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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

CBQ:Common Board Questions

Situation – Archie 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 Jovie’s nursing care plan is to loosen and remove excessive secretions in the airway.

1. Jovie listens to Archie’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

2. When documenting outcome of Archie’s treatment Jovie should include the following in his recording EXCEPT:

A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs

3. When assessing Archie for chest percussion or chest vibration and postural drainage, Jovie 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 restrictions and client’s tolerance for lying flat

4. Jovie prepares Archie for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client

5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration 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 – 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.

6. 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 while asking the client relevant questions

7. 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

8. Which of the following ethical principles refers to the duty to do good?

A. Beneficence
B. Fidelity
C. Veracity
D. Nonmaleficence

9. During which step of the nursing process does the nurse analyze data related to the patient's health status?

A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation

10. The basic difference between nursing diagnoses and collaborative problems is that

A. nurses manage collaborative problems using physician-prescribed interventions.
B. collaborative problems can be managed by independent nursing interventions.
C. nursing diagnoses incorporate physician-prescribed interventions.
D. nursing diagnoses incorporate physiologic complications that nurses monitor to detect change in status.

Situation – Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.

11. 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 sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding

12. 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 anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines

13. The nurse understands that one of these factors contributes to constipation:

A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives

14. You will do nasopharyngeal suctioning on 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 neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches

situation– Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.

15. You are to measure the client’s initial blood pressure reading by doing all of the following 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

16. A pulse oximeter is attached to Mr. Dizon’s finger 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 anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

17. In which type of shock does the patient experiences a mismatch of blood flow to the cells?

A. Distributive
B. Cardiogenic
C. Hypovolemic
D. Septic

18. The preferred route of administration of medication in the most acute care situations is which of the following routes?

A. Intravenous
B. Epidural
C. Subcutaneous
D. Intramuscular

19. After a few hours in the Emergency Room, Mr. Dizon 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

20. Through the client’s health history, you gather that Mr. Dizon 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

21. 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

22. 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

23. To ensure client safety before starting blood transfusions the following are needed before the procedure can be done EXCEPT:

A. take baseline vital signs
B. blood should be warmed to room temperature for 30 minutes before blood transfusions is administered
C. have two nurses verify client identification, blood type, unit number and expiration date of blood
D. get consent signed for blood transfusion
24. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:

A. 1 tsp of salt/day with iodine and sprinkle of MSG
B. 5 gms per day or 1 tsp of table salt/day
C. 1 tbsp of salt/day with some patis and toyo
D. 1 tsp of salt/day but no patis and toyo

25. Which of the following methods is the best method for determining nasogastric tube placement in the stomach?

A. X-ray
B. Observation of gastric aspirate
C. Testing of pH of gastric aspirate
D. Placement of external end of tube under water

26. Which of the following is the most important risk factor for development of Chronic Obstructive Pulmonary Disease?

A. Cigarette smoking
B. Occupational exposure
C. Air pollution
D. Genetic abnormalities

27. When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

A. 10-15 seconds
B. 30-35 seconds
C. 20-25 seconds
D. 0-5 seconds

28. The nurse auscultates the apex beat at which of the following anatomical locations?

A. Fifth intercostal space, midclavicular line
B. Mid-sternum
C. 2” to the left of the lower end of the sternum
D. 1” to the left of the xiphoid process

29. Which of the following terms describes the amount of blood ejected per heartbeat?

A. Stroke volume
B. Cardiac output
C. Ejection fraction
D. Afterload

30. You are to apply a transdermal patch of nitoglycerin to your client. The following are important guidelines to observe EXCEPT:

A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand

31. The GAUGE size in ET tubes determines:

A. The external circumference of the tube
B. The internal diameter of the tube
C. The length of the tube
D. The tube’s volumetric capacity

32. The nurse is correct in performing suctioning when she applies the suction intermittently during:

A. Insertion of the suction catheter
B. Withdrawing of the suction catheter
C. both insertion and withdrawing of the suction catheter
D. When the suction catheter tip reaches the bifurcation of the trachea

33. The purpose of the cuff in Tracheostomy tube is to:

A. Separate the upper and lower airway
B. Separate trachea from the esophagus
C. Separate the larynx from the nasopharynx
D. Secure the placement of the tube


34. Which priority nursing diagnosis is applicable for a patient with indwelling urinary catheter?

A. Self esteem disturbance
B. Impaired urinary elimination
C. Impaired skin integrity
D. Risk for infection

35. An incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area. The best nursing goal for this client is to:

A. Make sure that the bed linen is always dry
B. Frequently check the bed for wetness and always keep it dry
C. Place a rubber sheet under the client’s buttocks
D. Keep the patient clean and dry

36. As a Nurse Manager, DMLM enjoys her staff of talented and self motivated individuals. She knew that the leadership style to suit the needs of this kind of people is called:

A. Autocratic
B. Participative
C. Democratic
D. Laissez Faire

37. A fire has broken in the unit of DMLM R.N. The best leadership style suited in cases of emergencies like this is:

A. Autocratic
B. Participative
C. Democratic
E. Laissez Faire

38. Which step of the management process is concerned with Policy making and Stating the goals and objective of the institution?

A. Planning
B. Organizing
C. Directing
D. Controlling

39. In the management process, the periodic checking of the results of action to make sure that it coincides with the goal of the institution is termed as:

A. Planning
B. Evaluating
C. Directing
D. Organizing

40. The Vision of a certain agency is usually based on their beliefs, Ideals and Values that directs the organization. It gives the organization a sense of purpose. The belief, Ideals and Values of this Agency is called:

A. Philosophy
B. Mission
C. Vision
D. Goals and Objectives

41. Mr. CKK is unconscious and was brought to the E.R. Who among the following can give consent for CKK’s Operation?

A. Doctor
B. Nurse
C. Next of Kin
D. The Patient

42. Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is no longer capable to do so. As a Nurse, You know that this is called:

A. Last will and testament
B. DNR
C. Living will
D. Durable Power of Attorney

43. Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

A. Give extraordinary measures to save Mang Carlos
B. Stay with Mang Carlos and Do nothing
C. Call the physician
D. Activate Code Blue

44. It is not a legally binding document but nevertheless, Very important in caring for the patients.

A. BON Resolution No. 220 Series of 2002
B. Patient’s Bill of Rights
C. Nurse’s Code of Ethics
D. Philippine Nursing Act of 2002

45. In monitoring the patient in PACU, the nurse correctly identify that checking the patient’s vital signs is done every:

A. 1 hour
B. 5 minutes
C. 15 minutes
D. 30 minutes

46. diannemayde R.N is conducting a research on her unit about the effects of effective nurse-patient communication in decreasing anxiety of post operative patients. Which of the following step in nursing research should she do next?

