PREBOARDS 2

NURSING PRACTICE 2
Situation D. “This is a normal physiologic occurrence D. Gestational Hypertension
Routine postpartum care is being performed by where the body attempts to eliminate excess 9. To assess the progression of involution, the
Nurse Barbie in caring for a postpartum patient fluids.” nurse plans to assess the uterine fundus of the
who gave birth via normal spontaneous vaginal 5. The mother is currently having difficulty mother. Which part of the abdomen should
delivery. with voiding due to her perineal edema. What the nurse begin with her assessment?
1. Blood loss of _________ would lead to can Nurse Barbie do to stimulate the A. Symphysis pubis
Nurse Barbie to suspect that the patient is sensation of voiding? B. Umbilicus
experiencing postpartum hemorrhage. A. Reminding her to void every hour C. 5 cm below the xiphoid process
A. More than 300ml/24 hours B. Helping the mother into the shower. D. 5 cm below the umbilicus
B. More than 400ml/ 24 hours C. Insertion of a catheter R: After the first hour after birth, the fundus
C. More than 500ml/ 24 hours D. Running water in the sink or shower. can be found at the umbilicus or slightly above
D. Less than 200ml/ 24 hours R: Some women have too much perineal it and continues to decrease one
R: edema to be able to void this early. A woman fingerbreadth or 2cm in size daily. Measuring
300-500mL = NSVD with an episiotomy may be reluctant to void the distance of the fundus from under the
500-1000mL = CS because she knows that acid urine against her umbilicus helps to indicate progression of
2. This is a condition caused by a markedly sutures will sting. Assist by providing privacy involution.
distended uterus and intermittent uterine (but remain in proximity in case a woman 10. The priority nursing intervention during
contractions within 2 to 3 days after birth? becomes dizzy if this is her first time out of the immediate postpartum period is focused
A. Retained placenta = hemorrhage bed), running water at the sink, or offering the on ____.
B. Afterpains woman a drink of water. These activities and A. Monitoring for signs of infection
C. Uterine atony interventions help in stimulating urination B. Watching out for postpartum hemorrhage
D. Boggy uterus from the women. Inserting a catheter may C. Taking the vital signs every 2 hours
R: in some women, contraction of the uterus facilitate elimination of urine but it does not D. Assessing level of consciousness
after birth causes intermittent cramping stimulate the mother to void naturally. R: postpartum hemorrhages are one of the
termed afterpains, similar to that Situation primary causes of maternal mortality and is
accompanying a menstrual period. Afterpains A postpartum mother who underwent a considered the greater danger in the first 24
tend to be noticed most by multiparas rather normal spontaneous vaginal delivery asks the hours after birth because of the grossly
than primiparas and by women who have nurse when and how her body will return to denuded and unprotected uterine area left
given birth to large babies or multiple births. its prepregnancy state. after the placenta detaches, making it
In these situations, the uterus must contract 6. The uterus is known to return to its imperative for the nurse to watch out for this
more forcefully to regain its pre-pregnancy prepregnancy state in ____. complication.
size and has difficulty maintaining a steady A. 6 weeks Situation
contracted state. B. 6 days Liza, a multigravida currently at 20th weeks of
3. Nurse Barbie observes that her patient is C. 4 weeks gestation visited your clinic with complaints of
still adjusting to being a mother. In line with D. 35 days dizziness, vertigo, and heartburn. Upon
Ramona Mercer’s Maternal Role Attainment R: involution is the process where a woman’s assessment, it was determined that she was
Theory, which statement best describes the uterus shrinks into its prepregnancy state and malnourished.
process of becoming a mother? takes around 6 weeks to complete. Although 11. Liza, a multigravida currently at 20th
A. A woman learns mothering behavior as the uterus will never completely return to its weeks of gestation visited your clinic with
early as a teenager. prepregnancy state, its reduction in size is complaints of dizziness, vertigo, and
B. The woman learns to become comfortable dramatic. Immediately after birth, the uterus heartburn. Upon assessment, it was
with her role as a married individual. weighs about 1000g. at the end of the first determined that she was malnourished.
C. It reflects the transitional process from week, it weighs 500g. by the time involution is A. “I don’t need to take these as our bodies
being single to raising a family. complete (6 weeks), it weighs approximately have iron stores.”
D. It involves the dynamic transformation of a 50g, similar to its prepregnancy weight. B. “Iron supplements may cause my stool to
women’s persona. 7. The nurse knows that the process where become blackish green in color”
R: The primary concept of this theory is the the uterus changes after childbirth to return C. “The iron is best absorbed if taken on an
developmental and interactional process of to its previous, prepregnancy state is called empty stomach.”
the mother, which occurs over a period of __________. D. “Meat should be avoided as to ensure iron
time. In the process, the mother bonds with A. Involution is absorbed”
the infant, acquires competence in general B. Evolution R: oral iron supplements turn stools black or
caretaking tasks and then comes to express C. Subinvolution blackish green. Due to physiologic anemia,
joy and pleasure in her role as a mother. D. Inversion iron supplements are commonly taken by
4. The mother suddenly becomes worried 8. Among the following factors experienced by pregnant women to increase supply of
when a gush of blood comes out of her vagina the patient during her pregnancy and hemoglobin. Taking iron on an empty stomach
when she first arises from her bed. She asks subsequent delivery, which would most likely may aggravate nausea and vomiting in
Nurse Barbie why this has occurred. Nurse contribute to a slow uterine involution? pregnant women which is why it is
Barbie is correct when she says _________. A. Full bladder during labor recommended to take it with food. Food rich
A. “Blood pools at the top of the uterus and B. Difficult Birth – uterine involution may be in iron include organ meats, eggs, and green
passes upon rising or sitting on the bed” delayed by a condition such as the birth of leafy vegetables which is why these are
B. “This is due to the normal pooling of blood multiple fetuses, hydramnios, exhaustion from recommended to pregnant women as well.
in the vagina when the woman lies down to prolonged labor or a difficult birth, grand 12. Liza was concerned with taking her iron
rest or sleep.” multiparity, or physiologic effects of excessive supplements as she has been taking vitamin C
C. “Physical activity stimulates bleeding in the analgesis regularly. What will be the most appropriate
vagina” C. Perineal Laceration response to this?

GARCIA, GENEVA JANE C.

