FOUNDATION OF PROFESSIONAL NURSING PRACTICE part 1

FOUNDATION OF PROFESSIONAL NURSING

PRACTICE part 1

Situation 1 - Mr. Ibarra is assigned to the triage area and

while on duty, he assesses the condition of Mrs. Simon

who came in with asthma. She has difficulty breathing

and her respiratory rate is 40 per minute. Mr. Ibarra is

asked to inject the client epinephrine 0.3mg

subcutaneously

1. The indication for epinephrine injection for Mrs

Simon is to:

a. Reduce anaphylaxis

b. Relieve hypersensitivity to allergen

c. Relieve respirator distress due to bronchial spasm

d. Restore client’s cardiac rhythm

2. When preparing the epinephrine injection from an

ampule, the nurse initially:

a. Taps the ampule at the top to allow fluid to flow to

the base of the ampule

b. Checks expiration date of the medication ampule

c. Removes needle cap of syringe and pulls plunger to

expel air

d. Breaks the neck of the ampule with a gauze wrapped

around it

3. Mrs. Simon is obese. When administering a

subcutaneous injection to an obese patient, it is best

for the nurse to:

a Inject needle at a 15 degree angle' over the stretched

skin of the client

b. Pinch skin at the Injection site and use airlock

technique

c. Pull skin of patient down to administer the drug in a Z

track

d. Spread skin or pinch at the injection site and inject

needle at a 45-90 degree angle

4. When preparing for a subcutaneous injection, the

proper size of syringe and needle would be:

a. Syringe 3-5ml and needle gauge 21 to 23

b. Tuberculin syringe 1 mi with needle gauge 26 or 27

c. Syringe 2ml and needle gauge 22

d. Syringe 1-3ml and needle gauge 25 to 27

5. The rationale for giving medications through the

subcutaneous route is;

a. There are many alternative sites for subcutaneous

injection

b. Absorption time of the medicine is slower

c. There are less pain receptors in this area

d. The medication can be injected while the client is in

any position

Situation 2 - The use of massage and meditation to help

decrease stress and pain have been strongly

recommended based on documented testimonials.

6. Martha wants to do a study on, this topic. "Effects of

massage and meditation on stress and pain." The type

of research that best suits this topic is:

a. applied research

b. qualitative research

c. basic research

d. quantitative research

7. The type of research design that does not manipulate

independent variable is:

a. experimental design

b. quasi-experimental design

c. non-experimental design

d. quantitative design

8. This research topic has the potential to contribute to

nursing because it seeks to:

a. include new modalities of care

b. resolve a clinical problem

c. clarify an ambiguous modality of care

d. enhance client care

9. Martha does review of related literature for the

purpose of:

a. determine statistical treatment of data research

b. gathering data about what is already known or

unknown

c. to identify if problem can be replicated

d. answering the research question

10. Client’s rights should be protected when doing

research using human subjects. Martha identifies these

rights as follows EXCEPT:

a. right of self-determination

b. right to compensation

c. right of privacy

d. right not to be harmed

Situation 3 - Richard has a nursing diagnosis of

ineffective airway clearance related to excessive

secretions and is at risk for infection because of retained

secretions. Part of Nurse Mario's nursing care plan is to

loosen and remove excessive secretions in the airway,

11. Mario listens to Richard's bilateral sounds and finds

that congestion is in the upper lobes of the lungs. The

appropriate position to drain the anterior and posterior

apical segments of the lungs when Mario does

percussion would be:

a. Client lying on his back then flat on his abdomen on

Trendelenburg position

b. Client seated upright in bed or on a chair then leaning

forward in sitting position then flat on his back and on

his abdomen

c. Client lying flat on his back and then flat on his

abdomen

d. Client lying on his right then left side on

Trendelenburg position

12. When documenting outcome of Richard's treatment

Mario should include the following in his recording

EXCEPT:

a. Color, amount and consistent of sputum

b. Character of breath sounds and respirator/rate before

and after procedure

c. Amount of fluid intake of client before and after the

procedure

d. Significant changes in vital signs

13. When assessing Richard for chest percussion or

chest vibration and postural drainage Mario would

focus on the following EXCEPT:

a. Amount of food and fluid taken during the last meal

before treatment

b. Respiratory rate, breath sounds and location of

congestion

c. Teaching the client's relatives to perform 'the

procedure

d. Doctor's order regarding position restriction and

client's tolerance for lying flat

14. Mario prepares Richard for postural drainage and

percussion. Which of the flowing is a special

consideration when doing the procedure?

