RECALLS 6: NURSING PRACTICE 1

7. A smiling patient angrily states, 'I will not cough and breathe.
Situation: Health Centers regularly conduct “Operation
" How will the nurse interpret this finding? The patient is
Timbang” to assess the nutritional status of children years old.
a. signified meaning is wrong.
b. vocabulary is poor.
1. The sex of the children included in his study will be classified c. Effect is inappropriate
as male and female. This measurement us: d. personal space was violated
a. Interval
b. Ordinal
Rationale: reaction is not congruent with what the patient
c. Ratio
says
d. Nominal

8. A nurse wants to present information about influenza

Rationale:
immunization to the older adults in the community. Which type
→ Nominal - words; category, no order (na hindi
of communication should the nurse use?
mararank; gender, marital status, place of birth)
a. Interpersonal
→ Ordinal - words; with order (educational status,
b. Public
beginner/expert)
c. Small group
→ Ratio - numerical; no true zero - walang negative value
d. Intrapersonal
(age, weight, height)
→ Interval - numerical; with true zero (may mga negative;
Fahrenheit, Celsius) Rationale: older adults - general target audience/population

2. While age is what level of measurement? 9. A nurse is standing beside the patient'. bed. Nurse: How are
a. Ratio you doing? Patient: I don't feel good. Which of the following
b. Interval communication ELEMENTS is categorized as feedback?
c. Ordinal a. "'How are you doing?"
d. Nominal b. "I don’t feel good."
c. Nurse is standing
3. The nutritional status of children is determined by weight and d. Patient in bed
age. Weight is an example of what level of measurement?
a. Ordinal Rationale: Sender → Encoder → Message → Decoder →
b. Ratio Receiver → Feedback → Sender
c. Interval
d. Nominal
10. BEFORE meeting the patient, a nurse talks to other
4. The educational level of the parents is also recorded with the caregivers about the patient. Which phase of the helping
possible choices given as: relationship is the nurse in with this patient?
● Elementary level a. Termination
● Elementary graduate b. Working
● High school level c. Orientation
The above set of choices is an example of what level of d. Pre interaction
measurement?
a. Ratio Rationale: the nurse do “background checking” before
b. Interval meeting the patient
c. Nominal
d. Ordinal
Situation: Occurrence of conflicts is a natural part of the
5. The mothers of children are also asked particularly on the workplace. Conflict management is the ability to be able to
child’s health history. One of the questions, " Did your child identify and handle conflicts sensibly, fairly, and efficiently.
experience episodes of diarrhea within the last 6 months? " If
yes, skip item no. 4 and item no. 5. This question item is referred
to as: 11. The public health midwife was very upset regarding a
a. Funnel question - “tell me why or why not” reprimand issued by her supervisor. The former confronts her
b. Follow—up question supervisor in the hallway. How should the supervisor respond?
c. Contingency question a. Tell the midwife to calm down and act professionally.
d. Filter question b. Respond to the midwife in the hal 1 way.
c. Ignore the situation and forget about it.
d. Invite the midwife to come to the supervisor's office.
Rationale: Filter question is also known as contingency
question
Rationale: to privately handle the conflict

Situation: The ability to communicate is a very important skill 12. Which of the following actions by the public health nurse
for every nurse to have. The nurse must do so in an effective, indicates the use of effective conflict management skill?
caring, and professional manner, especially when a. Defends judgements of others
communicating with patients and their families. b. Negotiates with others
c. Asserts own position
6. During the INITIAL home visit the nurse lets the patient Know d. Avoids competition
that the visit is expected to end in about a month. Which phase
of the helping relationships the nurse is in with this patient? Rationale: to achieve a win-win situation; meeting halfway;
a. Interaction both are compensating and at the same time acquires
b. Working benefits from the situation
c. Termination
d. Orientation
13. Public health nurse Lily has become very disagreeable
among her team members. The other nurses know that she has
Rationale: during orientation phase, the patient should be been required to be transferred to another rural health unit. The
informed how long and when s/he would expect you to visit nurses decided to ignore the situation. This illustrates which
method of conflict resolution?
a. Collaboration
b. Avoidance

