NURSING PRACTICE 1

FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test items
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will
invalidate your answer.
3. AVOID ERASURES
4. Write the Subject title “NURSING PRACTICE 1” on the box provided.

Situation 1- taking care of dying clients is challenging. Mrs. Marina, a 65 year old client is
terminally ill with stage 4 cancer of the breast right with metastasis to the cervical spine and
lungs. She is ambulant but weak able to perform her activities of daily living and has no
complaints of pain.
1. You are assigned to take care of Mrs. Marina. She does not ask questions regarding her
condition and her relatives do not know how much knowledge she has about her prognosis.
Considering the client’s needs and to provide holistic care to the client, your plan of care
should focus on:
a. Continuous assessment of her condition to keep her clean and comfortable
b. Providing support to the client as she ambulates in the room
c. Ensuring that her physiologic needs are met especially nutrition
d. Assessing the client’s perception of her illness and thoughts about dying
2. During the physician’s visit where he discussed the client’s condition with Mrs. Marina’s
children, the client overhead part of the conversation where the doctor said, “she has shot
time left to live”. After the physician left the client said to the nurse “Why didn’t anyone tell
me? I’m not ready to die. “What would be your most appropriate response?
a. “this time must be very difficult for you” c. Death and birth are normal parts of the
b. “if it is consolation, everyone has to die cycle of life”
sooner or later” d. “you will be fine, you are in good hands”
3. Mrs. Marina’s condition worsens. She has begun to experience severe pain and manifest signs
of impending death. The children ask you if their mother is going to die soon. Which of the
following is your MOST APPROPRIATE response?
a. “the signs do not predict the exact c. “You are saddened that your mother is
time of death” dying”
b. “death is inevitable, it will come d. “Are you worried that your mother will
anytime now” die?”
4. The client died with her family around her. The children are crying hysterically and hanging on
to their mother. What nursing action is BEST for you to take?
a. Ask physician to prescribe tranquilizer for the family members
b. Allow the family some privacy and time to be with the client before doing after care
c. Allow the family to view the body then transport the body to the hospital morgue
immediately
d. Reassure the family that the body of their loved one will be cared of
5. Having witnessed the death of Mrs. Marina, you become aware of the tears that are welling in
your eyes. It is most appropriate to remember that when caring for a dying client.
a. The nurse’s emotional response sets an example as to how the family should grieve.
b. The nurse’s own feelings and thoughts about death influences her own ability to care for
the client and the family
c. Any show of emotions by the nurse is considered non-therapeutic
d. The nurse should send the family out when bathing the body and placing identification
tags

SITUATION 2- Mr. Rivera, 54 years old, is admitted to the medical unit for executive check-up.
His admitting notes reveal: temperature: 36.8 degrees C; pulse rate: 86/minute; respiratory rate:
18/minute; BP: 160/90mmHg.
6. When admitting Mr. Rivera, your most important INITIAL nursing action would be to:
a. Take him around the ward to show him the unit set up
b. Introduce Mr. Rivera to the other staff in the unit
c. Obtain Mr. Rivera’s nursing history
d. Identify needs of Mr. Rivera that may require immediate management
7. The chart’s admission notes state that Mr. Rivera has bi-pedal edema. During assessment you
VERIFY this by:
a. Doing palpation d. Checking the results of laboratory
b. Interviewing the client tests
c. Doing inspection
8. Mr. Rivera asks you what he should do to help reduce swelling of his feet and ankles. Your
most appropriate response would be the following EXCEPT.
a. Elevate his feet while seated or while lying in bed C. Request the doctor for diuretics
b. Reduce intake of salty food D. Inform him that edema is caused by
problem with his kidney
9. Mr. Rivera had blood extraction foe hematology, blood chemistry, lipid profile, FBS. The
laboratory results are in. Of the following, which is NOT within normal?
a. Cholesterol 4.28mmol/L b. HBA1C: 5.7% c. FBS: 6.5mmol/L d.
Hematocrit:39.7/L
10.You are planning Mr. Rivera’s Discharge from your unit. Your nursing responsibilities include all
EXCEPT:
a. Making a final assessment of the client c. Giving instructions regarding his home
b. Replying to queries regarding his medications
hospital bill d. Arranging for his transportation home

