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1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What shouldNurse Suzie does when one of the clients does NOT have a readable identification band?

A. Ask the client if she is Mrs. SantosB. Ask the client his nameC. Ask the room mate if the client is Mrs. SantosD. Compare the ID band with the bed tag

CORRECT ANSWER: BRATIONALE: Before administering a medication, identify the client correctly using the appropriate means ofidentification, such as checking the identification bracelet, asking the client to state his/her name or, both.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 802

2. Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any clientassigned to her unless she performs nursing procedures or conducts physical assessment. To guide staff nurse inthe use of touch, which of the following would be the BEST response of Lizette?

A. "Use touch when the situation calls for it".B. Touch serves as a connection between the nurse and the patient."C. "Use touch with discretion."D. Touch is used in physical assessment."

CORRECT ANSWER: B

RATIONALE: The therapeutic use of touch is a basic aspect of the nurse-client relationship and is normallyperceived as a gesture of warmth and friendship.Elizabeth M. Varcarolis. Foundations of psychiatric and Mental Nursing.4th ed.pp. 251

3. You are asked to teach the client, Mr. Lapuz who has right sided weakness the use of a cane. Which observationwill indicate that Mr. Lapuz is using the cane correctly?

A. The cane and one foot or both feet are on the floor at all timesB. He advances the cane followed by the left legC. Client keeps the cane on the right side along the weak legD. Client leans to the left side which is stronger

CORRECT ANSWER: D

RATIONALE: Lean your weight through the arm holding the cane as needed (left side)OPTION B: Advance the cane simultaneously with the opposite affected lower limb( less support) or advance theaffected leg forward to the cane while the weight is borne by the cane and the stronger leg (maximum support).OPTION C: Client should use the cane on his stronger side.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1102

4. George, a 43 year old executive, is scheduled for cardiac bypass surgery. While being prepared for surgery, hesays to the nurse "I am not going to have the surgery. I may die because of the risk". Which response by thenurse is most appropriate?

A. "Without the surgery you will most likely die sooner."B. There are always risks involved with surgery."C. There is a client in the other room who had successful surgery and you can talk to him".D. "This must be very frightening for you. Tell me how you feel about the surgery."

CORRECT ANSWER: DRATIONALE: The nurse is acknowledging the patients feelings and allows him to express it.OPTION A: threatening to the patientOPTION B: though presenting the reality but not addressing the clients feelingsOPTION C: belittling the clients feelings

5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriateinstruction by the nurse?

A. Report to the physician the effects of the medication on urinationB. Take the medicine early in the morningC. Take a full glass of water with the medicineD. Measure frequency of urination in 24 hours

CORRECT ANSWER: BRATIONALE: furosemide (Lasix) is a diuretic that will increase urination so it is important to instruct patient to takethe drug early in the morning to prevent problems in sleep because when taken at night, it will produced urinaryfrequency.OPTION A: Effects on urination is normal since it is a diureticsOPTION C: is not that importantOPTION D: measuring the total amount of output is more important than the frequency

Reproduction is strictly prohibited RN International Review Center

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6. Nurse Glenda gets a call from a neighbor who tells her that his 3 years old daughter has been vomiting and hasfever and asks for advice. Which of the following is the most appropriate action of the nurse?

A. Observe the child for an hour if the child does not improve, refer to the physician in the neighborhoodB. Recommend to bring the child immediately to the hospitalC. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the

hospitalD. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to

the hospital

CORRECT ANSWER: CRATIONALE: Complete nursing actionOPTION A: observing will not have any change in patients conditionOPTION B: have you done any nursing intervention?OPTION D: leaving the child to the neighbor without performing your nursing intervention

7. Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular accident. Whilebeing transported to the X-ray department, the straps accidentally broke and the client fell to the floor hitting hishead. In this situation, the nurse is:

A. Not responsible because of the doctrine of respondent superiorB. Free from any negligence that caused harm to the patientC. Liable along with the employer for the use of a detective equipment that harms the clientD. Totally responsible for the negligence

CORRECT ANSWER: CRATIONALE: The employer is liable because of respondeat superior principle. The nurse is liable for negligence.

8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerfulhymns. What is the BEST response of Edna?

A. Ignore the incidenceB. Report the incidence to the head nurseC. Respect the client's actions as this provides structure and support to the clientD. Call her attention so she can go to sleep

CORRECT ANSWER: CRATIONALE: It is important for nurses to develop a broad concept of spirituality. Many clients have spiritual

strengths that the nurse can nurture to help them attain or maintain a feeling of spiritual well-being, to recoverfrom illness and to face a peaceful death.OPTION A: In holistic nursing, the nurse provides care not only for the physical body and mind but also for theclients spirit.OPTION B: need not to be reportedOPTION D: Allow time and privacy for and provide comfort measures prior to private worship, prayer, meditation,reading or other spiritual activities.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 995,1004

9. A client asks for advice on low cholesterol food. You advise the client to eat the following:A. Chicken liver, cow liver, eggsB. Lean beef and pork, egg white, fishC. Balut, salted eggs, duck and chicken egg

D. Pork liempo, cow brain, lungs and kidney

CORRECT ANSWER: BRATIONALE: lean meats and pork are low in saturated fat; egg white and fish are protein rich foods.

All other choices are high in cholesterol. Foods high in cholesterol include meats, egg yolks, organ meats, wholemilk and milk products.

10. The code of ethics for nurses has an interpretive statement that provides:A. Continuity of care for the improvement of the clientB. Guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the

professionC. Standards of care in carrying out nursing responsibilitiesD. Identical care to all clients in any setting

CORRECT ANSWER: BRATIONALE: A code of ethics is a formal statement of a groups ideals and values. It is a set of ethical principlesthat (a) is shared by members of the group, (b) reflects their moral judgments over time. And (c) serve as astandard for their professional actions.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 73

11. Which of the following situations would possibly cause a nurse to be sued due to negligence?A. Nurse gave a client wrong medication and an hour later, client complained of dyspnea


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B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the client'smedicine cup

C. As the nurse was about to administer medication, the client questioned why the medication is still given whenin fact the physician discontinued it

D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error andcomplained.

CORRECT ANSWER: A

RATIONALE: The term negligence refers to the commission or omission of an act, pursuant to a duty, that a areasonably prudent person in the same or similar circumstance would or would not do and acting or the nonactingof which is the proximate cause of injury to another person or his property. The elements of professionalnegligence therefore are:

1. existence of a duty on the part of the person charged to use due care under circumstances2. failure to meet the standard of due care3. the forseeability of harm resulting from failure to meet the standard and4. the fact that the breach of this standard resulted in an injury to the plaintiff

Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp.160-161

12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admittedto the hospital:

A. Diabetic client type 2B. Client with chronic obstructive pulmonary disease (COPD)

C. Client with second degree burnsD. Client with psoriasis

CORRECT ANSWER: CRATIONALE: Burns are exceedingly challenging due to the high risk of infection since the skin is no longer abarrier to bacteria.Infection is the most common complication of burns and is the major cause of death in burn victims.http://www.umm.edu/altmed/articles/burns-000021.htmOPTION A: susceptible to infection with open wounds but with proper care, less susceptible than burn patientOPTION B and D: are the least susceptible

13. Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has observed her tobe too involved in his care. He complained to the head nurse about this. Which of the following would be the

BEST response of the nurse?A. "Dont worry. I will call the attention of your wife."B. "Your wife is just trying to help because she is worried about you."C. "What are your thoughts about your wife's involvement in your care?"D. Your wife can assist you well in your care and recovery."

CORRECT ANSWER: CRATIONALE: Therapeutic and allows expression of feeling and thoughtsOPTION A: False reassuranceOPTION B: disagreeingOPTION D: not addressing the patients feelings

14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612.

