NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE part 1

NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE

SITUATION: Nursing is a profession. The nurse should

have a background on the theories and foundation of

nursing as it influenced what is nursing today.

1. Nursing is the protection, promotion and

optimization of health and abilities, prevention

of illness and injury, alleviation of suffering

through the diagnosis and treatment of human

response and advocacy in the care of the

individuals, families, communities and the

population. This is the most accepted definition

of nursing as defined by the:

a. PNA

b. ANA

c. Nightingale

d. Henderson

2. Advancement in Nursing leads to the

development of the Expanded Career Roles.

Which of the following is NOT an expanded

career role for nurses?

a. Nurse practitioner

b. Nurse Researcher

c. Clinical nurse specialist

d. Nurse anaesthesiologist

3. The Board of Nursing regulated the Nursing

profession in the Philippines and is responsible

for the maintenance of the quality of nursing in

the country. Powers and duties of the board of

nursing are the following, EXCEPT:

a. Issue, suspend, revoke certificates of

registration

b. Issue subpoena duces tecum, ad

testificandum

c. Open and close colleges of nursing

d. Supervise and regulate the practice of

nursing

4. A nursing student or a beginning staff nurse who

has not yet experienced enough real situations

to make judgments about them is in what stage

of Nursing Expertise?

a. Novice

b. Newbie

c. Advanced Beginner

d. Competent

5. Benner’s “Proficient” nurse level is different

from the other levels in nursing expertise in the

context of having:

a. the ability to organize and plan activities

b. having attained an advanced level of

education

c. a holistic understanding and perception

of the client

d. intuitive and analytic ability in new

situations

SITUATION: The nurse has been asked to administer an

injection via Z TRACK technique. Questions 6 to 10 refer

to this.

6. The nurse prepares an IM injection for an adult

client using the Z track technique. 4 ml of

medication is to be administered to the client.

Which of the following site will you choose?

a. Deltoid

b. Rectus femoris

c. Ventrogluteal

d. Vastus lateralis

7. In infants 1 year old and below, which of the

following is the site of choice for intramuscular

Injection?

a. Deltoid

b. Rectus femoris

c. Ventrogluteal

d. Vastus lateralis

8. In order to decrease discomfort in Z track

administration, which of the following is

applicable?

a. Pierce the skin quickly and smoothly at

a 90 degree angle

b. Inject the medication steadily at around

10 minutes per millilitre

c. Pull back the plunger and aspirate for 1

minute to make sure that the needle did

not hit a blood vessel

d. Pierce the skin slowly and carefully at a

90 degree angle

9. After injection using the Z track technique, the

nurse should know that she needs to wait for a

few seconds before withdrawing the needle and

this is to allow the medication to disperse into

the muscle tissue, thus decreasing the client’s

discomfort. How many seconds should the nurse

wait before withdrawing the needle?

a. 2 seconds

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b. 5 seconds

c. 10 seconds

d. 15 seconds

10. The rationale in using the Z track technique in an

intramuscular injection is:

a. It decreases the leakage of discolouring

and irritating medication into the

subcutaneous tissues

b. It will allow a faster absorption of the

medication

c. The Z track technique prevent irritation

of the muscle

d. It is much more convenient for the nurse

SITUATION: A Client was rushed to the emergency room

and you are his attending nurse. You are performing a

vital sign assessment.

11. All of the following are correct methods in

assessment of the blood pressure EXCEPT:

a. Take the blood pressure reading on both

arms for comparison

b. Listen to and identify the phases of

Korotkoff’s sound

c. Pump the cuff to around 50 mmHg

above the point where the pulse is

obliterated

d. Observe procedures for infection control

12. You attached a pulse oximeter to the client. You

know that the purpose is to:

a. Determine if the client’s hemoglobin

level is low and if he needs blood

transfusion

b. Check level of client’s tissue perfusion

c. Measure the efficacy of the client’s antihypertensive

medications

d. Detect oxygen saturation of arterial

blood before symptoms of hypoxemia

develops

13. After a few hours in the Emergency Room, The

client is admitted to the ward with an order of

hourly monitoring of blood pressure. The nurse

finds that the cuff is too narrow and this will

cause the blood pressure reading to be:

a. inconsistent

b. low systolic and high diastolic

c. higher than what the reading should be

d. lower than what the reading should be

14. Through the client’s health history, you gather

that the patient smokes and drinks coffee. When

taking the blood pressure of a client who

recently smoked or drank coffee, how long

should the nurse wait before taking the client’s

blood pressure for accurate reading?