A. Review of related literature
B. Ask permission from the hospital administrator
C. Determine the research problem
D. Formulate ways on collecting the data

47. Before diannemaydee perform the formal research study, what do you call the pre testing, small scale trial run to determine the effectiveness of data collection and methodological problem that might be encountered?

A. Sampling
B. Pre testing
C. Pre Study
E. Pilot Study

48. On the study “effects of effective nurse-patient communication in decreasing anxiety of post operative patients” What is the Independent variable?

A. Effective Nurse-patient communication
B. Communication
C. Decreasing Anxiety
D. Post operative patient

49. On the study “effects of effective nurse-patient communication in decreasing anxiety of post operative patients” What is the Dependent variable?

A. Effective Nurse-patient communication
B. Communication
C. Anxiety level
D. Post operative patient

50. In the recent technological innovations, which of the following describe researches that are made to improve and make human life easier?

A. Pure research
B. Basic research
C. Applied research
D. Experimental research

51. Which of the following is not true about a Pure Experimental research?

A. There is a control group
B. There is an experimental group
C. Selection of subjects in the control group is randomized
D. There is a careful selection of subjects in the experimental group

52. 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

53. Process of formal negotiations of working conditions between a group of registered nurses and employer is

A. grievance
B. arbitration
C. collective bargaining
D. strike

54. 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. inservice education
C. advance training
D. continuing education

55. The law which regulated the practice of nursing profession in the Philippines is:

A. R.A 9173
B. LOI 949
C. Patient’s Bill of Rights
E. Code of Ethics for Nurses

56. This quality is being demonstrated by a Nurse who raise the side rails of a confuse and disoriented patient?

A. Autonomy
B. Responsibility
C. Prudence
D. Resourcefulness

57. Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the student. The case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of crimes. They are correct in identifying which of the following Circumstances that will be best applied in this case?

A. Justifying
B. Aggravating
C. Mitigating
D. Exempting

58. In signing the consent form, the nurse is aware that what is being observed as an ethical consideration is the patient’s

A. Autonomy
B. Justice
C. Accountability
D. Beneficence

59. Who among the following can work as a practicing nurse in the Philippines without taking the Licensure examination?

A. Internationally well known experts which services are for a fee
B. Those that are hired by local hospitals in the country
C. Expert nurse clinicians hired by prestigious hospitals
D. Those involved in medical mission who’s services are for free

60. Nurse Buddy gave Inapsine instead of Insulin to a patient in severe hyperglycemia. He reported the incident as soon as he knew there was an error. A nurse that is always ready to answer for all his actions and decision is said to be:

A. Accountable
B. Responsible
C. Critical thinker
D. Assertive

61.Which of the following best describes Primary Nursing?

A. Is a form of assigning a nurse to lead a team of registered nurses in care of patient from admission to discharge
B. A nurse is responsible in doing certain tasks for the patient
C. A registered nurse is responsible for a group of patients from admission to discharge
D. A registered nurse provides care for the patient with the assistant of nursing aides

62. The best and most effective method in times of staff and financial shortage is:

A. Functional Method
B. Primary Nursing
C. Team Nursing
E. Modular Method

63. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:

A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the PRN medication
B. Tell the nursing assistant to give the pain medication to the client complaining of pain
C. Tell the nursing assistant to go the client’s room and tell the client to wait
D. Finish the bed bath quickly then rush to the client in Pain

64. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is the best nursing intervention to prevent future falls?

A. Tell Angie not to get up from bed unassisted
B. Put the call bell within her reach
C. Put bedside commode at the bedside to prevent Angie from getting up
D. Put the bed in the lowest position ever

65. When injecting subcutaneous injection in an obese patient, It should be angled at around:

A. 45 °
B. 90 °
C. 180 °
D. Parallel to the skin
66. The following statements are all true about Z-Track technique except:

A. Z track injection prevent irritation of the subcutaneous tissues
B. The technique involve creating a Zig Zag like pattern of medication
C. It forces the medication to be contained at the subcutaneous tissues
D. It is used when administering Parenteral Iron


67. Communication is best undertaken if barriers are first removed. Considering this statement, which of the following is considered as deterrent factor in communication?

A. Not universally accepted abbreviations
B. Wrong Grammar
C. Poor Penmanship
D. Old age of the client

68. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Percussion, Palpation, Auscultation
C. Inspection, Palpation, Percussion, Auscultation
D. Inspection, Auscultation, Palpation, Percussion

69. To prevent injury and strain on the muscles, the nurse should observe proper body mechanics. Among the following, which is a principle of proper body mechanics?

A. Broaden the space between the feet
B. Push instead of pull
C. Move the object away from the body when lifting
D. Bend at the waist, not on the knees

70. . In taking the client’s blood pressure, the nurse should position the client’s arm:

A. At the level of the heart
B. Slightly above the level of the heart
C. At the 5th intercostals space midclavicular line
D. Below the level of the heart

71. What principle is used when the client with fever loses heat through giving cooling bed bath to lower body temperature?

A. Radiation
B. Convection
C. Evaporation
D. Conduction

72. The most effective way in limiting the number of microorganism in the hospital is:

A. Using strict aseptic technique in all procedures
B. Wearing mask and gown in care of all patients with communicable diseases
C. Sterilization of all instruments
D. Handwashing

73. The immunoglobulin of the mother that crosses the placenta to protect the child is an example of:

A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity


74. Richard is a subject of a research lead by his doctor. The nurse knows that all of the following is a correct understanding as his right as a research subject except:

A. I can withdraw with this research even after the research has been started
B. My confidentiality will not be compromised in this research
C. I must choose another doctor if I withdrew from this research
D. I can withdraw with this research before the research has been started

75. Which of the following is a normal finding during assessment of a Chest tube in a 3 way bottle system?

A. There is a continuous bubbling in the drainage bottle
B. There is an intermittent bubbling in the suction control bottle
C. The water fluctuates during inhalation of the patient
D. There is 3 cm of water left in the water seal bottle

76. In obtaining a urine specimen for culture and sensitivity on a catheterized patient, the nurse is correct if:

A. Clamp the catheter for 30 minutes, Alcoholize the tube above the clamp site, Obtain a sterile syringe and draw the specimen on the tube above the clamp
B. Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self sealing port
C. Disconnect the drainage bag, obtain a sterile syringe and draw the specimen from the drainage bag
D. Disconnect the tube, obtain a sterile syringe and draw the specimen from the tube

77. Which of the following is an example of secondary prevention?

A. Teaching the diabetic client on obtaining his blood sugar level using a glucometer
B. Screening patients for hypertension
C. Immunizing infants with BCG
D. Providing PPD on a construction site

78. Which of the following is a form of primary prevention?

A. Regular Check ups
B. Regular Screening
C. Self Medication
D. Immunization

79. An abnormal condition in which a person must sit, stand or use multiple pillows when lying down is:

A. Orthopnea
B. Dyspnea
C. Eupnea
D. Apnea

80. As a nurse assigned for care for geriatric patients, you need to frequently assess your patient using the nursing process. Which of the following needs be considered with the highest priority?