They mentioned his name and discussed details of his condition. Which of the following actions should the nursetake?A. Approach the two nurses and tell them that their actions are inappropriate especially in a public placeB. Wait till the nurses finish the discussion and report the situation to the supervisorC. Say nothing to avoid embarrassing the staff nursesD. Remain quiet and ignore the discussion

CORRECT ANSWER: ARATIONALE: The nurse maintains patient confidentiality within legal and regulatory parameters. The nurseshould approach his/her fellow nurses provided it is in a nice way not to embarrass them.OPTION B: In some cases it is appropriate to report it to the supervisor but you should not wait them to finish thediscussion because more information will be divulge.OPTION C and D are inappropriate because we have also our moral responsibility with our co-worker as mentionin the Code of Ethics.

15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father hasbeen getting out of bed at night and walks around the house in the early hours of the morning causing him to failand injure himself. Which instruction would you give?

A. Apply restraints during the night hours onlyB. Advise hospitalization to prevent future accidentsC. Keep a radio or TV for company and to orient the clientD. Have someone check on the client frequently at night


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CORRECT ANSWER: DRATIONALE: The older adult sleeps about 6 hours a night. About 20% to 25% is REM sleep. Stage IV sleep ismarkedly decreased and some instances absent. The first REM period is longer. Many elders awaken more oftenduring the night and it often takes them longer to go back to sleep. At this case, enhance the sense of safety andsecurity by checking on clients and making sure that the call lights is within reach.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1116-1117

SITUATIONAL

Situation 1 - Preparation and administration of medications is a nursing function that cannot be delegated. It is importantthat the nurse has a deep understanding of this responsibility that is meant to save patients' lives

16. You are to administer an intramuscular injection to Dulce, 1 1/2 year old girl. The most appropriate site toadminister the drug is:

A. dorso gluteal regionB. ventrogluteal regionC. vastus lateralisD. gluteal region

CORRECT ANSWER: BRATIONALE: The ventrogluteal region is the preferred site for intramuscular injection because:

Contains no large nerves or blood vessels

Provides the greatest thickness of gluteal muscle consisting of both the gluteus and medius and

gluteus minimus

Is seald off with bone

Contains consistently less fat than the buttocks area, thus eliminating the need to determine the

depth of subcutaneous fat.OPTION A: can be used in children and adult with full developed gluteal muscles, should not be used for childrenunder 3 years old unless the child has been walking for at least 1 year.OPTION C: Recommended for infants 7 months and youngerOPTION D: very general optionKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 826-827

17. An infant is ordered to receive 500 ml of D5NSS for 24 hours. The Intravenous infusion set is at 60 drops/ml. Howmany drops per minute should the flow rate be?A. 60 drops per minuteB. 21 drops per minuteC. 30 drops per minuteD. 15 drops per minute

CORRECT ANSWER: BRATIONALE: Drops per minute= Total infusion volume x drop factor

Total of infusion in minutes= 500 ml x 60 drops/ml

24 hrs x 60 min= 20.8333333 drops/min= 20-21

Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1391

18. Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml ofD5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops perminute should the rate be to infuse 1 liter of D5W for 8 hours?

A. 42 dropsB. 20 dropsC. 60 dropsD. 32 drops

CORRECT ANSWER: ARATIONALE: Drops per minute= Total infusion volume x drop factor

Total of infusion in minutes

= 1000 ml x 20 drops/ml8 hrs x 60 min

= 41. 6666667 drops/min= 41-42


19. Mr. Lagrito is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops perml. Approximately how many drops per minutes should the IV be regulated?

A. 13 14 drops


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B. 17 18 dropsC. 10 12 dropsD. 15 16 drops

CORRECT ANSWER: ARATIONALE: Drops per minute= Total infusion volume x drop factor

Total of infusion in minutes= 1000 ml x 10 drops/ml

12hr x 60min= 13.89 dropsKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1391

20. The Physician ordered Nembutal Na gr. XX. The bottle contains 100 mg/capsule. How many capsules will beadministered to the client?

A. 11 capsuleB. 12 capsulesC. 15 capsuleD. 10 capsule

CORRECT ANSWER: BRATIONALE: 1 grain= 60 mg

mg = 20 grain x 60 mg/ 1

gr

= 120 mg/100mg/capsule= 12 capsules

Situation 2- The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided toclients can be improved.

21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the careprovided to the patients in the unit by Nurse Arthur, the nurse supervisor should:

A. tell the nurse how to give bed baths correctlyB. ask another staff nurse to do the bed baths insteadC. provide a manual to be read on giving bed bathsD. bring the staff nurse to a client's room and demonstrate a cleansing bath

CORRECT ANSWER: DRATIONALE: A staff members inexperience can be hindrance to delegation; an institution can minimize thisthrough competency-based orientation and testing; the nurse delegating the task sometimes must teach thenovice the necessary skills to complete the task; with proper guidance, delegating can improve the novices skills.Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 94

22. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client.Together, they observe how well the dressings absorb the drainage. In what-step of the decision making processare they?

A. Testing optionsB. Considering effects on resultsC. Defining the problemD. Making final decisions

CORRECT ANSWER: ARATIONALE:Decision making is a critical thinking process for choosing the best actions to meet a desired goal.The steps include:

Identify the purpose

Set the criteria

Weigh the criteria

Seek alternatives

Examine the alternatives

Project

Implement

Evaluation

Examining alternatives- the nurse analyzes the alternatives to ensure that there is an objective rationale inrelatiion to the established criteria for choosing one strategy over another.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 252

23. To check if the nurses under her supervision use critical thinking, Mrs. David observers if the nurses actresponsibly when at work. Which of the following actions of a nurse demonstrates the attitude of responsibility?

A. Thinking of alternative methods of nursing careB. Sharing ideas regarding patient careC. Following standards of practice


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D. Planning other approaches for patient care

CORRECT ANSWER: ARATIONALE: Responsibility denotes obligation. It refers to what must to be done to complete a task and theobligation created by the assignment.Tomey, Ann Marriner. Guide to Nursing Management and Leadership. 7 th Edition. Pp. 47

24. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse

Julie uses such good clinical judgment when she gives priority care to this client:A. Roman, a client who is ambulatory and for surgery tomorrowB. A post-operative client, Rey, who has a blood pressure of 90/50 mmHgC. Mr. Abad, a client who needs instructions for home medicationsD. Fred, a client who received pain medication 5 minutes ago

CORRECT ANSWER: BRATIONALE: The patient is hypotensive and might be an indication of an early shock.OPTION A: 3RDOPTION C: 4THOPTION D: 2ND

25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a clients problem andits possible cause. The following is an example of a well written nursing diagnosis:

A. Acute pain related to altered skin integrity secondary to hysterectomyB. Electrolyte imbalance related to hypocalcemiaC. Altered nutrition related to high fat intake secondary to obesityD. Knowledge deficit related to proctosigmoidoscopy

CORRECT ANSWER: CRATIONALE: A nursing diagnosis has three components: (a) the problem and its definition (b) the etiology and(c) defining characteristics. It describes the clients health status clearly and concisely in a few words. To beclinically useful, diagnostic labels need to specific; when the word specify follows a NANDA label, the nurse statesthe area in which the problem occurs.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 279OPTION A: double diagnosisOPTION B and D: used a medical term on the etiology

Situation 3 - You are taking care of Mrs. Bernas, 66 years old, who is terminally ill with ovarian cancer stage IV.