a. 15 minutes

b. 30 minutes

c. 1 hour

d. 5 minutes

15. While the client has pulse oximeter on his

fingertip, you notice that the sunlight is shining

on the area where the oximeter is. Your action

will be to:

a. Set and turn on the alarm of the

oximeter

b. Do nothing since there is no identified

problem

c. Cover the fingertip sensor with a towel

or bedsheet

d. Change the location of the sensor every

four hours

16. The nurse finds it necessary to recheck the blood

pressure reading. In case of such re assessment,

the nurse should wait for a period of:

a. 15 seconds

b. 1 to 2 minutes

c. 30 minutes

d. 15 minutes

17. If the arm is said to be elevated when taking the

blood pressure, it will create a:

a. False high reading

b. False low reading

c. True false reading

d. Indeterminate

18. You are to assessed the temperature of the

client the next morning and found out that he

ate ice cream. How many minutes should you

wait before assessing the client’s oral

temperature?

a. 10 minutes

b. 20 minutes

c. 30 minutes

d. 15 minutes

19. When auscultating the client’s blood pressure

the nurse hears the following: From 150 mmHg

to 130 mmHg: Silence, Then: a thumping sound

continuing down to 100 mmHg; muffled sound

continuing down to 80 mmHg and then silence.

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What is the client’s blood pressure?

a. 130/80

b. 150/100

c. 100/80

d. 150/100

20. In a client with a previous blood pressure of

130/80 4 hours ago, how long will it take to

release the blood pressure cuff to obtain an

accurate reading?

a. 10-20 seconds

b. 30-45 seconds

c. 1-1.5 minutes

d. 3-3.5 minutes

Situation: Oral care is an important part of hygienic

practices and promoting client comfort.

21. 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. Mineral oil

c. hydrogen peroxide

d. Normal saline solution

22. 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 sidelying position

with head of bed lowered

b. Keep the client dry by placing towel

under the chin

c. Wash hands and observes appropriate

infection control

d. Clean mouth with oral swabs in a careful

and an orderly progression

23. 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 selfconfidence

d. improves appetite and taste of food

24. 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 ums

d. suctioning as needed while cleaning the

buccal cavity

25. Your client has difficulty of breathing and is

mouth breathing most of the time. This causes

dryness of the mouth with unpleasant odor. Oral

hygiene is recommended for the client and in

addition, you will keep the mouth moistened by

using:

a. salt solution

b. petroleum jelly

c. water

d. mentholated ointment

Situation – Ensuring safety before, during and after a

diagnostic procedure is an important responsibility of

the nurse.

26. To help Fernan better tolerate the

bronchoscopy, you should instruct him to

practice which of the following prior to the

procedure?

a. Clenching his fist every 2 minutes

b. Breathing in and out through the nose

with his mouth open

c. Tensing the shoulder muscles while lying

on his back

d. Holding his breath periodically for 30

seconds

27. Following a bronchoscopy, which of the

following complains to Fernan should be noted

as a possible complication:

a. Nausea and vomiting

b. Shortness of breath and laryngeal

stridor

c. Blood tinged sputum and coughing

d. Sore throat and hoarseness

28. Immediately after bronchoscopy, you instructed

Fernan to:

a. Exercise the neck muscles

b. Refrain from coughing and talking

c. Breathe deeply

d. Clear his throat

29. Thoracentesis may be performed for cytologic

study of pleural fluid. As a nurse your most

important function during the procedure is to:

a. Keep the sterile equipment from

contamination

b. Assist the physician

c. Open and close the three-way stopcock

d. Observe the patient’s vital signs

30. Right after thoracentesis, which of the following

is most appropriate intervention?

a. Instruct the patient not to cough or deep

breathe for two hours

b. Observe for symptoms of tightness of

chest or bleeding

c. Place an ice pack to the puncture site

d. Remove the dressing to check for

bleeding

Situation: Knowledge of the acid-base disturbance and

the functions of the electrolytes is necessary to

determine appropriate intervention and nursing actions.

31. A client with diabetes milletus has a blood

glucose level of 644 mg/dL. The nurse interprets

that this client is at most risk for the

development of which type of acid-base

imbalance?

a. Respiratory acidosis

b. Respiratory alkalosis

c. Metabolic acidosis

d. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood

gas analysis gives the following results: pH 7.48,

PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L.

