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Wednesday, November 21, 2007

diannemaydee : ANSWER KEY 300 items reviewer

Situation – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.

Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen

When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:

C. Amount of fluid intake of client before and after the procedure

When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:


C. Teaching the client’s relatives to perform the procedure

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

B. Client can tolerate sitting and lying positions

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


B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle

Situation – A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client.

When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

D. Do a physical examination while asking the client relevant questions

Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:

C. anger

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

A. Beneficence

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

A. Assessment

The basic difference between nursing diagnoses and collaborative problems is that

A. nurses manage collaborative problems using physician-prescribed interventions.

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

Instruction on health promotion regarding urinary elimination is important. Which would you include?

A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles

Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

C. loss of tone of the smooth muscles of the colon

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

D. prolonged use of laxatives


You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

C. the distance from the tip of the nose to the tip of the ear lobe

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

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

C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated

A pulse oximeter is attached to Mr. Dizon’s finger to:

D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops


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

A. Distributive


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

A. Intravenous


After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

C. higher than what the reading should be

Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

B. 30 minutes

While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to:

C. Cover the fingertip sensor with a towel or bedsheet

When taking blood pressure reading the cuff should be:

D. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery

-this is a typo error of brachial artery


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

B. blood should be warmed to room temperature for 30 minutes before blood transfusions is administered

Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:

D. 1 tsp of salt/day but no patis and toyo

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

A. X-ray

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

A. Cigarette smoking


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

A. 10-15 seconds

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

A. Fifth intercostal space, midclavicular line

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

A. Stroke volume


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


B. Patches may be applied to distal part of the extremities like forearm

The GAUGE size in ET tubes determines:


B. The internal diameter of the tube

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

B. Withdrawing of the suction catheter

The purpose of the cuff in Tracheostomy tube is to:

A. Separate the upper and lower airway
the placement of the tube

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

D. Risk for infection

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

D. Keep the patient clean and dry


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


D. Laissez Faire

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

A. Autocratic


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

A. Planning

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


B. Evaluating

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

A. Philosophy

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

C. Next of Kin

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

D. Durable Power of Attorney

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

B. Stay with Mang Carlos and Do nothing

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

B. Patient’s Bill of Rights


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

C. 15 minutes


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

A. Review of related literature

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

E. Pilot Study

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

A. Effective Nurse-patient communication

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

C. Anxiety level


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

C. Applied research

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

D. There is a careful selection of subjects in the experimental group

When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra

B. is assigning the responsibility to the aide but not the accountability for those tasks


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

C. collective bargaining

You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is

B. inservice education

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

A. R.A 9173

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

C. Prudence


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

C. Mitigating

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

A. Autonomy

Why is there an ethical dilemma?


C. Because the patient’s right coincide with the nurse’s responsibility

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

D. Those involved in medical mission who’s services are for free


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

A. Autonomy

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

A. Accountable


Which of the following best describes Primary Nursing?

C. A registered nurse is responsible for a group of patients from admission to discharge


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

A. Functional Method

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

A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the PRN medication

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

D. Put the bed in the lowest position ever

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

B. 90 °

The following statements are all true about Z-Track technique except:

C. It forces the medication to be contained at the subcutaneous tissues

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

A. Not universally accepted abbreviations

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

A. Inspection, Auscultation, Percussion, Palpation

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

A. Broaden the space between the feet

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

A. At the level of the heart

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

D. Conduction

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

D. Handwashing

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


B. Natural passive immunity

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

C. I must choose another doctor if I withdrew from this research


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

C. The water fluctuates during inhalation of the patient

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

B. Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self sealing port

Which of the following is an example of secondary prevention?

B. Screening patients for hypertension


Which of the following is a form of primary prevention?

D. Immunization

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

A. Orthopnea

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

D. Physiologic needs that are life threatening

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

A. Psychological preparation of the client

Legally, Patients chart are:

C. Owned by the hospital and should not be given to anyone who request it other than the doctor in charge


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

A. Promoting and maintaining the health of populations and preventing and minimizing the progress of disease

A major goal for home care nurses is

A. restoring maximum health function.

A written nursing care plan is a tool that:

B. Gives quality nursing care

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

D. Double effect

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

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

B. Telehealth program

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

C. Psychomotor

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

D. wellness program

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

C. Cold compress prevents edema and reduces pain

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

C. Increase oxygenation to the injured tissues for better healing

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

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


B. Disclosure


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

B. Feasibility

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

D. Mean

Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

B. Within 24 hours after discharge

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

C. Quasi-Legislative Power

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

C. The Size and Contour of the breast

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

C. BSE Once a month

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

A. Most frequently in nurses with needlesticks

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

B. Intense back pain


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

A. Soften and efface the cervix


Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.