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c. Accommodation 19. Which of the following statements BEST describes Public

d. Passive-aggressiveness Health Nursing?
a. Services are best implemented only in far flung and hard to
14. A health care worker approaches the public health reach areas.
supervision- with a complaint about the RHU Nurse and said, she b. Services are rendered free of charge to people in the
doesn't do the same amount of work as the other health catchment area.
professionals in the Health Unit. "After investigating the c. It involves home care to sick people who cannot be confined
complaint, the Nurse Supervisor believes the health care worker in the hospital.
does not understand the role of the RHU nurse. What kind of d. It puts emphasis on health promotive and preventive
conflict has this situation caused the health worker?
a. Interprofessional conflict 20. Collecting data and monitoring the health status of the
b. Individual conflict population defines which of the core public health functions?
c. Interprofessional conflict a. Quality assurance
d. Organizational conflict b. Assessment
c. Policy development
d. Health promotion
Rationale:
→ Interprofessional - with other professionals
→ Intraprofessional - within your profession (nurse vs. Situation: Public Health Nurses have important roles in
nurse, doctor vs. doctor) ensuring the well—being of the family. They themselves
should be empowered as they assist family clients in enabling
their capacities to maintain and improve their health status.
15. Which actions are MOST important in preventing conflict
from occurring?
1. Allocate resources fairly. - para iwas inggitan 21. Which of the following would BEST indicate a maturational
2. Keep problems confidential - problems are not opened crisis?
up A. Illness - situational
3. Address staff fears - acknowledging fears B. Death - maturational
4. Clearly state expectations - instructions must be clearly C. Marriage
defined; not assuming D. Unemployment - situational
5. Keep lines between roles flexible - pagiging bida bida;
malpractice
Rationale:
A. 2, 3, 5
→ Maturational crisis are expected life events
B. 1, 3, 4
(pregnancy)
C. 2, 4, 5
→ Situational crisis are unexpected life events (unwanted
D. 1, 2, 3
pregnancy, unexpected death)
→ Adventitious are acts of God; natural disasters; social
Situation: Public health nurses use their nursing skills in the crisis (flood, earthquake, fire, war, pandemic, murder,
application of public health functions and provision of social rape)
assistance to their clients.
22. Providing crisis intervention is an important part of primary
prevention in an important part of?
Additional Notes: PHN Goal: Promotion of Health and
a. Primary Prevention - healthy
Prevention of Illness
b. health promotion
c. secondary prevention - with increased risk; unhealthy
16. The public health nurse must participate in the essential d. tertiary prevention - post treatment, rehab
services that are relevant and accessible to the family and the
community. These include
Rationale: provision of intervention indicates crisis or
a. Working in enforcing laws to regulate health and ensure
presence of problem
safety.
b. Diagnosing and investigating health problems of the
country. 23. The nurse explains that families pass through predictive
c. Informing, educating, and empowering the people stages. This statement is based on models.
about health. a. Systems models
d. Monitoring health status and completing a community b. Focal
assessment. c. Structural—functional
d. Developmental
Rationale: through cleaning drives, mother’s talk
Rationale: Developmental or Maturational because they are
expected
17. Public health services are provided by government facilities.
What is the most appropriate response of a public health nurse
to the statement: The government should give these health 24. The nurse is educating the family regarding general needs
services free of charge to people? for adequate nutrition, rest, and physical activity. Which level of
a. "Yes, and for that reason, we should choose our prevention does this describe?
government officials wisely during elections. a. Tertiary prevention
b. "Yes, I agree. But right now, the government does not have b. Secondary prevention
enough resources to do that. c. Health Maintenance
c. "That is an ideal situation that our government should aspire d. Primary prevention
to attain in the near future. "
d. "Many of the health services are given free, but we
Rationale: Primary Prevention includes health teaching
people pay for them just the same through our taxes "

18. The current emphasis for public heal to practice is 25. The nurse observes that the family is exhibiting strengths
a. improving environmental sanitation in the face of hardships they are facing. The best description
b. controlling epidemic diseases of the strengths the nurse is observing is?
c. preventing communicable diseases a. Power
d. advocating for social justice b. Resilience
c. Projection
d. Faith

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 RECALLS 6: NURSING PRACTICE 1

b. Nurses have a personal end family plans as a part of their

Situation: As a Public Health Nurse in your local community,
disaster preparedness plan
about good it. is one of your main responsibilities to educate
c. Nurses who are prepared for disasters will be better able to
health practices.
help themselves, their families, and their communities in a
disaster. - situation.
26. One of the new mothers attending the discussion wants to d. Nurses have a responsibility to the public to be
know about vaccination. One of the key information you share is knowledgeable about disaster preparedness response
that
a. diarrhea and malnutrition are contraindicated - could still
Rationale: leaders would be the police or significant
proceed to vaccination as long as it is mild diarrhea
authorities; nurses are placed in triaging
b. If the vaccination schedule is Interrupted, it is necessary to
restart - doble doble na peklat from vaccine :<
c. it is safe to vaccinate a sick child who is suffering from 32. A Resident in Municipality F by the name Pedro sustained
a minor illness injury. First aid was initiated by Nurse Nami. This is given
d. minor infections with low fever (below 38.5 Degree Celsius) a. during the arrival of an ambulance or doctor
is contraindicated - if sinat lang okay lang; benefits from the b. before the arrival of ambulatory doctors or other qualified
vaccine overweighs the risk personnel. - nurse Nami is already a qualified personnel
already because she is a nurse
27. One of the participants asked you about what herbal plants c. before the arrival of an ambulance or doctor
to use when treating diarrhea. You answer that young leaves can d. during the arrival of an ambulance doctor or other qualified
be used as a home Ericaedy. personnel.
A. tsaang gubat
B. sambong
Rationale: first aid is done BEFORE
C. sambong
D. bayabas
33. One function of Nami in emergency and disaster is to provide
immediate care, EXCEPT
Rationale:
a. victim identification and reporting
b.to trauma care
c. Coordinate with military
d. first aid, triage, and transport of victims

