FUNDAMENTALS OF NURSING 1. Monica shared with the interviewer her most recent experiences about a restless pediatric patient whom she puts

up the side rails of the bed to prevent accidental falls. Which of the following attributes is shown by Monica? A. Resourcefulness B. Prudence

C. Honesty D. Reliability

2. The priority of the nurse in a caregiver role is to:

A. Recognize the needs of the client B. Provide direct nursing care

C. Implement nursing care measures D. Provide nursing intervention

3. What role do you play when you hold all the client’s information entrusted to you in the strictest confidence?

A. Patient’s Advocate B. Teacher/Educator

C. Patient’s Liaison D. Patient’s Arbiter

4. You made a mistake in giving the medicine to the wrong client. You notify the client’s doctor and write an incident

report. You are demonstrating: A. Responsibility B. Accountability

C. Authority D. Autocracy

5. The mentally-ill person responds positively to the nurse who is warm and caring. This demonstrates the nurse’s role

of: A. Counselor B. Mother Surrogate

C. Socializing Agent D. Change Agent

6. All of the following are the functions of the nurse manager EXCEPT:

A. Performing bedside nursing B. Coordination and delegation of patient’s care

C. Setting standards of performance D. Designating staff schedule

7. The most important quality being demonstrated by a nurse in a role of a counselor and a teacher is:

A. Assertiveness B. Firmness

C. Intelligence D. Active listening

8. Health education plan for Meldy’s stresses prevention of NCD or Non-Communicable Diseases that are influenced by

lifestyle. This include the following EXCEPT: A. Cancer B. Osteoporosis

C. Diabetes Mellitus Type I D. Cardiovascular disease

9. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate

services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. Prevent diseases B. Reduce the cost of health care

C. Promote health habits D. Identify disease symptoms

10. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST? A. Maintain maximum function B. Reduce risk factor

C. Promote habits related to health care D. Manage stress

11. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is

responsible for: A. Health promotion and prevention of illness B. Administration of written prescription for

treatment and therapies

C. Rehabilitative aspect of care D. Collaborating with other health care

12. Assessment areas for the nurse is working with the family on health promotion strategies would include:

A. The television shows that they watch B. The perceived health status and illness patterns of the family C. The family and all the relative’s statuses D. The mental status of family and friends

13. The primary preventive measures against HIV-AIDS is: A. Withdrawal B. Virus-killing drugs

C. Foams and gels used D. Condom use

14. A nurse has scheduled a hypertensive screening clinic. This service would be an example of which of the following types of health care? A. Tertiary prevention B. Secondary prevention

C. Primary prevention D. Quaternary prevention

15. The nurse who is planning a health promotion program with clients in the community will have at LEAST focus on:

A. Assisting clients to make informed decisions B. Organizing methods to achieve optimal mental health C. Reducing genetic risk factors for illness D. Providing information and skills to maintain lifestyle changes

16. Health as a condition in which a person maintains balance and equilibrium is postulated by: A. WHO B. Claude Bernard

C. Walter Cannon D. Florence Nightingale

17. In this stage of illness, the person accepts or rejects professional suggestion. The person also becomes passive and

may regress to an earlier stage. A. Symptom experience B. Medical care contact

C. Assumption of sick role D. Dependent patient role

18. Leah is suffering from constipation from being on bed rest. What measures would you suggest in order to prevent

this? A. Eat more frequent small meals instead of three large meals once a day B. Walk for at least half an hour daily to promote peristalsis C. Drink more milk and increase calcium intake D. Drink eight full glasses of fluid such as water daily

19. Lifestyle related diseases in general share common risk factors. These are the following EXCEPT:

A. Physical activity B. Smoking

C. Genetics D. Nutrition

20. In your health education class for clients with diabetes, you teach them the areas for control of diabetes which

includes all EXCEPT: A. Regular Physical Activity B. Thorough knowledge of foot care

C. Prevent nutrition D. Proper nutrition

21. Control of diabetes is under which level of prevention?

A. Primary B. Secondary

C. Tertiary D. Quaternary

22. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a multidose vial labeled

100mg/ml and Visatril comes in an ampule labeled 50 mg/ml. You are to give both medications. You will: A. Withdraw the medication from the vial first then from the ampule B. Inject air into the vial, then into the ampule C. Inject air into the ampule, aspirate the desired dose, then in to the vial D. Withdraw medication from the ampule then from the vial

23. When giving Demerol 50 mg from a multidose vial labeled 100mg/ml and visatril 50 mg from an ampule labeled 50

mg/ml, what is the total volume that you will inject to the client? A. 2 ml B. 1 ml

C. 1.5 ml D. 1.75 ml

24. In which of the following types of orders is error LEAST likely to occur:

A. Dictated B. Telephone

C. Verbal D. Written

25. A type of massage that involves a smooth, long and circular stroke used in the abdomen of a client during labor is

called: A. Petrissage B. Touch therapy

C. Tapotement D. Effleurage

26. When assessing the client’s incision one day after surgery, the nurse expects to see which of the following as signs of

a local inflammatory response? A. Yellow clear drainage B. Pallor around sutures

C. Redness and warmth D. Brown exudates at incision edges 27. When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest

portion of a dressing? A. At the top of the wound B. At the base of the wound

C. At the middle of the wound D. Over the total wound

28. Which of the following statements BEST explain the reason for using stress management with the clients?

A. Everyone is stressed B. It has been an accepted practice C. All stresses are harmful to the body D. Prolonged stress may cause physical and mental disturbance

29. Corticosteroids are potent suppressor of the body’s inflammatory response. Which of the following conditions do

they suppress? A. Sympathetic nervous system B. Pain receptors

C. Immune response D. Neural transmission

30. A client has a twisted ankle during a game. Which of the following nursing intervention is inappropriate during the

first 24 hours after the incident? A. Rest B. Heat application

C. Cold application D. Immobilization

31. Carlo, a 16-year old client comes to the ER with acute asthmatic attack. RR is 46 breaths/ minute and he appears to

be in acute respiratory distress. Using Maslow’s theory, which of the following action is initiated first? A. Promote emotional support B. Administer oxygen at 6 LPM C. Suction the client every 30 minutes D. Administer bronchodilator