1
PREBOARDS 2
NURSING PRACTICE 2
A. “This is okay as long as you take the two A. Compared to an adult’s reaction, a child’s 10 hours a day and is often visited by her
supplements 1 hour apart” reaction to the medication is more predictable peers and relatives.
B. “Stop taking Vitamin C supplements” B. When giving oral medication, the child as 21. Nurse Dani is concerned about Kim’s
C. “This is okay as absorption of iron is young as two years of age cannot be taught to ability to comply with the doctor’s instruction
enhanced with Vitamin C.” swallow drugs. to rest. What appropriate action should she
D. “This is not okay as absorption of iron is C. The child should be told to place the tablet take?
decreased by Vitamin C.” on top of their tongue and drink water to A. Ask her mother to explain to her why she
R: iron absorption increases in an acid wash down the tablet. needs to rest.
environment, so eating iron-rich foods or D. The possibility of error is greater in the B. Develop a routine with the patient to
swallowing iron pills with ascorbic acid (found giving of medication to children than to adults. balance her studies and her rest needs.
in orange juice) may increase absorption. R: Factors related to growth and maturation C. Tell her that she should prioritize her baby’s
13. Calcium supplements were also prescribed significantly after an individual’s capacity to health more than her studies
to Liza to be taken during the 2nd and 3rd metabolize and excrete drugs. Immaturity or D. Ask her why she is not complying with the
trimesters. To help facilitate absorption of defects in any of the important processes of prescription for bed rest.
calcium, which of the following should you absorption, distribution, biotransformation or R: It is important that in all interventions the
advise her to take with this? excretion can significantly after the effects of patient must always be involved in planning
A. Fat-soluble vitamins – ADEK : Vit. D for a drug. Therefore, there are several and implementation. It must be individualized
absorption of calcium considerations in administering medications to their needs. A routine balancing her
B. Water-soluble vitamins to children which makes medication error academic and physiologic needs is appropriate
C. Iron greater for this population. for the patient. We cannot mandate the
D. Milk 18. Nurse Young is to administer a medication individual to neglect certain priorities and
14. Liza asks you what the main source of via IM injection to an 10-month-old baby. aspect of her life.
nutrition for her baby is. You answer correctly What part should she use to reduce the risk of 22. During the interview, Patient Kim becomes
by stating that it is the ______. nerve damage and vascular injury? irritated with the nurse, stating “I don’t want
A. Amniotic Fluid A. Gluteus maximus – sciatic nerve to talk to you since you’re only a nurse. I’ll just
B. Placenta – nutrition & oxygen B. Vastus lateralis wait for the doctor. What would be Nurse
C. Fetal Circulation C. Deltoid muscle Dani’s best response?
D. Small Intestines D. Dorso-gluteal A. "I do not like the way that you dismiss me."
15. You performed a health teaching session 19. Intramuscular injections have been known B. “Noted. I should call your doctor.”
for Liza to manage her heartburn. Which to produce serious adverse effects according C. "So then you would prefer to speak with
statement by Liza indicates a need for further to research. Nurse Young knows that the most your doctor?"
teaching? common complication that may arise from this D. "Your doctor prescribed this for us to do
A. I will lie down after eating is ___________. nursing care."
B. I will drink milk between meals A. Infection R: An example of statement of clarification
C. I will eat small, frequent meals B. Paralysis and restating, a therapeutic communication
D. I will avoid fatty or spicy foods C. Hematoma strategy. This would help establish
R: 1. SFF D. Muscle contracture understanding of the content of the patient’s
2. sleep on left side w/ 2 pillows to elevate R: Repeated use of a single site has been statement.
torse associated with fibrosis of the muscle with 23. Due to the previous situation, Nurse Dani
3. do not lie down immediately after eating; subsequent muscle contracture which is the is now experiencing a dilemma. This occurs
try & wait at least 2 hours most common complication. This is also due when _____.
4. avoid fatty and fried foods, coffee, to the insufficient muscle mass of pediatric A. There is a conflict between the nurse's
carbonated drinks, tomatoes, citrus juices patients. Nerve damage is mostly involved decision and that of their superior
Situation only in areas with large nerves like gluteal B. Choices regarding patient care are unclear
Nurse Young was recently transferred to the muscle (near sciatic nerve). C. There is a conflict of two or more ethical
pediatric ward and was assigned to give 20. Nurse Young is to administer the IM principles
medications for the shift medication to the 10-month-old baby. To D. A decision must be made quickly under a
16. When giving medicine to pediatric ensure that the ordered medication is given to stressful situation
patients, dosage varies. Which of the following the right patient, what will Nurse Young do R: Although ethical reasoning is principle
should Nurse Alicia consider? first? based and has the client’s well-being at
A. Height and weight A. Check the patient's hospital bracelet. – 2nd center, being involved in ethical problems and
B. Size, surface area and age or for verification dilemmas is stressful for the nurse. The nurse
C. Size and surface area – height & weight B. Ask the parent/significant other to state may feel torn between obligations to the
D. Size, surface area, age and weight name of patient and birth date of patient. client, the family, and the employer. What is in
R: the correct dosage of most drugs for C. Verify patient’s allergies with chart and with the client’s best interest may be contrary to
children is based on body surface area. To patient. the nurse’s personal belief system. The
calculate surface area, height and weight of D. Compare medication order to identification different ethical principles may also have
the child is determined. Size can be area, bracelet. converging conflicts in a certain situation. This
volume, length, or height of the baby. Situation conflict is referred to as moral distress and
17.Before administering oral medications, Kim, a college student, was recently admitted dilemma and is considered a serious issue in
Nurse Young is being assessed by the head to the hospital due to having severe pre- the workplace.
nurse on her knowledge on administering eclampsia. Despite her physician advising her
medications for pediatric patients. Which of to rest, Kim insists on continuing her work
the following statements shows correct while admitted. She currently studies around
understanding by Nurse Young?

GARCIA, GENEVA JANE C.