Rationale: Nurse Nami should coordinate with nurses too

34. As a primary healthcare giver, which of the following

activities should Nurse Nami NOT involve in?
a. recovery of primary health care activities
b. water- safety and quality
c. food safety and food security
d. search, rescue, and evacuation

28. As part of your topic, you shared about the strategy that
Rationale: Option D is to be done by the military, police,
should be initiated by students and teachers for a “Healthy
firemen, or EMT
School". What is this strategy about?
a. Implementing Environment-al Sanitation activities
b. CPR demonstration - dito kaya ng mga preschool o kaya 35. To better address emerging public health issues, a public
nursery HAHA health nurse enrolls in a course in:
c. Selection of better school doctors and school nurses - ain’t a. Leadership
practical; si Dr. Vicki Belo nasa school niyo, shala! b. Ethics
d. Scrapbooking using recycled materials c. Communication
d. Research
Rationale: no stagnant waters, no wet floors; Option A is
much practical to do Rationale: root causes are identified through research;
nursing updates and trends
29. You also discussed having a "Healthy Market" which means
that the community should? 36. The PRIMARY purpose for requiring continuing education
a. sell fresh and healthy foods only is to
b. organize recycling teams a. Qualify for work abroad
c. collect garbage and recycle them b. Improve nursing competency after registration.
d. dispose waste and garbage separately c. Comply with the 'Board of Nursing requirements
d. Ensure Legal practice
30. During a community forum, you discussed herbal medicines.
You explained to the participants that “Botika sa Paso" is done Rationale: because not all new graduate nurses are with
by? improved or advanced nursing competencies and therefore
a. cultivating herbal plants in vacant or unused lots undergoes with continuing education/trainings/masterals
b. growing herbal plants in pots
c. planting herbs along the barangay streets
d. experimenting with herbal decoction 37. Accountability also includes a commitment to continuing
education to stay current. and knowledgeable. According to the
Guidelines Implementing Continuing Education or Nurses
Situation: A 6.2 magnitude earthquake struck last May 13, (CPE), from which of the following can a nurse earn credit units?
2022 Municipality F. Nami was a trained nurse in emergency 1. participation in seminars
and disaster preparedness. 2. engagement in a research project
3. as peer reviewer
31. Which of the following is NOT true regarding nurses' 4. innovations
responsibilities in disaster preparedness? A. 1, 3, and 4
a. Nurses will be the leaders in the incident command B. 2 and 3 only
structure set up at the disaster site C. 1, 2, 3, and 4
a. D. 1 and 2 only

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38. The PHN wants to emphasize to the new nurses that it is

Rationale: should be checked twice to know if the
important to observe professional accountability which is taking
temperature is still correct and right for the vaccines
responsibility for one's actions. She explains that accountability
can be done by:
Additional Notes:
1. asking for assistance from the doctor ● Covid - once nalabas sa freezer dapat
2. performing nursing tasks in a safe manner maadminister na
3. reporting and documenting assessment and ● Varicella - 72 hours na nilabas from freezer dapat
interventions - coz if it’s not documented it is not done naadminister na
4. evaluating the client's response to nursing care given

