During a physical assessment, the D.

Caregiver
nurse closes and door and provides
drape to promote privacy. The nurse is
performing her role as a/an:
A. Advocate B. Communicator 1.Formulating a nursing diagnosis is a joint function of:
C. Change agent D. Caregiver A. Patient and relatives B. Nurse and patient
C. Doctor and family D. Nurse and doctor
During the nursing rounds Nurse Cathy C. Change agent
2.The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical
is instructing the patient to avoid
sound. The nurse documents this as:
smoking to prevent the worsening of
A. Wheezes B. Rhonchi
respiratory problems. The patient
C. Gurgles D. Vesicular
asked about the things that he can do
Wheezes are indicated by continuous, lengthy, musical; heard during
when feelings of wanting to smoke
inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles
arises. The nurse enumerates ways of
are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft
dealing the situation. This is an
intensity on expiration.
example of a nurse's role as a/an:
3. Becky is on NPO since midnight as preparation for blood test. Adreno-
A. Advocate B. Clinician
cortical response is activated. Which of the following is an expected
C. Change agent D. Caregiver
response?
Newborn screening is done to every B. Secondary prevention
A. Low blood pressure B. Warm, dry skin
newborn in the Philippines. This is an
C. Decreased serum sodium levels D. Decreased urine output
example of: Promotion of early detection
Adreno-cortical response involves release of aldosterone that leads to
A. Primary prevention B. Secondary and early treatment of the
retention of sodium and water. This results to decreased urine output.
prevention disease is under secondary
4. When performing an abdominal examination, the patient should be in a
C. Tertiary prevention D. Rehabilitation prevention. Example, breast
supine position with the head of the bed at what position?
self exam, TB screening,
A. 30 degrees B. 90 degrees
genetic counseling.
C. 45 degrees D. 0 degree
One of Nurse Cathy's co-workers is D. Advanced beginner
5. Which of the following is inappropriate nursing action when administering
Annie who is flexible in any given
NGT feeding?
situation. Annie is performing her A- Novice is governed by rules
A. Place the feeding 20 inches above the point of insertion of NGT
duties well without supervision but still and usually inflexible. B- Expert
B. Introduce the feeding slowly
needs more experience and practice to nurses have intuitive grasp on
C. Instill 60ml of water into the NGT after feeding
develop a consciously planned nursing the situation dealt. C-
D. Assist the patient in fowler's position
care. According to Patricia Benner's Competent nurses are planning
The height of the feeding is above 12 inches above the point of insertion, bot
category in specialization in nursing, nursing care consciously. D-
20 inches. If the height of feeding is too high, this results to very rapid
Annie is a/an: Advanced beginners
introduction of feeding. This may trigger nausea and vomiting
A. Novice demonstrate acceptable
6. During application of medication into the ear, which of the following is
B. Expert performance.
inappropriate nursing action?
C. Competent
A. In an adult, pull the pinna upward
D. Advanced beginner
B. Instill the medication directly into the tympanic membrane
Which data would be of greatest C. Capillary refill greater than 3
C. Warm the medication at room or body temperature
concern to the nurse when completing seconds and buccal cyanosis
D. Press the tragus of the ear a few times to assist flow of medication into the
the nursing assessment of a 68-year-
ear canal
old woman hospitalized due to Capillary refill greater than 3
7. Kussmaul's breathing is:
Pneumonia? seconds and buccal cyanosis
A. Shallow breaths interrupted by apnea
A. Oriented to date, time and place indicate decreased oxygen to
B. Prolonged gasping inspiration followed by a very short, usually inefficient
B. Clear breath sounds the tissues which requires
expiration
C. Capillary refill greater than 3 immediate
C. Marked rhythmic waxing and waning of respirations from very deep to very
seconds and buccal cyanosis attention/intervention.
shallow breathing and temporary apnea
D. Hemoglobin of 13 g/dl Oriented to date, time and
D. Increased rate and depth of respiration
place, hemoglobin of 13 g/dl
8. The nurse is aware that Bell's palsy affects which cranial nerve?
are normal data.
