51. When
caring for a male client with a 3-cm stage I
pressure
ulcer on the coccyx, which of the
following
actions can the nurse institute
independently?
a. Massaging
the area with an astringent
every 2
hours.
b. Applying
an antibiotic cream to the area
three times
per day.
c. Using
normal saline solution to clean the
ulcer and
applying a protective dressing
as
necessary.
d. Using a
povidone-iodine wash on the
ulceration
three times per day.
52. Nurse
Oliver must apply an elastic bandage to a
client’s
ankle and calf. He should apply the
bandage
beginning at the client’s:
a. Knee
b. Ankle
c. Lower
thigh
d. Foot
53. A 10
year old child with type 1 diabetes develops
diabetic
ketoacidosis and receives a continuous
insulin
infusion. Which condition represents the
greatest
risk to this child?
a.
Hypernatremia
b.
Hypokalemia
c.
Hyperphosphatemia
61
d.
Hypercalcemia
54. Nurse
Len is administering sublingual nitrglycerin
(Nitrostat)
to the newly admitted client.
Immediately
afterward, the client may
experience:
a. Throbbing
headache or dizziness
b.
Nervousness or paresthesia.
c.
Drowsiness or blurred vision.
d. Tinnitus
or diplopia.
55. Nurse
Michelle hears the alarm sound on the
telemetry
monitor. The nurse quickly looks at
the monitor
and notes that a client is in a
ventricular
tachycardia. The nurse rushes to the
client’s
room. Upon reaching the client’s
bedside, the
nurse would take which action
first?
a. Prepare
for cardioversion
b. Prepare
to defibrillate the client
c. Call a
code
d. Check the
client’s level of consciousness
56. Nurse
Hazel is preparing to ambulate a female
client. The
best and the safest position for the
nurse in
assisting the client is to stand:
a. On the
unaffected side of the client.
b. On the
affected side of the client.
c. In front
of the client.
d. Behind
the client.
57. Nurse
Janah is monitoring the ongoing care
given to the
potential organ donor who has been
diagnosed
with brain death. The nurse
determines
that the standard of care had been
maintained
if which of the following data is
observed?
a. Urine
output: 45 ml/hr
b. Capillary
refill: 5 seconds
c. Serum pH:
7.32
d. Blood
pressure: 90/48 mmHg
58. Nurse
Amy has an order to obtain a urinalysis
from a male
client with an indwelling urinary
catheter.
The nurse avoids which of the
following,
which contaminate the specimen?
a. Wiping
the port with an alcohol swab
before
inserting the syringe.
b.
Aspirating a sample from the port on the
drainage
bag.
c. Clamping
the tubing of the drainage bag.
d. Obtaining
the specimen from the urinary
drainage
bag.
59. Nurse
Meredith is in the process of giving a
client a bed
bath. In the middle of the
procedure,
the unit secretary calls the nurse on
the intercom
to tell the nurse that there is an
emergency
phone call. The appropriate nursing
action is
to:
a.
Immediately walk out of the client’s
room and
answer the phone call.
b. Cover the
client, place the call light
within
reach, and answer the phone call.
c. Finish the
bed bath before answering
the phone
call.
d. Leave the
client’s door open so the client
can be
monitored and the nurse can
answer the
phone call.
60. Nurse
Janah is collecting a sputum specimen for
culture and
sensitivity testing from a client who
has a
productive cough. Nurse Janah plans to
implement
which intervention to obtain the
specimen?
a. Ask the
client to expectorate a small
amount of
sputum into the emesis basin.
b. Ask the
client to obtain the specimen
after
breakfast.
c. Use a
sterile plastic container for
obtaining
the specimen.
d. Provide
tissues for expectoration and
obtaining
the specimen.
61. Nurse
Ron is observing a male client using a
walker. The
nurse determines that the client is
using the
walker correctly if the client:
a. Puts all the
four points of the walker flat
on the
floor, puts weight on the hand
pieces, and
then walks into it.
b. Puts
weight on the hand pieces, moves
the walker
forward, and then walks into
it.
c. Puts
weight on the hand pieces, slides
the walker
forward, and then walks into it.
d. Walks
into the walker, puts weight on
the hand
pieces, and then puts all four
points of
the walker flat on the floor.
62. Nurse
Amy has documented an entry regarding
client care
in the client’s medical record. When
checking the
entry, the nurse realizes that
incorrect
information was documented. How
does the
nurse correct this error?
a. Erases
the error and writes in the correct
information.
b. Uses
correction fluid to cover up the
incorrect
information and writes in the
correct information.
c. Draws one
line to cross out the incorrect
information
and then initials the change.
d. Covers up
the incorrect information
completely
using a black pen and writes
in the
correct information
63. Nurse
Ron is assisting with transferring a client
from the
operating room table to a stretcher. To
provide
safety to the client, the nurse should:
a. Moves the
client rapidly from the table
to the
stretcher.
b. Uncovers
the client completely before
transferring
to the stretcher.
c. Secures
the client safety belts after
transferring
to the stretcher.
d. Instructs
the client to move self from the
table to the
stretcher.