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

C. Sperm can no longer reach the ova, because the fallopian tubes are blocked

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


C. a couple has been trying to conceive for 1 year


The correct temperature to store vaccines in a refrigerator is:

B. between 2 deg C and +8 deg C

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

A. Measles vaccine

This vaccine content is derived from RNA recombinants.

C. Hepatitis B vaccines


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

B. Nursing Health History and Assessment Worksheet

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

B. Graphic Flow Sheets

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

D. Medicine and Treatment Record

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

D. Nursing Kardex

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

A. Discharge Summary

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

D. Accurate documentation of actions and outcomes


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

B. Nursing Specialty Certification Council

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

A. Urgent referral

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

A. 40

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

C. Severe Dehydration


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

D. Difficulty to awaken

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

A. is there any fever?

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

D. Go to the next question, check for malnutrition


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

A. 1,000 ml to 1,400 ml be given within 4 hours

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

C. Acute Ear Infection


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

very severe disease

The nurse knows that the most common complication of Measles is:

A Pneumonia and larynigotracheitis


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

D. Flushing sensation is felt as the dye in injected

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


D. 332.5


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

C. Pustule

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

A. Community Organizing


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

C. Occupational health nursing


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

B. Health threat



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

D. The pressure of the gravid uterus will exert additional force thus, increasing the blood loss in the lower extremities

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

C. It will contribute to additional bone demineralization

All of the following are contraindication when giving Immunization except:

B. BCG Vaccine can be given to a child with Hepatitis B

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

C. When she’s 3 years old

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

D. Early feeding to speed passage of meconium

The community/Public Health Bag is:

B. an essential and indispensable equipment of the community health nurse

What is the rationale in the use of bag technique during home visits?

B. It saves time and effort of the nurse in the performance of nursing procedures

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

D. The inside surface


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

D. Two, plus “mama” and “papa”


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

C. Circulating nurse

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

C. Nurse Manager


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

B. Scrub nurse


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

C. Anaesthesiologist

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

D. Radiology department

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

D. Assess respiratory rate carefully

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

D. When the medical record is inaccurate, incomplete, and inadequate

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

D. Department of Health (DOH)

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

D. Medical records section


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

D. Practice respiratory isolation

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

D. Implement a regular maintenance and testing of alarm systems


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

A. Check the functionality of the pump before use

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

B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist

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

B. Nurse Supervisor

The breakdown in teamwork is often times a failure in:

D. Communication

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

D. Seek early treatment for respiratory infection

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

B. Hypothyroidism

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

A. Gag reflex


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

C. Urinary frequency


Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition.


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

A. Apply liberal amount of mineral oil to the area

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

C. Eat balanced meals at regular intervals


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

A. Increased weight

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

A. Increase the irrigating solution flow rate when abdominal cramps is felt

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


B. Sensation of pressure


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

D. Left sim’s position

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

B. Side lying position


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

C. Permanent colostomy


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

A. It is an incision into the colon to create an artificial opening to the exterior of the abdomen


Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.

D. Proctosigmoidoscopy

Symptoms associated with cancer of the colon include:

C. blood in the stools, anemia, and “pencil shaped” stools


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

D. Red, moist and slightly protruding from the abdomen


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

D. Mild soap and water

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


B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion

What does a sample group represent?

C. General population

As a nurse, you can help improve the effectiveness of communication among healthcare givers by:

B. Using standardized list of abbreviations, acronyms, and symbols


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

B. Hypothermia


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

C. Drain fluids and blood accumulated post operatively


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

C. lying prone with the head of the bed lowered 15-30 degrees

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

A. to rule out pneumothorax

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

A. hemorrhage


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


B. Prone with the head on pillow and turned to the side


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

B. offer soft foods for a week to minimize discomfort while swallowing

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

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

A. Avoid taking BP or blood sample from the arm with the shunt

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

A. Recommend protein of high biologic value like eggs, poultry and lean meats

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

A. E. Coli


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

B. ambulate more

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

C. Epidermis and dermis are both damaged


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

C. hyperkalemia and hyponatremia


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

D. Use Canvas shoes

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

D. Report the incident to your supervisor

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

C. Report the matter to your supervisor


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

C. Bring the crash cart to the room


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

F. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion

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


B. Mitigation

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

D. Defusion

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

C. Rescue

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

A. Administer bowel softener

Keeping Conrad’s head and neck alignment results in:

B. increased venous outflow

Earliest sign of skin reaction to radiation therapy is:

B. erythema

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

D. mentation

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

C. Miss, Use a pick up forceps when picking up those breads

In administering blood transfusion, what needle gauge is used?

A. 18

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

A. Check with another R.N the client’s name, Identification number, ABO and RH type.

The only IV fluid compatible with blood products is:

C. NSS


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

B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the physician


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

C. 4 hours


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

A. Stay with the client for the first 15 minutes of blood administration

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

B. A tracheostomy set and oxygen

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

D. Support the patient’s head and neck with pillows and sandbags.

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

D. Tetany


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


B. Calcium gluconate

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

The first step in decontamination is:

D. removal of the patients clothing and jewelry and then rinsing the patient with water

For a patient experiencing pruritus, you recommend which type of bath.