A. 2nd CN (Optic)
Which of the following is the most C. Making of individualized B. 3rd CN (Occulomotor)
important purpose of planning care patient care C. 4th CN (Trochlear)
with a patient? D. 7th CN (Facial)
A. Development of a standardized NCP. 9. When performing an admission assessment on a newly admitted patient,
B. Expansion of the current taxonomy the nurse percusses resonance. The nurse knows that resonance heard on
of nursing diagnosis percussion is most commonly heard over which organ?
C. Making of individualized patient care A. Thigh B. Liver
D. Incorporation of both nursing and C. Intestine D. Lung
medical diagnoses in patient care 10. To assess the adequacy of food intake, which of the following assessment
What nursing action is appropriate D. Aspirate urine from the parameters is best used?
when obtaining a sterile urine tubing port using a sterile A. Food preferences
specimen from an indwelling catheter syringe B. Regularity of meal times
to prevent infection? C. 3-day diet recall
A. Use sterile gloves when obtaining D. Eating style and habits
urine 11. Claire is admitted with a diagnosis of chronic shoulder pain. By definition,
B. Open the drainage bag and pour out the nurse understands that the patient has had pain for more than:
the urine A. 3 months B. 6 months
C. Disconnect the catheter from the C. 9 months D. 1 year
tubing and get urine Chronic pain is usually defined as pain lasting longer than 6months.
D. Aspirate urine from the tubing port 12. Prolonged deficiency of Vitamin B9 leads to:
using a sterile syringe A. Scurvy
Jake is complaining of shortness of C. Respiratory rate greater B. Pellagra
breath. The nurse assesses his than 20 breaths per minute A. Scurvy B. Pellagra
respiratory rate to be 30 breaths per C. Megaloblastic anemia D. Pernicious anemia
minute and documents that Jake is A respiratory rate of greater 13. Pia's serum sodium level is 150 mEq/L. Which of the following food items
tachypneic. The nurse understands that than 20 breaths per minute is does the nurse instruct Pia to avoid?
tachypnea means: tachypnea. A blood pressure of
A. Pulse rate greater than 100 beats 140/90 is considered
per minute hypertension. Pulse greater
B. Blood pressure of 140/90 than 100 beats per minute is
C. Respiratory rate greater than 20 tachycardia. Frequent bowel
A. Broccoli B. Sardines 30. The usual sequence for assessing the bowel is:
C. Cabbage D. Tomatoes A. Right lower quadrant, right upper quadrant, left upper quadrant, left lower
The normal serum sodium level is 135 to 145 mEq/L, the client is having quadrant
hypernatremia. Pia should avoid food high in sodium like processed food. B. Right lower lobe, right upper lobe, left upper lobe, left lower lobe C. Right
Broccoli, cabbage and tomatoes are good source of Vitamin C. hypochondriac, left hypochondriac and umbilical regions
14. hen assessing a patient's level of consciousness, which type of nursing D. Rectum, pancreas, stomach and liver
intervention is the nurse performing? 31. Constipation is a common problem for immobilized patients because of:
A. Independent B. Dependent A. Decreased tightening of the anal sphincter B. An increased defecation
C. Collaborative D. Professional reflex
15. Which of the following is a nursing diagnosis? C. Decreased peristalsis and positional discomfort D. Increased colon motility
A. Hypothermia B. Diabetes Mellitus 32. According to Maslow's hierarchy of needs, which of the following is a
C. Angina D. Chronic Renal Failure basic physiologic need after oxygen?
16. A skin lesion which is fluid-filled, less than 1 cm in size is called: A. Safety B. Activity C. Love D. Self esteem
A. Papule B. Vesicle 33. The term gavage indicates:
C. Bulla D. Macule A. Administration of a liquid feeding into the stomach
Vesicle is a circumscribed circulation containing serous fluid or blood and less B. Visual examination of the stomach
than 1 cm (ex. Blister, chicken pox). C. Irrigation of the stomach with a solution
17. S1 is heard best at the: D. A surgical opening through the abdomen to the stomach
A. 5th left intercostal space along the midclavicular line 34. Which communication skills is most effective in dealing with covert