SITUATION 3- Nurses in the medical unit are finding ways to improve collaborative relationship
with the physicians. Efforts to identify factors that foster or impede nurse-physician collaboration
are thoroughly examined. A review of the antecedent environmental factors was undertaken.
11.A variety of factors collected have been linked to the quality of nurse-physician collaboration.
Given this information, which of the following measures is appropriate to foster nurse-
physician collaboration?
a. Present collected data to the physicians and those involved in healthcare
b. Nurse and physician should be willing to consider each other’s position
c. Consider both environmental and professional factors
d. Arrange a meeting to discuss issues and concerns with the physician and other members
of the health team
12.Information gathered by nurses show the importance of 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?
a. Conduct in-service education for nurses to improve competencies to address the issues
b. Organize a conference on medication error participated by nurses, physicians and others
c. Involve a form of communication where 2 parties engage in problem solving discussion
d. Develop a policy where all members of the health team can use it as a reference
13.There are other problems that were identified during the gathering of data but at the moment
you have ready solution.in this situation which of the following is the MOST appropriate action
to be taken?
a. Nurse and physician should identify types of problems amenable to collaboration
b. Have priority to these problems because they are good candidates for collaboration
c. Immediate action must be done to assist the clients in their health problems
d. Prioritize problems needing immediate attention and solution
14.Given the above situation, which of the following actions should be done by both parties?
a. Continuous conference to keep track of the concerns of the clients
b. Conduct weekly conference for continuity of medical management
c. Encourage open communication for effective collaboration
d. Design condition to support desired levels of collaboration more effectively
15.Of the following nursing service staff, who are MOST likely to engage in problem solving
communication with the physician to ensure the quality of communication and outcomes?
a. Nurses who are on the management level to ensure effective problem solving with
physician
b. A team of experienced nurses with less experienced staff nurses
c. Any staff that you available for the conference and collaboration
d. Nurses assigned to the clients with identified problems

SITUATION 4- Therapeutic communication forms a connection between the client and the nurse.
Furthermore, it facilitates the establishment of the nurse-client relationship and fulfills the
purposes of nursing.
16.Mrs. Irma Santos, 45 year old, has terminal cancer of the breast. She cries and tells the nurse,
“why do I have to suffer this kind of illness? There is no cure for this and I wish my family
would not hope for a cure”. Which of the following is the most appropriate response of the
nurse?
a. “is your family ready to accept your condition”
b. “You feel angry that your family hopes for a cure for your illness?”
c. “you sound that you are likely to die”
d. “I think you and your family should discuss your condition with your physician”
17.While on your way to the cafeteria, you were greeted by a friend who happens to be visiting a
client under your care. She asks about the client’s condition. Which of the following would be
the most appropriate response of the nurse?
a. “I am not in a position to discuss her condition but you are my friend. I can tell you that
she is on her way to recovery.
b. “if you want to know her condition, why don’t you talk to her attending physician”
c. “I cannot discuss the status of the client with you”
d. “confidentiality, I can tell you that her condition is unstable”
18.An 18 year old client has been in the hospital for 3 days with infection of chlamydia. While
administering her 12:00 noon medication the client tells the nurse that she has a secret which
she wants the nurse to know but asked the nurse not to tell anybody. Which of the following is
the MOST appropriate response of the nurse?
a. “what you will tell me will be properly documented”
b. “yes, I promise to protect you when in entrusting your secret to me”
c. “yes you can trust me not to divulge your secret”
d. “I cannot promise to keep a secret if it affects your health”
19.A depressed client tells the nurse that she is very disappointed following her loss of job. “ I
am a failure and cannot perform my work right”. The following are appropriate responses of
the nurse EXCEPT:
a. Provide experiences that will be enhance her self esteem c. Stay with the client and
listen to what she says
b. Reassure the client that everything will get better soon d. Motivate the client by giving
positive support and environment
20. The nurse is interacting with a client who verbalized that she is hearing voices telling her
that “she is a bad girl”. Which of the following responses is the MOST appropriate?
a. “I understand what you feel but keep calm” c. “dont worry it will not harm you”
b. “nobody is around except the two of us” d. “it’s difficult for you to understand all
that you are experiencing right now”
SITUATION 5-Nedy, a now registered nurse applied for work as a research assistant. A thorough
understanding of the steps in the research process is important when doing a study.
21. Nurse Nedy knows that defining the purposes of the research project serves which
function?
a. States the focus of the research study d. Explains why the problem is significant
b. Identifies population group to be used to study
c. Determines statistical treatment
needed
22. During her job interview, Nurse was asked which type of research is intended to gain
insight by discovering “meaning”. Her best reply is:
a. Phenomenological c. Quantitative research
b. Qualitative research d. Anthropology based research
23. When another nurse tells Nedy that she performs hand washing eight times a day but
can’t explain why except to say “I’ve always done in this way”. Her answer is an example of:
a. Scientific knowledge c. Unsubstantiated knowledge
b. Authoritative knowledge d. Tradition knowledge
24. Nurse Nedy is doing research on the effect of cholesterol on blood pressure. Blood
pressure is what type of variable?
a. intervening variable b. Independent variable c. Exploratory variable
d. Dependent knowledge
25. the term used to refer to information collected in research is:
a. Abstract b. Mean c. Data d.
Subject
SITUATION 6- Nurses have responsibility to understand the current legal and ethical guidelines
that govern the practice of the nursing profession
26. A new registered nurse is being interviewed for a staff position in a private hospital. Which
of the following statements indicates her understanding of the practice of nursing in the
Philippines as provided for in the nursing law?
a. Only professional licensed nurses can practice nursing in the Philippines
b. A registered nurse can practice professional nursing in the hospital and community
settings
c. A nurse is certified to practice nursing in the Philippines
d. A registered nurse license provides basis for professional nursing practice
27. A nurse assigned in the surgical unit visited the mother of her friend confined in the
Medical Unit. She was observed by the staff nurse in the unit reading the chart of the client. In
this situation the action of the nurse is described as:
a. Acceptable because she is known to the client c. Appropriate because she is
part of the nursing staff of the hospital
b. Unethical because of possible breach of confidentiality d. Inappropriate because she is
not assigned in the unit
28. The nurse is concerned about the medical care of her client who has been confined in the
hospital for 2 weeks. She has a physician friend not connected with the agency whose opinion
she asked regarding the treatment care. In this case, the nurse acted:
a. In accordance with hospital policies ad c. Following the appropriate chain of
regulations command
b. In violation of the principle of d. Based on what is good for the client
confidentiality
29. A nurse researcher is conducting a research study on the concerns of the elderly regarding
hospitalization. An elderly client was offered to participate in the study. She signed the consent
but later decided to withdraw from the project. In this situation the elderly client.
a. may withdraw as long as the family requests withdrawal
b. may withdraw at any time of the study
c. cannot withdraw since the consent is a legal document and has been signed
d. cannot withdraw since the study has started
30. The nursing student asks permission from the head nurse to photocopy the record of the
patient that is presently taking care of. She is to present a case study and needed information
substantiate her data. Which of the following should be the appropriate action of the head nurse?
a. Refer nursing student to ask permission from the attending physician
b. Allow her to photocopy the pages related to the information needed
c. Allow her to write down pertinent but no identifying information
d. Do not allow photocopying due to confidentiality