26. When caring for a dying client you will perform which of the following activities?A. Encourage the client to reach optimal healthB. Assist client perform activities of daily livingC. Assist the client towards a peaceful deathD. Motivate client to gain independence

CORRECT ANSWER: CRATIONALE: Nurses need to ensure that the client is treated with dignity, that is with honor and respect. Dyingclients often feel they have lost control over their lives and over life itself. Helping clients die with dignity involvesmaintaining their humanity, consistent with their values, beliefs and culture. Clients want to be able to manage the

events preceding death so they can die peacefully. Nurses can help clients to determine their own physical,psychologic and social priorities.OPTIONS A, B and D are inappropriateSOURCE: Kozier & Erb. Fundamentals of Nursing. 1050

27. The client prepares for her eventual death and discusses with the nurse and her family how she would like herfuneral to look like and what dress she will use. This client is in the stage of:

A. acceptanceB. resolutionC. denialD. bargaining

CORRECT ANSWER: ARATIONALE: The model was introduced by Elizabeth Kbler-Ross in her 1969 book "On Death and Dying". Thestages have become well-known as the "Five Stages of Grief".The stages are:

1. Denial:"It can't be happening."2. Anger: "Why me? It's not fair."3. Bargaining: "Just let me live to see my children graduate."4. Depression: "I'm so sad, why bother with anything?"

5. Acceptance: "It's going to be OK."


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Acceptance-there is a difference between resignation and acceptance. You have to accept the loss, not just try tobear it quietly. Realization that it takes two to make or break a marriage. Realization that the person is gone (indeath) that it is not their fault, they didn't leave you on purpose. (even in cases of suicide, often the deceasedperson, was not in their right frame of mind) Finding the good that can come out of the pain of loss, findingcomfort and healing. Our goals turn toward personal growth. Stay with fond memories of person.SOURCE: http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model

28. The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM to Mrs. Leyba. Demerol is available in a

mutidose vial labeled 100mg/ml while Vistaril comes in an ampule labeled 50 mg/ml. You are to give bothmedications in one injection. You will:A. withdraw the medication from the vial first then from the ampuleB. inject air into the vial, then into the ampuleC. Inject air into the ampule, aspirate desired dose, then into the vialD. withdraw medication from the ampule then from the vial

CORRECT ANSWER: ARATIONALE: When mixing medications from one vial and one ampule, first prepare and withdraw the medicationfrom the vial (Ampules do not require the addition of air prior to withdrawal of drug). Then withdraw the requiredamount of medication from the ampule.OPTIONS B,C and D are incorrectKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 819

29. When giving Demerol 50 mg from a multidose vial labeled 100 mg/ml and Vistaril 50 mg from an ampule labeled50 mg/ml. What is the total volume that you will inject to the client?

A. 2 mlB. I mlC. 1.5 mlD. 1.75 ml

CORRECT ANSWER: CRATIONALE: Demerol: dose in hand = desired dose

Quantity on hand quantity desired100mg = 50mg1 ml x100mgx = 1ml (50 mg)

X= 50mg/ml100 mg

= 0.5 ml

Vistaril: 50mg/ml = 50mg/x= 1 ml

Demerol (0.5ml) + Vistaril (1ml) = 1.5 ml

30. Mrs. Bernas is emaciated and is at risk for developing which problem in skin integrity?A. BlistersB. Reddening of the skinC. Pressure soresD. Pustules

CORRECT ANSWER: CRATIONALE: Emaciation occurs when a human loses substantial amounts of much needed fat and often muscletissue, making that human look extremely thin. The cause of emaciation is a lack of nutrients from starvation ordisease. The shape of the bones in a severely-emaciated person is distinguishable, the shoulder blades areprominently sharp, and the ribs and spine can be clearly seen, while the arms and legs are not significantly widerthan the bones that support them. Death may occur. Risk for pressure sores increases due to the fact that patientis terminally ill so she is immobile.http://en.wikipedia.org/wiki/EmaciatedOPTION A: caused by constant frictionOPTION B: reddening of the skin is may be a manifestation of other problemOPTION D may be caused by infection

Situation 4 - You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility andimmobility.

31. Ramils right leg is injured and Nurse Karen has to move him from the bed to a wheel chair. Which of the followingis the appropriate nursing action of Nurse Karen?

A. Put the client on the edge of the bed and place the wheelchair at her backB. Face the client and place the wheelchair on her left sideC. Put the client on the edge of the bed and place the wheelchair on the other side of the bedD. Put the client on the edge of the bed and place the wheelchair on the client's left side


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CORRECT ANSWER: DRATIONALE: Lower the bed to its lowest position so the clients feet will rest flat on the floor. Lock the wheels ofthe bed. Place the wheelchair parallel to the bed as close to the bed as possible. Put the wheelchair on the side ofthe bed that allows the client to move toward his or her stronger side. Lock the wheels of the wheelchair and raisethe footplate. Give explicit instructions to the client. Ask the client to move forward and sit at the edge of the bed.This brings the clients center of gravity closer to the nurse.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1092

OPTION A: wheelchair should be at the clients stronger sideOPTION C: wheelchair should be parallel to the bed and as close to the bed as possible

32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented?A. Adduction of the shoulderB. Lateral flexion of the sternocleidosmastoid muscleC. Hyperextension of the kneesD. Anterior flexion of lumbar curvature

CORRECT ANSWER: CRATIONALE: Problems to be prevented in dorsal recumbent position includes:

Hyperextension of neck in thick-chested person

Posterior flexion of lumbar curvature

External rotation of the legs Hyperextension of knees (Put small pillow under the thigh to slightly flex the knee)

Plantar flexion (foot drop)

Pressure on heels


33. Joseph prefers to be in high fowler's position most of the time. The nurse should prevent which of the following?A. Posterior flexion of the lumbar curvatureB. Internal rotation of the shoulderC. External rotation of the hipD. Adduction of the shoulder

CORRECT ANSWER: A

RATIONALE: Problems to be prevented in Fowlers Position includes: Posterior flexion of lumbar curvature (Provide pillow at lower back or lumbar region to support

lumbar region)

Hyperextension of neck

Shoulder muscle strain, possible dislocation of shoulders, edema of hands and arms with

flaccid paralysis, flexion contracture of the wrist

Hyperextension of knees

Pressure on heels

Plantar flexion of feet (foot drop)


34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first?A. Move the patient to the edge of the bed near the nurseB. Adjust the bed to a flat positionC. Lock the wheels of the bedD. Raise the bed rails opposite the nurse

CORRECT ANSWER: CRATIONALE: Lock the wheels on the bed and raise the rail on the side of the bed opposite the nurse to ensureclient safety.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1084All options are correct but the nurse should first do option C to ensure clients safety, all the rest will follow as partof the procedure in moving your client up in bed.

35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent externalrotation of the right leg?

A. SandbagsB. Firm mattressC. PillowD. High foot board

CORRECT ANSWER: ARATIONALE: Roll or sandbag is placed laterally to trochanter of femur to prevent external rotation of legs.OPTION B: Firm mattress provides good body support at natural body curvatures


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OPTIONC: Pillows used or support or elevation of a body partOPTION D: prevent foot dropKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1080

Situation 5- As you begin work in the hospital where you are on probation, you are tasked to take care of a few patients.The clients have varied needs and you are expected to provide care for them.

36. An ambulatory client, Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote

safety for the client?A. Turning off the lights to promote sleep and restB. Instructing the client about the use of the call systemC. Raising the side railsD. Placing the bed in high position

CORRECT ANSWER: CRATIONALE: Raising the side rails promotes safety by preventing falls that may lead to injury or fracture.OPTION A: does address the safety needs but rather on the patients comfortOPTION B: more on emergency needs of patientOPTION D: the bed should be in lowest position as possible.

37. Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosedthe client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following

surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis?A. Impaired mobility related to pain secondary to an abdominal incisionB. Impaired movements related to pain due to surgeryC. Impaired mobility related to surgeryD. Severe pain related to surgery

CORRECT ANSWER: ARATIONALE: Nursing diagnosis should be concise, related to only one problem and written clearly.Noticed that OPTION C and D have the same etiology which is a surgical intervention; the diagnosis according toNANDA is Impaired mobility and not Impaired movements

38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling followinglaminectomy. Which of the following should be included in the nursing care plan?