B. 3rd intercostal space to the left of the midclavicular line communication?
C. Second right intercostal space at the sternal border A. Clarification B. Listening
D. Second left intercostal space at the sternal border C. Evaluation D. Validation
18. The correct site at which to verify a radial pulse measurement is the: 35. What phase of the therapeutic relationship is characterized by gathering
A. Brachial artery B. Apex of the heart information before meeting the client?
C. Temporal artery D. Inguinal site - Phase 1 - Pre-Interaction phase
19. o promote correct anatomic alignment in a supine patient, the nurse 36. What phase of the therapeutic relationship is characterized by meeting
should: clients, making conversation, and establishing rapport?
A. Place the patient's feet in dorsiflexion - Phase 2 - Orientation phase
B. Place a pillow under the patient's knees 37. What phase of the therapeutic relationship is characterized using
C. Hyperextend the patient's neck techniques related to therapeutic communication and allowing the client to
D. Adduct the patient's shoulder clarify any concerns?
20. Postural drainage to relieve respiratory congestion should take place: - Phase 3 - Working phase
A. Before meals B. After meals 38. What phase of the therapeutic relationship is characterized by finding
C. At the nurse's convenience D. At the patient's convenience healthy ways to conclude a relationship?
21. Mr. Jose is admitted to the hospital with a diagnosis of pneumonia and - Phase 4 - Termination phase
COPD. The physician orders an oxygen therapy for him. The most comfortable 39. The main purpose of the working phase of a therapeutic nurse-patient
method of delivering oxygen to Mr. Jose is by: relationship is to:
A. Croupette B. Nasal cannula 1. Establish a formal or informal contract that addresses the patients
C. Nasal catheter D. Partial rebreathing mask problems
22. The nurse's main priority when caring for a patient with hemiplegia? 2. Implement nursing interventions designed to achieve expected patient
A. Educating the patient outcomes.
B. Providing a safe environment 3. Develop rapport and trust so the patient feels protected and an initial care
C. Promoting a positive self-image plan can be identified
D. Helping the patient accept the illness 4. Clearly identify the role of the nurse and establish parameters of the
23. A sudden redness of the skin is known as: professional relationship.
A. Flush B. Cyanosis 40. The nurse uses reflective technique when communicating with an anxious
C. Jaundice D. Pallor patient. The nurse uses reflective technique in this situation because it
24. A patient states that he has difficulty sleeping in the hospital because of focuses on:
noise. Which of the following would be an appropriate nursing action? 1. Feelings
A. Administer a sedative at bedtime, as ordered by the physician 2. Content themes
B. Ambulate the patient for 5 minutes before he retires 3. Clarification of information
C. Give the patient a glass of warm milk before bedtime 4. Summarization of the topics discussed
D. Close the patient's door from 9pm to 7am 41. A patient says, "I don't know if I'll make it through this surgery." Which
25. If a patient sues a nurse for malpractice, the patient must be able to response by the nurse may block further communication by the patient?
prove: 1."You sound scared"
A. Error, proximal cause, and lack of concern 2."You think you will die"
B. Error, injury and proximal cause 3."Surgery can be frightening"
C. Injury, error and assault 4."Everything will be alright"
D. Proximal cause, negligence and nurse error 42. The patient states "My wife is going to be very upset that my prostate
26. Which of the following nursing theorists is credited with developing a surgery probably is going to leave me impotent." What is the best response
conceptual model specific to nursing, with man as the central focus? by the nurse?
A. Martha Rogers B. Dorothea Orem 1.I'm sure your wife will be willing to make the sacrifice in exchange for your
C. Florence Nightingale D. Sister Callista Roy well-being
27. Which of the following nursing theorists developed a conceptual model 2.The doctors are getting great results with nerve-sparing surgery today.
based on the belief that all persons strive to achieve self-care? 3.Your wife may not put as much emphasis on sex as you think.