SITUATION 7- Nurse Nida is conducting a clinical assessment of lota, 40 years old female client,
admitted for chronic renal disease.
31. Nurse Nida utilizes the most reliable indicators of lota’s fluid balance status which include the
following EXCEPT
a. her daily weight record c. complete blood count
b. the measurement of intake and d. result of urinalysis
output
32. While assessing Lota’s skin, nurse Nida noted that the skin flattens more slowly after the
pinch is released. This is an indication that the client is manifesting sign of:
a. 2+ pitting edema c. fluid volume deficits
b. shift of body fluids d. fluid overload
33. Nurse Nida continues with the assessment of the neck and instructed the client to lie flat on
bed. With the presenting complaints the nurse expects to not which of the following?
a. neck warm to touch c. jugular venous distention
b. collapse of neck veins d. difficulty in moving the neck
34. During the planning phase nurse Nida prioritizes nursing interventions to support client’s
attainment of expected outcome. In this case the goal of care for the client should be:
a. proper fluid balance of intake and c. prevent depletion of fluids
output is attained d. relief from vomiting and diarrhea
b. IV site should be free from infection
35. The following nursing interventions to prevent or correct fluid, electrolyte, and acid base
imbalances include the following EXCEPT:
a. fluid and blood products replacement d. appropriate patient and family
b. allaying of anxiety teaching
c. modification of fluid intake
SITUATION- 8 Nursing practice act requires nurses to maintain a safe environment for their
clients. Nurses must act to identify and minimize risks to clients.

