DIAGNOSTIC 10

SITUATION: Nursing has undergone an evolutionary process that has changed it from being simply an occupation towards the feature of practice that define nursing as a full-pledged profession 1. She established the first nursing philosophy based on health maintenance and restoration, and she is known to be the founder of modern nursing: a. Dorothea Dix b. Florence Nightingale c. Clara Barton d. Harret Tubman ANSWER: B Florence Nightingale is the founder of modern nursing. Her views in nursing were derived from spiritual philosophy, developed in her adolescence and adulthood and reflected the changing needs of society. She saw the role of nursing as having charge of somebodys health based on the knowledge of how to put the body in such a state to be free of disease or to recover from disease. Option A: Dorothea Dix provided nursing care during civil war. Option C: Clara Barton is noted for her role in establishing American Red Cross. Option D: Harret Tubman provided care and safety to slaves during civil war Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 6-9 2. Nurse Clara is evaluating the concept of nursing theories. Which would she rule out as a purpose of nursing theories? a. To help build a common nursing terminology b. To promote enhanced salaries and benefits for nurses c. To help establish criteria to measure the quality of nursing care d. To offer a framework for generating knowledge and new ideas ANSWER: A The purposes of nursing theories include helping to build a common nursing terminology, helping establish criteria to measure the quality of nursing care, and offering a framework for generating knowledge and new ideas. There is a direct link between theory, education, research, and clinical practice. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 41-42 3. Nurses must use critical thinking in their day-to-day practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial? a. Teaching new parents car seat safety b. Assisting an orthopedic client with the proper use of crutches c. Administering IV push meds to critically ill clients d. Educating a home health client about treatment options ANSWER: D Nurses who utilize good critical-thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad), and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills all of which

contribute to critical-thinking skills. Administering IV meds (even to critically ill clients), teaching correct use of crutches, and teaching new parents about car seat safety do not require as much reasoning. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 163 4. A rehab client has orders for active range of motion exercises to her shoulder following a stroke. The client doesn't like to do these because they are uncomfortable and she can't understand "what good they will do anyway." Which of the following statements by Nurse Daniel demonstrates the criticalthinking component of creativity? a."As soon as you get these into your routine, you'll feel better." b."Here's a marker. See how many circles you can make on this board in 10 minutes." c."You'll only get worse if you don't do these exercises." d."Your physician wouldn't have ordered these if they weren't important." ANSWER: B Making the exercise routine into something more like a game, or drawing a picture, or even "decorating the walls," for example would raise a challenge to the client, take the focus off the why, and still achieve the end result. Explaining the rationale for doing or not doing the exercises is not using creativity. It is merely explaining the reason Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 163 5. When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to: a. Identify client needs and deliver care to meet those needs b. Deliver care to a client in an organized way c. Make sure that standardized care is available to clients d. Implement a plan that is close to the medical model ANSWER: A The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Delivery or organized care is not part of the nursing process, though each phase is interrelated. The nursing process is not part of the medical model as nurses treat the client's response to the disease or problem. The nursing process is individualized for each client's care plan. It is not about standardizing care. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 175 6. Nurse Hannah makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. She was hopeful to see some improvements by this time. This represents which phase of the nursing process? a. Diagnosis b. Evaluation c. Assessment d. Implementation ANSWER: B Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes

have been achieved and making decisions about problem status. The client's wound is not healing and the nurse decides to modify the nursing interventions. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 176 7. Gelay is a nursing student learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? I. Develop a list of problems IV. Specify goals and outcomes II. Identify client strengths V. Identify problems that can be prevented III. Develop a plan a. I, II, and III b. I and II c. I, II and V d. all except III ANSWER: C Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Developing a plan and specifying goals and outcomes is part of the planning phase. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 176 8. The nurse is assessing a female's breasts. The nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What is the nurse's next action? a. Document the findings in the nurse's notes as normal c. Notify the physician b. Document the findings in the nurse's notes as abnormal d. Notify the charge nurse ANSWER: A The findings are all normal, so the nurse would document the assessment in the nurse's notes as normal. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 628 9. The nurse is preparing a client for an abdominal examination. Which of the following should be performed before the examination? a. Assess heart rate b. Ask client to drink 8 ounces of water c. Assess vital signs d. Ask client to urinate ANSWER: D The nurse should ask the client to urinate since an empty bladder makes the assessment more comfortable. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 632 10. During the initial data gathering, the patient reveals a weight loss of 17 pounds since the death of his spouse 5 weeks ago. He says that he is not sleeping and has no appetite. Using Maslows Hierarchy of Needs, the nurse assesses that the unmet needs are in the category of: a. Physiologic b. Safety and security c. Love and belonging d. Self-actualization

ANSWER: A Physiologic needs include oxygen, fluids, and nutrition and must be met before the higher levels Reference: Perry and Potter. Fundamentals of Nursing. 6th edition. Page 94 11. Which returned demonstration by the client indicates an accurate understanding of performing a blood glucose monitoring test? a. The client punctures the fingertip c. The client smears the blood on the reagent strip b. The client washes her hands d. The client puts on gloves ANSWER: B One of the first steps the client would perform is hand washing for infection control. If the client is performing the test on herself, then applying gloves is not necessary. Once the appropriate site is selected for puncture, the side of the finger is used where there are fewer nerve endings. Then once the specimen is obtained, one holds the reagent strip under the puncture site until enough blood covers the indicator square. It is not smeared on the pad, which would cause an inaccurate reading. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 806-808 12. Documentation of a client with Kussmauls breathing is made when the nurse assesses: a. Very slow respirations c. Abnormally slow and irregular respirations b. Abnormally deep but regular respirations d. Irregular periods of apnea and hyperventilation ANSWER: B Kussmauls respirationRespirations are abnormally deep, regular, and increased in rate which is common in diabetic ketoacidosis. Option A: BradypneaRate of breathing is regular but abnormally slow (less than 12 breaths per minute). Option C: HypoventilationRespiratory rate is abnormally low; depth of ventilation may be depressed. Hypercarbia, an abnormally elevated level of carbon dioxide in the blood, may occur. Option D: Cheyne-StokesRespiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 549 : Perry Clinical Nursing Skills and technique. 6th edition. Page 518 13. A client has just had a cup of coffee, and the nurse needs to measure the body temperature. The nurse should: a. Take a rectal temperature c. Wait for 30 minutes before taking the temperature b. Take an axillary temperature d. Postpone the measurement for 5 minutes ANSWER: C If a client has taking cold or hot food or fluids or smoking, the nurse should wait 30 minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the fluid, food, or warm smoke. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 532

14. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should: a. Apply mild pressure to advance c. Remove the thermometer immediately b. Ask the client to take deep breaths d. Remove the thermometer and reinsert it gently ANSWER: C If resistance is felt during insertion, withdraw immediately. Never force thermometer to prevent trauma to mucosa. Option A: If resistance is felt during insertion, withdraw immediately. Never force thermometer to prevents trauma to mucosa. Option B: With nondominant hand, separate clients buttocks to expose anus. Ask client to breathe slowly and relax. Fully exposes anus for thermometer insertion. Relaxes anal sphincter for easier thermometer insertion. Option D: If resistance is felt during insertion, withdraw immediately. Never force thermometer. Prevents trauma to mucosa. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 536 : Perry Clinical Nursing Skills and technique. 6th edition. Page 498 15. For a client who is having difficulty swallowing tablets and capsules, Nurse Mian should: a. Administer the medication with less fluid b. Crush the medications and administer with a small amount of food c. Insert a nasogastric tube and instill the medication d. Administer the tablets one at a time with plenty of liquid ANSWER: B Although not all medications can be crushed, this is best option for a client having difficulty swallowing. Option A: Administration of medication with less fluid could make it more difficult for the client to swallow. Option C: Insertion of a nasogastric tube requires an order from the provider. Option D: A client who is having difficulty swallowing may not be safe swallowing large capsules or tablets even one at a time. Reference: Perry and Potter. Fundamentals of Nursing. 6th edition. Page 853 : Perry Clinical Nursing Skills and Technique. 6th edition. Page 640 16. The nurse is to administer several medications to the client via the nasogastric (NG) tube. The nurses first action is to: a. Add the medication to the tube feeding being given c. Administer all of the medications mixed together b. Crush all tablets and capsules before administration d. Check for placement of the nasogastric tube ANSWER: D The nasogastric tube should be verified for placement before administering any medication through it. Option A: Medications should never be added to the tube feeding. Option B: Not all tablets can be crushed, such as sustainedrelease tablets, nor should all capsules be opened. Medications should be reviewed carefully before crushing a tablet or opening a capsule. Option C: Medications should be dissolved and administered separately, flushing between 15 to

30 ml (5ml for children) of water between each medication. When you have finished administering all medications, flush with another 15 to 30 ml (5 to 10 ml for children) of warm water to clear the tube. Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 646 : Kozier. Fundamentals of Nursing. 8th edition. Page 857 17. Medical asepsis includes: a. Hand washing b. Surgical procedures c. Autoclaving instruments d. Sterilization of equipment ANSWER: A Medical asepsis, or clean technique, includes procedures used to reduce the number of and prevent the spread of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Options B, C, and D. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. Nurses in the operating room (OR), labor and delivery, and procedural areas practice sterile technique where sterile instruments and supplies are used. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis. Reference: Perry Clinical Nursing skills and Technique. 6th edition. Page 192 18. To break the chain of infection at the reservoir level, the nurse should: a. Change a soiled dressing c. Cover the nose and mouth when sneezing b. Keep drainage systems intact d. Avoid contact of the uniform with soiled items ANSWER: A Reservoir (site or source of microorganism growth)control sources of body fluids and drainage. Perform hand hygiene. Bathe client with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. Option B: Portal of entry (site through which microorganism enters a host) urinary. Keep all drainage systems closed and intact, maintaining downward flow. Option C: Portal of exit (means by which microorganisms leave a site) respiratory. Avoid talking, sneezing, or coughing directly over wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering respiratory tract infection. Option D: Transmission (means of spread) reduce microorganism spread. Perform hand hygiene. Use personal set of

care items for each client. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform. Reference: Perry Clinical Nursing skills and Technique. 6th edition. Page 193 19. The most important aspect in the prevention and control of infection is: a. Hand washing c. Removing contaminated items promptly b. Covering and cleaning wounds d. Maintaining skin and respiratory precautions ANSWER: A The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Hand hygiene is a general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Hand washing refers to washing hands with plain soap and water. Options B, C, and D: Contaminated hands are a prime cause of transmission of infection. For example, a nurse caring for a client who has excessive pulmonary secretions assists the client in expectorating mucus and disposes of the tissues in a bedside container. Reference: Perry Clinical Nursing skills and Technique. 6th edition. Page 194 20. An appropriate measure in hand washing is for the nurse to: a. Use very hot water c. Lather for at least 10 to 15 seconds b. Leave rings and watches in place d. Keep the fingers and hands up and the elbows down ANSWER: C Perform hand hygiene using plenty of lather and friction for at least 10 to 15 seconds. Interlace fingers, and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. Option A: Regulate flow of water so that temperature is warm. Warm water removes less of the protective oils on hands than hot water. Option B: Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. Provides complete access to fingers, hands, and wrists. Wearing of rings increases number of microorganisms on hands. Option D: Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. Hands are the most contaminated parts to be washed. Water flows from least to most contaminated area, rinsing microorganisms into sink. Reference: Perry Clinical Nursing skills and Technique. 6th edition. Page 195-197 : Kozier. Fundamentals of Nursing. 8th edition. Page 685 21. A home health nurse has just changed a soiled dressing from an infected wound of a client's. After placing the soiled dressing in a paper bag provided by the client, how should the nurse dispose of it? a. Place the paper bag inside a plastic bag for disposal. c. Take the bag home and dispose of it.