A. Martha Rogers B. Dorothea Orem 4.Let's talk about how you feel about this surgery.
C. Florence Nightingale D. Sister Callista Roy 43. The patient states " I think that I am dying" The nurse responds, "You feel
28. The average daily amount of urine excreted by an adult is: as though you are dying?". What interview approach did the nurse use?
A. 500 to 600 ml B. 800 to 1,400 ml 1.Focusing 2. Reflecting
C. 1,000 to 1,200 ml D. 1,500 to 2,000 ml 3.Validating 4. Paraphrasing
29. The nurse should take a rectal temperature of a patient who has: 44. The nurse plans to foster a therapeutic relationship with a patient. It is
A. His arm in a cast B. Nasal packing most important that the nurse:
C. External hemorrhoids D. Gastrostomy feeding tubes 1. Works on establishing a friendship with the patient.
2. Use humor to defuse emotionally charged topics of discussion.  Daily weights
3. Sympathize with the patient when the patient shares sad feelings.  Vital signs every four hours
4. Demonstrate respect when discussing emotionally charged topics.  Record intake and output
45. A patient who is to receive nothing by mouth (NPO) in preparation for a 57. In the table below, choose which supplies are indicated or not indicated
bronchoscopy says,"I am worried about the test and I can't even have a drink for bathing and occupied bed making.
of water." What is the best response by the nurse? Indicated: Bath blanket
1. "Lets talk about your concerns regarding this test." Dirty linen receptacle
2. "I'll see if the doctor will let you have some ice chips" Clean gloves
3. "The doctor will review the results of the test as soon as possible." Not indicated: Sink with clean running cold water
4. As soon as the test is over I'll get you whatever you would like to drink." Sterile gloves
46. The nursing action that best reflects the concept of therapeutic Sterile drape
communication is: 58. What information should be recorded in the Neurological and
1. Using interviewing skills to discuss the patients concerns Integumentary portions of the I-SBAR's Assessment section? Select all that
2. Letting the patient control the focus of the conversation apply.
3. Setting time aside to talk with the patient Upper extremities warm and dry. Lower extremities cooler to touch.
4. Agreeing with the patient's statements. Sensation to dull, sharp, and temperature absent
47. The nurse is attempting to develop a helping relationship with a patient 59. The nurse is preparing to complete the bathing and bed making skill.
who was recently diagnosed with cancer. The nurse understands that a factor What assessment findings require further follow-up prior to the skill being
that is unique to this helping relationship is that it is: performed? Drag the assessment findings that require follow-up to the box
1. Characterized by allowing the patient to take the dominant role. on the right.
2. Distinguished by an equal sharing of information. Assessment findings that require further follow-up:
3. Specific to a person while guided by a purpose Latex allergy
4. Based on the needs of both participants. Liquid spill on floor
48. The nurse is collecting data for an admission nursing history. Which Sir rails lowered on both sides
question by the nurse is best to open the discussion? 1. An alert and oriented elderly male patient has been admitted to the
1. What brought you to the hospital? hospital with a diagnosis of chronic obstructive pulmonary disease (COPD).
2. Would it help to discuss your feelings? He is unshaven, has unkempt hair, and has a foul body odor. Asking which
3. Do you want to talk about your concerns? hygiene-related assessment question is a priority for the nurse?
4. Would you like to talk about why you are here? a. "Do you have friends or family nearby?"
49. The nurse must conduct a focused interview to complete an admission b. "Can you raise your arms up to brush your teeth?"
history. Which interviewing technique should the nurse use? c. "Do you become short of breath during your shower?"
1. Probing 2. Clarification d. "Are you able to get in and out of your bed at home?"
3. Direct questions 4. Paraphrasing Answer: c-
50. An agitated 80 year old patient states, "I'm having trouble with my 2. Which action by a female patient lets the nurse know the patient has
bowels." Which response by the nurse incorporates the interviewing skill of understood perineal care teaching?
reflection? a. The patient washes her perineum with a circular motion beginning at the
1. "You seem distressed about your bowels." urinary meatus.