A. Encourage the client to log roll when turningB. Encourage the client to do self-careC. Instruct the client to do deep breathing exercisesD. Ambulate the client in that ward premises every twenty minutes

CORRECT ANSWER: CRATIONALE: Walking is encouraged hours after surgery and breathing exercises may be performed to avoid lossof air in a lung or pneumonia. It is advised to bend at the hip, not at the waist, and to avoid twisting at theshoulders or hips. However at this time, options A, B and D can aggravate the pain experienced by the patient.Deep breathing exercise is one form of relaxation techniques.http://www.answers.com/topic/laminectomy?cat=health

39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr.

Lozano's hygiene and grooming needs have been met by the nursing staff. Which of the following activities shouldbe implemented to achieve the goal of independence for Mr. Lozano?A. Involving family members in meeting client's personal needsB. Meeting his needs till he is ready to perform self-careC. Preparing a day to day activity list to be followed by clientD. Involving Mr. Lozano in his care

CORRECT ANSWER: CRATIONALE: During this time, they will gradually increase their activities to the point where they are doing all oftheir own self-care such as bathing and eating, as well as beginning a walking program as part of theirrehabilitation program.OPTION A: we are developing independence to the clientOPTION B: the nurse should gradually increase the activityOPTION D: may be correct but the best is Option Chttp://www.heartpoint.com/mimore.html#anchor87783

40. Mr. Ernest Lopez is terminally ill and he chose to be at home with his family. What nursing actions are bestinitiated to prepare the family of Mr. Lopez?

A. Talk with the family members about the advantage of staying in the hospital for proper careB. Provide support to the family members by teaching ways to care for their loved oneC. Convince the client to stay in the hospital for professional careD. Tell the client to be with his family


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CORRECT ANSWER: BRATIONALE: As death approaches, the nurse assists the family and other significant people to prepare. Thenurse asks questions that help identify ways to provide support during the period before and after death. The mostimportant aspects of providing support to the family members of the dying client involve using therapeuticcommunication to facilitate their expression of feelings. The nurse also serves as a teacher, explaining what ishappening and what the family can expect. Family members should be encouraged to participate in the physicalcare of the dying person as much as they wish to and are able.

Kozier & Erb. Fundamentals of Nursing. 7

th

Edition.pp. 1048,1052

Situation 6- Myrna a researcher proposes a study on the relationship between health values and the health promotionactivities of staff nurses in a selected college of nursing.

41. In both quantitative and qualitative research, the use of a frame of reference is required. Which of the followingitems serves as the purpose of a framework?

A. Incorporates theories into nursing's body of knowledgeB. Organizes the development of study and links the findings to nursing's body of knowledgeC. Provides logical structure of the research findingsD. Identifies concepts and relationships between concepts

CORRECT ANSWER: BRATIONALE: Framework is the underpinnings of a study; often called a theoretical framework in studies based on

a theory, or a conceptual framework in studies rooted in a specific conceptual model. Their overall purpose is tomake research findings meaningful and generalizable. Theories allow researchers to knit together observationsand facts into orderly scheme. The linkage of findings into a coherent structure can make the body ofaccumulated evidence more accessible and, thus, more useful. Theories and conceptual models help to stimulateresearch and the extension of knowledge by providing both direction and impetus.OPTION A: describes only theoretical frameworkOPTION D: only for conceptual modelsPolit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 119-120

42. Myrna needs to review relevant literature and studies. The following processes are undertaken in reviewingliterature EXCEPT:

A. Locating and identifying resourcesB. Reading and recording notes

C. Clarifying a research topicD. Using the library

CORRECT ANSWER: DRATIONALE: The following are purposes of review of related literature:

Identification of a research problem and development or refinement of research questions or hypothesis

Orientation to what is known and not known about an area of inquiry, to ascertain what research can best

make a contribution to the existing base of evidence

Determination of any gaps or inconsistencies in a body of research

Determination of a need to replicate a prior study in a different setting or with a different study population

Identification or development of new or reined clinical interventions to test through empirical research

Identification of relevant theoretical or conceptual frameworks for a research problem

Identification of suitable designs and data collection methods for a study For those developing research proposals for finding, identification of experts in the fields who could be

used as consultants

Assistance in interpreting study findings and in developing implications and recommendations

OPTION D: There are variety of resources in the review of literaturePolit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 5

43. The primary purpose for reviewing literature is to :A. organize materials related to the problem of interestB. generate broad background and understanding of information related to the research problem of interestC. select topics related to the problem of interestD. gather current knowledge of the problem of interest

CORRECT ANSWER: ARATIONALE: Literature review is a critical summary of research on a topic of interest, often prepared to put aresearch problem in context.It is an umbrella effect, the main purpose of review of literature is to organize materials related to your topic.Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 722

44. In formulating the research hypotheses, researcher Myrna should state the research question as:A. What is the response of the staff nurses to the health values?B. How is variable health value" perceived in a population?


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C. Is there a significant relationship between health values and health promotion activities of the staff nurses?D. How do health values affect health promotion activities of the staff nurses?

CORRECT ANSWER: DRATIONALE: Research questions are the specific queries researchers want to answer in addressing the researchproblem. Research questions guide the type of data collected in a study.Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 65

45. The proposed study shows the relationship between the variables. Which of the following is the independentvariable?A. Staff nurses in a selected college of nursingB. Health valuesC. Health promotion activitiesD. Relationship between health values and health promotion activities

CORRECT ANSWER: BRATIONALE: Independent variable is the variable that is believed to cause or influence the dependent variable.Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 720

Situation 7- White working in a tertiary hospital, you are assigned to the medical ward.

46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a:

A. nurse supervisorB. social workerC. bookkeeping departmentD. physician

CORRECT ANSWER: BRATIONALE: A social worker counsels clients and support persons regarding social problems, such as finances,marital difficulties and adoption of children.Option D: responsible for medical diagnosis and for determining the therapy required by a person who has adisease or injury.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 94-95

47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-

help group of clients with cancer to:A. receive emotional supportB. to be part of a research studyC. provide financial assistanceD. assist with chemotherapy

CORRECT ANSWER: ARATIONALE: A self-help group is a small, voluntary organization composed of individuals who share a similarhealth, social or daily living problem. One of the central beliefs of the self-help movement is that people whoexperience a particular social or health problem have an understanding of that condition which those without it donot.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 436

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should bereferred to a:A. nutritionistB. dietitianC. physicianD. medical pathologist

CORRECT ANSWER: BRATIONALE: Anyone can use the term nutritionist, even without any formal education or training. It's not aprofessionally regulated term which means that there are no minimum qualifications for a person to call himselfor herself a nutritionist.Technically, only registered dietitians can use the term dietitian , which is a professionally regulated term. Aregistered dietitian is required to meet specific educational and professional standards.http://www.riverside-online.com/health_reference/Diet-Nutrition/AN00987.cfmDietitians in hospitals generally are concerned with therapeutic diets, may design special diets to meet thenutritional needs of individual clients and supervise the preparation of meals to ensure that clients receive theproper diet.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 94

49. When collaborating with other health team members, the best description of Nurse Rita's role is:A. encourages the client's involvement in his careB. shares and implements orders of the health team to ensure quality care


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C. she listens to the individual views of the team membersD. helps client set goals of care and discharge

CORRECT ANSWER: BRATIONALE: Collaboration among health care professionals becomes increasingly important as morepractitioners specialize in progressively more narrow areas of expertise while others take on generalist role.The nurse as a collaborator:With Nurse colleagues:

Shares personal expertise with other nurses and elicits the expertise of others to ensure quality clientcare

Develops a sense of trust and mutual respect with peers that recognizes their unique contributions

With other health care professionals:

Recognizes the contribution that each member of the interdisciplinary team can make by virtue of his or

her expertise and view of the situation.