36. A nurse is taking care of Mr. Antonio Cruz who is receiving oxygen therapy. A watcher
approaches her saying there is fire burning in the trash basket inside the medication room in the
nurse’s station. What INITIAL action should nurse do?
a. turn off the oxygen and remove all c. calm the clients and escort them to a
clients from the room safe area
b. get the fire extinguisher to put off the d. ask for help from the visitors
fire
37. What nursing action is essential when Mr. Cruz is to have oxygen administration at home?
a. assist the client and family check all electrical appliances in the vicinity for extension
cords
b. turn off all electrical devices inside the room of the client
c. instruct the clients to install a carpet inside the room
d. instruct relatives to have fire extinguisher ready
38. Anna, a charge nurse in the pediatric unit, is assessing the area for fire hazards. The
following situation is considered the GREATEST fire hazard:
a. cleaning supplies and cardboard boxes stored in the room with oxygen tank c. personal
items of clients kept under the bed
b. closet of clients filled with clothing and news papers d. some staff
smoking in the rest room
39. While doing her rounds, the nurse passed through a private room and saw flames and
smelled smoke. Which of the following should be the INITIAL action of the nurse?
a. evacuate all the clients in the building c. evacuate the clients out of the burning
b. ask for assistance room
d. evacuate the weakest clients first
40. The nurse is explaining universal precaution to the client. The primary purpose of universal
precaution as part of maintaining safe environment is to:
a. prevent health workers from acquiring communicable diseases c. prevent
nosocomial infection
b. reduce the spread of the disease d. prevent the spread of
communicable diseases

SITUATION 9- It is rainy season and the pediatric clinic where you are assigned is filled with
children and mothers waiting for attention and treatment.

41. Many children in the clinic have upper Respiratory Tract Infection (URTI). Alice has two
children with her at the clinic. To prevent the spread of URTI, the BEST instruction to give mothers
like Alice will be to:
a. teach child to use sleeves to wipe off nasal discharges
b. instruct mother and child to wear protective masks at all times
c. wipe off child’s nasal discharge so that no mucous crust forms on the nostrils
d. wash hands thoroughly with soap and water after handling mucous discharges
42. The nurse teaches Alice and other parents that URTI spreads through droplets after coughing
and sneezing. Your health instructions are effective when the parents do the following EXCEPT:
a. deposit sputum in issue and discard used tissue in a trash can
b. cover mouth and nose when coughing or sneezing
c. wash and dry hands by using a towel provided in the lavatory
d. wash hands thoroughly after contact with mucus secretions
43. Following the nurse’s instructions on how to prevent spread of infection, Alice teaches her
children how to prevent infecting their playmates when they have URTI, Which of the following
actions would be considered INEFFECTIVE in preventing spread of infection?
a. washing of hands after blowing nasal discharges
b. covering mouth and nose when sneezing or coughing with their skirt or shirt
c. covering nose and mouth with hands when sneezing then continue playing
d. pinning a handkerchief or face towel to wipe off mucus secretions or cover nose
44. You demonstrate proper hand washing technique to the parents in the clinic as a step to
prevent spread of infection. The parents perform the practical procedure correctly when they:
a. rub hands together in between fingers , using soap and rinse with running water
b. rub hands together for friction under running water
c. wash fingers with soap and rinse with water in a basin
d. wash hands with antimicrobial soap, apply rubbing alcohol, dry hands by allowing alcohol
to evaporate.
45. At home, Alice observes principle of infection control when she:
a. avoids shaking linen, clothes and towels used by sick child
b. keeps kitchen utensils and plates in cupboards where leftover food are stored
c. places handbags and baskets on food preparation areas
d. avoids shaking and stores used clothes and linen in the clothes cabinet

SITUATION 10- A number of client in your unit are at risk of developing pressure sores. As a
precaution, the supervisor emphasizes the nurse’s responsibility in ensuring proper care of
clients with problem of immobility.
46. While changing linen of Aling Mila, a comatose client, the nursing aide reports that she
noticed a reddened area in the left buttock of the client. Upon inspection, you noted that the
area blanches and is the size of a peso coin. Your MOST appropriate immediate nursing approach
would be to:
a. measure the size of the reddened area for proper documentation
b. instruct the nursing aide to finish bed making using dry fresh linen
c. endorse a schedule for turning and positioning the client round the clock
d. position the client on her right side
47. To decrease the occurrence of pressure sores on Aling Mila the nursing team’s goal is to
reduce pressure points. The MOST appropriate nursing intervention would be to:
a. elevate the head part of the bed as c. use a “donut” cushion while client is
little as possible seated
b. massage over the bony prominences d. place the client on a side lying position
48. While assessing clients assigned to your care, you observe that the client with the greatest
risk for developing a “bedsore” or pressure sore would be:
a. 4 year old girl in Buck’s traction b. 40 year old unconscious client
c. 82 year old client who has had mild d. 70 year old client with type 2 diabetes
stroke
49. While assessing the pressure sore of a 75 year old client, the nurse documents that healing is
taking place when she observes presence of:
a. Eschar b. exudate c. granulation tissues d. ragged edges around the
wound
50. In a nurse’s meeting in the ward, the senior nurse discusses prevention of pressure sores.
She identifies practices that are most likely to cause shearing injury to the skin and should
therefore be avoided. Of the following practices, which one causes the LEAST harm to the client?
a. failure to use a draw/lift sheet when moving the client upward
b. failure to lower the head part of the bed before moving the client upward
c. positioning an immobilized client without help from staff
d. dragging the heels of the client in bed as he is being positioned

