. 20ccc. 50cc d. 100cc

79. The best site for injecting a drug to a 6 month old child is the:a. Dorsoglutealb. Vastus lateralisc. Ventrgluteald. Rectus femoris

80. The nurse is going to irrigate the left ear of a 2 year-old child. What should be her position?a. Left lateralb. Right lateralc. Sitting with head tilted to the leftd. Sitting with head tilted to the right

81. To straighten the ear canal of a 5 year-old-child, you must:a. pull the external ear upward, backwardb. pull the external ear downward, backwardc. pull the external ear downward, forwardd. pull the external ear upward, forward

82. In inserting rectal suppositories, the adult client should be positioned in left lateral and encouraged to:

a. bear down during insertionb. hold breathe during insertionc. insert the suppository 1-2 inchesd. retain the suppository for 30-45 minutes

83. The mother brought her child at the health center because of diarrhea. IVF was inserted to rehydrate the client. The doctor ordered that the IVF should be regulated at 30gtts/min for the first three hours and the remaining solution should run for 8 hours. What will be the regulation of the remaining solution?

a. 5-16gtts/minb. 20-21gtts/minc. 24-25gtts/mind. 29-30gtts/min

84. The nurse teaches a client about insulin and how to inject it. The nurse explains to the client techniques to prevent inflammation and damage to tissue at the injection site. Which of the following techniques is best?

a. Injecting the needle at 45 degree angleb. Administering the insulin in alternate sitesc. Avoiding massage at the injection site after giving insulind. Facing the bevel of the needle toward the patient when injecting the needle

85. If a client is receiving iron pills, which of the following laboratory test should be assessed?a. Occult bloodb. Hematocritc. RBCd. Hemoglobin

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SITUATION: Nurses are also tasked to perform certain procedures as ordered by the doctor. These procedures are essential to meet the client’s needs.

86. When catheterizing a female client, all of the following are correct procedures EXCEPT:a. The client is positioned in horizontal recumbentb. The vestibule is swab with antiseptic solutionc. The catheter is lubricated with a water soluble jellyd. The catheter is inserted into the bladder

87. Which of the following techniques should be done when inserting a cathter into an adult male penis?

1. lifting the penis at 45 degree angle to the clients body2. insert the catheter 6-8 inches3. sterile technique should be observed 4. use Fr. 12 catheter to avoid trauma to the urethral sphincter

a. 1,2b. 1,2,3c. 2,3,4d. All

88. Why should the nurse should asks the client to hyperextend the neck during the insertion of the NGT towards the nasopharynx?

a. Avoid insertion of the tube to the tracheab. Lessen the nasopharyngeal curvature c. Prevent aspirationd. Close the glottis

89. Which of the following actions SHOULD NOT be done when giving NGT feeding?a. Place the client on fowler’s position b. Assess tube placementc. Allow the formula to flow by gravityd. Assist the client comfortably in right Sims after the feeding

90. If a client makes the following comments after about half of the blood is transfused, which one should cause the nurse to suspect that the client is having a transfusion reaction?

a. “I am thirsty.”b. “I feel so tired.”c. “I feel cold.”d. “I need to go to the toilet.”

91. A client appears to have a reaction to the blood being transfused. The nurse’s first course of action should be to:

a. Administer oxygen at 2 LPMb. Discontinue the transfusionc. Clamp the tubing to stop the blood flow and open the clamp to normal salined. See to it that the nurse-in-charge and the blood bank are notified immediately

92. A 24 hour urine collection was ordered. You should:a. add preservative to the urine when neededb. measure the urine output for the previous 24 hoursc. take the weight of the client before starting the collection of urined. add the last urine voided just before the 24 hour period ends

93. The nurses notes that the clients prothrombin time is 30 seconds. What will be the best action of the nurse?

a. Apply the support stockings before getting out of bed.b. Allow for rest periods while providing care.c. Encourage client to ambulate.d. Observe for bleeding tendencies.

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94. When dressing a contaminated wound, you must keep in mind the following EXCEPT:a. Use a non-irritating disinfectant solutionb. Isolate client from those with clean woundsc. Disinfect all instruments usedd. Apply heat around the area after dressing

SITUATION: Stress is always a fabric of life and may cause major life crisis.