5. evaluating the care when there is a complaint by the

44. The type of refrigerator/ freezer utilized to store vaccine in a
client.
health center should be:
A. 2, 4, 5
a. Standard chest—type freezer.
B. 1, 3, 5
b. Standard refrigerator with separate freezer door and
C. 2,3,4
seal.
D. 1, 2, 3
c. Dormitory type refrigerator and separate dormitory type
freezer.
39. Nami considers the following factors in patients' triage
d. Dormitory type refrigerator with small hanging freezer
EXCEPT
inside.
A. Pulse and respiration
B. Temperature
45. Vaccines can be mixed in single syringe when:
C. Mental status
a. There is a need to decrease the number of injections to be
D. Ability to walk
given.
b. Remaining vaccines need to be consumed during the day.
Rationale: START - simple triage and rapid treatment; c. Giving all live or all inactivated vaccines.
putting tags/ribbon on victims of disaster; d. Vaccines are licensed and labeled to be mixed.
→ GREEN - client can still walk and obey commands
→ YELLOW - client has minor injuries, can walk but can’t
Rationale: pentavalent - has 5 vaccines
talk
→ RED - has injuries, pulse and respiration are not stable
→ BLACK - can’t walk, does not respond, no pulse 46. Vaccines should NEVER be stored in which part of the
refrigerator?
a. Lower right-hand corner
40. In the first session, the nurse presented the organizational
b. Lower left-hand compartment
chart of the Rural Health Unit. Which of the following aspects of
c. Floor
organizational structure is Illustrated in the chart?
d. Door
1. type of work being done - this is found in job description
2. extent of coordination to be done - with separate
organization chart (pharmacists or doctors) Rationale: prone to breakage
3. levels of management
4. Line and staff relationship
A. 1 and 3 Situation: Collaboration in the unit is very essential in relation
B. 2, 3, and 4 to patient care. Management functions are also carried out in
C. 3 and 4 this constant collaboration by the nurse, in fact, one of the
D. 1, 3, and 4 nurses’ most important roles in patient care is as a
collaborator.
Situation: Public Health Nurse Fern is in charge of protecting
the vaccine supply in the Rural health Unit. In performing this 47. A new wing is being constructed in the hospital and the
responsibility, she is guided by the standards and guidelines Nursing Director is asked to help design it. To achieve maximum
on "How to Protect the Vaccines.” efficiency in carrying out using activities, the Nursing Director
would consider which of the following conditions to be most
helpful?
41. You are assigned to arrange the storage for a new delivery a. Environmental factors such as current economic status and
of vaccines in the health center. All of the following vaccines may global issues
be stored at the body of the refrigerator, except: b. How the structural plan facilities staff interaction and the
a. BCG rituals the nurses use to conduct work
b. DPT c. Type of equipment and technology and its effects on how
c. OPV - should be placed in the freezer work tasks are designed and carried out
d. Hepatitis B d. Work flow where equipment, medication, and other
items essential for patient care are stored and
Rationale: positioned
Temperature of:
→ Freezer: -15 to -25 degree Celsius 48. Information gathered by nurses shows the importance of
→ Refrigerator: 2 to 8 degree Celsius nurse-physician communication. With the current recognition
that many medical errors are caused by communication failure,
which of the following is the MOST appropriate intervention?
42. Which of the following vaccines go in the freezer? a. Involve a form of communication where 2 parties
a. Hepatitis B engage in problem solving discussion
b. Varicella or Chickenpox b. Organize a conference on medication error participated by
c. Tetanus nurses, physicians and others
d. Diphtheria c. Develop a policy where all members of the health team can
use it as a reference
43. The temperature in the refrigerator and freezer should be d. Conduct in-service education for nurses to improve
checked: competencies to address the issues
a. Twice a Month
b. Twice a day
c. Months a Day Rationale: E.g., doctor’s penmanship is illegible, nurses
d. Once a week should ask the doctor to clarify

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49. To improve quality client care, the nurses created “problem

Situation: Iseminger, Levitt and Kirk (2009) defined
solving committees” headed by senior nursing staff to review
presencing as the term describing the art of being present, or
standards of care and develop policies and procedures. Its
just being with a client during an “existential moment”. This
desired outcome is best shown in:
art of nursing presence to promote healing was published in
a. Allowing changes in staff rotation plan to accommodate
the journal Nursing Clinics of North America.
personal needs of the staff.
b. More nurses participating in doctor’s rounds and giving
immediate information to doctors regarding patient status. 55. Which nursing theorist is the most relevant in using this
c. Continuous evaluation of nursing practice and nursing intervention?
protocols in relation to desired patient outcomes. a. Hildegard Peplau - Interpersonal Relations Theory; more
d. Increasing staff communication like providing a bulletin common in Psych Nursing
board for sharing information among personnel. b. Dorothea Orem - Self Care Deficit
c. Jean Watson
d. Madeleine Leininger - Transcultural Theory; respecting
Rationale: evaluation determines if proposed solution is
culture of different race, religion
effective

Rationale: presence of a nurse is important in theory of

Situation: Nurse Marie is assigned to care for patients with human caring proposed by Jean Watson
different oxygen delivery systems.
56. Which of the following is not a benefit of using nurse
50. After each suctioning for copious secretions, what should presence in intervening for clients who are helpless, powerless,
Nurse Marie instruct a conscious patient to do? and vulnerable?
A. Hyperventilate a. Promote healing
B. Deep-breathe b. Prevent anxiety
c. Assume a tripod position c. Create sense of safety
d. Avoid unnecessary talking d. Improved client satisfaction