Listens to each individual views

Shares health care responsibilities in exploring options, setting goals and making decisions with clients

and families

Participates in collaborative interdisciplinary research to increase knowledge of a clinical problem or

situationWith professional nursing organizations:

Seeks opportunities to collaborates with and within professional organizations

Serves on committees in state (provincial) and national nursing organizations or special groups.

Supports professional organizations in political actions to create solutions for professional and health

concerns.With legislator:

Offers expert opinions on legislative initiatives related to health care

Collaborates with other hea;th care providers and consumers on health care legislation to best serve the

needs of the public.OPTION B is the best answer.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 111-112OPTION A and D are inappropriateOPTION C is only part of collaboration with other health care professionals.

50. Nurse Rita is successful in collaborating with health learn members about the care of Mr. Linao. This is becauseshe has the following competencies:

A. Communication, trust, and decision makingB. Conflict management, trust, negotiationC. Negotiation, decision makingD. Mutual respect, negotiation, trust

CORRECT ANSWER: ARATIONALE: The key elements necessary for collaboration include effective communication skills, mutualrespect, trust and a decision making process.Effective communication can occur only if the involved parties are committed to understanding each othersprofessional roles and appreciate each other as an individual.Mutual respect occurs when two or ko0re people show or feel honor or esteem toward one another. Trust occurswhen a person is confident in the actions of another person.

The decision making process at the team level involves shared responsibility for the outcome.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 112-113

Situation 8- The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in thecommunity setting your main objective is to provide safe nursing to your clients?

51. To provide safe quality nursing care to various clients in any setting, the most important tool of the nurse so is:A. critical thinking to decide appropriate nursing actionsB. understanding of various nursing diagnosesC. observation skills for data collectionD. possession of in scientific knowledge about client needs

CORRECT ANSWER: B

RATIONALE: Diagnosis is a reasoning process that uses critical thinking. A nursing diagnosis provides the basisfor selecting independent nursing interventions to achieve outcomes for which the nurse is accountable.Nursing diagnosis is a judgement made after thorough systematic data collection.The diagnostic process is used continuously by most nurses. As a result of attaining knowledge, skills andexpertise , the expert nurse may seem to perform these mental process automatically.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 281-282, 290

52. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by:A. Creating plans of care for particular clientele


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B. Identifying the correct nursing diagnoses for clientsC. Making a thorough assessment of client needs and problemsD. Using standards of nursing care as your criteria for evaluation

CORRECT ANSWER: BRATIONALE: A nursing diagnosis provides the basis for selecting independent nursing interventions toachieveoutcomes for which the nurse is accountable.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.290

53. The effectiveness of your nursing care plan for your clients is determined by:A. The number of nursing procedures performed to comfort the clientB. The amount of-medications administered to the client as orderedC. The number of times the client calls the nurseD. The outcome of nursing interventions based on plan of care

CORRECT ANSWER: DRATIONALE: Desired outcome or goal serves as criteria for evaluating client progress. Although developed in theplanning step of the nursing process, desired outcome serves as criteria for judging the effectiveness of nursinginterventions and client progress in the evaluation step.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 301

54. You are assigned to Mrs. Amado, age 49, who was admitted for possible surgery. She complained of recurrent

pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequentbouts of dizziness, blood pressure of 170/100 hot flashes. Which of the above symptoms would be an objectivecue?

A. Blood pressure measurement of 170/100B. Complaint of hot flashesC. Report of pain after ingestion of fatty foodD. Complaint of frequent bouts of dizziness

CORRECT ANSWER: ARATIONALE: Objective data, also referred to as sign or overt data, are detectable by an observer or can bemeasured or tested against an accepted standard.Subjective data, also referred to as symptoms or covert data, are apparent only to the person affected and can bedescribed or verified only by that person.

Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 262OPTIONS B,C and D are subjective cues

55. While talking with Mrs. Amado, it is most important for the nurse to:A. Schedule the laboratory exams ordered for herB. Do an assessment of the client to determine priority needsC. Tell the client that your shift ends after eight hoursD. Have the client sign an informed consent

CORRECT ANSWER: BRATIONALE: All phases of nursing process rely on accurate and complete data.OPTION B is nurse centeredOPTION D: signing of consent is the doctors responsibility

Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 5

Situation 9 - Oral care is an important part of hygienic practices and promoting client comfort.

56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presenceof sores. Which of the following is BEST to use for oral care?

A. Lemon glycerineB. Hydrogen peroxideC. Mineral oilD. Normal saline solution

CORRECT ANSWER: DRATIONALE: Mouth care for unconscious or debilitated people is important because their mouths tend to dry andconsequently predisposed to infections. The nurse can use commercially prepared applicators or foam swabs toclean the mucous membranes. Normal saline solution is recommended for oral hygiene for the dependent client.OPTION A: long term use of lemon glycerine swabs can lead to further dryness of mucosa and changes in toothenamel.OPTION B: Hydrogen peroxide is not recommended for use in oral car because it irritates healthy oral mucosaand may alter the microflora of the mouth.OPTION C: Mineral oil is contraindicated because aspiration of it can initiate an infection (lipid pneumonia).Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 727


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57. When performing oral care to an unconscious client, which of the following is a special consideration to preventaspiration of fluids into the lungs?

A. Put the client on a sidelying position with head of bed loweredB. Keep the client dry by placing towel under the chinC. Wash hands and observe appropriate infection controlD. Clean mouth with oral swabs in a careful and an orderly progression

CORRECT ANSWER: A

RATIONALE: Position the unconscious client in a side-lying position with the head of bed lowered. In this position,the saliva automatically runs out by gravity rather than being aspirated into the lungs.OPTIONS B, C and D did not address the questionKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 730

58. The advantages of oral care for a client include all of the following, EXCEPT :A. decreases bacteria in the mouth and teethB. reduces need to use commercial mouthwash which irritate the buccal mucosaC. improves client's appearance and self-confidenceD. improves appetite and taste of food

CORRECT ANSWER: BRATIONALE: The purpose of oral care are to remove food particles from around and between teeth; to removedental plaque; to enhance the clients feelings of well-being; to prevent sores and infection of the oral tissues.

OPTION B: part of maintaining oral hygiene is the use of appropriate commercial mouthwash.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 727

59. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This canbe avoided by:

A. Cleaning teeth and mouth with cotton swabs soaked with mouth wash to avoid rinsing the buccal cavityB. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabsC. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gumsD. Suctioning as needed while cleaning the buccal cavity

CORRECT ANSWER: DRATIONALE: The clients mouth is rinsed by drawing about 10 ml of water or alcohol-free mouthwash into thesyringe and injecting it gently into each side of the mouth. Watch carefully to make sure that all the rinsing solution

has run out of the mouth into the basin. If not, suction the fluid from the mouth. Fluid remaining in the mouthmaybe aspirated into the lungs.OPTION C: done when no foam swabs are availableKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 730

60. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouthwith unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouthmoistened by using:

A. salt solutionB. water C. petroleum jellyD. mentholated ointment

CORRECT ANSWER: DRATIONALE: The mentholated ointment such as lip balm has a primary purpose which is to provide an occlusivelayer on the lip surface to seal moisture in lips and protect them from external exposure. Dry air, coldtemperatures and wind all have a drying effect on skin by drawing moisture away from the body. Lips areparticularly vulnerable because the skin is so thin, and thus they are often the first to present signs of dryness.The patient has difficulty of breathing, anticipate that the patient might have O2 treatment so petroleum jelly iscontraindicated because it can burn the lips and mouth.http://en.wikipedia.org/wiki/Lip_balm

Situation 10- Errors while providing nursing care to patients must be avoided and minimized at all times. Effectivemanagement of available resources enables the nurse to provide safe quality patient care.