SITUATION 11- Primary prevention involves health promotion as protection against disease.
Activities of this type generally apply to the healthy individuals before any disease or dysfunction
occurs.
51. Nurses play a big role in the primary level of prevention. Examples of nurse activities
showing primary prevention are the following EXCEPT:
a. referrals to client support groups like those for cancer patients
b. teaching parents of toddlers about prevention of poisoning and accidents at home
c. family planning classes to newly weds
d. giving immunizations to children
52. Secondary prevention includes health maintenance activities which involves the following
EXCEPT:
a. nursing care to maintain skin integrity of a diabetic client
b. giving medications and treatments to discharged clients
c. proper positioning of clients with disability in the home setting
d. smoking cessation program
53. When teaching your clients about nutrition, you include the following food as rich sources of
good cholesterol, EXCEPT:
a. fish b. beef c. soya d. olive oil
54. A community based hospital offers acute care in addition to adult outpatient services,
exercise and yoga classes for young and old. This Hospital provide which type of services?
a. tertiary and illness prevention c. secondary and tertiary
b. primary and tertiary d. primary and secondary
55. Mr. Tan, 48 years old is attending a smoking cessation program to be held at the nearby high
school conducted by the school nurse. This program is classified as:
a. diagnosis and treatment b. health restoration c. rehabilitation d. health
promotion

SITUATION 12- To carry out management functions in any health care setting it is necessary for
the nurse to integrate leadership skills that he/she developed.
56. To improve quality client care the nurses created “problem solving committees” headed by
senior nursing staff to review standards of care and develop policies and procedures. Its desired
result is best seen in:
a. continuous evaluation of nursing practice/ protocols in relation to desired patient
outcomes
b. allowing changes in staff rotation plan to accommodate personal needs of the staff
c. increasing staff communication like providing a bulletin board for sharing information
among personnel
d. more nurses participating in doctor’s rounds and giving immediate information to doctors
regarding patient status
57. The nursing department’s organizational chart illustrates structure and relationships of the
nursing leaders and staff of the organization. The following are the functions of an organizational
chart EXCEPT:
a. list functions and duties of the staff
b. illustrates centrality of control in the organization and chain of command
c. indicates relationship of leaders to other management staff
d. identifies managerial levels
58. A hospital is constructing a new wing and the director of nursing is asked to help design it. to
achieve maximum efficiency in carrying out nursing activities the director of nursing would
consider which of the following conditions to be most helpful?
a. environmental factors such as current economic legal technological and social influences
that the organization must consider
b. how the structural plan facilities staff interaction and the rituals the nurses use to conduct
work
c. work flow where equipment, medication and other items essential for patient care are
stored and positioned
d. type of equipment and technology and its effects on how work tasks are designed and
carried out
59. Time management is important to provide quality care and prioritize work. The nurse finds
the following practices helpful in managing time for patient care EXCEPT:
a. keeping telephone communication short c. doing time and motion study to
b. blocking out time to accomplish determine time utilization
important activities d. dealing with interruption openly and
directly
60. The director of nursing wants to improve the quality of health care in the hospital. The
following activities are examples of quality assurance measurements EXCEPT:
a. Evaluating outcomes or end results of care provided to client
b. asking clients to accomplish client satisfaction survey forms
c. measuring quality of care against established standards of nursing care
d. checking if emergency carts or medications are properly stock
SITUATION 13- Mr. Reden, 52 years old, known diabetic (TYPE 2) is admitted with symptoms of
high blood pressure of 190/100mmhg, an unhealed wound on his right big toe and has bi-pedal
edema. He is on insulin. Co- management by the health team is recommended in the care of Mr.
Reden.
61. Based on the presenting condition of the client upon admission, the nurse would immediately
refer Mr. Reden to a/an
a. endocrinologist for management of c. cardiologist to stabilize blood pressure
diabetes mellitus d. diabetes nurse educator for self-
b. dietitian for nutritional management management of symptoms
62. The head nurse calls for a meeting of the staff nurse to plan care management for Mr. Reden.
The priority nursing action in the care of the client would be:
a. blood glucose monitoring c. accurate measurement of fluid intake
b. monitoring of blood pressure and output
d. accurate insulin administration
63. When assessment of the client’s lower extremities, the nurse notes the unhealed condition of
the client’s infected toe wound. The nurse would:
a. prepare equipment to wash and disinfect the affected toe
b. refer attending physician for proper wound management
c. call the head nurse for assistance as the nurse starts wound debridement
d. call relative to gather information about cause of wound infection
64. The nurse learns that the client does not regularly do blood glucose monitoring and still has
not learned how to do self-administration of insulin. To learn these you will refer the client to:
a. Pharmacist b. advance practice nurse c. diabetes nurse educator
d. medical intern
65. Mr. Reden’s condition improves and discharge planning is installed. This includes planning
his nutritional regimen to encourage compliance. The client will MOST likely be referred to:
a. Nutritionist b. endocrinologist c. dietitian d. cardiologist