Rationale: deep breathing is used for lung expansion and to Rationale: anxiety is only diminished
inflate the alveoli; hyperoxygenation is done BEFORE each
suctioning
57. Nurse Lily provides emotional and spiritual presence for the
patients in the Trauma Ward. Their interactions are at a
51. What is the common position patients are placed into for transpersonal level, causing a transformative experience.
suctioning? According to Osterman and Schwartz-Barcott (1996), what level
A. Modified Trendelenburg of being present for clients is this?
B. High-Fowler’s with head flexed - suctioning tube will not be a. Presence
advanced properly b. Partial Presence
c. Semi-Fowler’s - to promote lung expansion c. Total Presence
d. Orthopneic position d. Transcendent Presence

52. An oropharyngeal airway was inserted to a patient.

Rationale:
Assessment of the mouth may be done as appropriate for the
4 Stages:
patient’s condition every:
→ Stage 1 - Presence: the nurse is physically present
a.1 hour
→ Stage 2 - Partially Present: the nurse is physically
B. 8 hours
present and performs his duties and responsibilities
c. 4 hours
→ Stage 3 - Total Presence: with added physical,
d. 2 hours
emotional, and mental involvement (patient can talk to
the nurse regarding his concerns)
Rationale: mouth care is performed 2-4 hours; checking can → Stage 4 - Transcendent: + spiritual presence (bible
be done q8 hours study, praying)

53. Nurse Marie noticed that the patient on the nasal cannula 58. Nurse Tom is a novice nurse assigned to the Cancer
has encrustations on her nose. Which among these is best for Institute. He maintains his physical presence with the patients,
Nurse Marie to do first? and attends to some of their tasks on the patients’ behalf. He
a. Call the physician. interacts at a superficial level with them. According to Osterman
b. Apply a water-soluble lubricant as ordered. and Schwartz-Barcott (1996), what level of being present for
c. Tighten tubing and apply leucoplast to secure prongs on the clients is this?
nares. a. Presence
d. Use a sterile operating sponge to scrape off the b. Partial Presence
encrustation. c. Total Presence
d. Transcendent Presence
Rationale: to soften encrustations and so that it would not
be painful when removed Rationale: the nurse is only performing his tasks

54. As safety precautions for clients receiving oxygen, which

Situation: Obesity is an emerging concern for patients and
among these should Nurse Marie not do?
nurses. The nurse has an important role in assessing and
a. Place and arrange substances like acetone, alcohol, and
evaluating a patient's physiological status in relation to weight
oils at the bedside.
control.
b. Replace woolen blankets with cotton blankets.
c. Place a “No Smoking” sign on the client’s door and at the
foot or head of the bead. 59. An obese patient asks Nurse Bertha about using Orlistat
d. Ensure that all electric devices are in good working order (Xenical) for weight reduction. Nurse Bertha advises the patient
that _________.
a. drugs may be helpful in weight loss, but weight gain is
Rationale: oxygen is a flammable gas; patients are
likely to recur unless changes in diet and exercise are
instructed not to smoke and place anything that would cause
maintained
combustion near it such as acetone, alcohol, and oils - this
would ignite fire

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b. the long-term effect of orlistat is not known, and the drug

Situation: Safety in any health agency is a must. Nurse Jane
may cause serious side effects such as heart valve
wants this to be maintained in her unit.
problems
c. this drug can cause serious depletion of fat-soluble vitamins
and should be used only several weeks 64. The Nursing Practice Standards which Nurse Jane must let
d. weight-reduction drugs of any type are used for only those her staff follow includes, EXCEPT ___________.
who do not have the willpower to reduce their intake of food a. use a multidisciplinary approval to enhance client safety as
indicated
b. implement emergency measures during fires and disasters
Rationale: Orlistat is a lipase inhibitor → does not allow
c. risk elements should not be modified
body to absorb fat → all fats will go with feces
d. use infection control practices that prevent or control
transmission of the pathogens
60. When developing a weight-reduction plan for an obese
patient who is starting a weight loss program, which question is
Rationale: risk elements should be modified because it
MOST important for Nurse Bertha to ask?
varies per person
A. “What factors do you think led to your obesity?”
B. “Have you been on any previous diets?”
C. “What kind of physical activities do you enjoy?” 65. When a patient is placed in bed rest, the nurse must watch
D. “How long have you been overweight?” which part of the body most
A. Liver
B. Head
Rationale: to determine root cause; e.g., depressive state →
C. Legs
eating as coping mechanism
D. Skin