61. In the hospital where you work, increased incidence of medication error was identified as the number one problemin the unit. During the brainstorming session of the nursing service department, probable causes were identified.Which of the following is process related?

A. InterruptionsB. Use of unofficial abbreviationsC. Lack of knowledgeD. Failure to identify client

CORRECT ANSWER: DRATIONALE: Errors can and do occur usually because one client gets a drug intended for another.


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62. Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following isa safe medication practice related to this?

A. Maintain medication in its unit dose package until point of actual administrationB. Note both generic and brand name of the medication in the Medication Administration RecordC. Only officially approved abbreviations maybe used in the prescription ordersD. Encourage clients to ask question about their medications

CORRECT ANSWER: CRATIONALE: A physician usually determines the clients medication needs and orders medications. Mostagencies also have lists of abbreviations officially accepted for use in agency. Both nurses and physicians mayneed to refer to these lists. These abbreviations can be used on legal documents, such as clients charts.OPTION B: The name of the drug to be administered must be clearly written. In some settings only generic namesare permitted; however, trade names are widely used in hospitals and health agencies.OPTION A and D does not address the questionKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 794, 796

63. The hospital has an ongoing quality assurance program. Which of the following indicates implementation ofprocess standards?

A. The nurses check client's identification band before giving medicationsB. The nurse reports adverse reaction to drugs

C. Average waiting time for medication administration is measuredD. The unit has well ventilated medication room

CORRECT ANSWER: ARATIONALE: Quality Assurance program is an ongoing, systematic process designed to evaluate and promoteexcellence in the health care provided to clients.Quality assurance requires evaluation of three components:

Structure evaluation focuses on the setting in which care is given. It answers question: What effect does the

setting have on the quality of care? Structural standards describe desirable environmental and organizationalcharacteristics that influence care, such as equipment and staffing.

Process evaluation focuses on how the care was given. It answers questions such as these: Is the care

relevant to the clients need? Is the care appropriate, complete, and timely? Process standards focus on themanner in which the nurse uses the nursing process. Some examples of process criteria are Check clients

identification band before giving medication and Performs and records chest assessment, includingauscultation, once per shift.

Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Outcome criteria are written in terms of client responses or health status, just as they are for evaluation withinthe nursing process. For example: How many clients undergoing hip repairs develop pneumonia? or Howmany clients who have a colostomy experience an infection that delays discharge?

Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 322-323

64. Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care?A. Interviews nurses for comments regarding staffingB. Measures waiting time for clients per nurse's callC. Checks equipment for its calibration scheduleD. Determines how many clients post surgery have experienced infection

CORRECT ANSWER: DRATIONALE: refer to rationale of # 63OPTION A and C: structure evaluationOPTION B: process evaluation

65. An order for a client was given and the nurse in charge of the client reports that she has no experience of doingthe procedure before. Which of the following is the most appropriate action of the nurse supervisor?

A. Assign another nurse to perform the procedureB. Ask the nurse to find a way to learn the procedureC. Tell the nurse to read the procedure manualD. Do the procedure with the nurse

CORRECT ANSWER: DRATIONALE: A staff members inexperience can be hindrance to delegation; an institution can minimize thisthrough competency-based orientation and testing; the nurse delegating the task sometimes must teach thenovice the necessary skills to complete the task; with proper guidance, delegating can improve the novices skills.Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 94

Situation 11 - Mr. Jose's chart is the permanent legal recording of all information that relates lo his health caremanagement. As such, the entries in the chart must have accurate data.


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66. Mr. Jose's chart contains all information about his health care. The functions of records include all followingEXCEPT:

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

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

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

CORRECT ANSWER: DRATIONALE: Charting should be timely, complete, accurate, confidential and client specific. Documentationshould be done as soon as care is provided whenever possible and should reflect the clients present condition;late entries must be so noted.Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 76

67. An advantage of automated or computerized client care system is:A. the nursing diagnosis for a client's data can be accurately determinedB. cost of confinement will be reducedC. information concerning the client can be easily updatedD. the number of people to take care of the client will be reduced

CORRECT ANSWER: A

RATIONALE:With the Computerized clinical documentation system CDS there was: improved legibility and

completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct

patient care or charting by nursing staff. Incidental observations from the study included improved management

functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data

(labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement becauseof the ability to reconstruct lost charts; limited human data entry by automatic data logging;eliminated costs of printing forms. CDS cost was reasonable.http://www.biomedcentral.com/content/pdf/1472-6947-1-3.pdfThough almost all of the choices are advantages of using computerized client care system but the best isOPTION A.

68. Information in the patient's chart is inadmissible in court as evidence when:

A. the client's family refuses to have it usedB. the client objects to its useC. the handwriting is not legibleD. it has too many abbreviations that are "unofficial

CORRECT ANSWER: DRATIONALE: Medical records are usually used to give important evidence in legal proceedings such as policeinvestigations, determining cause of death, extent of injury incurred by the patient, among others. It is usually themedical records librarian, by virtue of subpoena duces tecum, who testifies that the patients records are kept andprotected from unauthorized handling and change. Only complete accurate records are accepted in court.Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp.177-178

According to Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 330: The record is considered inadmissibleas evidence when the client objects, because information the client gives to the physician is confidential.However, in Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp.106,

Confidential information may also be revealed as provided for by the law in Article IV, Section 4 (1) of the NewConstitution, which states that:

The privacy of communication and correspondence shall be inviolable except upon lawful order of thecourt or when public safety and order require otherwise.

69. Nursing audit aims to:A. provide research data to hospital personnelB. study client's illness and treatment regimen closelyC. compare actual nursing done to established standardsD. provide information to health-care providers

CORRECT ANSWER: CRATIONALE: Audit means the examination of records.These auditing procedures are completed to ensure

continuity of care and that health care standards are being met by the institution.Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 75

70. A telephone order is given for a client in your ward. What is your most appropriate action?A. Copy the order on to the chart and sign the physician's name as close to his original signature as possibleB. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone orderC. Write the order in the client's chart and have the head nurse co-sign itD. Tell the physician that you can not take the order but you will call the nurse supervisor


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CORRECT ANSWER: BRATIONALE: According to the 7th and 8th Guidelines for telephone orders: Read the order back to the prescriberat the end. Use words instead of abbreviations. Write the order on the physicians order sheet. Record date andtime and indicate I was a telephone order (TO). Sign name and credentials.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 346

Situation 12- Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take careof clients with various conditions

71. Which of the following client conditions should be Miss Roque's priority in the pediatric unit?A. The baby whose fontanel is bulging and firm while asleepB. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevatedC. A baby who is wailing after being awakened by the banging of the doorD. A baby boy whose circumcision has yellowish exudate

CORRECT ANSWER: BRATIONALE: it needs immediate intervention since it is a respiratory problem and elevation of temperature mayindicate infection which may alter the respiratory function of the infant.OPTION A is the case of hydrocephalus but the patient is calm so there is less risk of increasing the intracranialpressure.OPTION C is a normal response of the babyOPTION D may be a sign of infection but is less threatening than OPTION B

72. When suctioning the endotracheal tube, the nurse should:A. explain procedure to patient, insert catheter gently applying suction, withdrawn using twisting motionB. insert catheter until resistance is met then withdraw slightly, applying suction intermittently as catheter is

withdrawnC. Hyperoxygenate client then insert catheter using back and forth motionD. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is

withdrawn

CORRECT ANSWER: BRATIONALE: Resistance usually means that the catheter tip has reached the bifurcation of the trachea. Toprevent damaging the mucous membranes at the bifurcation, withdraw the catheter about 1 to 2 cm beforeapplying the suction. Apply intermittent suction for 5 to 10 seconds. Rotate the catheter by rolling it between your

thumb and forefinger while slowly withdrawing it.OPTION A: incorrect, catheter is inserted without applying suction to prevent tissue trauma and oxygen lossOPTION C: you dont insert catheter using back an forth motionOPTION D: suctioning is only for 5 to 10 secondsKozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1324

73. Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. WhileDoris is doing the sponge bath, what action of Doris needs correction?