95. Adaptation refers to the:a. preventive measures to avoid stressb. adjustments done by the individual to maintain homeostasisc. ability to succeed in all types of endeavord. situation that requires problem solving approach

96. A syndrome of psychosocial and physiological exhaustion, decrease perception and personal accomplishments due to chronic stress is known as:

a. adaptationb. stressorc. crisis interventiond. burn out

97. Which of the following theories explain that stress is demonstrated by a specific physiological reaction without consideration of cognitive influences on the person?

a. Stimulus-based modelb. Adaptation modelc. Response-based modeld. Transaction-based model

98. Which of the following actions are most helpful to relieve Sam of his stress?a. Teach him about the different coping mechanisms which he can utilizeb. Make an ongoing assessment of specific stressors, support given and coping statusc. Respect his privacy by allowing him to be alone as much as possibled. Encourage his family and friends too encourage him to work out his problems

99. Uma, 50 year-old and a cancer client, asked you to explain to him, his illness. Which of the following will be your best response?

a. “Are you afraid to die?”b. “Tell me how you feel about your illness?”c. “What do you want to know?”d. :Your doctor will explain to you more about your illness.”

100.Nurse Say is going to admit Mr. JB who is suffering from abdominal pain. Which of the following objectives is more appropriate if Nurse Say will utilize Adaptation Model of Stress?

a. Relief of painb. Relief of anxietyc. Promote comfortd. Prevent injury

101.After surgery (gastric resection) you will expect the drainage from the nasogastric tube to be bloody for at least:

a. 6-12 hoursb. 12-24 hoursc. 24-32 hoursd. 32-72 hours

102.Why is a cleansing enema ordered in preparation for IV Pyelography?a. to permit maximum filling of the bladder with radiopaque dyeb. to minimize discomfort during the procedurec. to facilitate passage of cystoscope into urethrad. to promote better visualization of his kidneys, ureters and bladder

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103.Immediately after the physician told Mr. Panero that he is to have a colostomy, what should the nurse do to support the patient?

a. give silent support to Mr. Panero’s feeling that the colostomy is temporaryb. allow Mr. Panero to substitute the nurses strength for his weaknessc. explain to patient what procedures will be carried out before the operationd. let Mr. Panero take the lead to be angry, to deny or to retreat

104.In history-taking, which of the following considerations is most important if the patient is elderly?

a. the usual routine information is adequateb. start with mental status examination to validate reliability of informantc. avoid long interviews, obtain needed information as quickly as possibled. adjust method and pace of information gathering due to clients sensory deficits

105.What principle is used in giving tepid sponge bath to lower elevated body temperature by assisting the skin in its thermoregulatory function?

a. dissipationb. conductionc. convectiond. radiation

106.As part of the diagnostic work-up, Mr. Andrade is scheduled for a bronchoscopy and a biopsy. Atropine, 1/150 grain, is ordered before the procedure. The nurse should explain that this medication is helpful because it:

a. reduces bronchial secretions and relaxes the bronchib. will induce sleep and prevent vomitingc. strengthens the heart rate and reduces bronchial secretions

107.Mr. Nebres has been started on sitz bath and will have to contribute them at home. Instructions should include directions to be sure to take them:

a. after exerciseb. after bowel movementc. before exercised. upon arising and at bedtime

108.Mr. De Luna asks you what to expect after his upper gastro intestinal series (UGIS). Your most appropriate response will be:

a. you will be able to move your bowels easilyb. you will be given an enema or a cathartic to expel the contrast mediac. your dietary regimen will be changedd. you will notice that your stool is dark in color

SITUATION: Accidents are the leading cause of death in persons younger than 45 years resulting in injuries, deaths and sufferings that cannot be measured in pesos. The role of the nurse in its prevention and management require that she has to be knowledgeable of the basics of emergency care.

109.Because falls accounts for the highest cause of home accidents, what home safety measures do NOT apply?

a. hand rails in bathrooms/ showersb. risers in stairs marked with contrasting color plus good lightingc. residential fire hazardsd. avoidance of slippery floor

110.Safety measures to prevent falls of hospital patients include bed side rails, which group of patients do not need side rails?

a. weak but desiring to be independentb. unconsciousc. those for executive/ general check-upd. confused

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111.Data collection in the treatment of emergencies is important before instituting nursing interventions. What is the ABC of emergency assessment?

a. Assist, Beware, Careb. Airway, Breathing, Circulationc. None of thesed. Analysis, Bleeding, Consciousness

112.What is the papillary response in unconscious patients caused by CVA or intracranial hemorrhage?

a. Equal maybe dilated or constrictedb. Equal usually dilated c. Fixed, no response to lightd. Usually unequal

113.What specific emergency care problem is suggested by shallow respiration?a. shockb. central nervous system problemc. airway obstructiond. acidosis

114.When an accident victim gasps for air or make efforts to overcome decreasing oxygenation. What is the proper term used?

a. laryngospasmb. airway obstructionc. carbon monoxide poisoningd. asphyxia

115.In the first step for cardio-pulmonary resuscitation, level of consciousness is assessed. If patient does not respond to shaking by answering you, what is the safest position to place the patient in?