A. Patients own feeling about his illness
B. Safety of the client especially those elderly clients who frequently falls
C. Nutritional status of the elderly client
D. Physiologic needs that are life threatening

81. The component that should receive the highest priority before physical examination is the:

A. Psychological preparation of the client
B. Physical Preparation of the client
C. Preparation of the Environment
D. Preparation of the Equipments

82. Legally, Patients chart are:

A. Owned by the government since it is a legal document
B. Owned by the doctor in charge and should be kept from the administrator for whatever reason
C. Owned by the hospital and should not be given to anyone who request it other than the doctor in charge
D. Owned by the patient and should be given by the nurse to the client as requested

83. Which of the following categories identifies the focus of community/public health nursing practice?

A. Promoting and maintaining the health of populations and preventing and minimizing the progress of disease
B. Rehabilitation and restorative services
C. Adaptation of hospital care to the home environment
D. Hospice care delivery

84. A major goal for home care nurses is

A. restoring maximum health function.
B. promoting the health of populations.
C. minimizing the progress of disease.
D. maintaining the health of populations.

85. A written nursing care plan is a tool that:

A. Check whether nursing care goals were achieved
B. Gives quality nursing care
C. Select the appropriate nursing intervention
D. Make a nursing diagnosis

86. Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:

A. Beneficence
B. Non malfeasance
C. Justice
D. Double effect

Situation – There are various developments in health education that the nurse should know about:

87. The provision of health information in the rural areas nationwide through television and radio programs and video conferencing is referred to as:

A. Community health program
B. Telehealth program
C. Wellness program
D. Red Cross program

88. In teaching the sister of a diabetic client about the proper use of a glucometer in determining the blood sugar level of the client, The nurse is focusing in which domain of learning according to bloom?

A. Cognitive
B. Affective
C. Psychomotor
D. Affiliative

89. A nearby community provides blood pressure screening, height and weight measurement, smoking cessation classes and aerobics class services. This type of program is referred to as

A. outreach program
B. hospital extension program
C. barangay health program
D. wellness program

90. After cleaning the abrasions and applying antiseptic, the nurse applies cold compress to the swollen ankle as ordered by the physician. This statement shows that the nurse has correct understanding of the use of cold compress:

A. Cold compress reduces blood viscosity in the affected area
B. It is safer to apply than hot compress
C. Cold compress prevents edema and reduces pain
D. It eliminates toxic waste products due to vasodilation

91. After receiving prescription for pain medication, Ronnie is instructed to continue applying 30 minute cold at home and start 30 minute hot compress the next day. You explain that the use of hot compress:

A. Produces anesthetic effect
B. Increases nutrition in the blood to promote wound healing
C. Increase oxygenation to the injured tissues for better healing
D. Induces vasoconstriction to prevent infection

Situation – A nursing professor assigns a group of students to do data gathering by interviewing their classmates as subjects.

92 She instructed the interviewees not to tell the interviewees that the data gathered are for her own research project for publication. This teacher has violated the student’s right to:

A. Not be harmed
B. Disclosure
C. Privacy
D. Self-determination

93. Before the nurse researcher starts her study, she analyzes how much time, money, materials and people she will need to complete the research project. This analysis prior to beginning the study is called:

A. Validity
B. Feasibility
C. Reliability
D. Researchability

94. Data analysis is to be done and the nurse researcher wants to include variability. These include the following EXCEPT:

A. Variance
B. Range
C. Standards of Deviation
D. Mean
95. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

A. Within 4 days after discharge
B. Within 24 hours after discharge
C. Within 1 hour after discharge
D. Within 1 week of discharge

96. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of 1999 entitled: “Adoption of a Nursing Specialty Certification Program and Creation of Nursing Specialty Certification Council.” This rule-making power is called:

A. Quasi-Judicial Power
B. Regulatory Power
C. Quasi-Legislative Power
D. Executive/Promulgating Power

97. Anita is performing BSE and she stands in front of the Mirror. The rationale for standing in front of the mirror is to check for:

A. Unusual discharges coming out from the breast
B. Any obvious malignancy
C. The Size and Contour of the breast
D. Thickness and lumps in the breast


98. An emerging technique in screening for Breast Cancer in developing countries like the Philippines is:

A. Mammography once a year starting at the age of 50
B. Clinical BSE Once a year
C. BSE Once a month
D. Pap smear starting at the age of 18 or earlier if sexually active

99. Transmission of HIV from an infected individual to another person occurs:

A. Most frequently in nurses with needlesticks
B. Only if there is a large viral load in the blood
C. Most commonly as a result of sexual contact
D. In all infants born to women with HIV infection

100. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting

101. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:

A. Soften and efface the cervix
B. Numb cervical pain receptors
C. Prevent cervical lacerations
D. Stimulate uterine contractions

102. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?

A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.

103. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:

A. a woman has no uterus
B. a woman has no children
C. a couple has been trying to conceive for 1 year
D. a couple has wanted a child for 6 months

104. The correct temperature to store vaccines in a refrigerator is:

A. between -4 deg C and +8 deg C
B. between 2 deg C and +8 deg C
C. between -8 deg C and 0 deg C
D. between -8 deg C and +4 deg C

105. Which of the following vaccines is not done by intramuscular (IM) injection?

A. Measles vaccine
B. DPT
C. Hepa-B vaccine
D. Tetanus toxoids

106. This vaccine content is derived from RNA recombinants.

A. Measles
B. Tetanus toxoids
C. Hepatitis B vaccines
D. DPT
107. This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?

A. Nursing Kardex
B. Nursing Health History and Assessment Worksheet
C. Medicine and Treatment Record
D. Discharge Summary

108. These are sheets/forms which provide an efficient and time saving way to record information that must be obtained repeatedly at regular and/or short intervals of time. This does not replace the progress notes; instead this record of information on vital signs, intake and output, treatment, postoperative care, post partum care, and diabetic regimen, etc. This is used whenever specific measurements or observations are needed to be documented repeatedly. What is this?

A. Nursing Kardex
B. Graphic Flow Sheets
C. Discharge Summary
D. Medicine and Treatment Record

109. These records show all medications and treatment provided on a repeated basis. What do you call this record?

A. Nursing Health History and Assessment Worksheet
B. Discharge Summary
C. Nursing Kardex
D. Medicine and Treatment Record

110. This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in patient care and factors related to daily living activities. This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?