SITUATION 14- A nurse is assigned to several clients and her functions include giving intravenous
(IV) medications and fluids. During the end of shift endorsement she receives incoming doctor’s
orders to run some IV fluids for clients assigned to her
66. Mr. Roman, 49 years old, has a doctor’s order to receive 1 liter of normal saline solution to
run for 24 hours. The nurse would set the intravenous fluid to infuse at how many milliliters (ml)
per hour and how many drops per minute. If the drop rate of the IV tubing is 15drops/ml?
a. 42 ml/hour, 10 drops/minute c. 5oml/hours, 18 drops/minute
b. 48 ml/hours, 15 drops/minute d. 36 ml/hour, 7 drops/minute
67. Bayani, 8 years old, has an order for D5 lactated Ringers 250 ml to infuse for 4 hours,
starting at 8 am, using IV tubing set with a drop factor of 60 micro drops (gtts)/ml. What should
be the rate of flow if the IV is tobe consumed at 12 noon?
a. 48 gtts/minute b. 63 gtts/minute c. 43gtts/minute d. 58
gtts/minute
68. While reading the doctor’s orders for the clients, you will seek clarification from the doctor
which of the following orders?
a. infuse 0.9% normal saline to keep vein open (KVO)
b. incorporate 20mEq potassium chloride in liter of D5 water at 50 ml/hour
c. flush peripherally inserted central catheter (PICC) with 10ml normal saline every 6 hours
d. infuse 500ml of normal saline for 2 hours
69. Mr. Roldan is newly admitted to the ward and before administering IV medications you read in
his chart that he has a peripherally inserted central catheter (PICC) that is now 4 weeks old.
Upon examination, you observed that the site is clean and free from manifestations of
infiltration, irritation and infection. Your most APPROPRIATE action would be to:
a. a.
document
apply cold observation
compresses intothe
thenurses
IV site notes to inform
d. elevate
the physician
extremity
and
to facilitate
other nurses
drainage
c.
b.
administer
stop infusing
the medication
IV fluids as ordered by gravity
b. c.discontinue
Flush the thecatheter
PICC line
withsince
normal
it is saline
4 weeks old d. give medications
through
solutionoral or intramuscular route
70. While assessing Mr. Pintor’s IV site you notice swelling and tenderness above the site your
most APPROPRIATE
SITUATION 15- Whilenursing
in the
action
ward,would
you be:
are assigned to clients with problems related to the
gastrointestinal tract.
71. The nurse is preparing Mr. Lim for cleansing enema. When administering enema the
maximum height at which the enema can should be held from the level of the bed is:
a. 14 inches b. 10 inches c. 16 inches d. 12 inches
72. While administering the enema, Mr. Lim complains of abdominal cramps. Which of the
following would be the MOST appropriate action of the nurse?
a. clamp the tubing a few minutes till the cramps subside then continue c. stop the procedure
and refer to the attending physician
b. pull the rectal tube slowly till the cramps subside d. lower the enema can to slow down
the inflow of the enema solution
73. Following surgery Mrs. Mora developed abdominal distention. To achieve maximum
effectiveness how long should the rectal tube be left in place?
a. 5 minutes b. 15 minutes c. 30 minutes d. 50 minutes
74. For ensuring that the nasogastric tube (NGT) is in place, the nurse prepares to feed Mrs. Mora
using the open system. With a 30ml syringe, the nurse proceeds with the feeding following this
sequence.
1. Hold the NGT high to prevent back flow and then clamp
2. Open clamp and raise or lower the syringe to regulate flow of formula
3. Remove the plunger of the syringe and attach to NGT
4. Fill up the syringe with feeding formula
5. Add 30 to 60 ml of water to irrigate syringe allowing it to run down the NGT
a. 2,3,4,1,5 b. 1,3,2,5,4 c. 3,4,2,5,1 d. 4,3,1,2,5
75. The nurse is to perform gastric gavage. What should be the best position of the client while
the gastric tube is being inserted?
a. supine position b. high fowler’s position c. Trendelenburg position d. low
fowler’s position