a. Respiratory rate of 16 to 20 per minute

b. Client can tolerate sitting and lying position

c. Client has no signs of infection

d. Time of fast food and fluid intake of the client

15. The purpose of chest percussion and vibration is to

loosen secretions in the lungs. The difference between

the procedure is;

a. Percussion uses only one hand white vibration uses

both hands

b. Percussion delivers cushioned blows to the chest with

cupped palms while gently shakes secretion loose on the

exhalation cycle

c. In both percussion and vibration the hands are on top

of each other and hand action is in tune with client's

breath rhythm

d. Percussion slaps the chest to loosen secretions while

vibration shakes the secretions along with the inhalation

of air

Situation 4 - A 61 year old man, Mr. Regalado, is

admitted to the private ward for observation; after

complaints of severe chest pain. You are assigned to take

care of the client.

16. When doing an initial assessment, the best way for

you to identify the client’s priority problem is to:

a. Interview the client for chief complaints and other

symptoms

b. Talk to the relatives to gather data about history of

illness

c. Do auscultation to check for chest congestion

d. Do a physical examination white asking the client

relevant questions

17. Upon establishing Mr. Regalado's nursing needs,

the next nursing approach would be to:

a. introduce the client to the ward staff to put the client

and family at ease

b. Give client and relatives a brief tour of the physical set

up the unit

c. Take his vital signs for a baseline assessment

d. Establish priority needs and implement appropriate

interventions

18. Mr. Regalado says he has "trouble going to sleep".

In order to plan your nursing intervention you will.

a. Observe his sleeping patterns in the next few days

b. Ask him what he means by this statement

c. Check his physical environment to decrease noise level

d. Take his blood pressure before sleeping and upon

waking up

19. Mr. Regalado's lower extremities are swollen and

shiny. He has pitting pedal edema. When taking care of

Mr. Regalado, which of the following intervention

would be the most appropriate immediate nursing

approach.

a. Moisturize lower extremities to prevent skin irritation

b. Measure fluid intake and output to decrease edema

c. Elevate lower extremities for postural drainage

d. Provide the client a list of food low in sodium

20. Mr. Regalado will be discharged from your unit

within the hour. Nursing actions when preparing a

client for discharge include all EXCEPT:

a. Making a final physical assessment before client

leaves the hospital

b. Giving instructions about his medication regimen

c. Walking the client to the hospital exit to ensure his

safety

d. Proper recording of pertinent data

Situation 5 - Nancy, mother of 2 young kids. 36 years old,

had a mammogram and was told that she has breast

cysts and that she may need surgery. This causes her

anxiety as shown by increase in her pulse and respiratory

rate, sweating and feelings of tension.

21. Considering her level of anxiety, the nurse can best

assist Nancy by:

a. Giving her activities to divert her attention

b. Giving detailed explanations about the treatments she

will undergo

c. Preparing her and her family in case surgery is not

successful

d. Giving her clear but brief information at the level of

her understanding

22. Nancy blames God for her situation. She is easily

provoked to tears and wants to be left alone, refusing

to eat or talk to her family. A religious person before,

she now refuses to pray or go to church stating that

God has abandoned her. The nurse understands that

Nancy is grieving for her self and is in the stage of:

a. bargaining

b. denial

c. anger

d. acceptance

23. The nurse visits Nancy and prods her to eat her

food. Nancy replies "what's the use? My time is running

out. The nurse's best response would be:

a. "The doctor ordered full diet for you so that you will

be strong for surgery."

b. "I understand how you fee! but you have 1o try for

your children's sake."

c. "Have you told your, doctor how you feel? Are you

changing your mind) about surgery?"

d. "You sound like you are giving up."

24. The nurse feels sad about Nancy's illness and tells

her head nurse during the end of shift endorsement

that "it's unfair for Nancy to have cancer when she is

still so young and with two kinds. The best response of

the head nurse would be:

a. Advise the nurse to "be strong and learn to control her

feelings"

b. Assign the nurse to another client to avoid sympathy

for the client

c. Reassure the nurse that the client has hope if she goes

through all statements prescribed for her

c. Ask the other nurses what they feel about the patient

to find out if they share the same feelings

25. Realizing that she feels angry about Nancy's

condition, the nurse Seams that being self-aware is a

conscious process that she should do in any situation

like this because:

a. This is a necessary part of the nurse -client

relationship process

b. The nurse is a role model for the client and should be

strong

C. How the nurse thinks and feels affect her actions

towards her client and her work

d. The nurse has to be therapeutic at all times and

should not be affected

Situation 6 – Mrs. Seva, 32 years old, asks you about

possible problems regarding her elimination now that

she is in the menopausal stage.