b. Throw the paper bag into a garbage can. d. Ask the client to dispose of the bag. ANSWER: A Placing the paper bag inside a plastic bag for disposal is sufficient for protection. The other answers are inappropriate. Correct implementation of aseptic practices includes hand washing; donning and removing a facemask, gown, and disposable gloves, managing equipment used for isolation clients, and maintaining a sterile field. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 22. The client reports that her teenager has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this teenager does not become iron deficient? (Select all that apply.) I. Tofu III. Brewer's yeast V. Okra II. Soybean milk IV. Orange juice VI. Apples a. I, IV and VI b. I, II, and III c. I, II and IV d. All except IV ANSWER: C While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency are tofu, soybean milk, and orange juice. Tofu and soybean milk are good sources of protein and iron. Orange juice supports iron absorption from foods since it is high in vitamin C. Brewer's yeast is a good source of vitamin B12 , which is often low in vegan diets. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1244-1245 23. Physician orders nasogastric tube insertion to a client who is unable to eat by mouth. Which of the following is a correct sequence of nasogastric tube insertion? I. Ask the client to tilt the head forward. IV. Have the client swallow a small amount of liquid. II. Insert the tube with its natural curve toward the client. V. Employ a slight twisting motion on the tube. III. Ask the client to hyperextend the neck. a. II, III, V, I, IV b. II, III, IV, V, I c. II, III, V, IV, I d. II, IV, III, V, I ANSWER: A The tube should first be inserted with its natural curve toward the client. At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction. A slight twisting motion may help pass the tube into the nasopharynx. At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus. The client should then be asked to swallow to move the epiglottis over the opening of the larynx, directing the tube toward the esophagus. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1267 24. As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? a. Have the client tilt the head back to open the passage c. Give the client a few sips of water

b. Remove the tube and attempt reinsertion d. Use firm pressure to pass the tube through the glottis ANSWER: C Swallowing ice or water may help calm the gag reflex and also facilitate the "swallowing" of the tube. This is a common response to the presence of a tube in the oropharynx, so removal of the tube is not necessary. The nurse should not use pressure to pass the tube. The client's head should be tilted forward at this point. Tilting the head back will open the airway, not the esophagus. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1267 25. For a rectal examination, the patient can be directed to assume which of the following positions? a. Genupecterol b. Sims c. Horizontal recumbent d. All of the above ANSWER: D All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. 26. Which of the following is inappropriate in collecting mid-stream clean catch urine specimen for urine analysis? a. Collect early in the morning, First voided specimen c. Collect 5 to 10 ml for urine b. Do perineal care before specimen collection d. Discard the first flow of the urine ANSWER: C Clean catch or mid stream voided specimens are collected when a urine culture is ordered to identify microorganisms causing urinary tract infection. At least 10 ml of urine is needed. The client is asked to wash and dry the genitals and perineal are with soap and water before collecting the urine. The first flow of urine is discarded, the specimen container is placed into the midstream of urine. Kozier, B. et. al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. 8th ed. Pearson Prentice Hall. 27. In assessing the clients chest, which position best show chest expansion as well as its movements? a. Sitting b. Prone c. Sidelying d. Supine ANSWER: A For efficiency, the examiner usually examines the posterior chest first, then the anterior chest. The sitting position is preferred because it maximizes chest expansion. Kozier, B. et. al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. 8th ed. Pearson Prentice Hall. 28. In collecting a routine specimen for fecalysis, which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure? a. The nurse scoop the specimen specifically at the site with blood and mucus b. She took 20ml of liquid stool specimen

c. Ask the client to call her for the specimen after the client wiped off his anus with a tissue d. Ask the client to defecate in a bedpan, Secure a sterile container ANSWER: C The nurse is responsible for collecting stool specimens ordered for laboratory analysis. The client is asked to defecate in a clean bedpan; void before the specimen collection; notify the nurse as soon as possible after defecation to immediately send the specimen in the laboratory. Usually about 1 inch of formed stool or 15 to 30 ml of liquid stool is adequate. Visible pus, mucus, or blood should be included in sample specimens. Kozier, B. et. al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. 8th ed. Pearson Prentice Hall. 29. In a routine sputum analysis, Which of the following indicates proper nursing action in sputum collection? a. Secure a clean container b. Discard the container if the outside becomes contaminated with the sputum c. Rinse the clients mouth with Listerine after collection d. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis ANSWER: C Sputum specimens are often collected in the morning. Upon awakening, the client can cough up the secretions that have accumulated during the night. To collect sputum specimen: 1 to 2 tablespoons of sputum is needed. If the outside of the container does get contaminated, wash it with a disinfectant. Sterile container is needed. Following sputum collection, offer mouthwash to remove unpleasant taste Kozier, B. et. al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. 8th ed. Pearson Prentice Hall. 30. Upon assessment, the nurse notes that the client is dyspneic, has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details? a. Anxiety c. Ineffective Breathing Pattern b. Impaired Gas Exchange d. Ineffective Airway Clearance ANSWER: D The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is bibasilar crackles. There are no data that support Ineffective Breathing Pattern or Impaired Gas Exchange; however, these diagnoses may be appropriate after additional assessment is performed. There are no data that support Anxiety as a diagnosis. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1365, 1395 31. A nurse is documenting a clients breath sounds. Rhonchi are heard as: a. Loud, low-pitched, coarse sounds c. Dry, grating sounds on inspiration b. High-pitched, musical squeaks d. High-pitched, fine sounds at the end of inspiration ANSWER: A