SITUATION 16- Proper Nutrition and elimination are important to health and the nurse has an
important role to play in assisting people from various age groups obtain proper information
76. Roman, 36 years old is diagnosed with peptic ulcer and asks you what food is best to add to
his diet so as not to exacerbate his symptoms. Your BEST response would be for him to take
a. leafy green vegetable dishes c. mocha, café latte and other similar
b. citrus fruit juices or shakes drinks
d. milk regularly 3-4 times daily
77. You are assigned to Mrs. Dulay, a client with an order for cleansing enema. While doing the
procedure, the client groans and complains of abdominal cramping. Your MOST appropriate initial
nursing action would be to:
a. reduce the flow of the fluid by clamping c. lower the height of the enema container
the enema tubing d. push the rectal tube further in by 2 inches
b. instruct the client to relax, inhale and
exhale slowly
78. An elderly client you are taking care of has fecal incontinence for 3 days now. He is able to
tolerate food but has no control of his bowel movement. He has soft watery stools and uses adult
diapers. While caring for his client you will watch out closely for risk of:
a. increased abdominal cramping c. malnutrition and weight loss
b. perineal and anal skin breakdown d. falls when he tries to go the bathroom
79. Dennis, 5 years old, is brought to the hospital for severe diarrhea. You are aware that a major
problem that may develop that will adversely affect Dennis would be:
a. severe abdominal cramping c. severe fluid electrolyte imbalance
b. excessive passing of flatus d. irritation of the anal sphincter
80. Miss Reyes, a client who had abdominal surgery under general anesthesia, is still in the
recovery room. You are aware that clients who went through general anesthesia will most likely
experience:
a. absence of peristalsis c. immediate return of gastrointestinal
b. tolerance for soft diet immediately motility
after operation d. excessive gas formation noted upon
auscultation

SITUATION- 17 Mariza, a staff nurse in the surgical ward, has been assigned to take care of Mrs.
Jose a 58 year old client who has an endotracheal tube
81. Nurse Mariza’s objective is to improve client’s respiration after she noted thickened tenacious
secretions. To loosen the secretions, the MOST appropriate nursing intervention is to:
a. instill mucomyst into the endotracheal tube and frequently turn client unless
contraindicated
b. administer humidified oxygen and place in side lying or prone position unless
contraindicated
c. increase fluid intake and ask client to do deep breathing and coughing exercises
d. Assess client’s respiratory status and perform clapping to loosen secretions.
82. Nurse Mariza performs endotracheal suctioning. The nurse appropriately does the suctioning
procedure when she perform which of the following:
a. rotates the catheter gently and suctions for not more than 10 seconds each time
b. observes and records the amount and character of the secretions after each suctioning
c. assesses the respiratory and circulatory status after cluster of 5-8 times suctioning
d. observes how long the client tolerates the catheter during the suctioning process
83. In the care of this client the nurse monitors the cuff pressure and takes care to reduce the
risk of tracheal issue necrosis by maintaining the cuff pressure to
a. 30-35mm Hg b. 10-15mm Hg c. 40-45mm Hg d. 20-25mm
Hg
84. When taking care of Mrs. Jose Mariza preforms oral and nasal care every 2 to 4 hours to
promote hygiene and comfort. As a precautionary measure for possible biting down of the oral
endotracheal tube the nurse should:
a. request an assistant to hold the c. provide humidified air prior to the
patient down procedure
b. use an oropharyngeal airway d. place the client on side lying position
85. The head nurse reminds Nurse Mariza about measures that must be strictly observed when
sanctioning the client through the endotracheal tube. This measure is:
a. turning on the suctioning apparatus during catheter insertion c. always use rubber gloves
when suctioning to prevent infection
b. suction by rotating 2 to 3 times before withdrawing the catheter d. hyper oxygenating the
client before and after the procedure

SITUATION 18- Client record is a structured device where all tasks concerning the diagnostic and
treatment process done on the client are documented. An account of what has occurred between
the client or the health care team has to be recorded once interaction has been undertaken.

