The June 2008 Nurse Licensure Examination (NLE) Answers
NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice 76 - 100
Situation – While working in a tertiary hospital, you are assigned to the medical ward.
76. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a:
A. Nurse supervisor
B. Social worker
C. bookkeeping department
D. physician
77. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to:
A. receive emotional support
B. to be a part of a research study
C. provide financial assistance
D. assist with chemotherapy
78. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a:
A. nutritionist
B. dietitian
C. physician
D. medical pathologist
79. When collaborating with other health team members, the best description of Nurse Rita’s role is:
A. encourages the client’s involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge
80. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust
Situation – The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to
provide safe nursing to your clients?
81. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs
82. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by:
A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation
83. The effectiveness of your nursing care plan for your clients is determined by
A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care
84. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue?
A. Blood pressure measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty food
D. Complaint of frequent bouts of dizziness
85. While talking with Mrs. Amado, it is most important for the nurse to:
A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent
Situation - Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
86. Given the above assessment data, the most immediate goal of the nurse would be which of the following?
A. Prevent urinary complication
B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea
87. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.
88. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’
D. to the patient lower abdomen
89. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
90. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation – You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.
91. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what rate should the IV fluid be flowing hourly?
A. 100 ml per hour
B. 210 ml per hour
C. 150 ml per hour
D. 190 ml per hour
92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he
receive at 11 am?
A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour
93. You are to apply a transdermal patch of nitoglycerin to your client. The following are
important guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand
94. You will be applying eye drops to Miss Romualdez. After checking all the necessary
information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops:
A. directly onto the cornea
B. pressing the lacrimal duct
C. into the outer third of the lower conjunctival sac
D. from the inner canthus going towards the side of the eye
95. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the
tube is likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
Situation – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes.
96. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention
97. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated
98. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life
99. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike
100. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education
June 2008
NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions.
2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
INSTRUCTIONS:
1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet
Set .
2. Write the subject title “Nursing Practice I” on the box provided.
3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.
Situation – Accurate computation prior to drug administration is a basic skill all nurses must have.
1. Rudolf is diagnosed with amoebiasis and is to received Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will received per oral administration?
A. 1,000 mg tid
B. 500 mg tid
C. 1,500 mg tid
D. 50 mg tid
2. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. which of the following should Nurse Paolo prepare for each oral dose?
A. 0.5 ml
B. 1.5 ml
C. 2.5 ml
D. 10 ml
3. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug, Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug?
A. Check the pump setting every 2 hours
B. Teach the client how the infusion pump operates
C. Have another nurse check the infusion pump setting
D. Set the alarm of the pump loud enough to be heard
4. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician: “give 3.00 cc of Lanoxin today for 1 dose only”. Which of the following is the most appropriate action by the nurse?
A. Clarify order with the attending physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin intravenously as it is the usual route of administration
D. Refer to the medication administration record for previous administration of Lanoxin
5. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse?
A. Hold the nurse administration of the client’s medication and refer to the head nurse
B. Put aside the medications she prepared and instead administer the client’s
medications
C. Tell the client that she will inform the physician about this
D. Bring the medications of the client to the nurse’s station and prepare accordingly
Situation – You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession.
6. Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an:
A. competent nurse
B. novice nurse
C. proficient nurse
D. advanced beginner
7. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:
A. the ability to organize and plan activities
B. having attained an advanced level of education
C. a holistic understanding and perception of the client
D. intuitive and analytic ability in new situations
8. As you become socialized into the nursing “culture” you become a patient advocate. Advocacy is explained by the following EXCEPT:
A. respecting a person’s right to be autonomous
B. demonstrating loyalty to the institution’s rights
C. shared respect, trust and collaboration in meeting health needs
D. protecting and supporting another person’s rights
9. Modern day nursing has led to the led development of the expanded role of the nurse as seen in the function of a:
A. Clinical nurse specialist
B. Critical care nurse
C. community health nurse
D. staff nurse
10. You join a continuing education program to help you:
A. Earn credits for license renewal
B. Get in touch with colleagues in nursing
C. Enhance your basic knowledge
D. Update your knowledge and skills related to field of interest
Situation – Mr. Jose’s chart is the permanent legal recording of all information that relates to his health care management. As such, the entries in the chart must have accurate data.
11. Mr. Jose’s chart contains all information about his health care. The functions of records include all except:
A. means of communication that health team members use to communicate their
contributions to the client’s health care
B. the client’s record also shows a document of how much health care agencies will
be reimbursed for their services
C. educational resource for student of nursing and medicine
D. recording of actions in advance to save time
12. An advantage of automated or computerized client care system is:
A. The nursing diagnoses for a client’s data can be accurately determined
B. Cost of confinement will be reduced
C. Information concerning the client can b easily updated
D. The number of people to take care of the client will be reduced
13. Information in the patient’s chart is inadmissible in court as evidence when:
A. The client’s family refuses to have it used
B. The client objects to its use
C. The handwriting is not legible
D. It has too many abbreviations that are “unofficial”
14. Nursing audit aims to:
A. provide research data to hospital personnel
B. study client’s illness and treatment regimen closely
C. compare actual nursing done to established standards
D. provide information to health-care providers
15. A telephone order is given for a client in your ward. What is your most appropriate action?
A. Copy the order on to the chart and sign the physician’s name as close to his
original signature as possible
B. Repeat the order back to the physician, copy onto the order sheet and
indicate that it is a telephone order
C. Write the order in the client’s chart and have the head nurse co-sign it
D. Tell the physician that you can not take the order but you will call the nurse
supervisor
Situation – Errors while providing nursing care to patients must be avoided and minimized at all time. Effective management of available resources enables the nurse to provide safe, quality patient care.
16. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related?
A. interruptions
B. use of unofficial abbreviations
C. lack of knowledge
D. failure to identify client
17. Miscommunication of drug orders was identified as a probable cause of medication errors. Which of the following is safe medication practice related to this?
A. Maintain medication in its unit dose package until point of actual administration
B. Note both generic and brand name of the medication in the Medication
Administration Method
C. Only officially approved abbreviations maybe used in prescription orders
D. Encourage clients to ask question about their medications.
18. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards?
A. The nurses check client’s identification band before giving medications
B. The nurse reports adverse reaction to drugs
C. Average waiting time for medication administration is measured
D. The unit has well ventilated medication room
19. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care?
A. Interviews nurses for comments regarding staffing
B. Measures waiting time for client’s per nurse’s call
C. Checks equipment for its calibration schedule
D. Determines whether nurses perform skin assessment every shift
20. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor?
A. Assign another nurse to perform the procedure
B. Ask the nurse to find way to learn the procedure
C. Tell the nurse to read the procedure manual
D. Do the procedure with the nurse
Situation – Oral care is an important part of hygienic practices and promoting client
comfort.
21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?
A. lemon glycerine
B. hydrogen peroxide
C. Mineral oil
D. Normal saline solution
22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on a sidelying position with head of bed lowered
B. Keep the client dry by placing towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression
23. The advantages of oral care for a client include all of the following, EXCEPT:
A. decreases bacteria in the mouth and teeth
B. reduces need to use commercial mouthwash which irritate the buccal
mucosa
C. improves client’s appearance and self-confidence
D. improves appetite and taste of food
24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid
rinsing the buccal cavity
B. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
C. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue,
lips and ums
D. suctioning as needed while cleaning the buccal cavity
25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:
A. salt solution
B. water
C. petroleum jelly
D. mentholated ointment
Situation - Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU.
26. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case his condition becomes severe to a point that he will be unable to make decisions for himself. This document is:
A. living will
B. informed consent
C. last will and testament
D. power of attorney
27. After one day, the patient’s condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should:
A. follow the patient because it is his right to die gracefully
B. follow the patient as it is his right to determine the medical regimen he needs
C. refuse the patient and encourage him to verbalize hid feelings
D. refuse the patient since euthanasia is not accepted in the Philippines
28. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. the choices involved do not appear to be clearly right or wrong
B. a clients legal right co-exist with the nurse’s professional obligation
C. decisions has to be made based on societal norms.
D. decisions has to be mad quickly, often under stressful conditions
29. A nurse who supports a patient and family’s need to make decisions that is right for them is practicing which of the following ethical principles?
A. Autonomy
B. confidentiality
C. privacy
D. truthfulness
30. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as:
A. power f attorney
B. living will
C. informed consent
D. medical records
Situation - Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education.
31. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration?
A. planning
B. controlling
C. directing
d. organizing
32. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of administration:
A. monitoring
B. evaluation
C. organizing
D. planning
33. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration:
A. monitoring
B. organizing
C. evaluation
D. planning
34. Revaluation and administrative process is BEST described as:
A. a continuing process of seeing that performance meets goals and targets
B. obtaining commitment of members to do better
C. informing personnel how well and how much improvement has been made
D. follow-up of activities that have been studied
35. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro?
1. Decision making skills 2. Forecasting skills
3. Auditing skills 4. Communications skills
A. 2 & 3
B. 1 & 4
C. 1 & 2
D. 2 & 4
Situation - Health is wealth specifically in this time of the century. The nurse is trained to promote well being of the people.
36. How does a nurse promote one’s well being?
A. periodic travels for rest and recreation
B. faithful and observance of healthy simple lifestyle
C. run away from polluted, stressful areas
D. avoid sleepless, over fatigue nights
37. The nurse can be involved with health promotion as a significant person in helping the family:
A. become a better family
B. prevent disease
C. control their symptoms
D. modify health promotive behaviors
38. The nurse should NOT leave medication at the bedside because:
a. the bedside table is not sterile
b. it is convenient for the nurse
c. the nurse will not be able to accurately document that the patient actually took the medication
d. the patient may forget to take it.
39. Non-pharmacologic pain management includes all the following EXCEPT:
a. relaxation techniques
b. massage
c. use of herbal medicines
d. body movement
40. When assessing a client’s blood pressure, the nurse finds it necessary to recheck the reading. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure?
a. 10
b. 30
c. 45
d. 60
Situation – The use of massage and meditation to help decrease stress and pain have
been strongly recommended based on documented testimonials.
41. Martha wants to do a study on this topic: “Effects of massage and meditation on stress
and pain”. The type of research that best suits this topic is:
A. Applied research
B. Qualitative research
C. Basic research
D. Quantitative research
42. The type of research design that does not manipulate independent variable is:
A. Experimental design
B. Quasi-experimental design
C. Non-experimental design
D. Quantitative design
43. This research topic has the potential to contribute to nursing because it seeks to
A. include new modalities of care
B. resolve a clinical problem
C. clarify an ambiguous modality of care
D. enhance client care
44. Martha does review of related literature for the purpose of
A. determine statistical treatment of data research
B. gathering data about what is already known or unknown about the
problem
C. to identify if problem can be replicated
D. answering the research question
45. Client’s rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT:
A. right of self-determination
B. right to compensation
C. right of privacy
D. right not to be harmed
Situation – Richard has a nursing diagnosis of ineffective airway clearance related to
excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.
46. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting
position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
47. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
48. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
49. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
50. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms
while vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand
action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the
secretions along with the inhalation of air.
Situation – A 61 year old man, Mr. Regalado, is admitted to the private ward for
observation after complaints of severe chest pain. You are assigned to take care of the
client.
51. When doing an initial assessment, the best way for you to identify the client’s priority
problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions
52. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions
53. Mr. Regalado says he has “trouble going to sleep”. In order to plan your nursing
intervention you will:
A. Observe his sleeping patterns in the next few days
B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up
54. Mr. Regalado’s lower extremities are swollen and shiny. He has pitting pedal edema.
When taking care of Mr. Regalado, which of the following interventions would be the most
appropriate immediate nursing approach?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium
55. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:
A. Making a final physical assessment before client leaves the hospital
B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data
Situation – Using Maslow’s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse’s knowledge and ability to identify and
immediately intervene to meet these needs is important to save lives.
56. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
A. Carol with tumor in the brain
B. Theresa with anemia
C. Sonnyboy with a fracture in the femur
D. Brigitte with diarrhea
57. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called:
A. Cyanosis
B. Hypoxia
C. Hypoxemia
D. Anemia
58. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of
insertion of the tubing for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
59. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions
are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction
60. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band?
A. Ask the client if she is Mrs. Santos
B. Ask the client his name
C. Ask the room mate if the client is Mrs. Santos
D. Compare the ID band with the bed tag
Situation – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno, shows increased interest.
61. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr.
Bruno is:
A. 1 tsp of salt/day with iodine and sprinkle of MSG
B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo
62. Your instructions to reduce or limit salt intake include all the following EXCEPT:
A. eat natural food with little or no salt added
B. limit use of table salt and use condiments instead
C. use herbs and spices
D. limit intake of preserved or processed food
63. Teaching strategies and approaches when giving nutrition education is influenced by
age, sex and immediate concerns of the group. Your presentation for a group of young
mothers would be best if you focus on:
A. diets limited in salt and fat
B. harmful effects of drugs and alcohol intake
C. commercial preparation of dishes
D. cooking demonstration and meal planning
64. Cancer cure is dependent on
A. use of alternative methods of healing
B. watching out for warning signs of cancer
C. proficiency in doing breast self-examination
D. early detection and prompt treatment
65. The role of the health worker in health education is to
A. report incidence of non-communicable diseases to community health center
B. educate as many people about warning signs of non-communicable
diseases
C. focus on smoking cessation projects
D. monitor clients with hypertension
Situation – As you begin to work in the hospital where you are on probation, you are
tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them.
66. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client?
A. Turning off the lights to promote rest and sleep
B. Instructing the client about the use of call system
C. Raising the side rails
D. Placing the bed in high position
67. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis?
A. Impaired mobility related to pain secondary to an abdominal incision
B. Impaired movements related to pain due to surgery
C. Impaired mobility related to surgery
D. Severe pain related to surgery
68. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan?
A. Encourage the client to log roll when turning
B. Encourage the client to do self-care
C. Instruct the client to do deep breathing exercises
D. Ambulate the client in ward premises every twenty minutes
69. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozano’s hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano?
A. Involving family members in meeting client’s personal needs
B. Meeting his needs till he is ready to perform self-care
C. Preparing a day to day activity list to be followed by client
D. Involving Mr. Lozano in his care
70. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are best initiated to prepare the family of Mr. Lopez?
A. Talk with the family members about the advantage of staying in the hospital for
proper care
B. Provide support to the family members by teaching ways to care for their
loved one
C. Convince the client to stay in the hospital for professional care
D. Tell the client to be with his family
Situation – Myrna, a researcher, proposes a study on the relationship between health
values and the health promotion activities of staff nurses in a selected college
of nursing.
71. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the following items serves as the purpose of a framework?
A. Incorporates theories into nursing’s body of knowledge
B. Organizes the development of study and links the findings to nursing’s body
of knowledge
C. Provides logical structure of the research findings
D. Identifies concepts and relationships between concepts
72. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT:
A. locating and identifying resources
B. reading and recording notes
C. clarifying a research topic
D. using the library
73. The primary purpose for reviewing literature is to:
A. organize materials related to the problem of interest
B. generate broad background and understanding of information related to the
research problem of interest
C. select topics related to the problem of interest
D. gather current knowledge of the problem of interest
74. In formulating the research hypotheses, researcher Myrna should state the research question as:
A. What is the response of the staff nurses to the health values?
B. How is variable “health value” perceived in a population?
C. Is there a significant relationship between health values and health
promotion activities of the staff nurses?
D. How do health values affect health promotion activities of the staff nurses?
75. The proposed study shows the relationship between the variables. Which of the following is the independent variable?
A. Staff nurses in a selected college of nursing
B. Health values
C. Health promotion activities
D. Relationship between health values and health promotion activities
Situation – While working in a tertiary hospital, you are assigned to the medical ward.
76. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a:
A. Nurse supervisor
B. Social worker
C. bookkeeping department
D. physician
77. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to:
A. receive emotional support
B. to be a part of a research study
C. provide financial assistance
D. assist with chemotherapy
78. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a:
A. nutritionist
B. dietitian
C. physician
D. medical pathologist
79. When collaborating with other health team members, the best description of Nurse Rita’s role is:
A. encourages the client’s involvement in his care
B. shares and implements orders of the health team to ensure quality care
C. she listens to the individual views of the team members
D. helps client set goals of care and discharge
80. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation and trust
Situation – The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting you main objective is to
provide safe nursing to your clients?
81. To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is:
A. critical thinking to decide appropriate nursing actions
B. understanding of various nursing diagnoses
C. observation skills for data collection
D. possession of in scientific knowledge about client needs
82. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by:
A. creating plans of care for particular clientele
B. identifying the correct nursing diagnoses for clients
C. making a thorough assessment of client needs and problems
D. using standards of nursing care as your criteria for evaluation
83. The effectiveness of your nursing care plan for your clients is determined by
A. the number of nursing procedures performed to comfort the client
B. the amount of medications administered to the client as ordered
C. the number of times the client calls the nurse
D. the outcome of nursing interventions based on plan of care
84. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgey. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue?
A. Blood pressure measurement of 170/100
B. Complaint of hot flashes
C. Report of pain after ingestion of fatty food
D. Complaint of frequent bouts of dizziness
85. While talking with Mrs. Amado, it is most important for the nurse to:
A. schedule the laboratory exams ordered for her
B. do an assessment of the client to determine priority needs
C. tell the client that your shift ends after eight hours
D. have the client sign an informed consent
Situation - Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.
86. Given the above assessment data, the most immediate goal of the nurse would be which of the following?
A. Prevent urinary complication
B. maintains fluid and electrolytes
C. Alleviate pain
D. Alleviating nausea
87. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?
A. remove urine from drainage tube with sterile needle and syringe and empty urine from the
syringe into the specimen container
B. empty a sample urine from the collecting bag into the specimen container
C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter int the specimen container.
D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container.
88. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. to the patient’s inner thigh
B. to the patient’s lower thigh
C. to the patient’
D. to the patient lower abdomen
89. Which of the following menu is appropriate for one with low sodium diet?
A. instant noodles, fresh fruits and ice tea
B. ham and cheese sandwich, fresh fruits and vegetables
C. white chicken sandwich, vegetable salad and tea
D. canned soup, potato salad, and diet soda
90. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. see to it that the drainage tubing touches the level of the urine
B. change he catheter every eight hours
C. see to it that the drainage tubing does not touch the level of the urine
D. clean catheter may be used since urethral meatus is not a sterile area
Situation – You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.
91. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8 am. At what rate should the IV fluid be flowing hourly?
A. 100 ml per hour
B. 210 ml per hour
C. 150 ml per hour
D. 190 ml per hour
92. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8 am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he
receive at 11 am?
A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour
93. You are to apply a transdermal patch of nitoglycerin to your client. The following are
important guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand
94. You will be applying eye drops to Miss Romualdez. After checking all the necessary
information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops:
A. directly onto the cornea
B. pressing the lacrimal duct
C. into the outer third of the lower conjunctival sac
D. from the inner canthus going towards the side of the eye
95. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the
tube is likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
Situation – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes.
96. The plan of the nurse supervisor is an example of
A. in service education process
B. efficient management of human resources
C. increasing human resources
D. primary prevention
97. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
A. makes the assignment to teach the staff member
B. is assigning the responsibility to the aide but not the accountability for
those tasks
C. does not have to supervise or evaluate the aide
D. most know how to perform task delegated
98. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should
A. empathize with the nurse and listen to her
B. tell her to take the day off
C. discuss how she is adjusting to her new job
D. ask about her family life
99. Process of formal negotiations of working conditions between a group of registered
nurses and employer is
A. grievance
B. arbitration
C. collective bargaining
D. strike
100. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
A. professional course towards credits
B. inservice education
C. advance training
D. continuing education
June 2008
NURSING PRACTICE II SET B
NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child
GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions.
2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
INSTRUCTIONS:
1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet
Set .
2. Write the subject title “Nursing Practice I” on the box provided.
3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.
1. Which statement is correct regarding the use of cervical cap?
A. It may affect the Pap Smear result
B. It does not need to be fitted by the physician
C. It does not require the use of spermicidal
D. It must be removed within 24hours
2. The major components of the communication process are?
A. Verbal, written, and nonverbal
B. Speaker, Listener and reply
C. Facial expression, tone of voice and gestures
D. Message, sender, channel, Receiver and Feedback
3. The extent of burns in children are normally assessed and expressed in terms of:
A. The amount of body surface that is unburned
B. Percentages of total body surface area (TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5 burn scale
4. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is:
A. Being raised by a parent of low intelligence (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty
5. Which of the following indicates the type(s) of acute renal failure?
A. Four types: hemorrhagic with and without clotting, and non hemorrhagic with and without clotting
B. One type: Acute
C. Three types: Prerenal, intrarenal, postrenal
D. Two types: Acute and subacute
6. A means of facilitating professional staff development is by building upon skills, abilities and of experience of each practitioner is called:
A. The novice to expert model
B. Situational leadership model
C. Career enhancement
D. Clinical ladder
7. Which of the following questions by the nurse would be best fit the philosophy of the nursing mutual participation model of care (NMPMC)?