2. "You're having trouble with your bowels?" b. The patient washes her perineum from front to back using a clean
3. "It's common to have problems with the bowels at your age." washcloth.
4. "When did you first notice having trouble with your bowels." c. The patient washes her perineum from back to front with long, firm
51. The nurse understands that the statement that is most accurate about strokes.
communication is: d. The patient washes her perineum lightly to prevent tissue damage.
1. Communication is inevitable Answer: b-
2. Behavior clearly reflects feelings. 3. The nurse on a medical floor in a hospital just completed a bed bath. The
3. Hands are the most expressive part of the body. nurse should take what action before leaving the patient's room? a. Place the
4. Verbal communication is essential for human relationships. call light within reach so the patient can call for help if needed, and leave the
52. he patient is upset and crying and mentions something about her job and bed as it was during the bath.
the nurse cannot understand. The nurse's best response is: b. Lower the bed to its lowest position, raise all four side rails so that the
1. It's natural to be worried about your job. patient does not fall out of bed, and place the call light within reach.
2. Your job must be very important to you. c. Lower the bed to its lowest position, raise the top two side rails to assist
3. Calm down so that I can understand what you are saying. the patient in turning and positioning, and place the call light within reach.
4. I am not quite sure I heard what you were saying about your work. d. Leave the bed in a position that is comfortable for the caregiver because
53. Prior to assisting with bathing, it is important to plan for providing more care will be needed, raise the top two side rails, and place the call light
culturally competent client-centered care. Which nursing actions incorporate within reach.
cultural aspects of care? Select all that apply. Answer: c-
 Consider client's preferences in bathing 4. Which actions by the nurse concerning oral care for an unconscious patient
 Be aware of cultural practices that may affect bathing activities are considered safe? (Select all that apply.)
 Ask the client and family how you can help make their experience a. Performing oral care with the patient in a supine position
more comfortable b. Performing oral care with the patient turned to the side
 Maintain client privacy c. Installing suction equipment at the bedside
54. The registered nurse can delegate an unlicensed assistive personnel (UAP) d. Providing oral care every 2 hours
to ______. UAP can also be delegated to _____. e. Using a hard-bristle toothbrush
assist with grooming; assist with perineal care Answer: b, c, d-
55. Prior to making an occupied bed, the nurse should organize supplies to 5. Which safety precaution is a priority for the nurse when bathing a patient
conserve time and prevent client discomfort. Which four (4) items will the with peripheral neuropathy?
nurse need to assemble before making an occupied bed? a. Keeping the top two side rails up during the bath
 Flat sheet b. Checking the bath water temperature before the bath
 Clean gloves c. Encouraging independence with perineal care during the bath
 Bath blanket d. Facilitating range-of-motion exercises and dangling before the bath
 Fitted sheet Answer: b
56. Based on the healthcare provider orders, which of these orders can be 6. Which nursing diagnosis is a priority for a patient who needs assistance
delegated to the unlicensed assistive personnel (UAP)? Select all that apply. with activities of daily living?
 Elevating head of bed (HOB) at 30 degrees a. Self-Care Deficit
b. Lack of Knowledge c. Activity Intolerance 3. A German client refuses to bathe everyday.
d. Able to Perform Self-Care
Answer: a- 4. The room temperature is set at 72F.