32. The nursing process is said to be dynamic. What makes it dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being B. The patient participates in the overall nursing care plan C. Nursing practice is expanding in the light of modern developments that take place D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these

change 33. One of the characteristics of the nursing process is that it is based on prioritization. Given these clients, priority

attention should be given to: A. Linda who shows severe anxiety due to trauma of the accident B. Ryan, a post-thyroidectomy patient, who is showing an increasing edema of the neck C. Noel who has lacerations of the arms and mild bleeding D. Andy whose left ankle is swelling and has some abrasions

34. A nurse is changing the central line dressing of a client receiving Total Parenteral Nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following? A. Tightness of tubing connections B. Client’s temperature

C. Expiration date on bag D. Time of the last dressing change

35. Which of the following should be given HIGHEST priority before physical examination is done to a patient?

A. Preparation of the equipment B. Preparation of the environment

C. Preparation of the patient D. Preparation of the nurse

36. During the assessment phase of the nursing process, the nurse is concerned with:

A. Interpreting data B. Designing nursing strategies C. Establishing a database D. Comparing client responses with the anticipated outcome

37. Objective data are also known as:

A. Covert data B. Inferences

C. Overt data D. Symptoms

38. Data or information obtained from the assessment of a patient is primarily used by the nurse to:

A. Ascertain the patient’s response to health problems B. Assist in constructing the taxonomy of nursing intervention C. C. Determine the effectiveness of the doctor’s order D. Identify the patient’s disease process

39. What is the example of a subjective data?

A. Color of wound drainage B. Odor of breath C. Respirations of 14 breaths/ minute D. The patient’s statement of: “I feel sick to my stomach”

40. Which of the following chart entries are not acceptable?

A. Patient states, “It hurts right here” (pointing to the chest) B. Patient ambulated to the bathroom C. Vital signs 130/70; 84; 20; 36 D. Pain relieved by Nitro glycerin 50 mg sublingually

41. Which of the following is the LEAST nursing activity in performing assessment of the patient?

A. Laboratory test B. Physical examination

C. Health history D. Systemic review

42. The MOST important initial nursing approach when admitting a client is to:

A. Introduce the client to the ward staff B. Orient the client to the physical setup of the unit C. Identify the most immediate needs of the client and implement the necessary intervention D. Make a nursing diagnosis

43. You want to know the sleeping pattern of Mr. Ong during the past few days. You will:

A. Interview the client’s relatives B. Take his BP before sleeping and upon waking up C. Observe his sleeping pattern over a period of time D. Perform physical assessment

44. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to:

A. Talk to the relatives B. Interview the client

C. Do auscultation D. Do a physical assessment

45. In giving epinephrine injection to a client, the nurse knows that which of the following is a side effect of the drug?

A. Diuresis B. Hypertension

C. Tachycardia D. Insomnia

46. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will:

A. Observe his sleeping pattern for the next few days B. Ask him what he meant by his statement C. Check the physical environment and decrease noise level D. Take his BP before sleeping and upon waking up

47. This is a SOAP recording of the patient’s problem of “Nervousness”. Which is the subjective data?

A. Mr. Z was nervous during the interview. He moved frequently in bed and his palms were sweaty. B. Mr. Z does not seem to tolerate stress too well which will aggravate his cardiac condition. He understand little

about his health which may be increasing his state of anxiety. C. “I am nervous at times.” He exerts himself physically and is hesitant to discuss problems. D. Mr. Z should:

i. Demonstrate an ability to cope with nervousness ii. Demonstrate an understanding of the relationship between his nervousness and cardiac condition

48. After assessing the client, the nurse should do which of the following next:

A. Prioritize the client’s problem B. Evaluate the client’s response to the nursing intervention C. Determine the client’s response to the actual and potential health problems D. Come out with specific nursing intervention that would alleviate the client’s problem

49. Which of the following nursing diagnosis is a correctly written nursing diagnosis?

A. Impaired physical mobility as evidenced by decreased range of motion on left shoulder from 180 degrees to 190 degrees of flexion and extension related to shoulder pain

B. Ineffective airway clearance related to thickened bronchial secretions as evidenced by adventitious lung sounds over the periphery of the right and left lung field

C. Potential for altered nutrition less than body requirements as evidenced by a 15-lb weight loss in 3 weeks D. Risk for injury related to decreased oxygen level in the blood as evidenced by irritability and restlessness

50. Your client, who happens to be a female resident of the barangay you are covering, is an adult survivor who states:

“Why couldn’t I make him stop the abuse? If I were a stronger person, I would have been able to make him stop. Maybe it was my fault to be abused.” Based on this, which would be your most appropriate nursing diagnosis? A. Social isolation B. Anxiety

C. Chronic low self-esteem D. Ineffective family coping

51. For the past 24 hours, TD with dry skin and mucous membrane has a urine output of 600 ml and a fluid intake of

800 ml. TD’s urine is dark amber. These assessments indicate which nursing diagnoisis? A. Impaired urinary elimination B. Deficient fluid volume C. Excessive fluid volume D. Imbalanced nutrition: less than body requirement

52. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm.