RhonchiLoud, low-pitched, rumbling coarse sounds heard most often during inspiration or expiration; may be cleared by coughing. Option B: WheezesHigh-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration; do not clear with coughing. Option C: Pleural friction rubDry, grating quality heard best during inspiration; does not clear with coughing; heard loudest over lower lateral anterior surface. Option D: CracklesFine crackles are high-pitched, fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 567 32. The pulmonic area for auscultation is found at the: a. Second intercostal space on the right side c. Third intercostal space (Erbs point) b. Second intercostal space on the left side d. Fourth intercostal space along the sternum ANSWER: B The pulmonic area is at the second intercostal space on left. Option A: The aortic area is at the second intercostal space on the clients right. Option C: The second pulmonic area is found by moving down left side of sternum to the third intercostal space, also referred to as Erbs point. Option D: The tricuspid area is located at the fourth left intercostal space along the sternum. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 571 33. The aortic area for auscultation is found at the: a. Second intercostal space on the right side c. Third intercostal space (Erbs point) b. Second intercostal space on the left side d. Fourth intercostal space along the sternum ANSWER: A The aortic area is at the second intercostal space on the clients right. Option B: The pulmonic area is at the second intercostal space on left. Option C: The second pulmonic area is found by moving down left side of sternum to the third intercostal space, also referred to as Erbs point. Option D: The tricuspid area is located at the fourth left intercostal space along the sternum. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 571 34. To hear low-pitched sounds, the best position to place the client in is: a. Supine b. Sitting up c. Dorsal recumbent d. Left lateral recumbent ANSWER: D Different positions help to clarify type of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). Supine is a common position to hear all sounds. Left lateral recumbent is the best position to hear lowpitched sounds. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 572

35. An appropriate technique for a nurse to implement during the assessment of the abdomen is: a. Assessing painful areas first b. Auscultating for 5 minutes over each quadrant c. Positioning the client in a supine position with the arms behind or over the head d. Palpating masses or organ enlargement deeply and firmly ANSWER: B To auscultate bowel sounds place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent. Option A: Painful areas are assessed last. Manipulation of body part can increase clients pain and anxiety and make remainder of assessment difficult to complete. Option C: Placing the arms under the head or keeping knees fully extended can cause the abdominal muscles to tighten. Tightening of muscles prevents adequate palpation. Option D: If masses are palpated, note size, location, shape, consistency, tenderness, mobility, and texture. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 581-585 36. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a: a. Macule b. Papule c. Vesicle d. Nodule ANSWER: A This finding is consistent with the definition of a macule. Option B: A papule is a palpable, circumscribed, solid elevation in skin, smaller than 1 cm. Option C: A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm. Option D: A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5 to 2.0 cm. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 577 37. An inspection of the lower extremities is being performed. The presence of arterial insufficiency is suspected when the nurse observes: a. Increased hair growth b. Cooler skin temperatures c. Marked edema d. Brown pigmentation ANSWER: B In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremities are lowered. They feel cool to touch because blood flow is blocked to the extremity. Option A: Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency. Option C: Marked edema is seen in venous insufficiency, not arterial insufficiency. Option D: Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 595

38. Pedrito is admitting his elderly mother to a long-term care facility for custodial care. During the intake interview, Pedrito is alternately tearful and defensive. The culturally competent nurse assesses the labile behavior as being related to the Filipino belief that: a. Medical facilities are a place of death. c. His language barrier is causing him to be misunderstood. b. Families should care for the elderly at home. d. Such facilities will limit visitation from the family. ANSWER: B Filipino culture prides itself in its ability to care for their elderly in the home. Family ties are very strong and visits by many family members are an indication of their love and concern. Referrence: Adrian Linton. Introduction to Medical-Surgical Nursing. Page 58 39. The nurse uses a stethoscope to auscultate a male patients chest. Which statement about a stethoscope with a bell and diaphragm is true? a. The bell detects high-pitched sounds best c. The bell detects thrills best b. The diaphragm detects high-pitched sounds best d. The diaphragm detects low-pitched sounds best ANSWER: B The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best. Reference: Lippincotts Nursing Procedure. 5th edition. Page 29 40. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? a. Impaired gas exchanges related to increased blood flow b. Fluid volume excess related to peripheral vascular disease c. Risk for injury related to edema d. Altered peripheral tissue perfusion related to venous congestion ANSWER: D Altered peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion. Reference: Brunner. Medical Surgical Nursing. 110th edition. Page 842 41. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? a. A history of increased aspirin use c. An active daily walking program b. Recent pelvic surgery d. A history of diabetes ANSWER: B The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of

the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the clients risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease Reference: Brunner. Medical Surgical Nursing. 110th edition. Page 842 42. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? a. Inadequate vitamin D intake c. Inadequate massaging of the affected area b. Inadequate protein intake d. Low calcium level ANSWER: B A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels arent factors in poor healing for this client. A pressure ulcer should never be massaged. Reference: Brunner. Medical Surgical Nursing. 110th edition. Page 73 43. Nurse Adriana inspects a clients back and notices small hemorrhagic spots. The nurse documents that the client has: a. Extravasation b. Osteomalacia c. Petechiae d. Uremia ANSWER: C Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood Reference: Brunner. Medical Surgical Nursing. 110th edition. Page 1646 44. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following? a. Fail to show changes in blood pressure c. Cause sciatic nerve damage b. Produce a false-high measurement d. Produce a false-low measurement ANSWER: B Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff cant record brachial artery measurements unless its excessively inflated. The sciatic nerve wouldnt be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 555 45. A nurse informs a client that the alarm on the pulse oximeter will not sound when: a. The client moves the probe c. The SpO2 falls below the set limit b. The probe falls off d. The display reaches full strength during each cardiac cycle ANSWER: D