A. Discharge Summary
B. Medicine and Treatment Record
C. Nursing Health History and Assessment Worksheet
D. Nursing Kardex

111. Most nurses regard this conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?

A. Discharge Summary
B. Nursing Kardex
C. Medicine and Treatment Record
D. Nursing Health History and Assessment Worksheet

112. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability?

A. Human rights of clients, regardless of creed and gender
B. The privilege of being a registered professional nurses
C. Health, being a fundamental right of every individual
D. Accurate documentation of actions and outcomes

113. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing accredited through the:

A. Professional Regulation Commission
B. Nursing Specialty Certification Council
C. Association of Deans of Philippine Colleges of Nursing
D. Philippine Nurse Association

114. Integrated management for childhood illness is the universal protocol of care endorsed by WHO and is use by different countries of the world including the Philippines. In any case that the nurse classifies the child and categorized the signs and symptoms in PINK category, You know that this means:

A. Urgent referral
B. Antibiotic Management
C. Home treatment
D. Out patient treatment facility is needed


115. You know that fast breathing of a child age 13 months is observed if the RR is more than:

A. 40
B. 50
C. 60
D. 30

116. Angelo, An 8 month old child is brought to the health care facility with sunken eyes. You pinch his skin and it goes back very slowly. In what classification of dehydration will you categorize Angelo?

A. No Dehydration
B. Some Dehydration
C. Severe Dehydration
D. Diarrhea

117. In responding to the care concerns of children with severe disease, referral to the hospital is of the essence especially if the child manifests which of the following?

A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken

118. A child with ear problem should be assessed for the following, EXCEPT:

A. is there any fever?
B. Ear discharge
C. If discharge is present for how long?
D. Ear pain

119. If the child does not have ear problem, using IMCI, what should you as the nurse do?

A. Check for ear discharge
B. Check for tender swellings behind the ear
C. Check for ear pain
D. Go to the next question, check for malnutrition

120. All of the following are treatment for a child classified with no dehydration except:

A. 1,000 ml to 1,400 ml be given within 4 hours
B. Continue feeding
C. Have the child takes as much fluid as he wants
D. Return the child to the doctor if condition worsens

121. An ear infection that persists but still less than 14 days is classified as:

A. Mastoiditis
B. Chronic Ear Infection
C. Acute Ear Infection
D. Otitis Media

122. If a child has two or more pink signs, you would classify the child as having:

A. No disease
B. Mild form of disease
C. Urgent Referral
D. Very severe disease
123. The nurse knows that the most common complication of Measles is:

A Pneumonia and larynigotracheitis
B. Encephalitis
C. Otitis Media
D. Bronchiectasis

124. A client scheduled for hysterosalpingography needs health teaching before the procedure. The nurse is correct in telling the patient that:

A. She needs to void prior to the procedure
B. A full bladder is needed prior to the procedure
C. Painful sensation is felt as the needle is inserted
D. Flushing sensation is felt as the dye in injected

125. In a population of 9,500. What is your estimate of the population of pregnant woman needing tetanus toxoid vaccination?

A. 632.5
B. 512.5
C. 450.5
D. 332.5

126. All of the following are seen in a child with measles. Which one is not?

A. Reddened eyes
B. Coryza
C. Pustule
D. Cough

127. Mobilizing the people to become aware of their own problem and to do actions to solve it is called:

A. Community Organizing
B. Family Nursing Care Plan
C. Nursing Intervention
D. Nursing Process

128. Prevention of work related accidents in factories and industries are responsibilities of which field of nursing?

A. School health nursing
B. Private duty nursing
C. Occupational health nursing
D. Institutional nursing

129. In one of your home visit to Mr. JUN, you found out that his son is sick with cholera. There is a great possibility that other member of the family will also get cholera. This possibility is a/an:

A. Foreseeable crisis
B. Health threat
C. Health deficit
D. Crisis

130. Why is bleeding in the leg of a pregnant woman considered as an emergency?

A. Blood volume is greater in pregnant woman; therefore, blood loss is increased
B. There is an increase blood pressure during pregnancy increasing the likelihood of hemorrhage
C. Pregnant woman are anemic, all forms of blood loss should be considered as an emergency especially if it is in the lower extremity
D. The pressure of the gravid uterus will exert additional force thus, increasing the blood loss in the lower extremities

131. Aling Maria is nearing menopause. She is habitually taking cola and coffee for the past 20 years. You should tell Aling Maria to avoid taking caffeinated beverages because:

A. It is stimulating
B. It will cause nervousness and insomnia
C. It will contribute to additional bone demineralization
D. It will cause tachycardia and arrhythmias

132. All of the following are contraindication when giving Immunization except:

A. BCG Vaccines can be given to a child with AIDS
B. BCG Vaccine can be given to a child with Hepatitis B
C. DPT Can be given to a child that had convulsion 3 days after being given the first DPT Dose
D. DPT Can be given to a child with active convulsion or other neurological disease

133. Theresa, a mother with a 2 year old daughter asks, “at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?” Your answer to this is:

A. At 2 years you may
B. As early as 1 year old
C. When she’s 3 years old
D. When she’s 6 years old


134. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn?

A. Keeping infants in a warm and dark environment
B. Administration of cardiovascular stimulant
C. Gentle exercise to stop muscle breakdown
D. Early feeding to speed passage of meconium

135. The community/Public Health Bag is:
A. a requirement for home visits
B. an essential and indispensable equipment of the community health nurse
C. contains basic medications and articles used by the community health nurse
D. a tool used by the Community health nurse is rendering effective nursing procedures during a home visit
136. What is the rationale in the use of bag technique during home visits?

A. It helps render effective nursing care to clients or other members of the family
B. It saves time and effort of the nurse in the performance of nursing procedures
C. It should minimize or prevent the spread of infection from individuals to families
D. It should not overshadow concerns for the patient

137. In consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area?

A. The lower lip
B. The outer surface
C. The upper tip
D. The inside surface

138. How many words does a typical 12-month-old infant use?

A. About 12 words
B. Twenty or more words
C. About 50 words
D. Two, plus “mama” and “papa”

139. During operation, The OR suite’s lighting, noise, temperature and other factors that affects the operation are managed by whom?

A. Nurse Supervisor
B. Surgeon
C. Circulating nurse
D. Scrub nurse

140. Before and after the operation, the operating suite is managed by the:

A. Surgeon
B. Nurse Supervisor
C. Nurse Manager
D. Chief Nurse

141. The counting of sponges is done by the Surgeon together with the:

A. Circulating nurse
B. Scrub nurse
C. Assistant surgeon
D. Nurse supervisor

142. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss?

A. Scrub Nurse
B. Surgeon
C. Anaesthesiologist
D. Circulating Nurse

143. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR?