You notice that JJ is restless and slightly diaphoretic. He has a temperature of 37.8 degrees C, a heart rate of 62 beats/min; regular, slightly labored respirations of 26 breaths/ min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. Decreased cardiac output B. Acute pain

C. Anxiety D. Risk for imbalanced body temperature

53. AW, a 3-year old boy just sustained full thickness burns on the face, chest and neck. What will be the PRIORITY

nursing diagnosis? A. Risk for infection related to epidermal disruption B. Impaired urinary elimination related to fluid loss C. Ineffective airway clearance related to edema D. Impaired body image related to physical appearance

54. BL was brought to the emergency room for severe left flank pain, nausea and vomiting. The physician gave a

tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your priority? A. Imbalanced nutrition: less than body requirements B. Impaired urinary elimination C. Acute pain D. Risk for infection

55. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing

diagnosis as the highest priority for this client? A. Altered nutrition: less than body requirements B. High risk for aspiration

C. High risk for fluid volume deficit D. Diarrhea

56. All of the following are applicable nursing diagnosis for a post mastectomy client EXCEPT:

A. Pain upon lying B. Body image disturbance

C. Potential for sexual dysfunction D. Self care deficit R/T immobility of the arm

57. While caring for a client who is immobile, the nurse documents the following information in the client’s chart:

“Turned the client from side to back every 2 hours”; “Skin intact; no redness noted”; “Client up in chair three time today”; “Improved skin turgor noted”. Which nursing diagnosis accurately reflects this information? A. Risk for impaired skin integrity related to immobility B. Impaired skin integrity related to immobility C. Constipation related to immobility D. Disturbed body image related to immobility

58. Which of the following objectives is written in behavioral terms?

A. Mang Carlos will know about diabetes related to foot care and techniques and equipments necessary to carry it out

B. Mang Carlos should learn about DM within the week C. Mang Carlos needs to understand the side effects of insulin

D. Mang Carlos will be able to calculate in two days his insulin requirement based on blood glucose levels obtained from a glucometer

59. Which of the following is the BEST rationale for written objectives? A. Ensure communication among staff members B. Facilitate the evaluation of the nurse’s performance C. Ensure learning on the part of the nurse D. Document the quality of care

60. A main function of the nursing care plan is to:

A. Prepare the nurse for the shift B. Serve as a record of financial charges

C. Serve as vehicle for communication D. Ensure that the message is received

61. Which of the following is true about discharge planning?

A. Basic discharge plans involve referral to community resources B. All discharge plans involve referral to community resources C. Simple discharge plans involve use of a discharge planner D. Complex discharge plans include interdisciplinary collaboration

62. MS. WO is found on the floor of her room. She fell while crawling over the side rails of her bed. She is unconscious

and has a large laceration on the head that is bleeding profusely. The nurse’s priority action would be: A. Apply direct pressure to the laceration on her head B. Ensure that the patient has open airway C. Notify the physician D. Check the patient’s vital signs

63. When caring for TU after an exploratory chest surgery and pnuemonectomy, your PRIORITY would be to maintain:

A. Chest tube drainage B. Ventilation exchange

C. Blood replacement D. Supplementary oxygen

64. This flip over card is usually kept in a portable file at the Nurse station. It has two parts: the activity and treatment

section and a nursing care plan section. A. Discharge summary B. Nursing health history

C. Medicine and treatment record D. Nursing Kardex

65. Which of the following sounds would a nurse expect to find on the auscultation of a normal lung?

A. Tympany over the right upper lobe B. Resonance over the left upper lobe C. Hyperresonance over the left lower lobe D. Dullness above the left 10th intercostals space

SITUATION: Eileen, 45 years old, is admitted to the hospital to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees C. 66. Given the above assessment data, the most immediate goal of the nurse would be which of the following>

A. Prevent urinary complication B. Alleviate pain

C. Maintain fluids and electrolytes D. Alleviate nausea

67. Linda, a diabetic client, is being evaluated by the nurse. Linda now demonstrates dexterity in measuring her blood

sugar level using glucometer. In evaluating Linda, you know she has achieved improvement in: A. Cognitive B. Physiologic

C. Affective D. Psychomotor

68. You continuously evaluate the client’s adaptation to pain. Which of the following behavior indicates appropriate

adaptation? A. The client reports pain reduction and decreased activity B. The client denies the existence of pain C. The client distract himself during pain episodes D. The client reports independence from watchers

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

A. Dilated pupils B. Constricted pupils

C. Bradycardia D. Bradypnea

70. A patient is receiving a dose of Fentanyl for the management of chronic pain. When administering the drug, which of the following is a potential side effect that you need to tell the client? A. Avoid driving or operating heavy machineries. The drug causes drowsiness. B. Avoid exercising. The drug causes palpitation and tachycardia. C. Do not go to high places. The drug causes tachypnea. D. Take a bath using cold water because the drug causes flushed and warm skin.

71. In giving health teaching, through which of the following is learning facilitated by the nurse?

A. Present the information continuously, avoiding questions to hold the attention of patient and family B. Plan teaching time at the nurse’s convenience to reduce distractions C. Present information that builds on the patient’s knowledge D. Organize information based on her expertise

72. Which of the following is a good indicator of an effective communication?

A. Use of highly technical terms to impress patients and family B. Use of language the patient and health worker is familiar with C. Avoidance of pictures and illustrations D. The use of medical jargons

73. In palpating the breast, the position of the client is:

A. Sitting B. Lithotomy

C. Supine D. Dorsal Recumbent

74. In vaginal examinations, the position of the client is usually:

A. Sim’s position B. Genopectoral

C. Supine D. Lithotomy

75. During assessment, the nurse percussed Ana Marie’s costovertebral angle by placing the left hand over his area and

shaking it with his right fist. This percussion technique would produce which sound? A. Flat B. Dull

C. Hyperresonance D. Tympany

76. The degree of the patient’s abdominal distention may be determined by:

A. Inspection B. Palpation

C. Percussion D. Auscultation

77. When performing an abdominal assessment, the nurse should follow which examination sequence?

A. Inspection, auscultation, percussion, and palpation B. Inspection, percussion, palpation, and percussion C. Inspection, auscultation, palpation, and percussion D. Inspection, palpation, percussion, and auscultation

78. Mang Ruben has emphysema and was rushed to the hospital because of severe dyspnea. The doctor ordered oxygen

and venturi mask was not available. Which is the best alternative that the nurse could use for Mang Ruben? A. Face mask B. Nasal cannula