Leave sensor in place until oximeter readout reaches constant value and pulse display reaches full strength during each cardiac cycle. Option A: Inform client that oximeter alarm will sound if sensor falls off or if client moves sensor. Option B: Inform client that oximeter alarm will sound if sensor falls off or if client moves sensor. Option C: If continuous SpO2 monitoring is planned, verify SpO2 alarm limits, which are preset by the manufacturer at a low of 85% and a high of 100%. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 536 46. Measurement of the systolic blood pressure begins when: a. The cuff is deflated b. The first sound is heard c. The sound muffles d. The sound disappears ANSWER: B Note point on manometer when first clear sound is heard. The sound will slowly increase in intensity. First Korotkoff sound reflects systolic blood pressure. Option A. Slowly release pressure bulb valve, and allow manometer needle to fall at rate of 2 to 3 mm Hg/sec. Option C: Place stethoscope earpieces in ears and be sure sounds are clear, not muffled. Earpieces should follow angle of ear canal to facilitate hearing. Option D: Continue to deflate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 10 to 20 mm Hg after the last sound. Beginning of the fifth Korotkoff sound is recommended as indication of diastolic pressure in adults. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 555 : Perry Clinical nursing skills and techniques. 6th edition. Page 528 47. An appropriate method for assessing a clients respirations is for the nurse to: a. Place the bed flat b. Remove all supplemental oxygen sources c. Explain to the client that the respirations are being assessed d. Relax and gently place the clients hand over the upper abdomen ANSWER: D Place clients arm in relaxed position across the abdomen or lower chest, or place nurses hand directly over clients upper abdomen. Option A: Be sure client is in comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. Position of discomfort may cause client to breathe more rapidly. Option B: Documentation should include any supplemental oxygen that the client is receiving. Option C: Inconspicuous assessment of respirations immediately after pulse assessment prevents client from consciously or unintentionally altering rate and depth of breathing. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 548 : Perry Clinical nursing skills and techniques. 6th edition. Page 517

planned for this client? a. Remove the tracheostomy inner cannula. b. Keep obturator at the clients bedside c. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes. d. Remove the tracheostomy ties and replace them with an elastic bandage. ANSWER: B The obturator should be kept at the clients bedside so that it will be readily available if the client tracheostomy tube should become dislodged. The cuff should not be deflated if the client is being mechanically ventilated. The tracheostomy ties are only removed when they are soiled and need to be changed. The tracheostomy inner cannula is only removed for cleaning Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1380, 1390 49. While the nurse is discussing a client's likely death with family members, one of the son ask, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is: a. "Often in the last hours you can look for relaxation followed by clearing of the eyes, looking around, focusing on faces, and clearing of the throat. Call the others in at that time." b. "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." c. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." d. "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with nuchal rigidity. Don't be alarmed when you hear a death rattle in the throat. " ANSWER: C Muscles relax with decreased activity. Muscle rigidity is not a usual pattern. The gag reflex is lost, and mucus accumulates in the back of the throat. Vision is blurred. Option A is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1092 50. Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is: a. Preparing the body to look as clean and natural as possible b. Pulling the sheet over the patient's face until the family is comfortably seated in the room c. Humor is helpful in relieving stress. However, use humor only after family has left d. Calling the physician to verify the time of death before taking the body to the morgue ANSWER: A

48. The nurse has received a client immediately after surgery for head and neck cancer. The client has a tracheostomy that was created during the surgery and is being mechanically ventilated. What nursing action should be

The body is to be handled with dignity at all times. This does not include using humor at this time. After the body is cleaned and the linen freshened, the sheet is pulled to cover the patient's shoulders. Laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly. Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1097 51. A client asks a nurse what may be left on during the surgery. The nurse tells the client that an item that may remain in place is: a. A hearing aid b. An artificial limb c. A pair of eyeglasses d. A pair of contact lenses ANSWER: A If client will be required to follow instructions in the OR, hearing aid may be left in place. Options B, C, and D. Assist client in removing prostheses, including dentures and oral appliances, glasses and contact lenses, artificial limbs and eyes, artificial eyelashes, and hearing aids if client will not be required to follow instructions in the OR. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 1187 52. When instructing a client about the performance of postoperative exercises, a nurse tells the client to: a. Repeat the breathing exercises twice b. Cough two to three times and inhale between each cough c. Place a pillow over the incisional site for splinting d. Use the chest and shoulder muscles while inhaling during diaphragmatic breathing ANSWER: C If surgical incision is to be either thoracic or abdominal, teach client to place pillow over incisional area and place hands over pillow to splint incision. Assess clients ability to deepbreathe and cough by placing hand on clients abdomen, having client take a deep breath, and observing movement of shoulders, chest wall, and abdomen. Observe chest excursion during a deep breath. Ask client to cough into tissue after taking a deep breath. Option A: Repeat breathing exercise three to five times. Option B: Inhale deeply a third time and hold breath to count of 3. Cough fully for two to three consecutive coughs without inhaling between coughs. Option D: Have client take slow, deep breaths, inhaling through nose, and pushing abdomen against hands. Tell client to feel middle fingers separate as client inhales. Explain that client will feel normal downward movement of diaphragm during inspiration. Explain that abdominal organs descend as chest wall expands. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 1194-1195 53. A priority for the nurse caring for clients in the post-anesthesia care unit or recovery room is a. Inspection of the surgical site c. Maintenance of a patent airway b. Assessment of circulation d. Determination of client discomfort ANSWER: C