a. Support patient in standing position for the Heimlich abdominal thrust maneuverb. Hyperextended neck using jaw thrust maneuverc. Prone, using Head-tilt, chin lift maneuverd. Supine, on firm surface

116.A nurse doing cardiopulmonary resuscitation (CPR) must be aware of the most common complication despite correct CPR technique. Identify from list below:

a. fracture of ribsb. lung contusion c. laceration of liverd. fractured sternum

117.Patients with cardiac arrests, are usually injected with atropine sulfate. What is its principal action in this case?

a. causes vasoconstrictionb. accelerates heart ratec. return serum PH to normal level d. suppresses ventricular fibrillation

118.When there is ventricular fibrillation in cardiac arrest, Epinephrine HCL is ordered. What is its expected effect?

a. shortens refractory period b. increases cardiac outputc. suppresses ventricular fibrillationd. improves force of contraction and regularity of heart beats

SITUATION: Aling Coring, 64 year old housewife is admitted to the hospital with diagnosis of hypertension. Her husband is a casual employee and they have 6 children.

119.Aling Coring has been found to be a non-compliant hypertensive patient. Your conclusion was based on her:

a. partially used medicationsb. age and lifestyle

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c. lifestyle and dietd. age and diet

120.Which of the following is correct using nursing diagnosis on Aling Coring’s condition?a. knowledge deficit regarding exerciseb. ineffective individual copingc. knowledge deficit regarding home blood pressure recordingd. non-compliance due to lack of understanding about seriousness of her illness

121.To enhance Aling Coring compliance, you should include in her care plan:a. side effects of anti-hypertensive drugsb. psychological characteristic of patientc. active patient involvementd. provide patient relationship

122.You explained the rationale for compliance which are:a. fewer illness-related sexual problems and psychosocial pressuresb. higher quality life and enhanced family relationsc. fewer illness related to job problems and lower pressure readingsd. more knowledge regarding medication and side effects of treatment regimen

SITUATION: The nurse is doing nursing intervention to pave the way for Jim to get rehabilitated.

123.The nurse assesses Jim’s ability to use his left hand to replace his right-hand functions. This nursing behavior directs nursing care toward replacing deficit with other skills to help him to:

a. show to his family bright hopes towards full recoveryb. adapt to changed caused by the illnessc. cooperate with other health team members in his treatment regimend. unload some activities of the health team

124.Jim is beginning to compensate the bad for the good arm’s functions. The nurse should evaluate the effect of the lack of arm function on Jim as a whole. Based on the findings, the nurse now modifies care to maintain not just the musculoskeletal but to maintain the function:

a. in all subsystemsb. gradually in most of the systemsc. moderately on the unaffectedd. partially on the unaffected

125.Helping Jim to make use of his left side as much as possible so that he returns to school and previous levels of functioning sooner. These nursing behaviors clearly show that displacement from usual activities would result in:

a. threat b. deficitc. problemd. stress

126.The nurse arranges the overbed table so Jim can feed himself using his left hand. The focus of nursing care is on Jim, in order to assess his ability to complete self-care; may be wholly compensatory or care may be:

a. traditionalb. supportive-educationalc. comprehensived. occasional

127.The nurse considers a health program towards Jim’s full adaptation when she includes all of the following, EXCEPT:

a. self-conceptb. interdependencec. dependenced. physiological factors

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SITUATION: You followed-up Aling Elma, a 55 year old. She was discharged from the hospital after a stroke. She has paralysis of the left side of the body. You made an assessment.

128.You prepare a plan of care for Aling Elma. Which of the following would be your priority objectives?

a. encourage a gradual increase in activity to provide reliefb. prevent or minimize the effects of immobilization in certain parts of the bodyc. teach a member of the family to check patient’s blood pressured. none of the above

129.One of the physicians instructions is to continue with patients passive range of motion exercises. In your visit, you therefore:

a. Explained to Elma’s daughter that the patient extremities must be exercised at least twice daily

b. Exercise the patients muscles by moving the extremities in a prescribed mannerc. Encourage the patient as you watch her to move extremities in a prescribed mannerd. Advised that the patient should exercise her extremities whenever she feels like

doing it

130.You further explained to Aling Elma’s daughter the need of properly position the patient in order to prevent:

a. muscular dystrophy and osteoporosisb. contractures and pressure soresc. osteoporosisd. muscular atrophy

131.During your home visits, you always advise Aling Elma or daughter to remind Aling Elma to do which of the following in order to prevent hypostatic pneumonia:

a. body massageb. deep breathing and coughingc. take regular meals and snacks to increase body resistantd. active and passive exercises

132.Concerned of Aling Elma’s health, you taught her daughter to explain a nourishing well-balanced diet. As you teach, you must know that protein is catabolized to meet energy needs when the diet is lacking in:

a. carbohydratesb. vitaminsc. fatsd. potassium

SITUATION: Mang Pantaleon, 35 years old, sustained multiple wound injury in both his legs after a vehicular accident. After suturing his wounds, Penicillin is prescribed.