C. Non-rebreather mask D. Venturi mask

79. Mario listens to Richard’s bilateral sounds and finds that congestion in the upper lobes of the lungs. The appropriate

position to drain the anterior and posterior apical segment 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 chair then leaning forward in sitting position then flat on his back and his

abdomen C. Client lying flat in his back and then flat on his abdomen D. Client lying on his right left side then left side on Trendelenburg position

80. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when

doing the procedure? A. Respiratory rate of 16 to 20 breaths 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

81. What is the difference between percussion and vibration?

A. Percussion uses only one hand while vibration uses two hands

B. Percussion delivers cushioned blow 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 secretion while vibration shakes the secretion along with the inhalation cycle

82. How long should you insert a catheter used in nasotracheal suctioning?

A. From the mouth to the midsternum B. From the tip of the nose, to the earlobe and to the xiphoid process C. From the tip of the nose to the earlobe D. From the tip of the nose, to the earlobe and to the side of the neck

83. After thoracentesis, the patient is put on what position?

A. Supine position B. Side lying, unaffected side

C. Side lying, affected side D. Semi-fowlers position

84. In preparing the client before incentive spirometry, the nurse should position the client:

A. Semi-fowlers B. High fowlers

C. Fowlers D. Orthopneic

85. A pulse oximeter is attached to Ms. Dizon to:

A. Determine if the client’s hemoglobin level is low and if she needs blood transfusion B. Check the level of tissue perfusion C. Check the client’s arterial blood gas D. Detect oxygen saturation of the arterial blood gas before symptoms of hypoxemia occur

SITUATION: Health education is essential and caring for clients in various health care settings. 86. Which of the following laboratory test results is the most important indicator of malnutrition in a client with a

wound? A. Serum potassium level B. Albumin level

C. Lymphocyte count D. Hematocrit level

87. When teaching a client with peripheral vascular disease about foot care, the nurse should include which of the

following instruction? A. Avoiding using cornstarch on the feet B. Avoid wearing cotton socks

C. Avoid using a nail clipper to cut the toe nails D. Avoid wearing canvas shoes

88. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

A. Holding sterile objects above the waist B. Pouring the solution onto a sterile field cloth C. Considering a 1 inch (2.5 cm) edge around the sterile field contaminated D. Opening the outermost flap of the sterile package away from the body

89. The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, “I don’t know about this

treatment. After everything is said and done, it may do a bit of good. This thing may get me anyway.” Which response by the nurse is most therapeutic? A. “You’re wondering if you made the right decision about the treatment.” B. “Many people beat cancer. You need to keep a positive attitude.” C. “Colon care can now be cures in many cases. Let’s hope you’ll be one of the lucky ones.” D. “Everyone with cancer worries but you may have every reason to be hopeful.”

90. JC had just finished a liver biopsy procedure. As a nurse, you would expect him to be at what positions?

A. Standing B. Sitting

C. Affected side D. Unaffected side

91. When assessing a client’s incision one day after surgery, the nurse expects to see which of the following as signs of a

local inflammatory response? A. Yellow clear drainage B. Pallor around sutures

C. Redness and warmth D. Brown exudates at incision edges

92. For a client with sleep pattern disturbance, the nurse could use which of the following measures to promote sleep?

A. Play soft or soothing music

B. Encourage less activity during the day C. Provide a cup of coffee and a snack in the evening D. Increase the client’s activity 2 hours before bedtime

93. Mr. Jose’s chart contains information about his health care. The functions of the records include all EXCEPT:

A. Means of communication that health team members use to communicate their contributions to the client’s health care

B. The client’s record also shows a document of how much health care agencies will be reimbursed for their services

C. Educational resource for student of nursing and medicine D. Recording of actions in advance to save time

94. In which situation is the client ready to learn?

A. A 45-year old man whose doctor just informed him that he has cancer B. A 3-year old child whose parents are reading a story book about going to the hospital; C. A 60-year old female who received medication 5 minutes ago for relief of abdominal pain D. A 70-year old man, recovering from a stroke, who has returned from physical therapy

95. A client with chronic renal failure is admitted with HR of 122 beats/ min, RR of 32 breaths/ min, BP of 190/100

mmHg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority of this client? A. Fear B. Excessive fluid volume

C. Urinary retention D. Self care deficient: toileting

96. The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days

after discharge. Which client action indicates an accurate understanding of the technique? A. The client takes slow, deep breaths to elevate the spirometer ball B. The client takes rapid, shallow breaths to elevate the ball C. The client tilts the spirometer down when using it D. The client should blow the spirometer device in high-fowlers postion

97. A client comes to the clinic for a routine checkup. To assess the client’s gag reflex, the nurse should use which

method? A. Place a tongue blade on the front of the tongue and ask the client to say “ah” B. Place a tongue blade lightly on the posterior aspect of the tongue C. Place a tongue blade on the middle of the tongue and ask the client to cough D. Place a tongue blade on the ovula

98. Four clients, injured in an automobile accident, enter the emergency department at the same tome and are

immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the: A. Lumbar spinal cord injury and lower extremity paralysis B. Maxillofacial injury and gurgling respirations C. Severe head injury and no blood pressure D. Second trimester pregnancy in premature labor

99. The nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

A. To provide support for the client and family in coping with terminal illness B. To ensure that the client gets counseling regarding health costs C. To teach the client and family about cancer and its treatment D. To help the client find appropriate treatment options

100. Shortly after being admitted to the CCU with an acute MI, a client reports midsternal chest pain radiating down

the left arm. The nurse notices that the client is restless and slightly diaphoretic and measures a temperature of 99.6 degrees C, a heart rate of 62 beats/min; regular, slightly labored respirations of 26 breaths/ min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. Risk for imbalance body temperature B. Decreased cardiac output C. Anxiety D. Pain