A. “Have you brushed your child’s teeth today?”
B. “How does your child look to you today?’
C. “Where have you been all morning?”
D. “Do you think your child’s color is worse?”
8. There are numerous definitions of the word “health”. Which definition below is from Florence Nightingale?
A. A state or a process of being and becoming an integrated and whole person
B. The state of being free from illness or injury
C. Being well and using every power the individual processes to the fullest extent
D. A state of complete physical, social, and mental well-being and not merely the absence of diasease or infirmity.
9. Informal communication takes place when the individual talk and is best described by saying the participants:
A. Are involved in a preexisting informal relationship
B. Talk with slang words
C. Have no particular agenda or protocol
D. Are relaxed
10. Tertiary care by the home health nurse is directed toward children with:
A. Problem is mobility
B. Short-term needs
C. Minor problems
D. Clinically apparent disease
11. The endometrium thickens during which phase of the menstrual cycle?
A. Secretory phase
B. Menstrual phase
C. Proliferative phase
D. Ischemic phase
12. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over a specific period of time is called:
A. Staffing pattern
B. Sill mix
C. Benchmaking
D. Patient classification
13. The mother of a 9 month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. The BEST response by the nurse is:
A. “These circumference normally are the same, but in some babies this just differs”
B. Perhaps your baby was small for gestational age or premature
C. “This is normal until the age of 1 year, when the chest will be greater”
D. “Let me ask you a few questions, and perhaps we can figure out the cause of this difference”
14. Which of the following approaches would work best when the nurse is communicating with an infant?
A. Use an adult voice just as you would for anyone
B. Communicate through the caregivers
C. Allow the child time to warm up to the nurse
D. Respond only after the child cries for a while
15. Evidence-based care started in medicine as a way to:
A. Promote technological advances in medicine
B. Incorporate collaboration within all health care disciplines
C. Integrate individual experience with clinical research
D. Teach medical students the art and science of medicine
16. Martina develops endometritis. What would be the best activity for her?
A. lying in bed with a cold cloth on her forehead
B. reading while resting in a trendelenburg position
C. sitting with her feet elevated while playing cards
D. walking around her room listening to music
17. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins
18. Fely has diarrhea for 2 days. She has sunken eyes, skin pinch goes back very slowly, and she is drinking poorly and irritable. She is not able to drink and there is no blood in the stool. How will you classify Fely’s illness?
A. persistent diarrhea
B. some dehydration
C. severe dehydration
D. no dehydration
19. The infectious agent that causes pulmonary tuberculosis is:
A. mycobacterium tubercle
B. Hansen’s bacillus
C. Wuchereria bancrofti
D. mycobacterium diphtheria
20. Your client, who happens to be female resident of the barangay you are covering, is an adult survivor who states: “Why couldn’t I make him stop the abuse? If I were stronger person, I would have been able to make him stop. Maybe it was my fault to be abused”. Based on this, which would be your most appropriate nursing diagnosis?
A. social isolation
B. anxiety
C. chronic low self-esteem
D. ineffective family coping
21. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. What instructions would you give her before this procedure?
A. void immediately before the procedure to reduce your bladder size
B. no more amniotic fluid forms afterward, that is why only a small amount is removed
C. the intravenous fluid infused to dilate your uterus does not hurt the fetus
D. the x-ray used to reveal your fetus position has no long-term effects
22. When planning teaching strategy for a pregnant woman, the nurse should do which of the following?
A. give information about how the woman can manage the specific problems she identifies as relevant in her life
B. omit information related to minor pains of pregnancy to prevent the woman from developing hypochondria
C. provide all information to the woman in a group session with other pregnant women so she can have someone to discuss it with
D. during the first prenatal visit, teach a woman the care measures necessary for health promotion throughout the pregnancy
23. Which of the following symptoms is LESS commonly noted in EARLY pregnancy?
A. frequency of urination
B. chills and fever
C. varicosities
D. Braxton Hicks’ Contractions
24. Bonnie, 3 months pregnant, has reported for her first prenatal visit. The nurse should instruct her to do which of the following?
A. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day
B. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism
C. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra calories
D. limit intake of amino acids to prevent development of diabetic ketoacidosis
25. The nurse is assisting Mr. and Mrs. Cruz to prepare for childbirth in the home setting. Which of the following supplies should be readily available for the infant immediately after birth?
A. vitamin K to avoid bleeding
B. mild soap without perfume so as not to irritate the skin
C. bulb syringe to suction fluid and mucous from the mouth
D. heating lamp to avoid chilling from water evaporation
26. You were the nurse assigned to work with a child who has had whole brain radiation. You have assessed the child to be sleeping up to 20 hours a day and is having some nausea, malaise, fever and dysphasia. Based on this assessment, you are to work with the patients in which of the following areas.
A. Accepting a reoccurrence of the tumor
B. Dealing with the side effects of radiation therapy
C. Caring for the dying child
D. Accepting the imminent death of their child
27. The nurse is planning interventions for a child who has inflammatory bowel disease (IBD) with a nursing diagnosis of “Nutrition: Less than body requirements”. Which of the following interventions will be most helpful in resolving this nursing problem?