61. When working with an obese patient who is enrolled in a

Rationale: patient on bed rest has increased risk for
behavior modification program, which nursing action is
pressure ulcers/sores
APPROPRIATE?
→ Stage 1: redness
a. Having the patient write down the caloric intake of each
→ Stage 2: with breakage in the skin; superficial only
meal
→ Stage 3: with fats
b. suggesting that the patient has a reward after achieving a
→ Stage 4: with bones and muscles
weight loss goal
c. encourage the patient to eat small amounts throughout
the day 66. The clients at risk require re-assessment of their status on
d. asking the patient about situations that tend to increase ____________
appetite A. shift basis
B. daily basis
C.as necessary basis
Rationale: would led to patient’s behavioral changes; would
D. injury
be habitual eventually
67. The nursing process facilitates an understanding of the
62. A patient who has been consistently following a diet and scope of challenges inherent in nursing care of clients at risk for
exercise program and successfully losing one pound weekly for ___________ EXCEPT:
several months is weighed at the clinic. However, he has not lost A. Infection
any weight for the last month. Nurse Bertha should first B. Suicide
_______________. C. Restraint - non-existent lol
a. ask the patient whether there have been any recent D. Injury
changes in exercise or diet patterns
b. discuss the possibility that the patient has reached a
Situation: Mr. Cruz is confined in the ICU in a provincial
temporary weight loss plateau
hospital for some complications of his type II diabetes. He is
c. Instruct the patient to weigh weekly and record the weights.
edematous and complained of severe chest pain. His vital
d. review the diet and exercise guideline with the patient
signs are: BP 160/98, temperature 37.2C; PR- 90 bpm; RR- 30
bpm.
63. Nurse Bertha is assessing patients at the outpatient clinic.
Which of the following patients is at risk for health complications
related to weight? 68. If Mr. Cruz would be for dialysis and you need to bring him
a. a thirty-three-year-old who has a body mass index (BMI) of to the dialysis unit, who among the following could be the best
24 kg/m - within normal BMI to help you wheel him to the area? A ______________.
b. A fifty-six-year-old who is 6 ft (180 cm) tall and weighs 150 A. institutional worker
lb (68 kg) - BMI: 20.99 B. member of the family
c. A seventy-one-year-old who is 5 ft 4 inches (160 cm), C. physician
weighs 120 lb (55 kg), and carries most of the weight in the D. nurse aide
thighs - BMI: 21.48
d. a twenty-four-year-old female with a waist
Rationale: physician would explain the procedure to the
measurement of 30 inches (75 cm) and a hip
patient and therefore is the best to help wheel in the patient
measurement of 34 inches (85 cm) - abnormal waist to hip
to the dialysis unit
ratio: 0.88

69. Turning Mr. Cruz every two hours would be difficult if you
Rationale:
do it alone. In order to keep the patient safe, the most number of
BMI: weight in kg/height in m^2
nurse who can team up with you will be ____________
→ Normal: 18.5-24.9
A. Four
Waist to Hip Ratio: waist in cm/hips in cm
B. One
→ Normal:
C. Two
• M: <0.95 D. Three
• F: <0.80

Rationale: in total, 4 nurses including you.

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70. As much as you have not been trained in initiating 77. You are caring for Pixies, sixteen years old, suffering from
Intravenous infusion, who among the following cannot also do it? acute leukemia. You want to actively listen to her concerns and
A. charge nurse understand her meanings. You know that active listening is used
B. staff nurse to _______.
C. nursing aide a. Treat patient’s medical problems - listening does not
D. physician guarantee healing; nakinig ka lang gumaling na sa cancer
lmao
b. Recognize the issue that is most important to the client
Rationale: this is out of their responsibility; IVT should be
c. Help the patient become dependent to the nurse in
done by licensed professionals
addressing his concerns
d. Make conclusions regarding client’s perception
71. Morning care had to be done by the ________
A. nursing student
Situation: Jasmine, 16 years old, and a high-school student,
B. all the options
visited the clinic because she suspects that she is pregnant.
C. staff nurse
Her pregnancy is confirmed by the school physician. Jasmine
D. nursing aide
requested nurse Laura not to tell her parents about her being
pregnant. She also expressed a desire to terminate her
Rationale: both staff nurse and nursing aide can perform pregnancy.
morning care, but can be delegated unless the case is
uncomplicated
78. Which of the following ethical concepts apply to patient
Jasmine’s case?
72. The order of the physician is for immediate intubation. For a. Bioethics - biological standpoint
the priority equipment, supplies and material to be used for the b. Deontology - duty-based
procedure, the nurse should collaborate with the _________. c. Teleology - consequences
A. operating room d. Intuitionism - alam mong right or wrong; intuition; strongly
B. central supply unit tied to culture
C. anesthesia department
D. emergency department
Rationale: it is not included in the duty of a 16-year-old to be
pregnant and Jasmine is aware of it that’s why she doesn't
Situation: Applying therapeutic communication skills is vital want her parents to be informed about it
in the nurse-client relationship.
79. Nurse Laura should be guided by the steps in helping
73. Which of the following statements is TRUE in relation to the Jasmine make an ethical decision. Sequence the steps below.
use of humor? 1. Gather data
A. Humor should focus on the client’s humanity 2. Make decision
B. Humor is used to build rapport 3. Identify and clarify the ethical problem
C. Constant use of humor can be healing 4. Act and assess the outcomes of decisions
D. Laughter increases neurotransmitter 5. Identify options or alternatives
A. 3, 1, 5, 2 & 4
Rationale: humor can bring lightness in stressful B. 1, 5, 2, 4 & 3
environments C. 1, 3, 5, 2 & 4
D. 2, 4, 1, 3 & 5