A. Answering the phone while wearing gloves used for sponge bathB. Rolling the patient like a log to do back rubC. Lining the rubber mat with bed sheet as incontinence pad for the patientD. Turning the patient on the left side with head slightly elevated

CORRECT ANSWER: ARATIONALE: The action promotes transfer of microorganism to the telephone which may also be transferred toothers.

74. Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application ismost important for Nurse Roque to do?

A. Use baby powder to reduce irritation under the castB. Assess sensation of each armC. Evaluate skin temperature in the areaD. Check radial pulses bilaterally and compare

CORRECT ANSWER: BRATIONALE: Assess sensation of each arm to detect any damage to nerve function or if there is any nervecompression. It is necessary because during the application of the cast, the most common complication is thecompartment syndrome which may be caused by decreased blood supply due to increased pressure in the area.Compartment syndrome without prompt treatment lead to nerve damage and muscle death.

75. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?A. Upon waking up, cough deeply and expectorate into containerB. Cough after pursed lip breathingC. Save sputum for two days in covered containerD. After respiratory treatment, expectorate into a container


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CORRECT ANSWER: ARATIONALE: Sputum specimens are often collected in the morning. Upon awakening, the client can cough upsecretions that have accumulated during the night. Ask the client to expectorate the sputum into the specimencontainer.OPTION B: Collected after postural drainageOPTION C: Specimen is sent immediately to the laboratory before any contaminating organism can grow.OPTION D: treatment alters the result

Kozier & Erb. Fundamentals of Nursing. 7

th

Edition.pp. 771

Situation 13 - Infections are quite commonly the reasons for a client's hospitalization. Appropriate interpretation ofdiagnostic tests and measures for infection control are helpful in the management of patient care.

76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result thenurse notices which of the following as abnormal finding?

A. Neutrophils 60%B. White blood cells (WBC) 90007mmC. Erythrocyte sedimentation (ESR) is 39 mm/hrD. Iron 75 mg/100 ml

CORRECT ANSWER: CRATIONALE: The normal ESR for women is 20-30 mm/hr; for men 15-20 mm/hr

OPTION A, B and D are all normalNormal values

Neutrophil 50%-70%WBC 4,500-10,000/mmIron 60-170 mg/100ml

77. Surgical sepsis is observed when:A. inserting an intravenous catheterB. disposing of syringes and needles in puncture proof containersC. washing hands before changing wound dressingD. placing dirty soiled linen in moisture resistant bags

CORRECT ANSWER: A

RATIONALE: An object is sterile only when it is free of all microorganisms. Sterile technique is indicated forprocedures that require penetration of clients skin such as with injections and IV catheter insertion. Steriletechnique is also employed for many procedures in general care areas (such as administering injections,changing wound dressings, performing urinary catheterizations and administering intravenous therapy.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 655Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 144

78. A client with viral infection will most likely manifest which of the following during the illness stage of the infection?A. Client was exposed to the infection 2 days ago but without any symptomsB. Oral temperature shows feverC. Acute symptoms are no longer visibleD. Client "feels sick" but can do normal activities

CORRECT ANSWER: BRATIONALE: Prodromal or illness stage is the presence of signs and symptoms of the disease.OPTION A: incubation periodOPTION C: recovery period

79. Which of the following laboratory test results indicate presence of an infectious process?A. Erythrocyte sedimentation rate (ESR) 12 mm/hrB. White blood cells (WBC) 18.000/mm3C. Iron 90g/100mlD. Neutrophils 67%

CORRECT ANSWER: BRATIONALE: Its beyond the normal value of 4,500 to 10,000/mm3. WBC of 10,000 to 15, 000 is an indicative ofinflammation. A more than 15, 000 is an indication of infection.OPTION A: below normal but Lower-than-normal levels occur with:

Congestive heart failure

Hyperviscosity

Hypofibrinogenemia (decreased fibrinogen levels)

Low plasma protein (due to liver or kidney disease)

Polycythemia

Sickle cell anemia


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http://www.nlm.nih.gov/medlineplus/ency/article/003638.htmOPTION C: normalOPTION D: normal

80. Among the clients you are assigned to take care of, who is most susceptible to infection?A. Diabetic clientB. Client with burnsC. Client with pulmonary emphysema

D. Client with myocardial infarction

CORRECT ANSWER: BRATIONALE: Burns are exceedingly challenging due to the high risk of infection since the skin is no longer abarrier to bacteria.Infection is the most common complication of burns and is the major cause of death in burn victims.http://www.umm.edu/altmed/articles/burns-000021.htmOPTION A: susceptible to infection with open wounds but with proper care, less susceptible than burn patientOPTION C and D: are the least susceptible

Situation 14 -A significant milestone influencing the development of nursing concepts and theories was theestablishment of journal of nursing research. Several nursing theorist have published the framework for practice accordingto their respective nursing theory.

81. Which of the following theorists consider and utilize nature and environment in the healing process?A. Julia SotejoB. Ida Jean OrlandoC. Florence NightingaleD. Imogene King

CORRECT ANSWER: CRATIONALE: Florence Nightingale, often considered as the first nurse theorist, defined nursing more than 100years ago as the act of utilizing the environment of the patient to assist him in his recovery.

82. In her theory, Imogene King defined nursing process as a dynamic interpersonal process between nurse, clientand health care system. In this theory, which of the following nursing skills is most important to help clientestablish positive adaptation to environment?

A. Assessment skillsB. Communication skillsC. Environment management skillsD. Technical skills

CORRECT ANSWER: BRATIONALE: Imogene M. King developed a general systems framework and a theory of goal attainment. Theframework speaks to three levels of systemsindividual or personal, group or interpersonal, and society or social.The theory of goal attainment speaks to the importance of interaction, perception, communication, transaction,self, role, stress, growth and development, time, and personal space. King emphasizes that both the nurse andthe client bring important knowledge and information to the relationship and that they work together to achievegoals. Research has supported that when the nurse and client communicate and work together toward mutuallyselected goals, the goals are more likely to be attained.

83. Who among the following theorists has identified twenty one specific client needs or problems in the area ofcomfort, hygiene, safety, physiologic balance, psychologic and social factors and sociological and communityfactors?

A. Faye AbdellahB. Dorothy JohnsonC. Sister Callista RoyD. Virginia Henderson

CORRECT ANSWER: ARATIONALE: Faye Abdellah developed a list of 21 unique nursing problems related to human needs in the 1960s.OPTION B: Behavioral Systems ModelThe person is a behavioral system comprised of a set of organized, interactive, interdependent, and integratedsubsystems.OPTION C:Adaptation ModelAda

ptation ModelThe person is an open adaptive system with input (stimuli), who adapts by processes or control mechanismsOPTION D: Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to theperformance of activities contributing to health or its recovery". She categorized nursing activities into 14components, based on human needs.

84. Which of the following nurse theorists has stated that the goals of nursing is to maintain and promote health, preventillness and care for and rehabilitate ill and disabled client through humanistic science and nursing.


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A. OremB. AbdellahC. NightingaleD. Rogers

CORRECT ANSWER: DRATIONALE: Martha E. Rogers developed the Science of Unitary Human Beings as nursings unique body ofknowledge. Human beings and their environments are infinite energy fields in continuous motion. They producepatterns and are unitary.OPTION A: Dorothea E. Orems general theory of nursing is made up of the three interrelated theories of self-care, self-care deficit, and nursing systems. Self-care deficit exists when the therapeutic self-care demandexceeds self-care agency.OPTION B: Faye Abdellah developed a list of 21 unique nursing problems.OPTION C: Florence Nightingale is recognized as founder of m

odern-day nursing. Her environmental model isbased on the idea that the impetus for healing lies within the individual human being and the focus of care is toplace the individual in an environment that is supportive to that healing process.