A. Two large meals a day instead of several minerals and snacks
B. Special IBD diet (diet that has been proven effective for crating IBD)
C. Salt free diet, high in potassium, vitamins and minerals
D. Diet as tolerated with lactose hydrolyzed milk instead of milk products and omission or highly seasoned foods and reduction of fiber.
28. Emotional intelligence consists of a number of competencies. Some of these are listed below. Which is NOT a characteristic of emotional intelligence?
A. Self-esteem
B. self-awareness
C. Empathy
D. Self-regulation
29. Data Collection for driving and restraining forces, including costs, desirability and feasibility is a:
A. People issue
B. Structural issue
C. Political issue
D. Technology issue
30. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when:
A. A child blames him or himself for the sexual abuse and begins to withdraw and isolate
B. Newspapers and media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim.
C. The child as been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop
D. The child’s agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge
Situation – Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice.
31. Which of the following is the primary focus of community health nursing practice?
A. Cure of illnesses
B. Prevention of illnesses
C. Rehabilitation back to health
D. Promotion of health
32. In community health nursing, which of the following is our unit of service as nurses?
A. The community
B. The extended members of every family
C. The individual members of the Barangay
D. The Family
33. A very important part of the Community Health Nursing Assessment Process includes:
A. the application of professional judgment in estimating importance of
facts to family and community
B. evaluation structures and qualifications of health center team
C. coordination with other sectors in relation to health concerns
D. carrying out nursing procedures as per plan of action
34. In community health nursing it is important to take into account the family health data
coupled with an equally important need to perform ocular inspection of the area as activities
which are powerful elements of:
A. evaluation
B. assessment
C. implementation
D. planning
35. The initial step in PLANNING process in order to engage in any nursing project or
activities at the community level involves
A. goal-setting
B. monitoring
C. evaluation of data
D. provision of data
Situation – Please continue responding as a professional nurse in these other health
situations through the following questions.
36. Transmission of HIV from an infected individual to another person occurs:
A. Most frequently in nurses with needlesticks
B. Only if there is a large viral load in the blood
C. Most commonly as a result of sexual contact
D. In all infants born to women with HIV infection
37. The medical record of a client reveals a condition in which the fetus cannot pass through
the maternal pelvis. The nurse interprets this as:
A. Contracted pelvis
B. Maternal disproportion
C. Cervical insufficiency
D. Fetopelvic disproportion
38. The nurse would anticipate a cesarean birth for a client who has which infection present
at the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis
39. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput
posterior position. The nurse would anticipate that the client will have:
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting
40. The rationales for using a prostaglandin gel for a client prior to the induction of labor is
to:
A. Soften and efface the cervix
B. Numb cervical pain receptors
C. Prevent cervical lacerations
D. Stimulate uterine contractions
Situation – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.
41. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are
blocked
D. The ovary no longer releases ova as there is no where for them to go.
42. The Dators are a couple undergoing testing for infertility. Infertility is said to exist
when:
A. a woman has no uterus
B. a woman has no children
C. a couple has been trying to conceive for 1 year
D. a couple has wanted a child for 6 months
43. Another client named Lilia is diagnosed as having endometriosis. This condition
interferes with fertility because:
A. endometrial implants can block the fallopian tubes
B. the uterine cervix becomes inflamed and swollen
C. the ovaries stop producing adequate estrogen
D. pressure on the pituitary leads to decreased FSH levels
44. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions
would you give her regarding this procedure?
A. She will not be able to conceive for 3 months after the procedure
B. The sonogram of the uterus will reveal any tumors present
C. Many women experience mild bleeding as an after effect
D. She may feel some cramping when the dye is inserted
45. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what
artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally into the uterus or cervix
B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husband’s sperm is administered intravenously weekly
46. A child suffers a head injury in a tumbling accident in gym class. The nurse’s best course of action is to:
A. Get the child up walking and makes sure he or she stays awake
B. Leave the child and go get help
C. Leave the child in the care of an older child and go get help
D. Stay with the child, keep assessing and have someone call the caregivers
47. The American Academy of Pediatrics suggests that caregivers do which of the following things in regard to physical activities for preschoolers?
A. Push the child to practice sports activities while they are more flexible
B. Encourage a variety of physical activities in a noncompetitive environment
C. Have the child engage in competitive sports to see where they excel
D. Keep physical activities to a minimum until the child is in grade school.
48. Which of the following arrangements is generally considered to be the best for the parents of hospitalized infant or young child?
A. Rooming in
B. Separate caregiver sleeping room on the unit
C. Day visits and sleeping at home
D. Staying at a nearby hotel or motel
49. When one person allows the conflict to be resolved at his or her own expense, this is referred in conflict management as:
A. Losing
B. Winning while losing
C. The win-lose approach
D. The lose-win approach
50. Which of the following statements best describes acquaintance rape?
A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so.
B. When two people don’t love each and engage in sexual activities
C. When someone on a date tricks the other person into having sexual intercourse
D. Sexual intercourse committed with force of the threat if force of the threat Of force without a person’s contact.
51. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy?
A. Presence of dark color in the neck
B. Increased vaginal discharge
C. Swelling of the face
D. Breast tenderness
52. A woman who is week 9 pregnant comes to the Health center with moderate bright red vaginal bleeding. On physical examination, the physician finds the client’s cervix 2 cm dilated. Which term best describes the client’s condition?