26. Instruction on health promotion regarding urinary

elimination is important. Which would you include?

a. Hold urine, as long as she can before emptying the

bladder to strengthen her sphincters muscles

b. If burning sensation is experienced while voiding,

drink pineapple-juice

c. After urination, wipe from anal area up towards the

pubis

d. Jell client to empty the bladder at each voiding

27. Mrs. Seva also tells the nurse that she is often

constipated. Because she is aging, what physical

changes predispose her to constipation?

a. inhibition of the parasympathetic reflex

b. weakness of sphincter muscles of the anus

c. loss of tone of the smooth muscles of the color

d. decreased ability to absorb fluids in the lower

intestines

28. The nurse understands that one of these factors

contributes to constipation:

a. excessive exercise

b. high fiber diet

c. no regular tine for defecation daily

d. prolonged use of laxatives

29. Mrs. Seva talks about rear of being incontinent due

to a prior experience of dribbling urine when laughing

or sneezing and when she has a full bladder. Your most

appropriate .instruction would be to:

a. tell client to drink less fluids to avoid accidents

b. instruct client to start wearing thin adult diapers

c. ask the client to bring change of underwear "just in

case"

d. teach client pelvic exercise to strengthen perineal

muscles

30. Mrs. Seva asked for instructions for skin care for her

mother who has urinary incontinence and is almost

always in bed. Your instruction would focus on

prevention of skin irritation and breakdown by

a. Using thick diapers to absorb urine well

b. Drying the skin with baby powder to prevent or mask

the smell of ammonia

c. Thorough washing, rising and during of skin area that

get wet with urine

d. Making sure that linen are smooth and dry at all times

Situation 7 - 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.

31. Which of these clients has a problem with the

transport of oxygen from the lungs to the tissues:

a. Carol with a tumor in the brain

b. Theresa with anemia

c. Sonny Boy with a fracture in the femur

d. Brigette with diarrhea

32. You noted from the lab exams in the chart of Mr.

Santos that he has reduced oxygen in the blood.

This condition is called:

a. Cyanosis

b. Hypoxia

c. Hypoxemia

d. Anemia

33. You will nasopharyngeal suctioning Mr. Abad. 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 cheek

c. the distance from the tip of the nose to the tip of the

ear lobe

d. eight to ten inches

34. While doing nasopharyngeal suctioning on .Mr.

Abad, 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 inserted with gentle suction

35. Myrna 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

b. Orthopnea

c. Dyspnea

d. Tachypnea

Situation 8 - You are assigned to screen for

hypertension: Your task is to take blood pressure

readings and you are informed about avoiding the

common mistakes in BP taking that lead to 'false or

inaccurate blood pressure readings.

36. When taking blood pressure reading the cuff should

be:

a. deflated fully then immediately start second reading

for same client

b deflated quickly after inflating up to 180 mmHg

c. large enough to wrap around upper arm of the adult

client 1 cm above brachial artery

d. inflated to 30 mmHg above the estimated systolic BP

based on palpation of radial or bronchial artery

37. Chronic Obstructive Pulmonary Disease (COPD) in

one of the leading causes of death worldwide and is a

preventable disease. The primary cause of COPD is:

a. tobacco hack

b. bronchitis

c. asthma

d. cigarette smoking

38. In your health education class for clients with

diabetes you teach, them the areas, for control .

Diabetes which include all EXCEPT:

a. regular physical activity

b. thorough knowledge of foot care

c. prevention nutrition

d. proper nutrition

39. You teach your clients the difference between, Type

I (IDDM) and Type II (NDDM) Diabetes. Which of the

following is true?

a. both types diabetes mellitus clients are all prone to

developing ketosis

b. Type II (NIDDM) is more common and is also

preventable compared to Type I (IDDM) diabetes which

is genetic in etiology

c. Type I (IDDM) is characterized by fasting

hyperglycemia

d. Type II (IDDM) is characterized by abnormal immune

response

40. Lifestyle-related diseases in general share areas

common risk factors. These are the following except

a. physical activity

b. smoking

c. genetics

d. nutrition

Situation 9 - Nurse Rivera witnesses a vehicular accident

near the hospital where she works. She decides to get

involved and help the victims of the accident.