2
PREBOARDS 2
NURSING PRACTICE 2
woman’s eyes is the kind of sudden D. Intervention
stimulation to be avoided. 29. If Patient Rosita’s pain was not
A - Stringent sodium restriction may activate satisfactorily relieved after administration of
the renin-angiotensin-aldosterone system and the medication, Nurse Josie should perform
result in increased blood pressure, which of the following actions upholding the
compounding the problem nursing process?
B – Visitors are usually restricted to support A. Wait for more time for the pain reliever to
people such as a husband, father of the child, take effect
mother or older children because noise and B. Collect additional data as to why the patient
crowd can trigger seizures. has not been relieved of pain.
Situation C. Teach the patient relaxation breathing
Head Nurse Kylie is currently facilitating a techniques.
training program for newly hired nurses at D. Refer to attending physician.
Olympia Medical Center (OMC). A key part of R: Despite pain being subjective, it must not
her training is giving scenarios for the nurses be ignored and neglected. If the pain relievers
to apply what was taught during the program. are not working, there must be some
She gave the group a situation: Patient Rosita problem. Before referring to the doctor,
is a pregnant woman admitted in the OB additional assessment must be taken for
Ward. possible cause of the unsuccessful relief of the
26. In caring for patient Rosita, Head Nurse pain.
Kylie is discussing with Nurse Josie, a newly 30. Head Nurse Kylie discusses in the training
hired nurse, on how to utilize the nursing the different elements of documentation. In
process for the pregnant patient. Nurse Josie order for the document to be comprehensive
is correct when she mentions the planning and timely, it must be:
phase includes: A. Complete and current
A. Reviewing the history of the patient during B. Accurate and concise
assessment C. Organized
B. Prioritizing the patient’s problems D. Factual
C. Identifying the nursing diagnoses R: Same meanings, different terms. Document
D. Collecting information of the patient’s events in the order in which they occur; for
problem has been resolved in the evaluation example, record assessments, then the
phase nursing interventions, and then the client’s
R: In the process of developing client care responses. Update or delete problems as
plans, the nurse engages in the ff. activities: needed. Not all data that a nurse obtains
• Setting priorities about a client can be recorded. However, the
• Establishing client goals/desired information that is recorded needs to be
outcomes complete and helpful to the client and health
• Selecting nursing interventions and care professionals.
activities Situation
24. Nurse Dani knows that regardless of what • Writing individualized nursing Mommy Oni is a 28-year-old primigravida that
just happened, she must still abide to the interventions on care plans is admitted to Solaris Birthing Center. She
ethical principle that states the nurse is 27. Nurse Thea, one of the assigned group confirms to have been in labor for the past 10
obligated to implement actions that will leaders during the training, is reviewing the hours, having contractions 5 minutes apart.
provide care and benefit to the patient. What steps of the nursing process with the group. With astute observation from Nurse Karen,
specific principle is this? Nurse Thea identifies which of the following she deduced that the patient is having
A. Beneficence – doing good is/are objective data? Select all that apply. hypotonic contractions. Mommy Oni also
B. Justice – resources; fairness I. Respiratory rate is 22/min. complains of more pain in her back than in her
C. Nonmaleficence – do no harm II. Feels pain after a 10-minute walk abdomen. Sonogram was performed which
D. Veracity – telling the truth III. Pain is rated as 3 on a scale of 10. showed her fetus to be “borderline” large for
25. In providing a safe environment for the IV. Skin is pinkish in color, warm, and dry. gestation and in occipito-posterior position.
patient with preeclampsia, what can Nurse A. II and III 31. Nurse Karen notices that Mommy Oni’s
Dani do? B. I and IV uterine contractions are short in duration and
A. Maintain fluid and sodium restrictions. C. III and IV irregular in frequency. During contractions,
B. Encourage frequent visits from family and D. I and II Mommy Oni is screaming with pain. Nurse
friends for psychosocial support 28. The very next day, Patient Rosita delivered Karen knows that the BEST nursing action to
C. Take the patient's vital signs every 4 hours. an alive baby girl. After delivery, she perform is?
D. Take off the room lights and draw the complained of leg pains. Nurse Josie took hold A. Try to divert attention from pain.
window shades. of Patient Rosita’s chart. In the chart, an order B. Administer pain reliever as ordered.
R: was provided to give PONSTAN 500 mg every C. Stay with the patient and offer her a back
D = Darken the room if possible because a 4 hours PRN for pain. After 40 minutes, the rub. – remember that pain is an exhausting
bright light can also trigger seizures. However, patient felt relieved. Nurse Josie should have phenomenon. Encourage the use of
the room should not be so dark that conducted what step of nursing process? nonpharmacologic comfort measure such as
caregivers need to use a flashlight to make A. Assessment breathing with the woman, giving back rubs,
assessments. Shining a flashlight beam into a B. Planning changing sheets, using cool washcloths and so
C. Evaluation

GARCIA, GENEVA JANE C.

3
PREBOARDS 2
NURSING PRACTICE 2
forth. Complementary therapies such as 34. As Nurse Karen monitors Mommy Oni, she often responsive to people they know and
aromatherapy or music are also helpful. should know which finding shows an adequate familiar with.
D. Document and report frequency and pattern of uterine contraction? 37. Leaving the child alone Seeking the help of
duration of contractions. A. Three to 5 contractions in a 10-minute the mother in giving the oral drug. Mixing the
R: With hypotonic uterine contractions, the period, with resultant cervical dilatation – in a drug with milk to cover up the unfavorable
number of contractions is unusually low or normal labor, one contraction every 2 – 3 taste. Getting angry with the mother and the
infrequent (not more two or three occurring mins or less than 5 contractions in a 10 min child.
in a 10 min period). They may occur after the period is ideal. A uterus must rest between A. has separation anxiety.
administration of analgesia, especially if the contractions, having sufficient uterine resting B. internalizes the attitudes of others.
cervix is not dilated to 3 to 4cm or if bowel or tone (soft to the touch) and uterine resting C. utilizes magical thinking.
bladder distention prevents descent or firm time (about one minute). D. is negativistic in all matters.
engagement. This can increase chances of B. Four contractions every 5 minutes, without
post partum bleeding and inadequate resultant cervical dilatation
oxygenation of fetus. Therefore, it is C. One contraction every 10 minutes, without
important to assess if the labor of the mother resultant cervical dilatation
is progressing. D. One contraction per minute, with resultant
32. Mommy Oni’s physician is considering cervical dilatation
augmenting her labor with the use of oxytocin. 35. Nurse Karen is an effective nurse when she
Nurse Karen would question the use of knows which of the nursing measures should
Oxytocin for Mommy Oni if? she LEAST consider doing to Mommy Oni
A. She had an amniocentesis performed having oxytocin drip?
38. Nurse Ria knows that in giving Trixie
during pregnancy A. Know how to recognize potential adverse
oxygen effectively, the best way to administer
B. Her fetus is large for gestational age by a reactions.
it is through the use of _______.
sonogram B. Administer oxytocin drug with caution
A. hood
C. Her membrane ruptured after only 1 hour C. Monitor patient closely when infusing
B. face Mask
of labor oxytocin
C. Incentive Spirometer
D. Her blood pressure is slightly elevated D. Inform patient about potential
D. nasal catheters
above normal complication.
R: Oxygen hood is a high-flow device (4-
R: Oxytocin can cause a biphasic effect on the R: Oxytocin is a drug that can cause adverse
6L/min) and leads to a lot of wastage, whereas
blood pressure. It can cause severe effects to a laboring woman. It is important to
nasal prongs/catheters are low-flow devices
hypertension and going to severe monitor the patient and her baby cautiously
requiring a low flow rate for infants. This tube
hypotension. Any irregularities in the blood for any adverse reactions. Although it is also
has soft prongs that gently fit into the baby’s
pressure can merit questioning of the use of important to inform the patient regarding the
nose. Face-mask, head boxed, incubators and
oxytocin. The use of oxytocin helps in the drug, it would be the least priority to do since
tents are not recommended because they
delivery of large for gestational age babies it can increase the anxiety of the patient while
waste oxygen and are potentially harmful. The
since it can cause hypotonic labor. Aside from in labor.
recommended methods for neonates, infants
that, the rupture of membranes needs faster Situation
and children are nasal prongs, nasal catheters
delivery since prolonged labor can cause Madam Irene’s daughter, one-year-old Trixie,
and nasopharyngeal catheters. A nasal
infection; therefore, requiring augmentation is is admitted at Sta. Teresa Medical Center due
catheter is a thin, flexible tube that is passed
possible. to Pneumonia. Upon admission, she was given
into the nose and ends with its tip in the nasal
33. Nurse Karen observes that Mommy Oni’s IV antibiotics, decongestant, antipyretic, and
cavity.
contractions are 70 seconds long and vitamins. She was also subjected to oxygen
39. With Trixie being given IV Antibiotic
occurring every 90 seconds when assessing therapy.
therapy, Nurse Ria should give the MOST
the frequency of her contractions after 36. As Nurse Ria gives Trixie her oral
common gauge used for IV cannula for her age
oxytocin was administered. Nurse Karen’s first medication, she immediately refuses, making
which is gauge ____.
action should be which of the following? Nurse Ria worried. Nurse Ria will handle the
A. 20
A. Give an emergency bolus of oxytocin to situation by:
B. 24
relax the uterus A. Leaving the child alone
C. 22
B. Discontinue the administration of the B. Seeking the help of the mother in giving the
D. 18
oxytocin infusion. oral drug.
C. Increase the rate of client’s IV infusion C. Mixing the drug with milk to cover up the
40. Nurse Ria is monitoring Trixie for
D. Ask client to turn to her left side and take unfavorable taste.
improvement of her condition. An
breaths deeply. D. Getting angry with the mother and the
IMPORTANT evaluation parameter that she
R: Contractions should occur: child.
should watch out is ____.
• No more often than every 2 mins R: Attachment to their parents is increasingly
A. Absence of fever.
• Should not be stronger than evident during the second half of the first
B. Absence of chest indrawing.
50mmHg pressure year. At approximately 6-12 months of age,
C. Respiratory rate of 45 beats per minute,
• Should last no longer than 70 sec infants show a distinct preference for the
D. Respiratory rate of 55 beats/ minute.
• If the contractions become more mother. They follow her more, cry when she
R: Pneumonia is often characterized by high-
frequent or longer in duration that leave, enjoy playing with her more, and feel
grade fever. Being afebrile is a sign that the
the safe limits, IV infusion of most secure in her arms. About 1 month after
infection is already resolving. It is also
oxytocin should be STOPPED showing attachment to the mother, many
characterized by tachypneic patients. The 45
IMMEDIATELY and seek help infants begin attaching to other members of
& 55 bpm of RR are still fast for a 1 y/o infant.
immediately the family, most often the father. They are
Situation