A. missed abortion
B. Incomplete abortions
C. Inevitable abortion
D. Threatened abortion
53. In a big government hospital, Nurse Pura is taking care of a woman with diagnosis of abruption placenta. What complication of this condition is most concerned to Nurse Pura?
A. Urinary tract infection
B. Pulmonary embolism
C. Hypocalcemia
D. Disseminated intravascular coagulation
54. Which of the following findings on a newly delivered woman’s chart would indicate she is at risk for developing postpartum hemorrhage?
A. Post-term delivery
B. Epidural anesthesia
C. Grand multiparity
D. Premature rupture of membrane
55. Mrs. Hacienda Gracia, 35 years old postpartum client is at risk of thrombophlebitis. Which of the following nursing interventions decrease her chances of developing postpartum thrombophlebitis?
A. Breastfeeding the newborn
B. Early ambulation
C. Administration of anticoagulant postpartum
D. Immobilization and elevation of the lower extremities
Situation – With increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. The following conditions apply.
56. Which among the following is the primary focus of prevention of cances?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection
57. In the prevention and control of cancer, which of the following activities is the most important function of the community health nurse?
A. Conduct community assembles
B. Referral to cancer specialist those clients with symptoms of cancer
C. Use the nine warning signs of cancer as parameters in our process of detection, control, and treatment modalities
D. Teach woman about proper/ correct nutrition
58. Who among the following are recipients of the secondary level of care for cancer cases?
A. Those under early case detection
B. Those under post case treatment
C. Those under early detection
D. Those scheduled for surgery
59. Who among the following are recipients of the tertiary level of care for cancer cases?
A. Those under treatment
B. Those under supportive care
C. Those under early detection
D. Those scheduled for surgery
60. In Community Health Nursing, despite the availability and the use of many equipment and devices to facilitate the job of the community health nurse, the best tool any nurse should be well be prepared to apply is a scientific approach. This approach ensures quality of care even at the community setting. This in nursing parlance is nothing less than the:
A. Nursing diagnosis
B. Nursing protocol
C. Nursing research
D. Nursing process
61. The tone and pitch of the voice, volume, inflection, speed, grunts and other vocalizations are referred to by which of the following terms?
A. Paraverbal clues
B. Ancillary speech
C. Third element
D. Enhancements
62. The plan-do-study-act cycle begins with:
A. Four stages
B. Five agendas
C. Three questions
D. Two concepts
63. During your shift, you noted one of your pregnant clients considered as “waiting case” manifests morning sickness and which later progressed. Which assessment finding may indicate possible developing complication?
A. Maternal pulse 90
B. Trace glucose in the urine
C. FHT 155
D. 1 + ketones in the urine
64. The nurse is working with a child who is going to have a bone marrow aspiration. The physician orders TAC (tetracaine, adrenaline and cocaine). Which of the following is the route of administration?
A. Application to the skin, covered with a dressing prior to the procedure
B. Subcutaneous
C. IV using very slow drip over approximately 4 hours prior to procedure
D. Nasal inhalation
65. Infant head control is judged by the:
A. Ability to hold the head without support
B. Presence or absence of head lag
C. Rigidity of the neck and head
D. Amount of neck wrinkling
66. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis, “Knowledge Deficit related to potential for altered tissue perfusion in fetus or mother related to maternal cardiovascular”?
A. Bedrest is maintained at home after the 36th wee of gestation
B. Fetal heart rate will remain between 120 and 160 beats a minute
C. Jugular vein distention is evident when lying at 45 degrees
D. Maternal blood pressure maintained above the 150 systolic
67. Pregnant women should be taught to be careful to avoid accidental injury. They are prone to falls for which of the following reasons?
A. additional weight from pregnancy may disturb balance when walking
B. fetal activity stimulates the nerves of the legs and causes weakness
C. high levels of hormones often impair judgment resulting in reckless behavior
D. increased adrenalin released during pregnancy causes women to move faster than usual
68 . When a nurse uses the IMCI model, the IMCI chart uses illness classification, e.g. the pink row needs:
A. no specific treatments such as antibiotics
B. urgent referral
C. appropriate antibiotics
D. no urgent measures
69. Which of the four signs of good attachment is true in this statement?
A. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward more areola is visible above than below
B. the chin should touch the breast, the mouth is wide open while the lower lip turned outward and more areola visible above than below
C. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and more areola visible below than above
D. the chin should touch the breast while the mouth is wide open and the lower lip turned inward, more areola is visible above than below
70. Which type of research inquiry investigates the issues of human complexity ( e. g. understanding the human expertise?)
A. positivism
B. quantitative research
C. logical position
D. natural inquiry
71. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness?
A. a child at a general danger sign
B. very severe febrile disease
C. severe pneumonia
D. severe malnutrition
72. Why are small for gestational age newborns at risk for difficulty maintaining body temperature?
A. their skin is more susceptible to conduction of cold
B. they are preterm so are born relatively small in size
C. they do not have as many fat stored as other infants
D. they are more active than usual so they throw off comes
73. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure?
A. headache and vomiting
B. a swollen tender tongue
C. a high choking voice
D. abdominal bleeding and pain
74. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever?
A. use plan C if there is bleeding from the nose or gums
B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test
C. give aspirin
D. prevent low blood sugar
75. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to:
A. ask what are the child’s problem
B. check the patient’s level of consciousness
C. check for the four main symptoms
D. check for the general danger signs
76. A child with diarrhea is observed for the following EXCEPT:
A. how long the child has diarrhea
B. skin Petechiae
C. presence of blood in the stool
D. signs of dehydration
77. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for home management at this case?