Maintain the ABCs of client care. Airway patent first. Breathing second. Option A: Observe condition of dressing and drains for any evidence of bright red blood. Option B: Maintain the ABCs of client care. Circulation third. Option D: Assess level of pain as client awakens. Provide pain medication as ordered and when vital signs have stabilized. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 1201, 1203 54. A nurse notes that urine does not flow after the catheterization of a female client. The nurse believes that the catheter has been placed into the vagina. The nurse should: a. Remove the catheter and reinsert it b. Irrigate the catheter with saline c. Leave the catheter in place and insert another one d. Insert the catheter 9 to 10 inches farther into the client to verify that it is in the vagina ANSWER: C If no urine appears, check if catheter is in vagina. If misplaced, leave catheter in vagina as landmark indicating where not to insert, and insert another catheter in the meatus. Reference: Lippincotts Nursing Procedure. 5th edition. Page 716 55. When the balloon on an indwelling urinary catheter is blown up, the client expresses discomfort. The nurse should: a. Remove the catheter b. Aspirate the fluid from the balloon and advance the catheter c. Continue to blow up the balloon, because discomfort is expected d. Pull back on the catheter slightly to determine tension ANSWER: B If resistance is noted to inflation or the client complains of pain, the balloon may not be entirely within the bladder. Stop inflation; aspirate any fluid injected into the balloon, and advance the catheter a little more before reattempting to inflate. Reference: Lippincotts Nursing Procedure. 5th edition. Page 717 56. Upon assessing the client in the morning, the nurse notes that there is urine leaking out around the indwelling urinary catheter. The nurse should first: a. Insert the catheter farther c. Remove the catheter and reinsert another b. Reinflate the catheter balloon d. Apply padding around the urinary meatus ANSWER: B Leakage of urine from around catheter indicates improper catheter placement, possible balloon deflation, or too small a catheter. Reinflate balloon or replace catheter. Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 1083 57. During the enema instillation, the client experiences cramping. The nurse should: a. Discontinue the procedure c. Slow the rate of the infusion b. Increase the height of the solution d. Have the client roll into a supine position ANSWER: C

If the patient complains of discomfort, abdominal cramping or the need to defecate stops the flow by pinching or clamping the tube. Then hold the patients buttocks together or firmly press toilet tissue against the anus. Instruct him to gently massage his abdomen and to breathe slowly and deeply through his mouth to help relax his abdominal muscles and promote retention. Resume administration at a slower rate after a few minutes when the discomfort passes, but interrupt the flow any time the patient complains of discomfort. Option B: Lower container or clamp tubing if client complains of cramping or if fluid escapes around rectal tube. Option D: An enema is given in the Sims position. Option C: Unnecessary Reference: Perry Clinical nursing skills and techniques. 6th edition. Page 1134 : Lippincotts Nursing Procedure. 5th edition. Page 688 58. A client has an order for enemas until clear before a major bowel surgery. After preparing the equipment and the solution, the nurse assists the client into which of the following positions to administer the enema? a. Left side lying position, head of bed elevated 45 degrees c. Leftlateral position, right leg flexed b. Right side lying position, head of bed elevated 45 degrees d. Right-lateral position, left leg flexed ANSWER: C When administering an enema, the client is placed in a left lateral position so that the enema solution can flow by gravity in the natural direction of the colon. The right leg is accurately flexed as possible because this position facilitates the flow of the solution by gravity into the sigmoid colon and descending colon which are on the left side. Having th right leg accurately flexed provides for adequate exposure of the anus. The head of the bed is not elevated. This is only done when the client has no sphincter control (after enema administration client is place in a supine position and head of bed may be elevated) Reference: Potter & Perry. Fundamentals of nursing. 6th edition. Page 1399. :Kozier. Fundamentals of Nursing. 8th edition. Page 1242 59. When assessing a client with a nasogastric tube, a nurse finds the client is coughing, dyspneic, and wheezing. The nurse should first: a. Suction the client c. Consult with the physician b. Aspirate GI contents d. Position the client on his or her side ANSWER: D Position the client on side to protect the airway. Suction the client nasotracheally or orotracheally to try to remove aspirated substance. Report the event immediately to the physician. Option A: Suction the client nasotracheally or orotracheally to try to remove aspirated substance. Option B: Aspiration of stomach contents into respiratory tract (immediate response) in the alert client, evidenced by coughing, dyspnea, cyanosis, or decreases in oxygen saturation values during the procedure is what caused the coughing and dyspnea. Option C: Consult physician regarding need for chest radiograph. Reference: Lippincotts Nursing Procedure. 5th edition. Page 673