A. Rehabilitation department
B. Laboratory department
C. Maintenance department
D. Radiology department

144. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

A. Instruct client to observe strict bed rest
B. Check for epidural catheter drainage
C. Administer analgesia through epidural catheter as prescribed
D. Assess respiratory rate carefully

145. The patient’s medical record can work as a double edged sword. When can the medical record become the doctor’s/nurse’s worst enemy?

A. When the record is voluminous
B. When a medical record is subpoenaed in court
C. When it is missing
D. When the medical record is inaccurate, incomplete, and inadequate

146. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency?

A. Department of Interior and Local Government (DILG)
B. Metro Manila Development Authority (MMDA)
C. Records Management Archives Office (RMAO)
D. Department of Health (DOH)

147. In the hospital, when you need the medical record of a discharged patient for research you will request permission through:

A. Doctor in charge
B. The hospital director
C. The nursing service
D. Medical records section

148. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT:

A. Avoid emotional stress and extreme temperature
B. Avoid pollution like smoking
C. Avoid pollens, dust, seafood
D. Practice respiratory isolation

149. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?

A. Limit suppliers to a few so that quality is maintained
B. Implement a regular inventory of supplies and equipment
C. Adherence to manufacturer’s recommendation
D. Implement a regular maintenance and testing of alarm systems

150. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you improve the safety of using infusion pumps?

A. Check the functionality of the pump before use
B. Select your brand of infusion pump like you do with your cellphone
C. Allow the technician to set the infusion pump before use
D. Verify the flow rate against your computation

151. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?

A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse

152. When surgery is on-going, who coordinates the activities outside, including the family?

A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist

153. The breakdown in teamwork is often times a failure in:

A. Electricity
B. Inadequate supply
C. Leg work
D. Communication

154. To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:

A. Take a shower instead of tub baths
B. Avoid situations that involve physical activity
C. Continue the same restriction on fluid intake
D. Seek early treatment for respiratory infection

155. When administering Tapazole, The nurse should monitor the client for which of the following adverse effect?

A. Hyperthyroidism
B. Hypothyroidism
C. Drowsiness
D. Seizure

156. Post bronchoscopy, the nurse priority is to check which of the following before feeding?

A. Gag reflex
B. Wearing off of anesthesia
C. Swallowing reflex
D. Peristalsis


157. Changes normally occur in the elderly. Among the following, which is a normal change in an elderly client?

A. Increased sense of taste
B. Increased appetite
C. Urinary frequency
D. Thinning of the lens

158. Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition. NO Choices


159. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?

A. Apply liberal amount of mineral oil to the area
B. Use karaya paste and rings around the stoma
C. Clean the area daily with soap and water before applying bag
D. Apply talcum powder twice a day

160. What health instruction will enhance regulation of a colostomy (defecation) of clients?

A. Irrigate after lunch everyday
B. Eat fruits and vegetables in all three meals
C. Eat balanced meals at regular intervals
D. Restrict exercise to walking only

161. After ileostomy, which of the following condition is NOT expected?

A. Increased weight
B. Irritation of skin around the stoma
C. Liquid stool
D. Establishment of regular bowel movement

162. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

A. Increase the irrigating solution flow rate when abdominal cramps is felt
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Position client in semi-Fowler
D. Hang the solution 18 inches above the stoma

163. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

A. Sensation of taste
B. Sensation of pressure
C. Sensation of smell
D. Urge to defecate

164. In performing a cleansing enema, the nurse performs the procedure by positioning the client in:

A. Right lateral position
B. Left lateral position
C. Right sim’s position
D. Left sim’s position

165. Mang Caloy is scheduled to have a hemorrhoidectomy, after the operation, you would expect that the client’s position post operatively will be:

A. Knee chest position
B. Side lying position
C. Sims position
D. Genopectoral position

166. You would expect that after an abdominal perineal resection, the type of colostomy that will be use is?

A. Double barrel colostomy
B. Temporary colostomy
C. Permanent colostomy
D. An Ileostomy

169. You are an ostomy nurse and you know that colostomy is defined as:

A. It is an incision into the colon to create an artificial opening to the exterior of the abdomen
B. It is end to end anastomosis of the gastric stump to the duodenum
C. It is end to end anastomosis of the gastric stump to the jejunum
D. It is an incision into the ileum to create an artificial opening to the exterior of the abdomen

170. Symptoms associated with cancer of the colon include:

A. constipation, ascites and mucus in the stool
B. diarrhea, heart burn and eructation
C. blood in the stools, anemia, and “pencil shaped” stools
D. anorexia, hematemesis, and increased peristalasis

171. 24 Hours after creation of colostomy, Nurse Violy is correct if she identify that the normal appearance of the stoma is :

A. Pink, moist and slightly protruding from the abdomen
B. Gray, moist and slightly protruding from the the abdomen
C. Pink, dry and slightly protruding from the abdomen
D. Red, moist and slightly protruding from the abdomen

172. In cleaning the stoma, the nurse would use which of the following cleaning mediums?

A. Hydrogen Peroxide, water and mild soap
B. Providone Iodine, water and mild soap
C. Alcohol, water and mild soap
D. Mild soap and water

173. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable
174. As a nurse, you can help improve the effectiveness of communication among healthcare givers by:

A. Use of reminders of ‘what to do’
B. Using standardized list of abbreviations, acronyms, and symbols
C. One-on-one oral endorsement
D. Text messaging and e-mail

175. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics.

A. Hyperglycemia
B. Hypothermia
C. Hyperthermia
D. Hypoglycemia

176. Mang Edgardo has a chest tube inserted in place after a Lobectomy. The nurse knows that that Chest tube after this procedure will:

A. Prevents mediastinal shift
B. Promote chest expansion of the remaining lung
C. Drain fluids and blood accumulated post operatively
D. Remove the air in the lungs to promote lung expansion


177. Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions, EXCEPT:

A. straddling a chair with arms and head resting on the back of the chair
B. lying on the unaffected side with the bed elevated 30-40 degrees
C. lying prone with the head of the bed lowered 15-30 degrees
D. sitting on the edge of the bed with her feet supported and arms and head on a padded overhead table

178. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

A. to rule out pneumothorax
B. to rule out any possible perforation
C. to decongest
D. to rule out any foreign body

179. The RR nurse should monitor for the most common postoperative complication of:

A. hemorrhage
B. endotracheal tube perforation
C. osopharyngeal edema
D. epiglottis

180. The PACU nurse will maintain postoperative T and A client in what position?

A. Supine with neck hyperextended and supported with pillow
B. Prone with the head on pillow and turned to the side
C. Semi-fowler’s with neck flexed
D. Reverse trendelenburg with extended neck


181. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You as the RN will make sure that the family knows to:

A. offer osterized feeding
B. offer soft foods for a week to minimize discomfort while swallowing
C. supplement his diet with Vitamin C rich juices to enhance healing
D. offer clear liquid for 3 days to prevent irritation

Situation – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so that an A-V shunt was surgically created.