64. Nurse
Myrna is providing instructions to a
nursing
assistant assigned to give a bed bath to a
client who
is on contact precautions. Nurse
Myrna
instructs the nursing assistant to use
which of the
following protective items when
giving bed
bath?
a. Gown and
goggles
b. Gown and
gloves
c. Gloves
and shoe protectors
d. Gloves
and goggles
65. Nurse
Oliver is caring for a client with impaired
mobility
that occurred as a result of a stroke. The
client has
right sided arm and leg weakness. The
nurse would
suggest that the client use which of
the
following assistive devices that would
provide the
best stability for ambulating?
a. Crutches
b. Single
straight-legged cane
c. Quad cane
d. Walker
66. A male
client with a right pleural effusion noted
on a chest
X-ray is being prepared for
thoracentesis.
The client experiences severe
dizziness
when sitting upright. To provide a safe
environment,
the nurse assists the client to
which
position for the procedure?
a. Prone
with head turned toward the side
supported by
a pillow.
b. Sims’
position with the head of the bed
flat.
c. Right
side-lying with the head of the bed
elevated 45
degrees.
d. Left
side-lying with the head of the bed
elevated 45
degrees.
67. Nurse
John develops methods for data
gathering.
Which of the following criteria of a
good
instrument refers to the ability of the
instrument
to yield the same results upon its
repeated
administration?
a. Validity
b.
Specificity
c.
Sensitivity
d.
Reliability
68. Harry
knows that he has to protect the rights of
human
research subjects. Which of the following
actions of
Harry ensures anonymity?
a. Keep the
identities of the subject secret
b. Obtain
informed consent
c. Provide
equal treatment to all the
subjects of
the study.
d. Release
findings only to the participants
of the study
69.
Patient’s refusal to divulge information is a
limitation
because it is beyond the control of
Tifanny”.
What type of research is appropriate
for this
study?
a.
Descriptive- correlational
b.
Experiment
c.
Quasi-experiment
d.
Historical
70. Nurse
Ronald is aware that the best tool for data
gathering
is?
a. Interview
schedule
b.
Questionnaire
c. Use of
laboratory data
d.
Observation
71. Monica
is aware that there are times when only
manipulation
of study variables is possible and
the elements
of control or randomization are
not
attendant. Which type of research is
referred to
this?
a. Field
study
b.
Quasi-experiment
c.
Solomon-Four group design
d. Post-test
only design
72. Cherry
notes down ideas that were derived from
the
description of an investigation written by the
person who
conducted it. Which type of
reference
source refers to this?
a. Footnote
b.
Bibliography
c. Primary
source
d. Endnotes
73. When
Nurse Trish is providing care to his
patient, she
must remember that her duty is
bound not to
do doing any action that will cause
the patient
harm. This is the meaning of the
bioethical
principle:
a.
Non-maleficence
b.
Beneficence
c. Justice
d.
Solidarity
74. When a
nurse in-charge causes an injury to a
female
patient and the injury caused becomes
the proof of
the negligent act, the presence of
the injury
is said to exemplify the principle of:
a. Force
majeure
b.
Respondeat superior
c. Res ipsa
loquitor
d. Holdover
doctrine
75. Nurse
Myrna is aware that the Board of Nursing
has
quasi-judicial power. An example of this
power is:
a. The Board
can issue rules and
regulations
that will govern the practice
of nursing
b. The Board
can investigate violations of
the nursing
law and code of ethics
c. The Board
can visit a school applying for
a permit in
collaboration with CHED
d. The Board
prepares the board
examinations
76. When the
license of nurse Krina is revoked, it
means that
she:
a. Is no longer
allowed to practice the
profession
for the rest of her life
b. Will
never have her/his license re-issued
since it has
been revoked
c. May apply
for re-issuance of his/her
license
based on certain conditions
stipulated
in RA 9173
d. Will
remain unable to practice
professional
nursing
77. Ronald
plans to conduct a research on the use of
a new method
of pain assessment scale. Which
of the
following is the second step in the
conceptualizing
phase of the research process?
a.
Formulating the research hypothesis
b. Review
related literature
c.
Formulating and delimiting the research
problem
d. Design
the theoretical and conceptual
framework
78. The
leader of the study knows that certain
patients who
are in a specialized research setting
tend to
respond psychologically to the
conditions
of the study. This referred to as :
a. Cause and
effect
b. Hawthorne
effect
c. Halo
effect
d. Horns
effect
79. Mary
finally decides to use judgment sampling
on her
research. Which of the following actions
of is
correct?
a. Plans to
include whoever is there during
his study.
b.
Determines the different nationality of
patients
frequently admitted and
decides to
get representations samples
from each.
c. Assigns
numbers for each of the
patients,
place these in a fishbowl and
draw 10 from
it.
d. Decides
to get 20 samples from the
admitted
patients
80. The
nursing theorist who developed
transcultural
nursing theory is:
a. Florence
Nightingale
b. Madeleine
Leininger
c. Albert
Moore
d. Sr.
Callista Roy
81. Marion
is aware that the sampling method that
gives equal
chance to all units in the population
to get
picked is:
a. Random
b.