7. Which statements are true regarding back massage? (Select all that apply.) The nurse is preparing to provide hygienic care to a client. On what will the
a. Only a licensed massage therapist can perform back massage. nurse focus this care?
b. Back massage may stimulate the deep muscles. 1. Clothes
c. Massage provides relaxation and comfort. 2. Family
d. Tapotement stimulates the skin. 3. Hair
e. A massage may promote sleep. 4. Nu tritional
Answer: b, c, d, e- A client needs to have soft contact lenses removed. What should the nurse
8. A patient diagnosed with head lice has an order for pediculicidal shampoo. do when removing the lenses?
Which statement should the nurse include with teaching about this 1. Gently pinch the lens and lift it out.
shampoo? 2. Have the client look up.
a. It can be used only on patients with the ability to stand in the shower. 3. Pull the lower eyelid upward.
b. It can cause central nervous system side effects, including dizziness. 4. Use the pad of the ring finger.
c. It is used by pregnant women and young children. The nurse is caring for a client with diabetes. What should the nurse include
d. It is safe for patients with seizures or epilepsy. as foot care for this client?
Answer: b- 1. Cut toenails in a rounded shape and file.
9. Which statement indicates an understanding by the unlicensed assistive 2. Dry toes thoroughly.
personnel of eye care during a patient's bath using washcloths and a bath 3. Wash feet with water at a temperature of 90F to 98.6F.
basin? 4 Inspect feet thoroughly once a week.
a. "The eyes are washed with soap and water from the inner canthus to the A client has the nursing diagnosis Risk for Impaired Skin Integrity related to
outer canthus." immobility. Which nursing intervention should be identified for this clients
b. "The eyes should always be washed using sterile normal saline and a gauze problem
sponge." 1. Encourage the client to eat at least 40% of meals.
c. "The eyes are washed from the outer canthus to the inner canthus using 2. Keep linens dry and wrinkle-free.
water only." 3. Restrict fluid intake.
d. "The eyes are washed with water using a clean part of the washcloth for 4. Turn client every 3 hours.
each eye." A client has hard contact lenses. What should the nurse do to assist the client
Answer: d- in the care of the lenses?
10. A new patient is assigned to the unit. When attempting to provide 1. Pinch the lenses out of the clients eyes to remove.
personal care for the patient, which patient-centered care needs should the 2. Remove both of the clients lenses before storing in the appropriate storage
nurse consider? (Select all that apply.) cup.
a. Age 3. Document when the lenses need to be removed and cleaned every 2
b. Skin condition weeks.
c. Transportation concerns 4. Ask the client how many hours the lenses are worn each day.
d. Patient’s feelings and wishes During an assessment, the nurse learns a client has soft contact lenses that
e. Time constraints have not been removed or cleaned for weeks. What should the nurse do?
f. Religious beliefs 1. Nothing, because these types of lenses can be worn for months.
g. Cultural tradition 2. Remove the clients lenses, wrap in tissue, and place in the bedside table.
h. Disability restrictions 3. Assist the client to remove and clean the contacts.
i. Admission complaint 4. Ask the physician for ophthalmology consult because the client will need
Answer: a, b, d, f, g, h- help removing the lenses.
- The client has a hearing aid with an earpiece that is connected by a cord to a
The nurse is preparing to provide morning care to a client. What should the receiver that the client keeps in a shirt pocket. The nurse would document
nurse explain to the client as the reason for a daily bath? this as which type of hearing aid?
1. Assess skin integrity 1. Body hearing aid
2. Develop a nurseclient relationship 2. In-the-canal aid
3. Moisturize the skin 3. Completely-in-the-canal aid
4. Stimulate circulation 4. Eyeglasses aid
The nurse is preparing to bath a client on the first postoperative day. Which
nursing intervention should take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath.
The nurse is shampooing a clients hair. Which assessment finding should the
nurse consider as expected?
1. Dry, dark, thin
2. Smooth, taut, shiny
3. Smooth texture and not oily or dry
4. Tender, warm scalp
The nurse identifies the diagnosis Self-Care Deficit related to cognitive
impairment as appropriate for a client. What should the nurse select as an
expected outcome for this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment.
3. The client, with supervision, will brush her teeth.
4. The nurse will stress the importance of adequate fluid intake.
The nurse is reviewing assigned clients for morning care needs. Which
situation could pose a threat to one clients personal hygiene?
1. A client has a newly formed ileostomy.
2. A client performs meticulous foot care.