41. Her priority nursing action would be to:

a. Assess damage to property

b. Assist in the police investigation since she is a witness

c. Report the incident immediately to the local police

authorities

d. Assess the extent of injuries incurred by the victims, of

the accident

42. Priority attention should be given to which of these

clients?

a. Linda who shows severe anxiety due to trauma of the

accident

b. Ryan who has chest injury, is pate and with difficulty

of breathing

c. Noel who has lacerations on the arms with mildbleeding

c. Andy whose left ankle swelled and has some abrasions

43. In the emergency room, Nurse Rivera is assigned to

attend to the client with .lacerations on the arms, while

assessing the extent of the wound the nurse observes

that the wound is now starting to bleed profusely. The

most immediate nursing action would be to:

a. Apply antiseptic to prevent infection

b. Clean the wound vigorously of contaminants

c. Control and. reduce bleeding of the wound

d. Bandage the wound and elevate the arm

44. The nurse applies pressure dressing on the bleeding

site. This intervention is done to:

a. Reduce the need to change dressing frequently

b. Allow the pus to surface faster

c. Protect the wound from micro organisms in the air

d. Promote hemostasis

45. After the treatment, the client is sent home and

asked to come back for follow-up care. Your

responsibilities when the client is to be discharged

include the following EXCEPT:

a. Encouraging the client to go to the, outpatient clinic

for follow up care

b. Accurate recording, of treatment done and

instructions given to client

c. Instructing the client to see you after discharge for

further assistance

d. Providing instructions regarding wound care

Situation 10 - While working in the clinic, a new client,

Geline, 35 years old, arrives for her doctor's

appointment. As the clinic nurse, you are to assist the

client fiil up forms, gather data and make an assessment.

46. The nurse purpose of your initial nursing interview

is to:

a. Record pertinent information in the client chart for

health team to read

b Assist the client find solutions to her health concerns

c. Understand her lifestyle, health needs and possible

problems to develop a plan of care

d. Make nursing diagnoses for identified health problems

47. While interviewing Geline, she starts to moan and

doubles up in pain, She tells you that this pain occurs

about an hour after taking black coffee without

breakfast for a few weeks now. You will record this as

follows:

a. Claims to have abdominal pains after intake of coffee

unrelieved by analgesics

b. After drinking coffee, the client experienced severe

abdominal pain

c. Client complained of intermittent abdominal pain an

hour after drinking coffee

d. Client reported abdominal pain an hour after drinking

black coffee for three weeks now

48. Geline tells you that she drinks black coffee

frequently within the day to "have energy and be wide

awake" and she eats nothing for breakfast and eats

strictly vegetable salads for lunch and dinner to lose

weight. She has lost weight during the past two weeks,

in planning a healthy balanced diet with Geline, you

will:

a. Start her off with a cleansing diet to free her body of

toxins then change to a vegetarian, diet and drink plenty

of fluids

b. Plan a high protein, diet; low carbohydrate diet for her

considering her favorite food

c. Instruct her to attend classes in nutrition to find food

rich in complex carbohydrates to maintain daily high

energy level

d. Discuss with her the importance of eating a variety of

food from the major food groups with plenty of fluids

49. Geline tells you that she drinks 4-5 cups of black

coffee and diet cola drinks. She also smokes up to a

pack of cigarettes daily. She confesses that she is in her

2nd month of pregnancy but she does not want to

become fat that is why she limits her food intake. You

warn or caution her about which of the following?

a. Caffeine products affect the central nervous system

and may cause the mother to have a "nervous

breakdown"

b. Malnutrition and its possible effects on growth and

development problems in the unborn fetus

c. Caffeine causes a stimulant effect on both the mother

and the baby

d. Studies show conclusively that caffeine causes mental

retardation

50. Your health education plan for Geline stresses

proper diet for a pregnant woman and the prevention

of non-communicable diseases that are influenced by

her lifestyle these include of the following EXCEPT:

a. Cardiovascular diseases

b. Cancer

c. Diabetes Mellitus

d. Osteoporosis

Situation 11 - Management of nurse practitioners is

done by qualified nursing leaders who have had clinical

experience and management experience.