ANSWER KEY 1. Monica shared with the interviewer her most recent experiences about a restless pediatric patient whom she puts

up the side rails of the bed to prevent accidental falls. Which of the following attributes is shown by Monica? A. Resourcefulness B. Prudence

C. Honesty D. Reliability

2. The priority of the nurse in a caregiver role is to:

A. Recognize the needs of the client B. Provide direct nursing care

C. Implement nursing care measures D. Provide nursing intervention

3. What role do you play when you hold all the client’s information entrusted to you in the strictest confidence?

A. Patient’s Advocate B. Teacher/Educator

C. Patient’s Liaison D. Patient’s Arbiter

4. You made a mistake in giving the medicine to the wrong client. You notify the client’s doctor and write an incident

report. You are demonstrating: A. Responsibility B. Accountability

C. Authority D. Autocracy

5. The mentally-ill person responds positively to the nurse who is warm and caring. This demonstrates the nurse’s role

of: A. Counselor B. Mother Surrogate

C. Socializing Agent D. Change Agent

6. All of the following are the functions of the nurse manager EXCEPT:

A. Performing bedside nursing B. Coordination and delegation of patient’s care

C. Setting standards of performance D. Designating staff schedule

7. The most important quality being demonstrated by a nurse in a role of a counselor and a teacher is:

A. Assertiveness B. Firmness

C. Intelligence D. Active listening

8. Health education plan for Meldy’s stresses prevention of NCD or Non-Communicable Diseases that are influenced by

lifestyle. This include the following EXCEPT: A. Cancer B. Osteoporosis

C. Diabetes Mellitus Type I D. Cardiovascular disease

9. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate

services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. Prevent diseases B. Reduce the cost of health care

C. Promote health habits D. Identify disease symptoms

10. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST?

A. Maintain maximum function B. Reduce risk factor

C. Promote habits related to health care D. Manage stress

11. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is

responsible for: A. Health promotion and prevention of illness B. Administration of written prescription for

treatment and therapies

C. Rehabilitative aspect of care D. Collaborating with other health care

12. Assessment areas for the nurse is working with the family on health promotion strategies would include:

A. The television shows that they watch B. The perceived health status and illness patterns of the family C. The family and all the relative’s statuses D. The mental status of family and friends

13. The primary preventive measures against HIV-AIDS is: A. Withdrawal B. Virus-killing drugs

C. Foams and gels used D. Condom use

14. A nurse has scheduled a hypertensive screening clinic. This service would be an example of which of the following types of health care? A. Tertiary prevention B. Secondary prevention

C. Primary prevention D. Quaternary prevention

15. The nurse who is planning a health promotion program with clients in the community will have at LEAST focus on:

A. Assisting clients to make informed decisions B. Organizing methods to achieve optimal mental health C. Reducing genetic risk factors for illness D. Providing information and skills to maintain lifestyle changes

16. Health as a condition in which a person maintains balance and equilibrium is postulated by: A. WHO B. Claude Bernard

C. Walter Cannon D. Florence Nightingale

17. In this stage of illness, the person accepts or rejects professional suggestion. The person also becomes passive and

may regress to an earlier stage. A. Symptom experience B. Medical care contact

C. Assumption of sick role D. Dependent patient role

18. Leah is suffering from constipation from being on bed rest. What measures would you suggest in order to prevent

this? A. Eat more frequent small meals instead of three large meals once a day B. Walk for at least half an hour daily to promote peristalsis C. Drink more milk and increase calcium intake D. Drink eight full glasses of fluid such as water daily

19. Lifestyle related diseases in general share common risk factors. These are the following EXCEPT:

A. Physical activity B. Smoking

C. Genetics D. Nutrition

20. In your health education class for clients with diabetes, you teach them the areas for control of diabetes which

includes all EXCEPT: A. Regular Physical Activity B. Thorough knowledge of foot care

C. Prevent nutrition D. Proper nutrition

21. Control of diabetes is under which level of prevention?

A. Primary B. Secondary

C. Tertiary D. Quaternary

22. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a multidose vial labeled

100mg/ml and Visatril comes in an ampule labeled 50 mg/ml. You are to give both medications. You will: A. Withdraw the medication from the vial first then from the ampule B. Inject air into the vial, then into the ampule C. Inject air into the ampule, aspirate the desired dose, then in to the vial D. Withdraw medication from the ampule then from the vial

23. When giving Demerol 50 mg from a multidose vial labeled 100mg/ml and visatril 50 mg from an ampule labeled 50

mg/ml, what is the total volume that you will inject to the client? A. 2 ml B. 1 ml

C. 1.5 ml D. 1.75 ml

24. In which of the following types of orders is error LEAST likely to occur:

A. Dictated B. Telephone

C. Verbal D. Written

25. A type of massage that involves a smooth, long and circular stroke used in the abdomen of a client during labor is

called: A. Petrissage B. Touch therapy

C. Tapotement D. Effleurage

26. When assessing the client’s incision one day after surgery, the nurse expects to see which of the following as signs of

a local inflammatory response? A. Yellow clear drainage B. Pallor around sutures

C. Redness and warmth D. Brown exudates at incision edges 27. When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest

portion of a dressing? A. At the top of the wound B. At the base of the wound

C. At the middle of the wound D. Over the total wound

28. Which of the following statements BEST explain the reason for using stress management with the clients?

A. Everyone is stressed B. It has been an accepted practice C. All stresses are harmful to the body D. Prolonged stress may cause physical and mental disturbance

29. Corticosteroids are potent suppressor of the body’s inflammatory response. Which of the following conditions do

they suppress? A. Sympathetic nervous system B. Pain receptors

C. Immune response D. Neural transmission

30. A client has a twisted ankle during a game. Which of the following nursing intervention is inappropriate during the

first 24 hours after the incident? A. Rest B. Heat application

C. Cold application D. Immobilization

31. Carlo, a 16-year old client comes to the ER with acute asthmatic attack. RR is 46 breaths/ minute and he appears to

be in acute respiratory distress. Using Maslow’s theory, which of the following action is initiated first? A. Promote emotional support B. Administer oxygen at 6 LPM C. Suction the client every 30 minutes D. Administer bronchodilator