A. give drugs every 4 hours
B. continue feeding the child
C. give the child more fluids
D. inform when to return to the health center
78. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to:
A. beneficence
B. nonmaleficence
C. respect for person
D. autonomy
79. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of:
A. justice and beneficence
B. fidelity and nonmaleficence
C. beneficence and nonmaleficence
D. fidelity and justice
80. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?
A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”
Situation 7 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK
PREGNANCIES: Particular women with preexisting or Newly Acquired illness. The following
conditions apply
81. Bernadette is a 22-year old woman. Which condition would make her more prone than
others to developing a Candida infection during pregnancy?
A. Her husband plays golf 6 days a week
B. She was over 35 when she became pregnant
C. She usually drinks tomato juice for breakfast
D. She has developed gestational diabetes
82. Bernadette develops a deep vein thrombosis following an auto accident and is
prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
A. Some infants will be born with allergic symptoms to heparin
B. Her infant will be born with scattered petechiae on his trunk
C. Heparin can cause darkened skin in newborns
D. Heparin does not cross placenta and so does not affect a fetus
83. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need
further instruction on prenatal care. What statement signifies this fact?
A. I’ve stopped jogging so I don’t risk becoming dehydrated.
B. I take an iron pill every day to help grow new red blood cells
C. I am careful to drink at least eight glasses of fluid every day
D. I understand why folic acid is important for red cell formation
84. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit
or discontinue this toward the end of pregnancy?
A. Aspirin can lead to deep vein thrombosis following birth
B. Newborns develop a red rash from salicylate toxicity
C. Newbors develop withdrawal headaches from salicylates
D. Salicylates can lead to increased maternal bleeding at childbirth
85. Bernadette received a laceration on her leg from her automobile accident. Why are
lacerations of lower extremities potentially more serious in pregnant women than others?
A. Lacerations can provoke allergic responses because of gonadothropic hormone
B. Increased bleeding can occur from uterine pressure on leg veins
C. A woman is less able to keep the laceration clean because of her fatigue
D. Healing is limited during pregnancy, so these will not heal until after birth.
Situation 8 – Still in your self-managed Child Health Nursing Clinic, you encounter these
cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.
86. Josie brought her 3 months old child to your clinic because of cough and colds. Which of
the following is your primary action?
A. Give cotrimoxazole tablet or syrup
B. Assess the patient using the chart on management of children with
cough
C. Refer to the doctor
D. Teach the mother how to count her child’s breathing
87. In responding to the care concerns of children with severe disease, referral to the
hospital is of the essence especially if the child manifests which of the following?
A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken
88. Which of the following is the most important responsibility of a nurse in the prevention
of unnecessary deaths from pneumonia and other severe diseases?
A. Giving antibiotics
B. Taking of the temperature of the sick child
C. Provision of Careful Assessment
D. Weighing of the sick child
89. You were able to identify factors that lead to respiratory problems in the community
where your health facility serve. Your primary role therefore in order to reduce morbidity
due to pneumonia is to:
A. Teach mothers how to recognize early signs and symptoms of pneumonia
B. Make home visits to sick children
C. Refer cases to hospitals
D. Seek assistance and mobilize the BHWs to have a meeting with mothers
90. Which of the following is the principal focus of the CARI program of the Department of
Health?
A. Enhancement of health team capabilities
B. Teach mothers how to detect signs and where to refer
C. Mortality reduction through early detection
D. Teach other community health workers how to assess patients.
Situation – Among common conditions found in children especially among poor
communities are ear infections/problems. The following questions apply.
91. A child with ear problem should be assessed for the following, EXCEPT:
A. is there any fever?
B. Ear discharge
C. If discharge is present for how long?
D. Ear pain
92. If the child does not have ear problem, using IMCI, what should you as the nurse do?
A. Check for ear discharge
B. Check for tender swellings behind the ear
C. Check for ear pain
D. Go to the next question, check for malnutrition
93. A ear discharge that has been present for more than 14 days can be classified as:
A. mastoiditis
B. chronic ear infection
C. acute ear infection
D. complicated ear infection
94. An ear discharge that has been present for less than 14 days can be classified as:
A. chronic ear infection
B. mastoiditis
C. acute ear infection
D. complicate ear infection
95. If the child has severe classification because of ear problem, what would be the best
thing that you as the nurse can do?
A. instruct mother when to return immediately
B. refer urgently
C. give an antibiotic for 5 days
D. dry the ear by wicking
Situation – If the child with diarrhea registers one sign in the pink row and one in the
yellow row in the IMCI Chart:
96. We can classify the patient as:
A. moderate dehydration
B. some dehydration
C. no dehydration
D. severe dehydration
97. The child with no dehydration needs home treatment. Which of the following is not
included in the rules for home treatment in this case:
A. continue feeding the child
B. gives oresol every 4 hours
C. know when to return to the health center
D. give the child extra fluids
98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as:
A. severe persistent diarrhea
B. dysentery
C. severe dysentery
D. persistent diarrhea
99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly,
the classification would be:
A. no dehydration
B. moderate dehydration
C. some dehydration
D. severe dehydration
100. Genetic testing should be performed on a child only if:
A. The parents both want it performed
B. It is in the best interest of the clinic
C. It is necessary for the child to survive
D. No one objects