B. colloidal (oatmeal)

Induction of vomiting is indicated for the accidental poisoning patient who has ingested.


D. aspirin


Because severe burn can affect the person’s totality it is important that-you apply interventions focusing on the various dimensions of man. You also have to understand the rationale of the treatment.


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

C. Third degree burn


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

A. I and O hourly

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

D. Fluid Resuscitation

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


B. Hyperkalemia


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

D. U wave

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

A. IV



What type of debridement involves proteolytic enzymes?

D. Chemical

Which topical antimicrobial is most frequently used in burn wound care?

D. Sulfamylon

Hypertrophic burn scars are caused by:


B. random layering of collagen

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

A. case study

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

C. Audio-visual recording


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

A. Nurse’s own beliefs and attitude about the mentally ill

In order to establish a therapeutic relationship with the client, the nurse must first have:

A. Self awareness


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

B. Counter Transference

the most important quality of a nurse during a Nurse-Patient interaction is:

C. Listening

Selective inattention is seen in what level of anxiety?

B. Moderate


Obsessive compulsive disorder is characterized by:

B. Persistent thoughts and behavior


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

D. You are Maria Salvacion

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

C. Religious delusion


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

A. Thought content


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

B. Delusion

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

A. Psychotherapy

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

C. Crisis

Obsessive compulsive disorder is classified under:

B. Neurotic disorders


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

A. Risk for injury

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

B. Risk for injury directed to others

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

D. Offer sealed foods

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

B. Autonomy vs. Shame and Doubt


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

A. The same sex

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

C. Situational crisis


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

A. Active and Directive


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

D. Generativity vs. Stagnation

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

A. Numbness, anger, resolution and reorganization


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

A. Dilated pupils
cardia
D. Bradypnea

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

C. Suicide precaution


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

A. Thiamine

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

A. Paraparesis

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

A. Serotonin

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

A. temporal

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

B. General Anesthesia


The expected side effect after ECT is commonly associated with:

A. Transient loss of memory, confusion and disorientation

The purpose of ECT in clients with depression is to:

B. Mainly Biologic, increasing the norepinephrine and serotonin level

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

D. Risk for injury

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

A. I’ll be back in an hour

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

B. All depressed clients are considered potentially suicidal

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

A. Marijuana

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

B. Orientation

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

C. “What makes you feel you’re worthless?”


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

D. communication skills

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

B. mother surrogate

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

A. schizoid

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

A. 24 hours

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

A. Child and any siblings will live in a safe environment


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

A. Narcotic


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

C. Feel a sense of satisfaction in reflecting on her productive life


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

D. Self awareness


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

A. Graciela’s buttocks are resting on the bed.

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

B. Vomiting

This is a tricyclic antidepressant drug:

D. Imipramine (Tofranil)

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

B. Cohesiveness


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

D. includes characteristics of tolerance and withdrawal


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

D. Acquire academic skills of 6th grade level

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

B. Codependent

You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following is true?

B. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology

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

C. genetics


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

D. Use of Nursing Interventions Classification

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

D. The Standards of Care includes the various steps of the nursing process and the standards of professional performance

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

B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours

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

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


B. a & b are strong justifications


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

D. Speak softly then hold her hands gently

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

B. Perform range of motion exercises

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

D. audible level

Membership dropout generally occurs in group therapy after a member:

C. Experiences feelings of frustration in the group

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


B. Who wants to respond next?

The goal of remotivation therapy is to facilitate:

A. Insight

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

B. ego

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

H. includes characteristics of tolerance and withdrawal

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

D. promote homeostasis and minimize the client’s withdrawal symptoms

Commonly known as “shabu” is:

D. Methampetamine hydrochloride

5 comments:

sergio said...

hi there my name is sergio, ask ko lang po if true po ba mga answers dito, im relating the question number 42 & 43, can you send me the rationale hirs my email. im studying through ur website....

sergio said...

hi there my name is sergio, ask ko lang po if true po ba mga answers dito, im relating the question number 42 & 43, can you send me the rationale hirs my email legendcrazybong@yahoo.com

StuffedNurse said...

pls email ms diannemaydee at eye_contact_poor@yahoo.com for the rationales

Anonymous said...

More power to your blog. It greatly helps for graduates reviewing for NLE. Thank you very much.

NurseReview.org said...

Kudos to you StuffedNurse!

For those taking the December 2007 NLE Important Stuff To Read Before Taking December 2007 Nursing NLE Examination

December 2007 Nursing Board Exam Results will also be post at NurseReview.org. For those of you who want to get a copy of the nursing passers for Dec 2007, please leave your email address at List of NLE December 2007 Passers

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