Situation 1: Using Maslow’s need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse’s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.
1. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
a. Aya with tumor in the brain
b. Sarah with anemia
c. Peter with a fracture in the femur
d. Susan with diarrhea
2. You noted from the lab exams in the chart of Mr. Aslan that he has reduced oxygen in the blood. This condition is called:
a. Cyanosis c. Hypoxemia
b. Hypoxia d. Anemia
3. You will do nasopharyngeal suctioning on Mr. Aslan. Your guide for the length of insertion of the tubing for an adult would be:
a. Tip of the nose to the base of the neck
b. The distance from the tip of the nose to the middle of the neck
c. The distance from the tip of the nose to the tip of the ear lobe
d. Eight to ten inches
4. While doing nasopharyngeal suctioning on Mr. Aslan, the nurse can avoid trauma to the area by:
a. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
b. Using gloves to prevent introduction of pathogens to the respiratory system
c. Applying no suction while inserting the catheter
d. Rotating catheter as it is inserter with gentle suction
5. Jessica has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. The nurse documents this condition as:
a. Apnea c. Dyspnea
b. Orthopnea d. Tachypnea
Situation 2. Nurses have both independent and dependent functions in the care of patients. The only dependent functions involve administration of medication and treatment.
6. Which of the following gauge of the needle is most appropriate for skin testing?
a. gauge 23 c. gauge 21
b. gauge 26 d. gauge 18
7. Mrs. Aquino was to receive an antibiotic intramuscularly. Which of the following factors might influence the nurse's decision on the route of administration?
a. Presence of kidney disorder
b. Client's age and level of alertness
c. Permeability of the skin surface
d. Condition of the muscle tissue
8. A 63 year old patient is to receive an insulin injection. Nurse Elaine knows that only small doses of medication are usually injected via the subcutaneous route. She is correct when she instill:
a. 0.5 ml b. 5 m c. 0.1 ml d. 0.01 ml
9. A 10 year old patient is to be given penicillin injection IM. Before it is carried out, skin testing has to be done. Which of the following is the direction of the needle during a skin testing?
a. 15 degree angle
b. 45 degree angle
c. Needle is almost parallel to the skin
d. 90 degree angle
10. Which of the following is the most preferred site in administering IM injection among infants and toddlers?
1. vastus lateralis 3. dorsogluteal
2. ventrogluteal 4. deltoid
a. 1 and 2 c. 1 and 4
b. 1 and 3 d. 2 and 4
Situation 3. When a person becomes ill, hygienic practices frequently becomes secondary to her functions. People who are ill often lack the energy to attend to their hygienic needs and therefore require assistance from the nurse in this aspect.
11. Which of the following hygienic care is most appropriate for the nurse to provide to her bedridden client during afternoons?
a. Changing clients pajamas
b. Assisting with a bed bath
c. Straightening bed linens
d. Providing back rub
12. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
a. Put the client on a side-lying position with head of bed lowered
b. Keep the client dry by placing towel under the chin
c. Wash hands and observe appropriate infection control
d. Clean mouth with oral swabs in a careful and an orderly progression
13. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?
a. Lemon glycerine
b. Hydrogen peroxide
c . Mineral oil
d. Normal saline solution
14. The advantages of oral care for a client include all of the following, EXCEPT:
a. Decreases bacteria in the mouth and teeth
b. Reduces need to use commercial mouthwash which irritate the buccal mucosa
c. Improves client’s appearance and self-confidence
d. Improves appetite and taste of food
15. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by:
a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
b. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
c. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums
d. Suctioning as needed while cleaning the buccal cavity
Situation 4. Proper food and nutrition are important factors that contribute to fast recovery and rehabilitation of clients. As such, meeting the nutritional needs of clients must be a major part of the nursing care plan.
16. Kilua, 55 years old, is undergoing dialysis once a week. He has a chronic renal problem and is on low sodium diet. Which of the following is most appropriate for him?
a. Arrozcaldo, melon, tea
b. Canned fish, fresh cucumber, diet coke
c. Ham and cheese sandwich, banana and coffee
d. Jollibee burger, papaya, ice tea
17. Gon, a hypertensive client in the OPD, is advised by the physician to have a low cholesterol diet. Which of the following menus would you best recommend?
a. Chicken salad, omelet, milk
b. Ampalaya salad, broiled fish, tea
c. Fried chicken, French fries, coffee
d. Broiled shrimp, steamed okra, coke
18. Leorio, a 3-year old child, is admitted due to diarrhea for 2 days. For a clear liquid diet, which of the following is best for the child?
a. Water c. Pedialyte
b. Orange juice d. Broth
19. Kurapika, a 10-month old baby, has had measles. He had loose bowel movement while in the hospital. Which of the following would you advice the mother to continue hydration therapy at home?
a. Rice based solution or “am”
b. Diluted soup and tea
c. Orange juice or coke
d. Discontinue breast milk
20. Which of the following should be included in the teaching plan for a client with ulcerative colitis who is about to be discharge?
1. High protein diet 3. High residue diet
2. Low protein diet 4. Bland diet
a. 2 and 4 c. 2 and 3
b. 1 and 4 d. 1 and 3
Situation 5. Nurse Hinata is assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility.
21. Naruto’s right leg is injured and nurse Hinata has to move him from the bed to the wheel chair. Which of the following is the appropriate nursing action of nurse Hinata?
a. Put the client on the edge of the bed and place the wheelchair at her back
b. Face the client and place the wheelchair on her left side
c. Put the client on the edge of the bed and place the wheelchair on the other side of the bed
d. Put the client on the edge of the bed and place the wheelchair on the client’s left side
22. Ino has to be maintained on a dorsal recumbent position. Which of the following should be prevented?
a. Adduction of the shoulder
b. Lateral flexion of the sternocleidomastoid muscle
c. Hyperextension of the knees
d. Anterior flexion of the lumbar curvature
23. Neji prefers to be in high fowler’s position most of the time. The nurse should prevent which of the following?
a. Posterior flexion of the lumbar curvature
b. Internal rotation of the shoulder
c. External rotation of the hip
d. Adduction of the shoulder
24. Gaara asks to be assisted to move up the bed. Which of the following should nurse Hinata do first?
a. Move the patient to the edge of the bed near the nurse
b. Adjust the bed to flat position
c. Lock the wheels of the bed
d. Raise the bed rails opposite the nurse
25. Which of the following supportive devices can be used most effectively by nurse Hinata to prevent external rotation of the right leg?
a. Sandbags c. Pillow
b. Firm mattress d. High foot board
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