182. Which of the following action would be of highest priority with regards to the external shunt?

A. Avoid taking BP or blood sample from the arm with the shunt
B. Instruct the client not to exercise the arm with the shunt
C. Heparinize the shunt daily
D. Change dressing of the shunt daily

183. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:

A. Recommend protein of high biologic value like eggs, poultry and lean meats
B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
C. Allowing the client cheese, canned foods and other processed food
D. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet

184. The most common causative agent of Pyelonephritis in hospitalized patient attributed to prolonged catheterization is said to be:

A. E. Coli
B. Klebsiella
C. Pseudomonas
D. Staphylococcus


185. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you instructed her to force fluids and do which of the following?

A. Balanced diet
B. Ambulate more
C. Strain all urine
D. Bed rest

186. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be:

A. Structures beneath the skin are damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

187. During the first 24 hours after the thermal injury, you should asses Sergio for:

A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia

188. All of the following are instruction for proper foot care to be given to a client with peripheral vascular disease caused by Diabetes. Which is not?

A. Trim nail using nail clipper
B. Apply cornstarch to the foot
C. Always check for the temperature of the water before bathing
D. Use Canvas shoes

189. You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?

A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your supervisor

190. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found out that what is on record does not tally with the drugs used. Which among the following will you do first?

A. Write an incident report and refer the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any patient who might have been given narcotics

191. You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.

A. Start basic life support measures
B. Call for the Code
C. Bring the crash cart to the room
D. Go to see Fiolo and assess for airway patency and breathing problems

192. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

E. Lubricates the tip of the catheter prior to inserting into the stoma
F. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
G. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
H. Clamps of the flow of fluid when felling uncomfortable

193. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.”?

A. Recovery
B. Mitigation
C. Response
D. Preparedness

194. Which of the following terms refer to a process by which the individual receives education about recognition of stress reaction and management strategies for handling stress which may be instituted after a disaster?

A. Clinical incident stress management
B. Follow-up
C. Defriefing
D. Defusion

195. Fires are approached using the mnemonic RACE, in which, R stands for:

A. Run
B. Race
C. Rescue
D. Remove

196. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?

A. Administer bowel softener
B. Position Conrad with his head turned toward the side of the tumor
C. Provide sensory stimulation
D. Encourage coughing and deep breathing

197. Keeping Conrad’s head and neck alignment results in:

A. increased inthrathoracic pressure
B. increased venous outflow
C. decreased venous outflow
D. increased intrabdominal pressure

198. Earliest sign of skin reaction to radiation therapy is:

A. desquamation
B. erythema
C. atrophy
D. pigmentation

199. A guideline that is utilized in determining priorities is to asses the status of the following, EXCEPT:

A. perfusion C. respiration
B. locomotion D. mentation

200. Miss Kate is a bread vendor and you are buying a bread from her. You noticed that she receives and changes money and then hold the bread without washing her hand. As a nurse, What will you say to Miss Kate?

A. Miss, Don’t touch the bread I’ll be the one to pick it up
B. Miss, Please wash your hands before you pick up those breads
C. Miss, Use a pick up forceps when picking up those breads
D. Miss, Your hands are dirty I guess I’ll try another bread shop

201. In administering blood transfusion, what needle gauge is used?

A. 18
B. 22
C. 23
D. 24

202. Before administration of blood and blood products, the nurse should first:

A. Check with another R.N the client’s name, Identification number, ABO and RH type.
B. Explain the procedure to the client
C. Assess baseline vital signs of the client
D. Check for the BT order

203. The only IV fluid compatible with blood products is:

A. D5LR
B. D5NSS
C. NSS
D. Plain LR

204. In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention should focus on:

A. Slow the infusion, Call the physician and assess the patient
B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the physician
C. Stop the infusion, Call the physician and assess the client
D. Slow the confusion and keep a patent IV line open for administration of medication

205. The nurse knows that after receiving the blood from the blood bank, it should be administered within:

A. 1 hour
B. 2 hours
C. 4 hours
D. 6 hours

206. During blood administration, the nurse should carefully monitor adverse reaction. To monitor this, it is essential for the nurse to:

A. Stay with the client for the first 15 minutes of blood administration
B. Stay with the client for the entire period of blood administration
C. Run the infusion at a faster rate during the first 15 minutes
D. Tell the client to notify the staff immediately for any adverse reaction

207. As Leda’s nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include:

A. An airway and rebreathing tube
B. A tracheostomy set and oxygen
C. A crush cart with bed board
D. Two ampules of sodium bicarbonate


208. Which of the following nursing interventions is appropriate after a total thyroidectomy?

A. Place pillows under your patient’s shoulders.
B. Raise the knee-gatch to 30 degrees
C. Keep you patient in a high-fowler’s position.
D. Support the patient’s head and neck with pillows and sandbags.

209. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develop postoperatively?

A. Cardiac arrest C. Respiratory failure
B. Dyspnea D. Tetany

210. After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm. What would you anticipate to administer?

A. Magnesium sulfate C. Potassium iodide
B. Calcium gluconate D. Potassium chloride

211. NURSES are involved in maintaining a safe and healthy environment. This is part of quality care management.

The first step in decontamination is:
A. to immediately apply a chemical decontamination foam to the area of contamination
B. a through soap and water wash and rinse of the patient
C. to immediately apply personal protective equipment
D. removal of the patients clothing and jewelry and then rinsing the patient with water
E.
212. For a patient experiencing pruritus, you recommend which type of bath.

A. water
B. saline
C. colloidal (oatmeal)
D. sodium bicarbonate
213. Induction of vomiting is indicated for the accidental poisoning patient who has ingested.

A. rust remover
B. toilet bowl cleaner
C. gasoline
D. aspirin

214. A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin. The nurse is correct in classifying this burn as:

A. First degree burn
B. Second degree burn
C. Third degree burn
E. Partial thickness burn

215. During the first 24 hours of burn, nursing measures should focus on which of the following?

A. I and O hourly
B. Strict aseptic technique
C. Forced oral fluids
D. Isolate the patient

216. During the Acute phase of burn, the priority nursing intervention in caring for this client is:

A. Prevention of infection
B. Pain management
C. Prevention of Bleeding
D. Fluid Resuscitation

217. The nurse knows that the most fatal electrolyte imbalance in burned client during the Emergent phase of burn is:

A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hyponatremia

218. Hypokalemia is reflected in the ECG by which of the following?

A. Tall T waves
B. Widening QRS Complex
C. Pathologic Q wave
D. U wave

219. Pain medications given to the burn clients are best given via what route?

A. IV
B. IM
C. Oral
D. SQ

220. What type of debridement involves proteolytic enzymes?

A. Interventional C. Surgical
B. Mechanical D. Chemical

221. Which topical antimicrobial is most frequently used in burn wound care?
A. Neosporin
B. Silver nitrate
C. Silver sulfadiazine
D. Sulfamylon

222. Hypertrophic burn scars are caused by:

A. exaggerated contraction
B. random layering of collagen
C. wound ischemia
D. delayed epithelialization


223. This study which is an in depth study of one boy is a:

A. case study
B. longitudinal study
C. cross-sectional study
D. evaluative study

224. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process recording?