133.Which of the following may developed when a patient is under penicillin treatment?a. hypersensitivityb. drug tolerancec. infection at injection sited. ringing at the ear

134.For pain, the doctor ordered Demerol IM 75mg, stat. The available stock is 50mg per ml in a 10cc. How much will you inject?

a. 1/2mlb. 1 1/2mlc. 1mld. 1.75ml

135.When giving any medication, which of the following is of prime importance to record?a. the expected effect of the drugb. the action of the drugc. the route of administrationd. side effects of the drug

136.In penicillin intramuscular injection, which of the following is most important?

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a. ask name of patient before injectingb. do a skin test for any allergyc. explain the procedure to the patientd. dilute the penicillin vial as ordered

SITUATION: Mrs. Gonzaga is admitted to the hospital with a diagnosis of hypertension. Her vital signs are a temperature of 98.4oF (36.9oC), a pulse rate of 80 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 190/110. She is placed on antihypertensive drug therapy and a low sodium diet.

137. Which independent nursing intervention would be appropriate for Mrs. Gonzaga?a. Assess the patient’s blood pressure before administering antihypertensive medicationb. Place the patient in the Trendelenburg postionc. Assess the temperature, pulse, rate and respiratory rate every hourd. Wear gloves when auscultating the blood pressure

138. The physician orders a platelet count to be performed on Mrs. Gonzaga after breakfast. The nurse is responsible for:

a. Instructing the patient about the diagnostic testb. Writing the order for this testc. Giving the patient breakfastd. All of the above

139. Give Mrs. Gonzaga breakfast at the scheduled time is a nursing intervention belonging to which of the following categories?

a. referralb. teachingc. diagnosisd. therapy

140. A diagnostic nursing intervention for Mrs. Gonzaga would be:a. assess the patient’s blood pressure every four hoursb. maintain the patient on bed restc. administer Phenobarbital 30mg by mouth every four hoursd. ask the dietician to explain the 500mg low sodium diet to the patient

141. An interdependent therapeutic nursing intervention for Mrs. Gonzaga would be:a. administer 30mg of oral Phenobarbital every four hoursb. escort the patient to the laboratory for a platelet countc. refer the patient to the dieticiand. assess vital signs every four hours

142. Mrs. Gonzaga continues to have an elevated blood pressure of 184/106, and the physician orders bed rest. The nurse explains to the patient the primary reason for bed rest is to:

a. decrease cardiac outputb. decrease metabolic activityc. conserve energyd. reduce oxygen use

143. Mrs. Gonzaga has been given a copy of her diet. The nurse discusses the foods allowed on a 500mg low sodium diet. These include:

a. a ham and swiss cheese sandwich on whole wheat bread b. mashed potatoes and broiled chickenc. a tossed salad with oil and vinegar and olivesd. chicken bouillon

144. A patient with signs and symptoms of congestive heart failure and leg edema has been placed on diuretic therapy. Which of the following data would best gauge his progress?

a. fluid intake and outputb. vital signsc. weightd. urine specific gravity

145. The best way to observe whether a patient is complying with fluid restriction is through:

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a. weightb. fluid intake and output recordsc. urine pHd. urine specific gravity

146. Postural drainage to relieve respiratory congestion should take place:a. before meals b. after mealsc. at the nurses convenienced. at the patients convenience

147. Immobility impairs bladder elimination, resulting in such disorders as:a. increased urine acidity and relaxation of the perineal muscles, causing incontinenceb. urine retention, bladder distention, and infectionc. diuresis, natriuresis, and decreased urine specific gravityd. decreased calcium and phosphate levels in the urine

148. Constipation is a common problem for immobilized patients because of:a. decreased peristalsis and positional discomfortb. an increased defecation reflexc. decreased tightening of the anal sphincterd. increased colon motility

149. Which of the following statements is incorrect about a patient with dysphagia?a. the patient will find pureed or soft foods, such as custards, easier to swallow than waterb. Fowler’s or semi-Fowler’s position reduces the risk of aspiration during swallowingc. The patient should always feed himselfd. The nurse should perform oral hygiene before assisting with feeding

150. A healthy adult’s body compensates for decreased urine output by:a. decreased sweatingb. increased sweatingc. thirstd. bladder distention

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