The nurse interprets that the client has which

acid base disturbance?

a. Respiratory acidosis

b. Metabolic acidosis

c. Respiratory alkalosis

d. Metabolic alkalosis

33. A client has an order for ABG analysis on radial

artery specimens. The nurse ensures that which

of the following has been performed or tested

before the ABG specimens are drawn?

a. Guthrie test

b. Romberg’s test

c. Allen’s test

d. Weber’s test

34. A nurse is reviewing the arterial blood gas values

of a client and notes that the ph is 7.31, Pco2 is

50 mmHg, and the bicarbonate is 27 mEq/L. The

nurse concludes that which acid base

disturbance is present in this client?

a. Respiratory acidosis

b. Metabolic acidosis

c. Respiratory alkalosis

d. Metabolic alkalosis

35. Allen’s test checks the patency of the:

a. Ulnar artery

b. Carotid artery

c. Radial artery

d. Brachial artery

Situation 6: Eileen, 45 years old is admitted to the

hospital with a diagnosis of renal calculi. She is

experiencing severe flank pain, nauseated and with a

temperature of 39 0C.

36. Given the above assessment data, the most

immediate goal of the nurse would be which of

the following?

a. Prevent urinary complication

b. maintains fluid and electrolytes

c. Alleviate pain

d. Alleviating nausea

37. After IVP a renal stone was confirmed, a left

nephrectomy was done. Her post-operative

order includes “daily urine specimen to be sent

to the laboratory”. Eileen has a foley catheter

attached to a urinary drainage system. How will

you collect the urine specimen?

a. remove urine from drainage tube with

sterile needle and syringe and empty

urine from the syringe into the

specimen container

b. empty a sample urine from the

collecting bag into the specimen

container

c. Disconnect the drainage tube from the

indwelling catheter and allow urine to

flow from catheter into the specimen

container.

d. Disconnect the drainage from the

collecting bag and allow the urine to

flow from the catheter into the

specimen container.

38. Where would the nurse tape Eileen’s indwelling

catheter in order to reduce urethral irritation?

a. to the patient’s inner thigh

b. to the patient’ buttocks

c. to the patient’s lower thigh

d. to the patient lower abdomen

39. Which of the following menu is appropriate for

one with low sodium diet?

a. instant noodles, fresh fruits and ice tea

b. ham and cheese sandwich, fresh fruits

and vegetables

c. white chicken sandwich, vegetable

salad and tea

d. canned soup, potato salad, and diet soda

40. How will you prevent ascending infection to

Eileen who has an indwelling catheter?

a. see to it that the drainage tubing

touches the level of the urine

b. change he catheter every eight hours

c. see to it that the drainage tubing does

not touch the level of the urine

d. clean catheter may be used since

urethral meatus is not a sterile area

Situation: Hormones are secreted by the various glands

in the body. Basic knowledge of the endocrine system is

necessary.

41. Somatocrinin or the Growth hormone releasing

hormone is secreted by the:

a. Hypothalamus

b. Posterior pituitary gland

c. Anterior pituitary gland

d. Thyroid gland

42. All of the following are secreted by the anterior

pituitary gland except:

a. Somatotropin/Growth hormone

b. Thyroid stimulating hormone

c. Follicle stimulating hormone

d. Gonadotropin hormone releasing

hormone

43. All of the following hormones are hormones

secreted by the Posterior pituitary gland except:

a. Vasopressin

b. Anti-diuretic hormone

c. Oxytocin

d. Growth hormone

44. Calcitonin, a hormone necessary for calcium

regulation is secreted in the:

a. Thyroid gland

b. Parathyroid gland

c. Hypothalamus

d. Anterior pituitary gland

45. While Parathormone, a hormone that negates

the effect of calcitonin is secreted by the:

a. Thyroid gland

b. Parathyroid gland

c. Hypothalamus

d. Anterior pituitary gland

Situation: The staff nurse supervisor requests all the staff

nurses to “brainstorm” and learn ways to instruct

diabetic clients on self-administration of insulin. She

wants to ensure that there are nurses available daily to

do health education classes.

46. The plan of the nurse supervisor is an example of

a. in service education process

b. efficient management of human

resources

c. increasing human resources

d. primary prevention

 47. When Mrs. Guevarra, a nurse, delegates aspects

of the clients care to the nurse-aide who is an

unlicensed staff, Mrs. Guevarra

a. makes the assignment to teach the staff

member

b. is assigning the responsibility to the

aide but not the accountability for

those tasks

c. does not have to supervise or evaluate

the aide

d. most know how to perform task

delegated

48. Connie, the new nurse, appears tired and

sluggish and lacks the enthusiasm she had six

weeks ago when she started the job. The nurse

supervisor should

a. empathize with the nurse and listen to

her

b. tell her to take the day off

c. discuss how she is adjusting to her new

job

d. ask about her family life

49. Process of formal negotiations of working

conditions between a group of registered nurses

and employer is

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a. grievance

b. arbitration

c. collective bargaining

d. strike

50. You are attending a certification on

cardiopulmonary resuscitation (CPR) offered and

required by the hospital employing you. This is

a. professional course towards credits

b. in-service education

c. advance training

d. continuing education