A. Non verbal narrative account
B. Analysis and interpretation
C. Audio-visual recording
D. Verbal narrative account

225. The most significant factor that might affect the nurse’s care for the psychiatric patient is:

A. Nurse’s own beliefs and attitude about the mentally ill
B. Amount of experience he has with psychiatric clients
C. Her abilities and skill to care for the psychiatric clients
D. Her knowledge in dealing with the psychiatric clients
226. In order to establish a therapeutic relationship with the client, the nurse must first have:

A. Self awareness
B. Self understanding
C. Self acceptance
D. Self motivation

227. Nurse Edna thinks that the patient is somewhat like his father. She then identifies positive feeling for the patient that affects the objectivity of her nursing care. This emotional reaction is called:

A. Transference
B. Counter Transference
C. Reaction formation
D. Sympathy

228. The most important quality of a nurse during a Nurse-Patient interaction is:

A. Understanding
B. Acceptance
C. Listening
D. Teaching

229. Selective inattention is seen in what level of anxiety?

A. Mild
B. Moderate
C. Severe
D. Panic

230. Obsessive compulsive disorder is characterized by:

A. Uncontrollable impulse to perform an act or ritual repeatedly
B. Persistent thoughts and behavior
C. Recurring unwanted and disturbing thoughts
D. Pathological persistence of unwilled thoughts

231. Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is the child of the covenant that would save this world from the evil forces of Satan. One morning, while caring for her, she stood in front of you and said “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:

A. Tell me more about being the Virgin Mary
B. So, You are the Virgin Mary?
C. Excuse me but, you are not anymore a Virgin so you cannot be the Blessed Virgin Mary.
D. You are Maria Salvacion

232. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

A. Delusion of grandeur
B. Visual Hallucination
C. Religious delusion
D. Auditory Hallcucination

233. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

A. Thought content
B. Mood
C. Affect
D. Attitude

234. Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia. During the morning assessment, Mang David shouted “Did you know that I am the top salesman in the world? Different companies want me!” As a nurse, you know that this is an example of:

A. Hallucination
B. Delusion
C. Confabulation
D. Flight of Ideas

235. The recommended treatment modality in clients with obsessive compulsive disorder is:

A. Psychotherapy
B. Behavior therapy
C. Aversion therapy
D. Psychoanalysis

236. A state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms is called:

A. Mental illness
B. Mental health
C. Crisis
D. Stress

237. Obsessive compulsive disorder is classified under:

A. Psychotic disorders
B. Neurotic disorders
C. Major depressive disorder
D. Bipolar disorder

238. Which nursing diagnosis is a priority for clients with Borderline personality disorder?

A. Risk for injury
B. Ineffective individual coping
C. Altered thought process
D. Sensory perceptual alteration

239. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

A. Risk for injury directed to self
B. Risk for injury directed to others
C. Impaired nutrition less than body requirements
D. Ineffective individual coping

240. A paranoid client refuses to eat telling you that you poisoned his food. The best intervention to this client is:

A. Taste the food in front of him and tell him that the food is not poisoned
B. Offer other types of food until the client eats
C. Simply state that the food is not poisoned
D. Offer sealed foods

241. Toilet training occurs in the anal stage of Freud’s psychosexual task. This is equivalent to Erikson’s:

A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority

242. During the phallic stage, the child must identify with the parent of:

A. The same sex
B. The opposite sex
C. The mother or the primary caregiver
D. Both sexes

243. Ms. ANA had a car accident where he lost her boyfriend. As a result, she became passive and submissive. The nurse knows that the type of crisis Ms. ANA is experiencing is:

A. Developmental crisis
B. Maturational crisis
C. Situational crisis
D. Social Crisis

244. Persons experiencing crisis becomes passive and submissive. As a nurse, you know that the best approach in crisis intervention is to be:

A. Active and Directive
B. Passive friendliness
C. Active friendliness
D. Firm kindness

245. The psychosocial task of a 55 year old adult client is:

A. Industry vs. Inferiority
B. Intimacy vs. Isolation
C. Integrity vs. Despair
D. Generativity vs. Stagnation

246. The stages of grieving identified by Elizabeth Kubler-Ross are:

A. Numbness, anger, resolution and reorganization
B. Denial, anger, identification, depression and acceptance
C. Anger, loneliness, depression and resolution
D. Denial, anger, bargaining, depression and acceptance

247. Which physiologic effect should the nurse expect in a client addicted to hallucinogens?

A. Dilated pupils
B. Constricted pupils
C. Bradycardia
D. Bradypnea

248. Miss CEE is admitted for treatment of major depression. She is withdrawn, disheveled and states “Nobody wants me” The nurse most likely expects that Miss CEE is to be placed on:

A. Neuroleptics medication
B. Special diet
C. Suicide precaution
D. Anxiolytics medication

249. In alcoholic patient, the nurse knows that the vitamin deficient to these types of clients that leads to psychoses is:

A. Thiamine
B. Vitamin C
C. Niacin
D. Vitamin A

250. Which of the following terms refers to weakness of both legs and the lower part of the trunk?

A. Paraparesis
B. Hemiplegia
C. Quadriparesis
D. Paraplegia

251. Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

A. Serotonin
B. Enkephalin
C. Norepinephrine
D. Acetylcholine

252. The lobe of the brain that contains the auditory receptive areas is the ____________ lobe.

A. temporal
B. frontal
C. parietal
D. occipital

253 In preparation for ECT, the nurse knows that it is almost similar to that of:

A. ECG
B. General Anesthesia
C. EEG
D. MRI

254. The expected side effect after ECT is commonly associated with:

A. Transient loss of memory, confusion and disorientation
B. Nausea and vomiting
C. Fractures
D. Hypertension and increased in cardiac rate

255. The purpose of ECT in clients with depression is to:

A. Stimulation in the brain to increase brain conduction and counteract depression
B. Mainly Biologic, increasing the norepinephrine and serotonin level
C. Creates a temporary brain damage that will increase blood flow to the brain
D. Involves the conduction of electrical current to the brain to charge the neurons and combat depression

256. The priority nursing diagnosis for a client with major depression is:

A. Altered nutrition
B. Altered thought process
C. Self care deficit
D. Risk for injury

257. A patient tells the nurse “I am depressed to talk to you, leave me alone” Which of the following response by the nurse is most therapeutic?