74. You ask your newly admitted patient, “What can we do to 80. The INITIAL advice of nurse Laura to patient Jasmine is
help you?” You know that this open-ended question will which of the following?
_____________. a. Jasmine will inform her teacher about her condition and to
A. result in specific information from the patient request the teacher to tell her parents.
B. allow patient to elaborate on his response b. Jasmine will request the doctor to inform the parents
C. allow patient to briefly answer question c. Jasmine will choose a significant other close to the parents
D. put the patient at ease to be the one to relay about her pregnancy
d. Advise her that as a minor, her parents should be duly
75. As you listen to a patient, you need to provide feedback that informed about her pregnancy
is __________.
a. behavior-focused and evaluative - feedback does not
depend on the behavior of the patient Rationale: Based on Philippine Laws, adult age is 18 years
b. well-timed and general old; Jasmine is a minor, informed consent is to be signed by
c. general and content-focused her parents because at 16 surgery is high risk
d. well-timed and content-focused
81. Jasmine analyzed the advice of Nurse Laura and realized the
Rationale: well-timed - agad agaran yung sagot and must value of life and family. This attitude of realization is termed as
able to answer the patient’s concerns immediately _____________
A. Justice
B. Ethics
76. Which of the following is the BEST SEQUENCE of C. Autonomy
communication techniques to use during an assessment D. Values clarification
interview? Begin with ____________.
a. Giving a broad opening and move to asking focused 82. Patient Jasmine’s decision regarding her pregnancy is
questions termed as _____________
b. Giving information and move to asking focused questions A. Autonomy
c. Asking focused questions and close-ended questions B. Justice
d. Providing information and proceed to stating observations C. Veracity
D. Fidelity

Rationale: Jasmine decides for herself; self-governance; self

determination

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 RECALLS 6: NURSING PRACTICE 1

Situation: Melchora, 65 years of age, has just been widowed hindi na sila inuutusan
a year ago. Her two children are now all living in the U.S. She
used to love cooking but since she is now living alone, she
89. To determine proper drug dosages for children, calculations
eats meals irregularly. Most of the time, she just watches
are MOST precisely made on the basis of the child’s __________.
television. Her chief complaint is constipation.
A. Weight
B. Height
83. When assessing Melchora, Nurse Lenn should ask the C. body surface area
following, EXCEPT: D. age
A. Dietary and fluid intake
B. Cultural beliefs
Rationale:
C. Lifestyle
D. Bowel pattern

Rationale: is not a common cause for constipation

84. When auscultating the bowel sound of Melchora, the nurse

should be able to hear ___________.
A. loud and gurgling sound
B. increased bowel sound - diarrhea
C. decreased bowel sound
D. absent sound

Additional Notes: Bowel sound - Borborygmi

85. The MOST APPROPRIATE nursing diagnosis for Melchora’s

case is _________________.
a. risk of constipation related to lifestyle 90. Nurse Tricia administered the intramuscular medication of
b. perceived constipation related to eating habits Iron by the z-track method. This method is used to
c. dysfunctional gastrointestinal motility related to ________________.
lifestyle A. provide more even absorption of the drug
d. constipation related to inactivity - medical diagnosis is not B. provide faster absorption of the drug
used for nursing diagnosis C. prevent the drug from irritating sensitive tissue
D. reduce discomfort from the needle
86. Which of the following are the most simple and cost-
effective interventions that the Nurse can advise Melchora to Rationale: iron can stain the skin and therefore z track is
resolve constipation? used to prevent irritations
1. Encourage increased fiber in diet
2. Encourage physical activity and regular exercise
91. The doctor ordered to give a one-year-old patient an
3. Regular time for elimination
intramuscular injection. The appropriate and preferred muscle
4. Laxative - patient is geriatric; needs prescription;
to select for this child is the _______________.
dependent nursing intervention
A. Dorsogluteal
A. 1, 2, & 3
B. Deltoid - for 3 years old
B. 3 and 4
C. Ventrogluteal
C. 1, 3 & 4
D. Vastus lateralis - for 0-3 years old
D. 2, 3 & 4