: Perry Clinical nursing skills and techniques. 6th edition. Page 1020 60. An evaluation by a nurse that indicates that the placement of a nasogastric or nasointestinal tube is correct is: a. Nasointestinal aspirate with a pH of less than 6 c. Gastric aspirate with a pH of 2 after client fasting b. Pleural fluid pH of less than 6 d. Gastric aspirate with a pH of 4 and continuous tube feedings ANSWER: C Gastric fluid from client who has fasted for at least 4 hours usually has pH range of 1 to 3. Option A: Fluid from NI tube of fasting client usually has pH greater than 6. Option B: pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Option D: Client with continuous tube feeding may have pH of 5 or higher. Reference: Lippincotts Nursing Procedure. 5th edition. Page 672 : Perry Clinical nursing skills and techniques. 6th edition. Page 1023 61. An appropriate technique for a nurse to implement when providing a tube feeding after checking the placement of the tube is to: a. Cool the formula c. Empty the feeding bag quickly over 10 to 15 minutes b. Lower the head of the bed d. Raise the syringe to 1 foot above the insertion site ANSWER: D Fill syringe with measured amount of formula. Release tube, and elevate syringe to no more than 18 inches (45 cm) above insertion site and allow it to empty gradually by gravity. Option A: Cold formula causes gastric cramping. Option B: Place client in high-Fowlers position, or elevate head of bed at least 30 degrees to prevent aspiration. Option C: Allow bag to empty gradually over 15 to 30 minutes. Reference: Lippincotts Nursing Procedure. 5th edition. Page 672-673 : Perry Clinical nursing skills and techniques. 6th edition. Page 10291033 62. A patient recently diagnosed with inoperable lung cancer tells the nurse, I am looking forward to seeing my daughter graduate from college in 2 years. The nurse recognizes that according to Kbler-Ross, this stage of grief is: a. Denial b. Anger c. Bargaining d. Depression ANSWER: A Kbler-Ross identifies denial as the person refusing to acknowledge the loss. Anger: The anger being directed at nurse or staff about matters that normally would not bother them. Bargaining: Seeks to bargain to avoid loss. Depression: grieves over what has happened and what cannot be. Acceptance: Comes to term with loss Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1083 63. The following are the classic criteria of a profession by Flexner. Which is not included? a. A profession utilizes in its practice a well-defined and well-organized body of knowledge that is intellectual in nature and describes its phenomena or concern. b. A profession is guided by a code of ethics that regulates the relationship between the professional and the client

c. It has a clear standard of educational preparation for entry into practice. d. A profession depends on other institutions in the formulation of its professional policy and in the monitoring of its practice and its practitioners. Answer: D. Letters A, B and C are all criteria of a profession. Letter D is the right answer because it is not included since a profession should be autonomous and works on its own for the formulation of its professional policy and in the monitoring of its practice and its practitioners. Kozier, B. et. al. (2004) Fundamentals of Nursing: Concepts, Process and Practice. 7th ed. Pearson Prentice Hall. 64. According to Benners Stages of Nursing Expertise, a nurse who has limited performance, inflexible and governed by theories rather than experience is in what stage? a. Novice b. Advanced Beginner c. Competent d. Proficient Answer. A. A novice nurse has no experience yet (such as a nursing student) so performance is still limited, inflexible and governed by context-free rules and regulations. Kozier, B. et. al. (2004) Fundamentals of Nursing: Concepts, Process and Practice. 7th ed. Pearson Prentice Hall. 65. Who has the power to appoint, remove and suspend members of the Board of Nursing (BON)? a. PRC chairman c. Commission on Appointment b. Philippine Nursing Academy (PNA) d. President of the Philippines Answer. D The President of the Republic of the Philippines has the power to appoint, remove and suspend the member/s of the Board of Nursing (BON) Bellosillo J.N. et. al. (2008) Fundamentals of Nursing Law, Jurisprudence and Ethics. 2008 ed. 66. The following are the qualifications of the members of the Board of Nursing (BON) under R.A. 9173. Which is not included? a. Must have at least three years of continuous practice of the profession prior to appointment b. Filipino citizen c. Must be a member of good standing of the accredited professional organization of nurses d. RN and a holder of Masters degree in nursing, education or other allied medical profession Answer. A To qualify as a member of the Board of Nursing (BON), one should have at least 10 years of continuous practice of the nursing profession prior to appointment, the last five years of which is in the Philippines. Bellosillo J.N. et. al. (2008) Fundamentals of Nursing Law, Jurisprudence and Ethics. 2008 ed. 67. The maximum possible years of service in the office for Board of Nursing (BON) members is: a. 3 year b. 4 years c. 5 years d. 6 years Answer: D

The chairperson and members of the board shall hold office for a period of three (3) years or more until their successors shall have been appointed and qualified provided that no chairperson and member shall be appointed/reappointed for more than two (2) terms or a period of six years as declared in R.A. 9173. Bellosillo J.N. et. al. (2008) Fundamentals of Nursing Law, Jurisprudence and Ethics. 2008 ed. 68. The nurse who is talking with another nurse on how incompetent the doctor was during lumbar puncture can be charged with? a. Slander b. Assault c. Libel d. Malpractice Answer: A Defamation, which includes libel or slander, is an intentionally false communication or publication that may cause the loss of a persons reputation. Slander is defamation by the spoken words, stating unprivileged or false words by which reputation is damaged. Libel is defamation by means of print Kozier, B. et. al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. 8th ed. Pearson Prentice Hall. 69. As a nurse, Sam knows that she should be accountable for her actions. Accountability for safe nursing practice requires: a. Completion of Bachelor of Science in nursing program c. Understanding of the different nursing theories b. Clinical competence in bedside care d. Evaluation of performance of nurses yearly Answer: B Accountability means answerable to oneself and others for ones action. When nurses undertake to practice their profession, they are held responsible and accountable for the quality of performance of their duties. Negligence refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same manner or similar circumstance would or would not do, and an act or the nonacting of which is the proximate cause of injury to another person or his property. If a nurse fails to meet the standard, there is negligence. In order to have a safe nursing practice, a newly Bachelor of Science in Nursing should pass the board examination, which is the minimum requirement to be able to safely practice nursing; understanding the nursing theories does not necessarily link to safely practice nursing; Evaluation of the performance of nurses may be done in order to see how nurses do their but it is upon the discretion of the hospital management. Nurses should always be clinically competent in their duties to prevent negligence. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Pages 160-161. 70. When the nurse witnesses the consent form for an operation after securing her signature, she is attesting to the fact that: a. The patient fully comprehends the nature & extent of surgery including the risk involved