A. I’ll be back in an hour
B. Why are you so depressed?
C. I’ll seat with you for a moment
D. Call me when you feel like talking to me

258. One of the following statements is true with regards to the care of clients with depression:

A. Only mentally ill persons commit suicide
B. All depressed clients are considered potentially suicidal
C. Most suicidal person gives no warning
D. The chance of suicide lessens as depression lessens

259. An adolescent client has bloodshot eyes, a voracious appetite and dry mouth. Which drug abuse would the nurse most likely suspect?

A. Marijuana
B. Amphetamines
C. Barbiturates
D. Anxiolytics

260. During which phase of therapeutic relationship should the nurse inform the patient for termination of therapy?

A. Pre orientation
B. Orientation
C. Working
D. Termination

261. A client says to the nurse “I am worthless person, I should be dead” The nurse best replies:

A. “Don’t say you are worthless, you are not a worthless person”
B. “We are going to help you with your feelings”
C. “What makes you feel you’re worthless?”
D. “What you say is not true”

262. The nurse’s most unique tool in working with the emotionally ill client is his/her

A. theoretical knowledge
B. personality make up
C. emotional reactions
D. communication skills

263. The mentally ill person responds positively to the nurse who is warm and caring. This is a demonstration of the nurse’s role as:

A. counselor
B. mother surrogate
C. therapist
D. socializing agent

264. The past history of Camila would most probably reveal that her premorbid personality is:

A. schizoid
B. extrovert
C. ambivert
D. cycloid

265. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:

A. 24 hours
B. 36 hours
C. 48 hours
D. 12 hours


266. If it is established that the child is physically abused by a parent, the most important goal the nurse could formulate with the family is that:

A. Child and any siblings will live in a safe environment
B. Family will feel comfortable in their relationship with the counselor
C. Family will gain understanding of their abusive behavior patterns
D. Mother will be able to use verbal discipline with her children

267. Cocaine is derived from the leaves of coca plant; the nurse knows that cocaine is classified as:

A. Narcotic
B. Stimulant
C. Barbiturate
D. Hallucinogen

268. To successfully complete the tasks of older adulthood, an 85 year old who has been a widow for 25 years should be encouraged to:

A. Invest her creative energies in promoting social welfare
B. Redefine her role in the society and offer something and offer something of value
C. Feel a sense of satisfaction in reflecting on her productive life
D. Look to recapture the opportunities that were never started or completed

269. In a therapeutic relationship, the nurse must understand own values, beliefs, feelings, prejudices & how these affect others. This is called:

A. Therapeutic use of self
B. Psychotherapy
C. Therapeutic communication
D. Self awareness

270. While on Bryant’s traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction?

A. Graciela’s buttocks are resting on the bed.
B. The traction weights are hanging 10 inches above the floor.
C. Graciela’s legs are suspended at a 90 degree angle to her trunk.
D. The traction ropes move freely through the pulley.

271. The nurse notes that the fall might also cause a possible head injury. She will be observed for signs of increased intracranial pressure which include:

A. Narrowing of the pulse pressure
B. Vomiting
C. Periorbital edema
D. A positive Kernig’s sign

272. This is a tricyclic antidepressant drug:

A. Venlafaxine (Effexor)
B. Flouxetine (Prozac)
C. Sertraline (Zoloft)
D. Imipramine (Tofranil)

273. The working phase in a therapy group is usually characterized by which of the following?

A. Caution
B. Cohesiveness
C. Confusion
D. Competition

274. Substance abuse is different from substance dependence in that, substance dependence:

A. includes characteristics of adverse consequences and repeated use
B. requires long term treatment in a hospital based program
C. produces less severe symptoms than that of abuse
D. includes characteristics of tolerance and withdrawal

275. Ricky’s IQ falls within the range of 50-55. he can be expected to:

A. Profit from vocational training with moderate supervision
B. Live successfully in the community
C. Perform simple tasks in closely supervised settings
D. Acquire academic skills of 6th grade level

276. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just become worse while relating with other drug users. The mother’s behavior can be described as:

A. Unhelpful
B. Codependent
C. Caretaking
D. Supportive

277. 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 (IIDM) is characterized by fasting hyperglycemia
D. Type II (NIDDM) is characterized by abnormal immune response

278. Lifestyle-related diseases in general share areas common risk factors. These are the following except:

A. physical activity
B. smoking
C. genetics
D. nutrition

279. The following mechanisms can be utilized as part of the quality assurance program of your hospital EXCEPT:

A. Patient satisfaction surveys
B. Peer review to assess care provided
C. Review of clinical records of care of client
D. Use of Nursing Interventions Classification

280. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is?

A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice
B. It refers to the scope of nursing practice as defined in Republic Act 9173
C. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing practice
D. The Standards of Care includes the various steps of the nursing process and the standards of professional performance

281. you are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone?

A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours
C. Have the registered nurse, family and doctor sign the order
D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

282. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council, which two (2) of the following serves as the strongest for its enforcement?

(a) Advances made in Science and Technology have provided the climate for specialization in almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, industry and services imposed by the national laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care.

A. b & c are strong justifications
B. a & b are strong justifications
C. a & c are strong justifications
D. a & d are strong justifications

283. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

A. Tell her family that probably she can’t hear them
B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently

284. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke?

A. Place June on an upright lateral position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for support

285. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she says that the battery should be functional, the device is turned on and adjusted to a:

A. therapeutic level
B. comfortable level
C. prescribed level
D. audible level

286. Membership dropout generally occurs in group therapy after a member:

A. Accomplishes his goal in joining the group
B. Discovers that his feelings are shared by the group members
C. Experiences feelings of frustration in the group
D. Discusses personal concerns with group members

287. Which of the following questions illustrates the group role of encourager?

A. What were you saying?
B. Who wants to respond next?
C. Where do you go from here?
D. Why haven’t we heard from you?

288. The goal of remotivation therapy is to facilitate:

A. Insight
B. Productivity
C. Socialization
D. Intimacy

289. Being in contact with reality and the environment is a function of the:

A. conscience
B. ego
C. id
D. super ego

290. Substance abuse is different from substance dependence in that, substance dependence:

E. includes characteristics of adverse consequences and repeated use
F. requires long term treatment in a hospital based program
G. produces less severe symptoms than that of abuse
H. includes characteristics of tolerance and withdrawal

291. During the detoxification stage, it is a priority for the nurse to:

A. teach skills to recognize and respond to health threatening situations
B. increase the client’s awareness of unsatisfactory protective behaviors
C. implement behavior modification
D. promote homeostasis and minimize the client’s withdrawal symptoms

292. Commonly known as “shabu” is:

A. Cannabis Sativa
B. Lysergic acid diethylamide
C. Methylenedioxy methamphetamine
D. Methampetamine hydrochloride

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