GARCIA, GENEVA JANE C.

4
PREBOARDS 2
NURSING PRACTICE 2
Patient Boa Hancock is a postpartum patient D. II, IV and I and plan can be ordered by the attending
admitted at Marineford General Hospital 44. After Nurse Luffy put out the fire, he physician.
where she delivered a stillborn. She is hooked noticed that Boa Hancock has absconded. 47. Patient Anya’s physician gives a doctor’s
to an intravenous fluid (IVF) and is currently What is the ethico-legal responsibility of Nurse order to administer Ofloxacin eardrop on
being monitored postpartum. She tells her Luffy? Patient Anya. As Nurse Fiona prepares to
nurse, Nurse Luffy, that she wants to leave the A. Autonomy administer the order, she needs to hold the
hospital. However, she doesn’t have an order B. Nonmaleficence bottle with her hands to warm up the solution
from Dr. Chopper to be discharged from the C. Beneficence to prevent dizziness for ______.
hospital. D. Justice A. 5-6 minutes
41. Given that Nurse Luffy is aware of the R: The ethico-legal responsibility of the nurse B. 1 to 2 minutes
ethico-legal concerns regarding Boa Hancock’s is to prevent the patient from getting harmed. C. 3-4 minutes
request, he has to avoid liabilities. Which of Tha patient is still at their recovery phase D. 6-7 minutes
the following actions is APPROPRIATE for which means they are not yet stable to leave R: Hold the bottle in your hands for 1 to 2
Nurse Luffy to do? the hospital especially without any mins to warm up the solution before putting it
A. Notify nursing supervisor of the patient’s instructions. Aside from that, the facility just in your ear. Otherwise, putting cold solution in
plans to leave recovered from a fire. Hazards can still harm your ear could cause you to become dizzy.
B. Arrange medication prescriptions at the the patient. It is important for the nurse and 48. Nurse Fiona washed her hands and gently
patient’s preferred pharmacy. the team to find the patient. started cleaning any discharges that can be
C. Notify directly the attending obstetrician. 45. Nurse Rayleigh told Nurse Luffy that removed easily from the outer ear. As Nurse
D. Ask the patient about transportation plans absconding is inevitable in any health care Fiona positions Patient Anya, she vividly
from the hospital. facility. If the patient suddenly absconded, remembers that the next step in the
R: Every hospital has their own policy Nurse Luffy should IMMEDIATELY inform procedure is to:
regarding discharge against medical device. It which of the following? A. Gently press the tragus of the ear four
would be most appropriate to relay the plan A. Attending physician times in a pumping motion.
of the patient to the nurse supervisor of the B. Security guard on duty B. Gently pull the outer ear
charge nurse so they can be able to activate C. Resident on duty C. Drop the medicine into the ear canal.
the process based on hospital policies. The D. Nursing staff D. Keep the ear up for five minutes.
process could include residents and attending R: Absconding patient = a patient who has R: Straighten the auditory canal. Pull the pinna
explanation of hospitalization necessity, been absent from a clinical area without upward and backward for clients over 3 years
signing of consents, discharge instructions, having notified staff of the intention to leave. of age. The auditory canal is straightened so
notification of billing and other steps. Failed to return to the clinical area at the that the solution can flow the entire length of
42. With Patient Boa Hancock being on agreed time ex. After attending activity the canal. This is before giving the medication.
postpartum, Nurse Luffy reminds her on the outside the clinical area, including playrooms 49. Based on her previous knowledge on otitis
importance and need of early ambulation. As for children. media, Nurse Selma remembers that children
per Nurse Luffy’s instruction, which of the Situation like Patient Anya are predisposed to Acute
following is INCORRECT in doing ambulation? Patient Anya Forger is a 5-year-old child otitis media due to the following risk factors,
A. Assist the patient from sitting to standing currently admitted at the pediatric ward of EXCEPT _____.
position. Ostania Medical Memorial Center (OMMC). A. absence of breastfeeding
B. Raise the head of the bed slowly to achieve She was admitted due to having severe B. Swimming – otitis externa
sitting position of the patient. otalgia, irritability, and fever. Yor Forger, her C. exposure to cigarette smoke
C. Allow the patient to rise from the bed to a mother, informed Nurse Fiona that Patient D. poor hygiene
standing position unassisted. Anya developed Upper Respiratory Infection R: Predisposing factors include URIs, allergies,
D. Assist patient to rise from lying to sitting three weeks prior to admission. The admitting down syndrome, cleft palate, daycare
position. diagnosis of Patient Anya is Acute Otitis Media attendance, exposure to secondhand smoke
R: Gradual ambulation is important for any (AOM). and bottle propping during feeding. Infants
patient coming from a procedure like delivery 46. Nurse Fiona performs her initial fed breast milk have a lower incidence of OM
of a baby. This is to prevent orthostatic assessment on Anya. She notices that Patient than formula-fed infants. Breastfeeding may
hypotension and eventual fall incidents. Anya keeps crying and constantly pulling her protect infants against respiratory viruses and
Leaving the patient unassisted especially when right ear. Being Patient Anya’s nurse, she allergy because it contains secretory
standing can cause accidents like fall. knows that the MOST APPROPRIATE action to immunoglobulin A, which limits the exposure
43. As Nurse Luffy is waiting for an update do is: of the eustachian tube and middle ear mucosa
from Nurse Rayleigh, his supervisor, regarding A. Request parent to carry the child to microbial pathogens and foreign proteins.
Boa Hancock’s request to go home, he B. Take Catherine's vital signs. 50. Nurse Fiona’s nursing interventions to
proceeds to check his patient. As he entered C. Refer to the attending physician. promote drainage and reduce pressure from
the room, he discovers that the basket D. Assess the description and frequency of fluid from is to have Patient Anya assume any
containing wastes caught on fire. In response pain. of the following positions, EXCEPT?
to the emergency, Nurse Luffy calmly recalled R: Ear pulling or tugging accompanied by A. tilt head to side if sitting up
that the correct steps to do in this situation is: crying is an indication of pain from a child with B. lie on the affected area
I. Rescue the patient. acute otitis media. This warrants appropriate C. put the pillows behind the head
II. Activate the fire alarm. pain management such acetaminophen, D. lie on the non-affected ear
III. Close the door to confine the fire. ibuprofen or topical pain relief drops. With R: All of the choices promote drainage on the
IV. Put off the fire with fire extinguisher. that, it must be referred to the physician. affected ear. Lying on the non-affected ear
A. IV, II and I Consistent severe pain can also warrant does not promote drainage on the other side.
B. I, II, III and IV possible myringotomy procedure to relieve Situation
C. I, II and IV the pressure. These therapeutic management