32. The nursing process is said to be dynamic. What makes it dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being B. The patient participates in the overall nursing care plan C. Nursing practice is expanding in the light of modern developments that take place D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to

these change 33. One of the characteristics of the nursing process is that it is based on prioritization. Given these clients, priority

attention should be given to: A. Linda who shows severe anxiety due to trauma of the accident B. Ryan, a post-thyroidectomy patient, who is showing an increasing edema of the neck C. Noel who has lacerations of the arms and mild bleeding D. Andy whose left ankle is swelling and has some abrasions

34. A nurse is changing the central line dressing of a client receiving Total Parenteral Nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following? A. Tightness of tubing connections B. Client’s temperature

C. Expiration date on bag D. Time of the last dressing change

35. Which of the following should be given HIGHEST priority before physical examination is done to a patient?

A. Preparation of the equipment B. Preparation of the environment

C. Preparation of the patient D. Preparation of the nurse

36. During the assessment phase of the nursing process, the nurse is concerned with:

A. Interpreting data B. Designing nursing strategies C. Establishing a database D. Comparing client responses with the anticipated outcome

37. Objective data are also known as:

A. Covert data B. Inferences

C. Overt data D. Symptoms

38. Data or information obtained from the assessment of a patient is primarily used by the nurse to:

A. Ascertain the patient’s response to health problems B. Assist in constructing the taxonomy of nursing intervention C. Determine the effectiveness of the doctor’s order D. Identify the patient’s disease process

39. What is the example of a subjective data?

A. Color of wound drainage B. Odor of breath C. Respirations of 14 breaths/ minute D. The patient’s statement of: “I feel sick to my stomach”

40. Which of the following chart entries are not acceptable?

A. Patient states, “It hurts right here” (pointing to the chest) B. Patient ambulated to the bathroom C. Vital signs 130/70; 84; 20; 36 D. Pain relieved by Nitro glycerin 50 mg sublingually

41. Which of the following is the LEAST nursing activity in performing assessment of the patient?

A. Laboratory test B. Physical examination

C. Health history D. Systemic review

42. The MOST important initial nursing approach when admitting a client is to:

A. Introduce the client to the ward staff B. Orient the client to the physical setup of the unit C. Identify the most immediate needs of the client and implement the necessary intervention D. Make a nursing diagnosis

43. You want to know the sleeping pattern of Mr. Ong during the past few days. You will:

A. Interview the client’s relatives B. Take his BP before sleeping and upon waking up C. Observe his sleeping pattern over a period of time D. Perform physical assessment

44. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to:

A. Talk to the relatives B. Interview the client

C. Do auscultation D. Do a physical assessment

45. In giving epinephrine injection to a client, the nurse knows that which of the following is a side effect of the drug?

A. Diuresis B. Hypertension

C. Tachycardia D. Insomnia

46. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will:

A. Observe his sleeping pattern for the next few days B. Ask him what he meant by his statement C. Check the physical environment and decrease noise level D. Take his BP before sleeping and upon waking up

47. This is a SOAP recording of the patient’s problem of “Nervousness”. Which is the subjective data?

A. Mr. Z was nervous during the interview. He moved frequently in bed and his palms were sweaty. B. Mr. Z does not seem to tolerate stress too well which will aggravate his cardiac condition. He understand little

about his health which may be increasing his state of anxiety. C. “I am nervous at times.” He exerts himself physically and is hesitant to discuss problems. D. Mr. Z should:

i. Demonstrate an ability to cope with nervousness ii. Demonstrate an understanding of the relationship between his nervousness and cardiac condition

48. After assessing the client, the nurse should do which of the following next:

A. Prioritize the client’s problem B. Evaluate the client’s response to the nursing intervention C. Determine the client’s response to the actual and potential health problems D. Come out with specific nursing intervention that would alleviate the client’s problem

49. Which of the following nursing diagnosis is a correctly written nursing diagnosis?

A. Impaired physical mobility as evidenced by decreased range of motion on left shoulder from 180 degrees to 190 degrees of flexion and extension related to shoulder pain

B. Ineffective airway clearance related to thickened bronchial secretions as evidenced by adventitious lung sounds over the periphery of the right and left lung field

C. Potential for altered nutrition less than body requirements as evidenced by a 15-lb weight loss in 3 weeks D. Risk for injury related to decreased oxygen level in the blood as evidenced by irritability and restlessness

50. Your client, who happens to be a female resident of the barangay you are covering, is an adult survivor who states:

“Why couldn’t I make him stop the abuse? If I were a stronger person, I would have been able to make him stop. Maybe it was my fault to be abused.” Based on this, which would be your most appropriate nursing diagnosis? A. Social isolation B. Anxiety

C. Chronic low self-esteem D. Ineffective family coping

51. For the past 24 hours, TD with dry skin and mucous membrane has a urine output of 600 ml and a fluid intake of 800

ml. TD’s urine is dark amber. These assessments indicate which nursing diagnoisis? A. Impaired urinary elimination B. Deficient fluid volume C. Excessive fluid volume D. Imbalanced nutrition: less than body requirement

52. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm.