86. An entry in the nurse notes for a client with urinary tract infection states: “Encouraged fluid
intake to 2,500 ml per day” Which description of the nurse’s statements applies?
a. it describes the amount of fluid intake c. it is incorrect as it lack’s accuracy of
desired measurement
b. it establishes accuracy using an exact d. it does not specify fluids allowed
measurement
87. The nurse is recording the treatments administered to her clients. The following information
should be included in her charting, EXCEPT:
a. health teaching c. time administered
b. client’s response compared to d. equipment used
previous treatment
88. A male nurse is giving a change of shift report for all clients in the medical unit at the nurse’s
station. During this reporting the nurse is expected to:
a. review the condition of the client by reading the documented information
b. report the condition of the client and compare with what the incoming staff need to know
c. provide significant information about the client as baseline for the next shift
d. read the data about the client objectivity
89. The nurse is preparing Mr. Nick Gomez for transfer from the Intensive Care Unit to his private
room. To promote continuity of care what information should be included in the transfer report?
1. Clients name age, physical and medical diagnosis and allergies
2. Correct health status of the client at the time of transfer
3. Any critical observation and intervention to help the receiving nurse
4. need for special treatment
a. 1 and 2 b. 3 and 4 c. 1,2,3 and 4 d. 1,2, and 4
90. Mr. Douglas Nava, a 55 year old executive, request the nurse if he can read his medical
records upon discharge. What is the MOST appropriate action of the nurse?
a. allow the client to read his chart because of his client’s right c. ask the client to write a
written request
b. tell the client that he is not allowed to read his chart d. refer the request of the
client to the physician
SITUATION 19- Nurse Carmen is coping with transition from student nurse to a professional nurse.
Along with accumulation of knowledge, skills and competencies she is leaving enough space for
her unique personality to develop. Using Benner’s Stages from Novice to Expert the following
questions apply.
91. Which of the following stages begins in nursing school?
a. Expert b. novice c. proficient d. advanced beginner
92. As a new graduate nurse Carmen begins nursing practice as a/an:
a. Novice b. proficient c. competent d. advanced beginner
93. Nurse Carmen’s performance as a new graduate is characterized as:
a. having feeling of mastery c. formulating principle
b. possessing intuitive grasps d. exhibiting rule-governed behavior
94. Nurse Carmen successfully passed the nurse licensure examination. She now enjoyed as staff
nurse in general hospital. How long will take approximately for Nurse Carmen to achieve the
competent level?
a. 12 months b. 18 months c. 6 months d. 30 months
95. In order to attain the expert level, nurse Carmen experience level should be:
a. Innovative b. state-of-the art c. extensive d. varied

SITUATION 20- Nurses are obliged to fulfill their responsibility and provide ethical and moral care
that demonstrates respect for others.
96. The nurse manager is preparing staff development classes for new nurses. Which of the
following should be include in relation to ethical decision making?
a. ethical decisions arrived at for client care are based on the recommended of family and
significant others
b. ethical decision making is based on knowledge, facts and strong commitment to right or
wrong
c. ethical decision making is the responsibility of the nurse alone
d. ethical decision making is based on the philosophy of individual values and beliefs
97. Ria, daughter of the client, refuse to inform her father about his diagnosis. The nurse is
concerned about whether or not she will tell the client about his diagnosis. This is an example of
an ethical:
a. conflict b. concern c. dilemma d. issue
98. After the client was informed by y\the physician that he is positive for stage IV cancer of the
prostate, he requested the nurse to withhold the information from his wife and children. Which of
the following is an appropriate action of the nurse?
a. encourage the client to tell his wife
b. refuse to do the request but offer support and guidance
c. pretend not to have understood the request and consult supervisor
d. ask patient to give her time to think about it and refer to the physician
99. When the nurse finished performing foot care on the client, she was requested to come back
to change the linen. The nurse changed the linen as requested by the client. The nurse is
demonstrating which of the following ethical rules?
a. non maleficence b. confidentiality c. justice d. fidelity
100. The nursing shift is over and the outgoing nurse was about to leave the unit when the
relative of the client called because the client fell out of bed. The nurse hurriedly went to the
client’s room to attend to the client. Which of the following ethical principles illustrate the action
of the nurse?

a. Justice b. autonomy c. beneficence d. non maleficence