GARCIA, GENEVA JANE C.

5
PREBOARDS 2
NURSING PRACTICE 2
Nurse May is a nurse that is currently rotated adolescent, Nurse May is bound to take care 57. Nurse Elle further discussed with the
in the Pediatrics Ward of Kawayan Medical of adolescents who are emotionally disturbed. mothers that there are risk factors that can
Center. To better appreciate her role as a As such, it is vital for Nurse May to have prior lead to postpartum hemorrhage. Nurse Elle
professional nurse in the area, she needs to knowledge of warning signs of suicide which correctly explains that the following are risk
review the principles and concepts of human occur for at least a month before an attempt. factors EXCEPT:
growth development. Which of the following warning signs should A. ruptured uterus
51. As she was assigned to provide care to NOT alert Nurse May? B. uterine atony
pediatric patients, Nurse May should recall A. increase in initiative C. overdistended uterus – adolescents = not
which of the following correct information? B. verbalization of suicidal thoughts. contract easily
A. Toddler period ranges from 12 to 36 C. Crying D. retroversion of the uterus – uterine
months. D. Sleep disturbances deviation = fertility
B. An infant's tongue is smaller than the adult R: Uterine atony, laceration of the cervix or
– the young child’s tongue is relatively larger vagina, hematoma development in the cervix,
in the oropharynx than the adult’s perineum or labia, retained placental
C. Early childhood period ranges from 3 to 7 fragments are the causes of postpartum
years – early childhood: 1 to 6 y/o hemorrhage.
Middle childhood: 6-11 y/o 58. Nurse Elle reviews the normal postpartum
Late childhood: 11-19 y/o 55. Head Nurse Jona regularly performs course and expects to note sexual activity
D. Breast milk provides complete infant rounds in the Pediatric Ward. In one of her during:
nutrition – exclusive only up to 6 months nursing rounds, she asked Nurse Ester about A. After weeks from the delivery
52. Nurse May is checking Baby Janjan’s the age inclusivity where a person transitions B. 4 days after the delivery
temperature when her mother asks about from childhood to adulthood or graduation. C. When the client's bladder is full
what age does growth and development Nurse Ester knows that the CORRECT age D. The day after the delivery
become more rapid. Nurse May knows that range is from ________. R: Couples can begin intercourse as early as 4
rapid growth and development occurs during A. 15 to 18 weeks after giving birth, if desire and comfort
which time? B. 12 to 16 allow. This is the best answer since it does not
A. Ten C. 11 to 18 mention anytime timeframe. There is no
B. Nine D. 13 to 18 specific answer in this question, but it will be
C. Twelve specific in the next question.
D. Eleven 59. During the health education session, one
R: An average weight for a 6 month old child is mother asked Nurse Elle if sexual activity will
7.3kg (16 pounds). Weight gain slows during return if no complications develop. Nurse Elle
the second 6 months. By 1 year of age, the explains that through a normal postpartum
infant’s birth weight has tripled, for an course, they would expect the return of sexual
average weight of 9.75kg(21.5 pounds). activity during what time?
Height increases by 2.5cm (1 inch) a month Situation A. In 4 to 6 weeks
during the first 6 months of life and also slows Nurse Elle is working in the Birthing station of B. At any time
during the second 6 months. Maayo General Hospital, where five C. After the 6-week physician check-up
53. The mother of Baby Janjan further asked postpartum mothers delivered 2 hours, 4 D. When her normal menstrual period has
Nurse May how to determine if her baby is at hours, and 6 hours ago, respectively. Upon resumed
the right age of her development. Nurse May their obstetric history, she discovered that all 60. Nurse Elle instructs the postpartum
explained that one of the key determinants of of them have had past pregnancies. Nurse mothers that there may be possibilities of
the baby’s development is her gross and fine Elle, being a nurse educator, opted to conduct them experiencing postpartum hemorrhage in
motor development. She emphasized further health education about postpartum the future. Nurse Elle emphasizes that proper
that there are actions that can stimulate and hemorrhage which would deem vital to all nutrition and diet may prevent or lessen the
growth and fine motor movement, such as postpartum mothers present. occurrence of hemorrhage. An example would
which of the following? 56. Nurse Elle explains to the mothers about be the inclusion of Vitamin K intake to lessen
1. Push/pull early indications for hypovolemia caused by the bleeding itself. Nurse Elle knows that the
2. Use of scissors and pencil appropriately postpartum hemorrhage. She is CORRECT patient should take Vitamin K with _______
3. Poking straws into holes when she states that early signs and for easier absorption.
4. Stand on tiptoes if shown first symptoms that can be observed is: A. Proteins
A. 1 and 2 A. increasing pulse and decreasing blood B. Carbohydrates
B. 2 and 3 pressure C. Minerals
C. 3 and 4 B. altered mental status and level of D. Fats - ADEK
D. 1, 2, 3 and 4 consciousness Situation
C. dizziness and increasing respiratory rate Nurse Sherry is the head nurse of the OB/GYN
D. cool, clammy skin, and pale mucous ward of Marianas General Hospital. In one of
membranes her nursing rounds, she noticed that there is a
R: Excessive blood loss can cause several lack of data filled up in the Intake & Output
complications like increased heart rate, rapid sheets of various patients of the ward.
breathing and decreased blood flow. These 61. Based on the discovered findings, what
54. According to the World Health would be the most appropriate action for
Organization (WHO), suicide has become a symptoms can restrict blood flow to your liver,
brain, heart or kidneys and lead to shock. Also, Head Nurse Sherry to do?
global phenomenon. As a pediatric nurse that
deals with different children from toddler to the key term used in the question is “EARLY”
signs.

GARCIA, GENEVA JANE C.