Accidental
c. Quota
d. Judgment
82. John
plans to use a Likert Scale to his study to
determine
the:
a. Degree of
agreement and disagreement
b.
Compliance to expected standards
c. Level of
satisfaction
d. Degree of
acceptance
83. Which of
the following theory addresses the four
modes of
adaptation?
a. Madeleine
Leininger
b. Sr.
Callista Roy
c. Florence
Nightingale
d. Jean
Watson
84. Ms.
Garcia is responsible to the number of
personnel
reporting to her. This principle refers
to:
a. Span of
control
b. Unity of
command
c. Downward
communication
d. Leader
85. Ensuring
that there is an informed consent on
the part of
the patient before a surgery is done,
illustrates the
bioethical principle of:
a.
Beneficence
b. Autonomy
c. Veracity
d.
Non-maleficence
86. Nurse
Reese is teaching a female client with
peripheral
vascular disease about foot care;
Nurse Reese
should include which instruction?
a. Avoid
wearing cotton socks.
b. Avoid
using a nail clipper to cut toenails.
c. Avoid
wearing canvas shoes.
d. Avoid
using cornstarch on feet.
87. A client
is admitted with multiple pressure
ulcers. When
developing the client's diet plan,
the nurse
should include:
a. Fresh
orange slices
b. Steamed
broccoli
c. Ice cream
d. Ground
beef patties
88. The
nurse prepares to administer a cleansing
enema. What
is the most common client
position
used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’
left lateral
89. Nurse
Marian is preparing to administer a blood
transfusion.
Which action should the nurse take
first?
a. Arrange
for typing and cross matching of
the client’s
blood.
b. Compare
the client’s identification
wristband
with the tag on the unit of
blood.
c. Start an
I.V. infusion of normal saline
solution.
d. Measure
the client’s vital signs.
90. A 65
years old male client requests his
medication
at 9 p.m. instead of 10 p.m. so that
he can go to
sleep earlier. Which type of nursing
intervention
is required?
a.
Independent
b. Dependent
c.
Interdependent
d.
Intradependent
91. A female
client is to be discharged from an acute
care
facility after treatment for right leg
thrombophlebitis.
The Nurse Betty notes that
the client's
leg is pain-free, without redness or
edema. The
nurse's actions reflect which step of
the nursing
process?
a.
Assessment
b. Diagnosis
c.
Implementation
d.
Evaluation
92. Nursing
care for a female client includes
removing
elastic stockings once per day. The
Nurse Betty
is aware that the rationale for this
intervention?
a. To
increase blood flow to the heart
b. To
observe the lower extremities
c. To allow
the leg muscles to stretch and
relax
d. To permit
veins in the legs to fill with
blood.
93. Which
nursing intervention takes highest priority
when caring
for a newly admitted client who's
receiving a
blood transfusion?
a.
Instructing the client to report any
itching,
swelling, or dyspnea.
b. Informing
the client that the transfusion
usually take
1 ½ to 2 hours.
c.
Documenting blood administration in
the client
care record.
d. Assessing
the client’s vital signs when
the
transfusion ends.
94. A male
client complains of abdominal discomfort
and nausea
while receiving tube feedings. Which
intervention
is most appropriate for this
problem?
a. Give the
feedings at room temperature.
b. Decrease
the rate of feedings and the
concentration
of the formula.
c. Place the
client in semi-Fowler's position
while
feeding.
d. Change
the feeding container every 12
hours.
95. Nurse
Patricia is reconstituting a powdered
medication
in a vial. After adding the solution to
the powder,
she nurse should:
a. Do
nothing.
b. Invert
the vial and let it stand for 3 to 5
minutes.
c. Shake the
vial vigorously.
d. Roll the
vial gently between the palms.
96. Which
intervention should the nurse Trish use
when
administering oxygen by face mask to a
female
client?
a. Secure
the elastic band tightly around
the client's
head.
b. Assist
the client to the semi-Fowler
position if
possible.
c. Apply the
face mask from the client's
chin up over
the nose.
d. Loosen
the connectors between the
oxygen
equipment and humidifier.
97. The
maximum transfusion time for a unit of
packed red
blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
98. Nurse
Monique is monitoring the effectiveness
of a
client's drug therapy. When should the
nurse
Monique obtain a blood sample to
measure the
trough drug level?
a. 1 hour
before administering the next
dose.
b.
Immediately before administering the
next dose.
c.
Immediately after administering the
next dose.
d. 30 minutes
after administering the next
dose.
99. Nurse
May is aware that the main advantage of
using a
floor stock system is:
a. The nurse
can implement medication
orders
quickly.
b. The nurse
receives input from the
pharmacist.
c. The
system minimizes transcription
errors.
d. The
system reinforces accurate
calculations.
100. Nurse
Oliver is assessing a client's abdomen.
Which
finding should the nurse report as
abnormal?
a. Dullness
over the liver.
b. Bowel
sounds occurring every 10
seconds.
c. Shifting
dullness over the abdomen.
d. Vascular
sounds heard over the renal
arteries.
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