85. Nursing care becomes necessary when clients is unable to fulfill biological, physiological development or social needsexplains which of the following theories:

A. Adaptation theoryB. Self-care deficit theoryC. Theory of the Unity of Man

D. Transcultural care theory

CORRECT ANSWER: BRATIONALE: Dorothea E. Orems general theory of nursing is made up of the three interrelated theories of self-care, self-care deficit, and nursing systems. Self-care deficit exists when the therapeutic self-care demandexceeds self-care agency.OPTION A: RoysAdaptation ModelAda

ptation ModelThe person is an open adaptive system with input (stimuli), who adapts by processes or control mechanismsOPTIONC: Martha E. Rogers developed the Science of Unitary Human Beings as nursings unique body ofknowledge. Human beings and their environments are infinite energy fields in continuous motion. They producepatterns and are unitary.OPTION D: Since Madeline Leiningers work began in the 1950s with transcultural nursing, she has viewed theworld as multicultural. Being a nurse and an anthropologist, she believed the individuality of the patient, as a

cultural being is fundamental. A nurse must understand a patients heritage and traditions before a nurse canassist a patient with wellness and illness issues. Leininger established the Transcultural Nursing Society in 1989to provide nurses with educational and certification opportunities.

Situation 15- When creating your lesson plan for cerebrosvascular disease or STROKE, it is important to include the riskfactors of stroke.

86. The most important risk factor is:A. cigarette smokingB. hypertensionC. binge drinkingD. heredity

CORRECT ANSWER: BRATIONALE: Hypertension-most important risk factor for all stroke types; no defined BP indicating increasedstroke risk, but risk increases proportionately as BP increases.http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/CVD.html

87. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are thefollowing EXCEPT:

A. embolic strokeB. hemorrhagic strokeC. diabetic strokeD. thrombotic stroke

CORRECT ANSWER: CRATIONALE: Strokes can be classified into two main categories, including the following:

ischemic strokes - strokes caused by blockage of an artery.

hemorrhagic strokes - strokes caused by bleeding.

An ischemic stroke occurs when a blood vessel that supplies the brain becomes blocked or "clogged" and impairsblood flow to part of the brain. Ischemic strokes are further divided into two groups, including the following:

thrombotic strokes - caused by a blood clot that develops in the blood vessels inside the brain.

embolic strokes - caused by a blood clot that develops elsewhere in the body and then travels to one of

the blood vessels in the brain via the bloodstream.


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Hemorrhagic strokes occur when a blood vessel that supplies the brain ruptures and bleeds. Hemorrhagic strokesare divided into two main categories, including the following:

intracerebral hemorrhage - bleeding from the blood vessels within the brain.

subarachnoid hemorrhage - bleeding in the subarachnoid space (the space between the brain and the

membranes that cover the brain).http://medicalcenter.osu.edu/patientcare/healthcare_services/stroke/types/

88. Hemorrhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT:

A. phlebitisB. traumaC. damage to blood vesselD. aneurysm

CORRECT ANSWER: ARATIONALE: Hemorrhage is any profuse internal or external bleeding from the blood vessels. The most obviouscause of hemorrhage is trauma or injury to a blood vessel. Hemorrhage can also be caused by aneurysms orweak spots in the artery wall that are often present at birth. Over time, the blood vessel walls at the site of ananeurysm tend to become thinner and bulge out like water balloons as blood passes through them, making themmore likely to leak and rupture.Hypertension, or high blood pressure, is often a contributing factor in brain hemorrhage, which can cause astroke. Other times, vessels simply wear out with age. Uncontrolled diabetes can also weaken blood vessels,

especially in the eyes; this is called retinopathy (ret-i-NOP-a-thee). Use of medications that affect blood clotting,including aspirin, can make hemorrhage more likely to occur.Bleeding disorders can also spark hemorrhages. Among them are hemophilia (he-mo-FIL-e-a), an inheriteddisorder that prevents the blood from clotting.http://www.humanillnesses.com/original/Gas-Hep/Hemorrhage.htmlOPTION A: Phlebitis is an inflammation of vein

89. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked tothis?

A. AmphetaminesB. CocaineC. ShabuD. Demerol

CORRECT ANSWER: BRATIONALE: Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the useof oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use ofcocaine or intravenous drugs.Stroke secondary to cocaine probably occurs because cocaine causes blood vessels to narrow (constrict) whilealso increasing blood pressure ( hypertension ). This vasoconstriction can be severe enough to reduce or blockblood flow through the arteries in the brain.Stroke secondary to cocaine is most common in men under 40 years old. Risks include a history of recent cocaineuse. In a few people who experience stroke after using cocaine, an underlying arteriovenous malformation isfound, which may have predisposed them to developing a stroke. In these cases the stroke is due to bleeding inthe brain as opposed to decreased blood flow.http://www.umm.edu/ency/article/000743.htm

90. A participant in the STROKE class asks what is a risk factor of stroke. Your best response Is:A. "More red blood cells thicken blood and make clots more possible."B. "Increased RBC count is linked to high cholesterol."C. "More red blood cells increase hemoglobin content."D. "High RBC count increases blood pressure."

CORRECT ANSWER: ARATIONALE: High red blood cell count: Even a moderate elevation in red blood cell count can be a risk factor forstroke. A high number of red blood cells thickens the blood, leading to blood clots.http://www.texasheartinstitute.org/HIC/Topics/Cond/strokris.cfm

Situation 16- Accurate computation prior to drug administration is a basic skill all nurses must have.

91. Ronald is diagnosed with amoebiasis and is to receive Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divideddoses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will receive peroral administration?

A. 1,000 mg tidB. 500 mg tidC. 1,500 mg tidD. 250 mg tid

CORRECT ANSWER: B


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RATIONALE: 1gram=1,000 milligram1.5 gm x 1,000 mg = 1,500 mg1,500 /3doses= 500 per oral administration

92. Riza, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is125 mg/ml. Which of the following should Nurse Paulo prepare for each oral dose?

A. 0.5 mlB. 1.25 ml

C. 2.5 mlD. 1.0 ml

CORRECT ANSWER: ARATIONALE: Q= Drug prescribed/ drug available or stock

= 62.5 mg/125mg/ml= 0.5 ml

93. The physician ordered Potassium Chloride (KCl) in D5W 1 liter to be infused In 24 hours for Mrs. Gomez. SincePotassium Chloride is a high risk drug. Nurse Robert used an intravenous pump. Which of the following shouldNurse Robert do to safely administer this drug?

A. Check the pump setting every 2 hoursB. Teach the client how the infusion pump operatesC. Have another nurse check the infusion pump setting

D. Set the alarm of the pump loud enough to be heard

CORRECT ANSWER: ARATIONALE: The nurse must frequenty check the infusion pump.Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1393

94. Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician; "give 3.00 cc ofLanoxin today for 1 dose only". Which of the following is the most appropriate action by the nurse?

A. Clarify order with the attending physicianB. Discuss the order with the pediatric heart specialist in the unitC. Administer Lanoxin intravenously as it is the usual route of administrationD. Refer to the medication administration record for previous administration of Lanoxin

CORRECT ANSWER: BRATIONALE: Dosage for infants ages 1 month to 2 years: For rapid digitalization, give 30 to 50 mcg/kg IV over 24hours, divided as 0.1 mg/ml. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in twoor three equal portions daily. Option B is the best answer.Nursing 2008. Drug Handbook.26th edition.pp.230

95. When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nursethat they buy her medicines and showed the container of medications of the client. Which of the following is themost appropriate action by the nursed?

A. Hold the administration of the client's medication and refer to the he

nle dec 07 np1 ratio

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