6
PREBOARDS 2
NURSING PRACTICE 2
A. Ask the staff nurses the reasons for the vascular compartment to the interstitial space B. Credibility – confidence in the truth of data,
failure to properly fill up the Intake & Output or compartment. accurate
flow sheet. When there is fluid shifting due to third- C. Transferability – in quanti: generalizability
B. Give the staff nurses first warning. spacing, the fluid remains in the body but is D. Dependability – immerges in report, feeling
C. Conduct a needs assessment. essentially unavailable for use, causing tone of participants
D. Review the Orientation Program. isotonic fluid volume deficit 70. While conducting the interview as their
R: The Head nurse wants to determine the Situation method of data collection in the study, the
factors that may have affected the nurse to Nurse Melanie and her fellow staff nurses research group utilized audio recording
not be able to fill the date of the I&O. assigned in the delivery room of Pandacan devices to capture what transpired in the
62. With the presenting issue in the ward, Medical Center, is interested in conducting a interview session. After transcribing the data,
Head Nurse Sherry decided to coach her staff research study on the experiences of pregnant the research group is aware that the
nurses. One of the questions she asked was women in labor. They are planning on making APPROPRIATE action to do with the audio tape
what fluids should not be included in it qualitative research to yield accurate results, is:
documenting the Intake/Output flowsheet. with Nurse Melanie as the lead researcher. A. Keep the audiotape in a vault and dispose
The staff nurse is correct if she said: 66. In the presentation of results and of it a year after.
A. Intravenous Fluids discussion portion of the qualitative study, B. Submit the audiotape to their research
B. Gelatin Nurse Melanie should use as a reference in adviser.
C. Solid Foods the write-up the ______ person. C. Throw it in the trash bin immediately after
D. Beverages A. First it was used
R: Solid foods are not part of the intake that B. Second D. Post the recording on their university
will be written in the intake and output of C. Fourth research website for others to listen.
patient. Input list include: ice chips, foods that D. Third R: Some important ethical concerns that
are liquid at room temp, tube feeding, R: Third – less subjectivity – it removes direct should be taken into account while carrying
parenteral fluids, IV medications, reference to the researcher. In many reports out qualitative research are: anonymity,
catheter/tube irrigants. of qualitative research, scholars prefer to use confidentiality and informed consent. You
63. Head Nurse Sherry also emphasized to the the first-person in their writing, as this must ensure that personal data are kept
staff nurses that which of the following should matched the intention of giving voice to their secure and are not disclosed to unauthorized
be EXCLUDED in documenting the Output list? participants’ perspectives. Indeed, style guides persons. You should use a locked storage
A. Drainage from tubes published by specific associations provide container such as a filing cabinet in a locked
B. Solid/hard feces guidance on this issue. office for paper-based personal data; for
C. Urine 67. Nursing is always regarded as both an art digital data, password-protected or
D. Vomitus and a science. In the field of human science, preferably, encrypted storage
R: Urinary output, vomitus, liquid feces, tube nursing deals with the critical and Situation
drainage and wound & fistula drainage fundamental differences in attitude towards Nurse Christine is the head nurse of the
64. Another question asked by Head Nurse their respective phenomena. Which of the OB/GYN area at Santa Monica General
Sherry is about the time to record the Intake following is an aim of human sciences? Hospital. To increase better performance in
and Output. The staff nurse is correct when A. Construct prediction - QUANTI the area, she conducted an in-service program
she said that the BEST TIME to record the B. Seek causal explanation – EXPERIMENTAL on staff development.
intake and output is: QUANTI 71. Head Nurse Christine discussed with the
A. During endorsement C. Sets control – MCRV QUANTI nurses in the area that the MOST frequently
B. After endorsement D. makes meaningful interpretation - neglected area in management is
C. Right before endorsement PHENOMENOLOGICAL __________.
D. Any time before duty 68. Nurse Melanie’s research group is A. Managerial knowledge
R: Fluid I&O measurements are totaled at the observing the activities occurring in the B. Professional development
end of the shift (every 8 to 12 hours), and the delivery room. One of the activities happening C. Clinical skills
totals are recorded in a client’s chart. In involves social processes, which can be further D. Successful communication – break in chain
intensive care areas, nurses may record I&O explored. To explore this, which of the of communication
hourly. Usually, the staff on the night shift following qualitative research method should 72. Being the head nurse in the area, Nurse
totals the amounts of I&O recorded for each be used? Christine knows that a vital component in the
shift and records the 24 hour total. A. Grounded theory – processes; social process of supervising is delegation of tasks.
65. Mommy Mathilda, a pregnant patient in structures; social interaction She knows that the delegation is MOST
the ward, is also diagnosed with Chronic Heart B. Historical research – anything from the empowering to the staff because:
Failure. In patients with chronic heart failure, past, issues, describe the issue in the past A. Effective delegation does not require nurses
monitoring intake and output is considered C. Descriptive Phenomenology – experience; to know the abilities and weaknesses of their
vital. The MAIN purpose of recording accurate lived experience; meaning; essence staff
data on intake and output of these patients is D. Case study – in depth or in-detail study of B. Delegation frees the manager to do other
to _____________. persons or entities task while empowering staff.
A. determine if client is improving or not 69. After the research group is done analyzing C. Delegation fosters the responsibility of staff
B. find out if there is still water retention in the data of their study about experiences of while increasing professional growth.
the interstitial cells pregnant women in labor, they proceed to D. Delegation starts at top management down
C. detect cardiac overload return to the participants in order to to subordinates
D. determine weight gain/loss determine the accuracy of the emerged R: Supervision is defined as “provision of
R: HYPOVOLEMIC SHOCK FROM INTERNAL themes. The research group is doing which guidance and direction, evaluation and follow-
HEMORRHAGE OR THIRD-SPACE LOSSES, criteria of trustworthiness? up by the licensed nurse for the
when extracellular fluid is shifted from the A. Confirmability - objectivity accomplishment of a nursing task delegated to

GARCIA, GENEVA JANE C.