You notice that JJ is restless and slightly diaphoretic. He has a temperature of 37.8 degrees C, a heart rate of 62 beats/min; regular, slightly labored respirations of 26 breaths/ min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. Decreased cardiac output B. Acute pain

C. Anxiety D. Risk for imbalanced body temperature

53. AW, a 3-year old boy just sustained full thickness burns on the face, chest and neck. What will be the PRIORITY

nursing diagnosis? A. Risk for infection related to epidermal disruption B. Impaired urinary elimination related to fluid loss C. Ineffective airway clearance related to edema D. Impaired body image related to physical appearance

54. BL was brought to the emergency room for severe left flank pain, nausea and vomiting. The physician gave a

tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your priority? A. Imbalanced nutrition: less than body requirements B. Impaired urinary elimination C. Acute pain D. Risk for infection

55. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing

diagnosis as the highest priority for this client? A. Altered nutrition: less than body requirements B. High risk for aspiration

C. High risk for fluid volume deficit D. Diarrhea

56. All of the following are applicable nursing diagnosis for a post mastectomy client EXCEPT:

A. Pain upon lying B. Body image disturbance

C. Potential for sexual dysfunction D. Self care deficit R/T immobility of the arm

57. While caring for a client who is immobile, the nurse documents the following information in the client’s chart:

“Turned the client from side to back every 2 hours”; “Skin intact; no redness noted”; “Client up in chair three time today”; “Improved skin turgor noted”. Which nursing diagnosis accurately reflects this information? A. Risk for impaired skin integrity related to immobility B. Impaired skin integrity related to immobility C. Constipation related to immobility D. Disturbed body image related to immobility

58. Which of the following objectives is written in behavioral terms?

A. Mang Carlos will know about diabetes related to foot care and techniques and equipments necessary to carry it out

B. Mang Carlos should learn about DM within the week C. Mang Carlos needs to understand the side effects of insulin

D. Mang Carlos will be able to calculate in two days his insulin requirement based on blood glucose levels obtained from a glucometer

59. Which of the following is the BEST rationale for written objectives?

A. Ensure communication among staff members B. Facilitate the evaluation of the nurse’s performance C. Ensure learning on the part of the nurse D. Document the quality of care

60. A main function of the nursing care plan is to:

A. Prepare the nurse for the shift B. Serve as a record of financial charges

C. Serve as vehicle for communication D. Ensure that the message is received

61. Which of the following is true about discharge planning?

A. Basic discharge plans involve referral to community resources B. All discharge plans involve referral to community resources C. Simple discharge plans involve use of a discharge planner D. Complex discharge plans include interdisciplinary collaboration

62. MS. WO is found on the floor of her room. She fell while crawling over the side rails of her bed. She is unconscious

and has a large laceration on the head that is bleeding profusely. The nurse’s priority action would be: A. Apply direct pressure to the laceration on her head B. Ensure that the patient has open airway C. Notify the physician D. Check the patient’s vital signs

63. When caring for TU after an exploratory chest surgery and pnuemonectomy, your PRIORITY would be to maintain:

A. Chest tube drainage B. Ventilation exchange

C. Blood replacement D. Supplementary oxygen

64. This flip over card is usually kept in a portable file at the Nurse station. It has two parts: the activity and treatment

section and a nursing care plan section. A. Discharge summary B. Nursing health history

C. Medicine and treatment record D. Nursing Kardex

65. Which of the following sounds would a nurse expect to find on the auscultation of a normal lung?

A. Tympany over the right upper lobe B. Resonance over the left upper lobe C. Hyperresonance over the left lower lobe D. Dullness above the left 10th intercostals space

SITUATION: Eileen, 45 years old, is admitted to the hospital to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees C. 66. Given the above assessment data, the most immediate goal of the nurse would be which of the following>

A. Prevent urinary complication B. Alleviate pain

C. Maintain fluids and electrolytes D. Alleviate nausea

67. Linda, a diabetic client, is being evaluated by the nurse. Linda now demonstrates dexterity in measuring her blood

sugar level using glucometer. In evaluating Linda, you know she has achieved improvement in: E. Cognitive F. Physiologic

G. Affective H. Psychomotor

68. You continuously evaluate the client’s adaptation to pain. Which of the following behavior indicates appropriate

adaptation? A. The client reports pain reduction and decreased activity B. The client denies the existence of pain C. The client distract himself during pain episodes D. The client reports independence from watchers

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

A. Dilated pupils B. Constricted pupils

C. Bradycardia D. Bradypnea

70. A patient is receiving a dose of Fentanyl for the management of chronic pain. When administering the drug, which of the following is a potential side effect that you need to tell the client? A. Avoid driving or operating heavy machineries. The drug causes drowsiness. B. Avoid exercising. The drug causes palpitation and tachycardia. C. Do not go to high places. The drug causes tachypnea. D. Take a bath using cold water because the drug causes flushed and warm skin.

71. In giving health teaching, through which of the following is learning facilitated by the nurse?

A. Present the information continuously, avoiding questions to hold the attention of patient and family B. Plan teaching time at the nurse’s convenience to reduce distractions C. Present information that builds on the patient’s knowledge D. Organize information based on her expertise

72. Which of the following is a good indicator of an effective communication?

A. Use of highly technical terms to impress patients and family B. Use of language the patient and health worker is familiar with C. Avoidance of pictures and illustrations D. The use of medical jargons

73. In palpating the breast, the position of the client is:

A. Sitting B. Lithotomy

C. Supine D. Dorsal Recumbent

74. In vaginal examinations, the position of the client is usually:

A. Sim’s position B. Genopectoral

C. Supine D. Lithotomy

75. During assessment, the nurse percussed Ana Marie’s costovertebral angle by placing the left hand over his area and

shaking it with his right fist. This percussion technique would produce which sound? A. Flat B. Dull

C. Hyperresonance D. Tympany

76. The degree of the patient’s abdominal distention may be determined by:

A. Inspection B. Palpation

C. Percussion D. Auscultation

77. When performing an abdominal assessment, the nurse should follow which examination sequence?

A. Inspection, auscultation, percussion, and palpation B. Inspection, percussion, palpation, and percussion C. Inspection, auscultation, palpation, and percussion D. Inspection, palpation, percussion, and auscultation

78. Mang Ruben has emphysema and was rushed to the hospital because of severe dyspnea. The doctor ordered oxygen

and venturi mask was not available. Which is the best alternative that the nurse could use for Mang Ruben? A. Face mask B. Nasal cannula