87. Health education should include which of the following? Rationale: pinakamalaking muscle nila at that age and is
1. Responding to the urge to defecate and establishing a less vascular
daily pattern
2. Role of dietary fiber and fluid in maintaining bowel
function Situation: Patient Peppa, three years old, was brought to the
3. Role of exercise and activity in maintaining bowel clinic by her mother due to ear ache and low-grade fever.
function While performing her physical assessment, Nurse Georgy
4. Safe and correct use of pharmaceutical agents - found Patient Peppa’s right ear to be inflamed and warm to
dependent nursing action; needs prescription touch. The Pediatrician ordered ear drops to be instilled to the
A. 2, 3 and 4 affected ear.
B. 1, 2, 3 and 4
C. 2 and 3 92. Nurse Georgy performs further physical assessment on
D. 1, 2 and 3 Patient Peppa BEFORE drug administration, which includes the
following, EXCEPT _______________.
Situation: Nurse Tricia is working on the hospital’s pediatric a. Appearance of the pinna and meatus of the ear
unit. She is assigned as a medication and treatment nurse b. Presence of the interference during the drug
administration
c. Type of any ear discharge
88. In preparing to give medications to a preschool-age child,
d. Location and extent of inflammation of the ear
which of the following statements is an APPROPRIATE
interaction by Nurse Tricia?
93. The MOST APPROPRIATE nursing action before instilling
a. “Let me explain about the injection that you will be getting”
ear drops to Peppa is to ______.
b. “Do you want to take your medication now?” - more
A. Check the medication to be within room temperature
complicated questions
B. Refrigerate the medication for thirty minutes
c. “Would you like medication with water or juice?” - choices
C. Fill up the dropper with no more than one millimeter
are offered in toddlers
D. Clean the outer surface of the dropper
d. “If you don’t take the medication now, you will not get
better.”
Rationale: medication should be room temperature to
prevent vertigo
Rationale: preschoolers are in initiative vs guilt stage in Erik
Erikson’s theory; gives them a chance to performed task na

RECALLS 6: NURSING PRACTICE 1

 RECALLS 6: NURSING PRACTICE 1

94. In installing any drug into the ears, Nurse Georgy performs 100. Which of the following statements is NOT true about the
in SEQUENCE. Which of the following steps? benefits of blood donation?
1. Allow the drug to flow into the ears slowly a. enhances production of new blood cells
2. Tilt the head away from the nurse - tilt to visualize the b. burns calories
ear and to prevent medication from spilling out c. reduces cancer risk - creation of new blood cells as
3. Put a small cotton loosely into the ear compensation when donating blood
4. Wait for 15 minutes before instilling drops on the other d. D.is a good prevention against infection
ear
5. Instill the ear drops into the affected ear
Rationale: donating of blood does not guarantee prevention
A. 1, 4, 2, 5, 3
of infections
B. 2, 5, 1, 3, 4
C. 4, 1, 5, 3, 2
D. 3, 1, 4, 5, 2

95. After instilling medications to the right ear, what is the MOST
appropriate instruction to the mother?
A. Remain in the position for 5 minutes
B. Pack a cotton pledge tightly to the ear
C. Have the patient remain in the position for one hour
D. Advice the mother not to let Cheyenne drink hot water

Rationale: to allow the drug to be absorbed

96. In administering otic medication, Nurse Georgy

a. Don the gloves - not necessary when instilling otic drops
b. Perform hand hygiene
c. Explain procedure and postpone - nagexplain ka tapos di
mo rin ginawa :’)
d. Check identification band and proceed

Situation: You will start working as a field nurse at the

Philippine Red Cross. You are reviewing RA 7719 or the Blood
Services Act of 1994. This law ensures a safe and accessible
blood supply by promoting voluntary blood donation.

97. You are aware that a person is ELIGIBLE to donate blood in

which of the following conditions?
A. Taking antibiotics or maintenance medications
B. Pregnancy and recent childbirth
C. Having high or low blood cholesterol
D. Having used self—injected, non-prescribed drugs

Rationale: blood cholesterol cannot be transferred and

therefore would not affect another person
→ As long as you are not pregnant, self-administering
medications thru injections, taking antibiotics, anemic,
newly tattooed and pierced

98. You keep a list of "Walking Blood Donors You mobilize the
community to register _ in this list with their blood types. Some
instructions for blood donors are the following:
1. Register at any Blood Center Until in a government
hospital.
2. Go to any hospital or clinic and register as a potential
donor. - not all clinic can perform
3. Your complete health history will be taken .
4. You will be given honorarium upon registration
5. Ä physical examination and vital signs will be taken.
6. A blood test will be taken to determine your blood type.

Which of these will you include in your instructions?

A. 2, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 4, 5, 6
D. 2, 4, 5, 6

99. After donating blood, you advise the donor to do the

following, EXCEPT to
A. increase fluid intake following blood donation.
B. skip the next meal to a low the body system to rest.
C. leave the adhesive dressing from 3—6 hours.
D. avoid carrying or lifting heavy objects using the donating arm.

Rationale: after donating blood, do not skip meals instead

eat foods rich in iron, folic acid, such as liver and eggs

RECALLS 6: NURSING PRACTICE 1