7
PREBOARDS 2
NURSING PRACTICE 2
UAP”. Onsite supervision becomes a strong competency of the delegate for nursing care continue the conversation. They show
tool for gathering information for personnel or other duties. The key to delegation is to patients that the nurse is interested.
evaluation or corrective action. Also, personal understand how your BON defines nursing 79. When Nurse Dan says, “Tell me more
contact through supervision gives the practice and the skills required by UAP that about about your experience. I wish to hear
delegate an opportunity to ask questions and define competence. Responsibility is a part of about…” He is displaying which therapeutic
learn skills. licensed position and cannot be used as communication technique?
73. During the in-service program, Head criteria for delegation. A. Restating
Nurse Christine discussed one of the common Situation B. Seeking clarification
conflict resolution methods which is Therapeutic Communication is an important C. Open-ended questions
negotiation. She asked one staff what the aspect in providing better rapport as it D. Summarizing
focus of negotiation is. The staff answered promotes understanding between the sender R: The best answer is FOCUSING. The nurse
correctly if she said negotiation creates a and receiver. Nurse Dan, a staff nurse in the should seek clarification throughout
________. Medical-Surgical ward of Taginting Medical interactions with clients. Doing so can help the
A. Soothing situation Center, should be abreast with common nurse to avoid making assumptions that
B. Third party consultation therapeutic communication techniques if he understanding has occurred when it has not. It
C. Trade-off wants to have an effective and achievable helps the client to articulate thoughts, feelings
D. Win-win situation – negotiations focuses on nursing care. and ideas more clearly.
understanding who the perceived winners and 76. Karylle, a patient with gastrointestinal 80. Nurse Dan tells the patient, “You will be
losers are; the best negotiations result in win- problems explicitly says, “I am not sure if I wheeled in to the OR and will be hooked to an
win solutions. Negotiations, especially should undergo colonoscopy or not as I am IVF where the anesthesia will be given
collaborative negotiations, assumes that scared.” To give a proper response, which of intravenously." The therapeutic
people have both diverse and common the following therapeutic communication communication technique that Nurse Dan
interests and that the negotiation can result in technique is the MOST appropriate for Nurse used is ____________.
both parties gaining something, creating a Dan to use? A. Clarification
win-win solution. trade-off supports a cause of A. Touch B. Summarizing
person in exchange for the goal at hand. B. Clarifying C. Giving information
74. Head Nurse Christine emphasized that C. Restating D. Reflection
after delegation of duty comes supervision. D. Silence R: Informing the client of facts increases his or
She stated that the PRIMARY purpose of R: The nurse repeats what the client has said her knowledge about a topic or lets the client
supervision is it: in approximately or nearly the same words the know what to expect. The nurse is functioning
A. Influences the organization’s approach in client has used. This restatement lets the as a resource person. Giving information also
recruitment, promotion and personnel client know that he or she communicated the builds trust with the client. Giving information
evaluation. idea effectively. This encourages the client to is making available the facts that the client
B. Improves staff compliance with policy and continue. Or if the client has been needs.
procedures. misunderstood, he or she can clarify his or her Situation
C. Assigns appropriate work tasks to the best- thoughts. Patient Sheena is a 12-year-old pediatric
qualified 77. When Karylle said, "Whenever I see my patient admitted at Calantag Hospital Private
D. Enhances the delivery of quality nursing husband visit me, I feel depressed,” Nurse Dan Room, where she was equipped with a
care. replied, “Your husband depresses you?” Nurse tracheostomy tube. Nurse Kenny is the person
R: NCSBN (2021) defined supervision as Dan responded with which therapeutic assigned to care of Sheena.
“provision of guidance or oversight by a communication technique? 81. Nurse Kenny is a newly registered nurse,
qualified nurse for the accomplishment of a A. Restatement so he does not have the experience and skill
nursing task or activity with initial direction of B. Focusing caring for Patient Sheena who has a
the task or activity and periodic inspection of C. Focusing tracheostomy tube. As an inexperienced
the actual act of accomplishing the task or D. Seeking clarification nurse, he can ask for anyone of the following
activity.” Onsite supervision becomes a strong R: The nurse restated the patient’s statement. to perform the care, EXCEPT:
tool for gathering information for personnel Repeating the main idea of what the client has A. Medical Resident
evaluation or corrective action. Also, personal said let’s the client know whether an B. Medical Intern
contact through supervision gives the expressed statement has been understood C. Charge Nurse
delegate an opportunity to ask questions and and gives him or her the chance to continue or D. Mother of child with care of tracheostomy
learn skills. to clarify if necessary. tube experience
75. Head Nurse Christine reinforced that 78. As Nurse Dan continued to converse with R: Sunctioning a tracheostomy or
Delegation involves transferring of nursing Patient Karylle, he said, “Tell me more about endotracheal tube is a sterile, invasive
care to an individual. She stated that when your experience when you had the technique requiring application of scientific
delegating care to the staff, there are various colonoscopy” Which therapeutic knowledge and problem solving. This skill is
criteria to observe. What is considered the communication technique is Nurse Dan performed by a nurse or respiratory therapist
BEST criterion when delegating staff? utilizing? and is not delegated to UAP. Furthermore,
A. Responsibility A. Focusing when allowing the mother is performing the
B. Adaptability B. Clarifying tracheostomy care the NURSE should always
C. Flexibility C. Encouraging elaboration assess the competency of the mother.
D. Competence D. Restating 82. Dr. Dizon, the otolaryngologist, arrived at
R: Delegation as “transferring to a competent R: Encouraging elaboration (FACILITATION): the room to perform the changing of
individual, the authority to perform as technique that assists patients to more tracheostomy tube. He asked Nurse Kenny to
selected nursing task in a selected situation.” completely describe problems. These prepare for the appropriate equipment and
The amount of supervision depends upon the responses encourage patients to say more and supplies needed for the procedure. Nurse

GARCIA, GENEVA JANE C.