C. Non-rebreather mask D. Venturi mask

79. Mario listens to Richard’s bilateral sounds and finds that congestion in the upper lobes of the lungs. The appropriate

position to drain the anterior and posterior apical segment 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 chair then leaning forward in sitting position then flat on his back and his

abdomen C. Client lying flat in his back and then flat on his abdomen D. Client lying on his right left side then left side on Trendelenburg position

80. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when

doing the procedure? A. Respiratory rate of 16 to 20 breaths 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

81. What is the difference between percussion and vibration?

A. Percussion uses only one hand while vibration uses two hands

B. Percussion delivers cushioned blow 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 secretion while vibration shakes the secretion along with the inhalation cycle

82. How long should you insert a catheter used in nasotracheal suctioning?

A. From the mouth to the midsternum B. From the tip of the nose, to the earlobe and to the xiphoid process C. From the tip of the nose to the earlobe D. From the tip of the nose, to the earlobe and to the side of the neck

83. After thoracentesis, the patient is put on what position?

A. Supine position B. Side lying, unaffected side

C. Side lying, affected side D. Semi-fowlers position

84. In preparing the client before incentive spirometry, the nurse should position the client:

A. Semi-fowlers B. High-fowlers

C. Fowlers D. Orthopneic

85. A pulse oximeter is attached to Ms. Dizon to:

A. Determine if the client’s hemoglobin level is low and if she needs blood transfusion B. Check the level of tissue perfusion C. Check the client’s arterial blood gas D. Detect oxygen saturation of the arterial blood gas before symptoms of hypoxemia occur

SITUATION: Health education is essential and caring for clients in various health care settings. 86. Which of the following laboratory test results is the most important indicator of malnutrition in a client with a

wound? A. Serum potassium level B. Albumin level

C. Lymphocyte count D. Hematocrit level

87. When teaching a client with peripheral vascular disease about foot care, the nurse should include which of the

following instruction? A. Avoiding using cornstarch on the feet B. Avoid wearing cotton socks

C. Avoid using a nail clipper to cut the toe nails D. Avoid wearing canvas shoes

88. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

A. Holding sterile objects above the waist B. Pouring the solution onto a sterile field cloth C. Considering a 1 inch (2.5 cm) edge around the sterile field contaminated D. Opening the outermost flap of the sterile package away from the body

89. The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, “I don’t know about this

treatment. After everything is said and done, it may do a bit of good. This thing may get me anyway.” Which response by the nurse is most therapeutic? A. “You’re wondering if you made the right decision about the treatment.” B. “Many people beat cancer. You need to keep a positive attitude.” C. “Colon care can now be cures in many cases. Let’s hope you’ll be one of the lucky ones.” D. “Everyone with cancer worries but you may have every reason to be hopeful.”

90. JC had just finished a liver biopsy procedure. As a nurse, you would expect him to be at what positions?

A. Standing B. Sitting

C. Affected side D. Unaffected side

91. When assessing a client’s incision one day after surgery, the nurse expects to see which of the following as signs of a

local inflammatory response? A. Yellow clear drainage B. Pallor around sutures

C. Redness and warmth D. Brown exudates at incision edges

92. For a client with sleep pattern disturbance, the nurse could use which of the following measures to promote sleep?

A. Play soft or soothing music

B. Encourage less activity during the day C. Provide a cup of coffee and a snack in the evening D. Increase the client’s activity 2 hours before bedtime

93. Mr. Jose’s chart contains information about his health care. The functions of the records include all EXCEPT:

A. Means of communication that health team members use to communicate their contributions to the client’s health care

B. The client’s record also shows a document of how much health care agencies will be reimbursed for their services

C. Educational resource for student of nursing and medicine D. Recording of actions in advance to save time

94. In which situation is the client ready to learn?

A. A 45-year old man whose doctor just informed him that he has cancer B. A 3-year old child whose parents are reading a story book about going to the hospital C. A 60-year old female who received medication 5 minutes ago for relief of abdominal pain D. A 70-year old man, recovering from a stroke, who has returned from physical therapy

95. A client with chronic renal failure is admitted with HR of 122 beats/ min, RR of 32 breaths/ min, BP of 190/100

mmHg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority of this client? A. Fear B. Excessive fluid volume

C. Urinary retention D. Self care deficient: toileting

96. The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days

after discharge. Which client action indicates an accurate understanding of the technique? A. The client takes slow, deep breaths to elevate the spirometer ball B. The client takes rapid, shallow breaths to elevate the ball C. The client tilts the spirometer down when using it D. The client should blow the spirometer device in high-fowlers postion

97. A client comes to the clinic for a routine checkup. To assess the client’s gag reflex, the nurse should use which

method? A. Place a tongue blade on the front of the tongue and ask the client to say “ah” B. Place a tongue blade lightly on the posterior aspect of the tongue C. Place a tongue blade on the middle of the tongue and ask the client to cough D. Place a tongue blade on the ovula

98. Four clients, injured in an automobile accident, enter the emergency department at the same tome and are

immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the: A. Lumbar spinal cord injury and lower extremity paralysis B. Maxillofacial injury and gurgling respirations C. Severe head injury and no blood pressure D. Second trimester pregnancy in premature labor

99. The nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

A. To provide support for the client and family in coping with terminal illness B. To ensure that the client gets counseling regarding health costs C. To teach the client and family about cancer and its treatment D. To help the client find appropriate treatment options

100. Shortly after being admitted to the CCU with an acute MI, a client reports midsternal chest pain radiating down

the left arm. The nurse notices that the client is restless and slightly diaphoretic and measures a temperature of 99.6 degrees C, a heart rate of 62 beats/min; regular, slightly labored respirations of 26 breaths/ min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. Risk for imbalance body temperature B. Decreased cardiac output C. Anxiety D. Pain