8
PREBOARDS 2
NURSING PRACTICE 2
Kenny is aware that the CORRECT department completed in less than 3 hours. This is usually administered intramuscularly after delivery.
to collaborate with is: termed as ________ labor. What is the primary action of this medication?
A. Emergency Department A. Precipitous – precipitous or precipitate A. Reduces the amount of lochia drainage.
B. Central Supply Unit labor occurs when uterine contractions are so B. Prevents postpartum hemorrhage – this
C. Anesthesia Department strong that a woman gives birth only a few, medication is used after childbirth to help stop
D. Operating Room Department rapidly occurring contractions. It is often bleeding from the uterus. Methylergonovine
83. Nurse Kenny informed his head nurse, defined as a labor that is completed in fewer belongs to a class of drugs known as ergot
Jane, that he still does not have the skill and than 3 hours. Preterm labor occurs before 36 alkaloids. It works by increasing the rate and
experience to perform this procedure. To weeks if gestation. Induced labor occurs with strength of contractions and the stiffness of
assure that Nurse Kenny learns the proper administration of oxytocin. the uterus muscles. These effects help to
way of caring for patients with tracheostomy B. Preterm decrease bleeding.
tube, Head Nurse Jane knows to collaborate C. Induced C. Decreases uterine contractions.
with who among the following personnel? D. Prolonged D. Maintains normal blood pressure.
A. Asst. Chief Nurse for Clinical 87. Patient Madellaine is referred to the R: Medication to prevent post-partum
B. Chief of Unit physician, Dr. Matthew. Upon doctor’s hemorrhage:
C. Asst. Chief Nurse to Education & Training recommendation, routine blood examinations • Oxytocin
D. Chief of Clinics were taken. After reviewing the serum • Methergine
84. Dr. Dizon ordered a change of the electrolyte levels, Dr. Matthew ordered IV • prostaglandins
tracheostomy tube ties for Patient Sheena. infusion of Isotonic fluid as prescribed. With Situation
Among the following, which should Dr. Dizon Nurse Patricia’s knowledge on IV fluids, which A doctor ordered oxygenation of 4 liters per
collaborate with in performing this task? IV solution should she prepare? minute for Joseph, a 10-year-old child with
A. Medical Intern A. 5 percent dextrose in water - isotonic bronchitis.
B. Medical Resident B. 0.45 percent sodium chloride solution - 91. What is the first standard step in oxygen
C. Nursing Aide hypotonic therapy?
D. Staff Nurse – the nurse provides C. 10 percent dextrose in water - hypertonic A. Prepare the patient for the oxygen
tracheostomy care for the client with a new or D. 3 percent sodium chloride solution - treatment
recent tracheostomy to maintain patency of hypertonic B. Check the chart for ordered flow rate and
the tube and reduce the risk of infection. 88. Patient Madellaine, having been in labor, oxygen delivery method.
85. Dr. Dizon is going to perform suctioning would anticipate some emotional support. To C. Gather all the equipment and supplies.
on patient Sheena using a single-used catheter keep Patient Madellaine calm during labor, D. Assess patient's condition.
for tracheostomy. To perform the skill of Nurse Patricia should perform which of the R: before administering oxygen, check:
suctioning using a single-used catheter for following nursing intervention? • the order for oxygen, including the
tracheostomy safely, he needs how many A. Giving praise for her the sense of administering device and the liter
assistants? satisfaction regarding quick labor. flow rate (L/min) or the % of
A. Four B. Support in maintaining a sense of alcohol oxygen
B. Two C. Explanation of the effect of labor on the • the levels of oxygen (PaO2) and
C. Three newborn. carbon dioxide (PaCO2) in the
D. One – if the client does not have copious D. Allowing the patient to express pain and client’s arterial blood (Pao is
secretions, hyperventilate the lungs with a anxiety. normally 80 to 100mmHg; PaCO2 is
resuscitation bag before sunctioning. Summon R: It is important to help relieve strong normally 35 to 45mmHg
an assistant, if one is available for this step. emotions capable of amplifying pain (ex. • whether the client has COPD
Using your nondominant hand, turn on the Anxiety, anger & fear). When clients have no Note: if the client has not had arterial
oxygen to 12 to 15L/min. if the client is opportunity to talk about their pain and blood gases ordered, oxygen saturation
receiving oxygen, disconnect the oxygen associated fears, their perceptions and should be checked using a noninvasive
source from the tracheostomy tube using your reactions to the pain can be intensified. oximeter.
nondominant hand. Attach the resuscitator to Situation 92. All of the following needs to be considered
the tracheostomy or ETT. Compress the Ambu Jonah, a multiparous patient experiencing true when administering oxygen therapy, EXCEPT
bag 3-5 times, as the client inhales. This is best labor pains, is noted to have complete _____.
done by a second person who can use both dilatation of the cervix and effacement of 100 A. need for a humidifier.
hands to compress the bag. In infants and percent. B. length of tubing.
children. An assistant should always be 89. A nursing student asks the nurse why C. determine the age of Joseph.
present while tracheostomy care if performed. Patient Jonah’s labor now is much shorter D. manner of administering oxygen,
Situation compared to her previous deliveries. Which of continuous or intermittent.
Madellaine, a multipara patient is admitted at the following is the BEST RESPONSE? R: Humidifiers are devices that add water
Nicanor Buenavente General Hospital due to A. Onset of contraction was gradual. vapor to inspired air. Developmental factors
having labor pain that started an hour ago. B. Multigravida patient has shorter labor. have important influences on respiratory
Upon performing the vaginal examination, C. Cervical lengthening was longer. function. Oxygen therapy is prescribed by the
Nurse Patricia noted that the cervix is D. Induction of labor was done. primary care provider, who specifies the
completely dilated and 100% effaced. With R: In multiparas, dilatation may proceed concentration, method of delivery and
this assessment, Patient Madellaine is before effacement is complete. effacement depending on the method, liter flow per
experiencing true labor pains. must occur at the end of dilatation, however, minute (L/min).
86. During the shift, Nurse Patricia is keeping before the fetus can be safely pushed through 93. The nurse knows that the PRIORITY
watch of Patient Madellaine’s labor. She is the cervical canal. nursing action when administering oxygen
aware that one of the problems that can occur 90. Methylergonovine maleate (Methergin) is therapy is to ______.
with labor is that the labor and delivery can be prescribed by the physician and was

GARCIA, GENEVA JANE C.

9
PREBOARDS 2
NURSING PRACTICE 2
A. attach the humidifier and connect tubing to C. Objective
the oxygen delivery device. D. Accurate
B. connect the flow meter to the pipe in R: Characteristics of charting:
oxygen outlet • objective
C. turn on the oxygen • complete
D. check the flow. • accurate
R: It is important for nurse to also • appropriate
assess/check the equipment used for nursing • sequence
interventions. To ensure that oxygen is • timeliness
delivered to the patient it must be turned on. • legible
94. Which precautionary measure done by the • permanent
nurse is PRIORITY during oxygen therapy? 99. Kardex is used during nursing
A. Limit visitors. endorsements. Which of the following is NOT
B. Attach "No Smoking" signage true about Kardex?
C. Check humidifier's water regularly A. kept up to date
D. Connect belt to oxygen tank. B. a quick reference for current information
R: Place cautionary signs reading “No about the client.
Smoking: Oxygen in Use” on the client’s door C. consists of folded card for each patient.
at the foot or head of the head and on the D. part of the medical record.
oxygen equipment. R: The Kardex may or may not become a part
95. Joseph, while on continuous oxygen of the client’s permanent record. In some
therapy, still complains of having difficulty organizations it is a temporary worksheet
breathing. The nurse's INITIAL intervention is written in pencil for ease in recording
to ______. frequent changes in details of a client’s care.
A. Give PRN medication. Accurate notations consist of facts or
B. Refer patient to the physician observations rather than opinions or
C. Assess the patency of the tubing. interpretations.
D. Re-assess the patient. 100. When an error is made during charting,
R: It is important for nurse to also ensure the what should the nurse do?
patency of the tubings in order to accurately A. Recopy the sheet and destroy the original
deliver the oxygen needed to relieve the sheet
patient’s dyspnea. B. Use a single line to cross out the error, the
Situation write the date, time and sign the correction
Due to an increasing number of errors in made.
regard to documentation and record C. Use correction fluid to erase the error
management, Head nurse Levi is conducting a D. Use eraser to remove the wrong entry
lecture on proper nursing documentation and
R: when a recording mistake is made,
management of records in her ward.
96. Due to an increasing number of errors in
draw a single line through it to identify it
regard to documentation and record as erroneous with your initials or name
management, Head nurse Levi is conducting a above or near the line (depending on
lecture on proper nursing documentation and agency policy). Do not erase, blot out, or
management of records in her ward. use correction fluid. The original entry
A. Reduce the number of forms of the chart must remain visible.
B. List the patients’ health problems.
C. Record the patient's progress.
D. Provide confidentiality of the chart.
97. When charting patient's progress
accurately, which of the following principles
should be followed?
A. Statements are qualified by the use of
"seems' and "appears"
B. Assumptions and conclusions are reported
C. Specific and definite words or phrases are
used.
D. General statements and measurement are
used.
R: Notations on records must be accurate and
correct. Accurate notations consist of facts or
observations rather than opinions or
interpretations.
98. All of the following are characteristics of a
chart, EXCEPT?
A. Complete
B. Subjective

GARCIA, GENEVA JANE C.

10