b. The immediate family of the patient have been informed of the surgery c. The patient gave his consent to the surgery without undue influence d. The patient placed his signature on the document with authenticity, voluntariness & capacity Answer: D Often the nurse is asked to obtain a signed consent form. The nurse is not responsible for explaining the procedure but for witnessing the clients signature on the form. Reference: Barbara Kozier, Fundamentals of Nursing 8th edition, Pages 60-61. 71. Every nurse is conclusively presumed to know that the law is an essential component of nursing practice. This concept about laws specifically supports safe practice. Which of the following is a function of law in nursing? a. Law differentiates duties and responsibilities from those of other health professionals. b. Intuitional policies on duties & responsibilities must have the force of law c. Laws reflect the moral values of society. d. Laws are principles & processes that resolve disputes without use of coercion. Answer: A The law serves a number of functions in nursing: a) It provides a framework for establishing which nursing actions in the care of clients are legal, b) it differentiates the nurses responsibilities from those of other health professionals, c) it helps establish the boundaries of independent nursing action, d) it assists in maintaining a standard of nursing practice by making nurses accountable under the law. Reference: Barbara Kozier, Fundamentals of Nursing 8th edition, Page 53. 72. Jason wants to know his duties as a nurse now that he has claimed his license from the PRC. If you are to tell him what he wants to know, which of the following is not considered as a legal function of nurses? a. Suturing perineal lacerations c. Supervision and care women in labor b. Performing internal examinations d. Prescribing herbal & symptomatic medicines Answer: D A person shall be deemed to be practicing nursing when singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but is not limited to, nursing care during conception, labor, delivery, infancy, childhood, adulthood and old age. Nurses can perform internal examinations during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established. Prescription of drugs is beyond the scope of nursing practice and doing such act can make a nurse liable for malpractice. Reference: Lydia M. Venzon, Professional Nursing in the Philippines, Pages 180, 184.

73. Melai is a graduate of the 4-year Bachelor of Science in Nursing in University of the Visayas. The curriculum that she took up in this school prepares her to become a: a. Generalist nurse b. Dean c. Clinical Faculty d. Primary Hospital Chief nurse Answer: A The four-year Bachelor of Science in Nursing Program offers a competency-based community oriented curriculum to educate future nurse practitioners to assume their roles and responsibilities in the Philippine Health Care System. It also aims to prepare nurses for entry level positions in any health care setting in the country. As a generalist, a nurse has the capabilities for providing basic nursing care to any type of patients. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Pages 7, 42. 74. The certificate of registration in nursing is valid unless suspended & revoked by the Board of Nursing. Which of the following laws supports this power? a. PD 223 b. RA 7164 c. RA 8983 d. RA 9173 Answer: D The license to practice nursing is not a permanent or vested right since it may be granted upon condition and it may be held subject to conditions. If these conditions are breached or violated, the authority that issues such may revoke this license. As provided by the Philippine Nursing Act of 2002, RA 9173 Section 23, the commission shall have the power to revoke or suspend the certificate of registration upon the grounds specified. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Page 20. 75. The first level position of a registered nurse is as a staff nurse in a hospital. She must have these qualifications: 1. Filipino citizen 2. With at least one-year of work experience as nurse volunteer 3. With at least 9 units in the masters degree program in nursing 4. With a valid professional license 5. Must have 60 units continuing professional education a. 1,2,3 b. 3,4,5 c. 1,4 d. 1,5 ANSWER: C One way to be a registered nurse in the Philippines is to take the nurse licensure examination. In order to apply for this exam, the applicant should be a citizen of the country. After passing the examination, the PRC will issue a professional license that would be a proof that the registered nurse has satisfied the minimum requirement to perform the entry level position in any setting, i.e. staff nurse in a hospital. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Pages 13, 17-18. 76. Nurse Aya is an applicant for a faculty position in University of Santo Tomas College of Nursing. In order to be qualified, she should possess which of the following? a. RN; BSN c. RN;BSN with at least 9 academic units in the masters degree program b. RN; BSN; Masters degree in nursing d. RN; BSN with one year nursing practice in the clinical field of specialization

Answer: B Requirements to become a faculty in the college of nursing are a) be a registered nurse in the Philippines; b) have at least 1 year clinical practice in the field of specialization; c) be a member of good standing in the accredited professional organization of nurses, and d) be a holder of a Masters degree in nursing, education, or other allied medical and health sciences conferred by a college or university duly recognized by the Government of the Republic of the Philippines. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Page 49. 77. Nurse Micaela is working as a nurse supervisor of Isla Hospital. She is very competent in her work that she is being eyed for as the new chief nurse since the person occupying the position is leaving for New Zealand. She is worried that she might not get the position because her credentials are not enough. Which of the following are the minimum academic qualifications of chief nurses in primary hospitals? a. Filipino citizen b. RN; BSN with at least 9 academic units in the masters degree program c. RN; BSN; Masters degree in nursing d. RN; BSN with at least 2 years experience in general nursing service administration Answer: B For primary hospitals, the minimum academic qualifications and experiences for a chief nurse shall be a degree of Bachelor of Science in Nursing, with at least 9 units in management and administration at the graduate level. 2 years experience in the general nursing service administration is a requirement to be in the supervisorial or managerial position in the nursing service. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Page 37. 78. Utilitarianism is one of the ethical frameworks a nurse manager use in decision making. As a clinical staff nurse, you plan to decide by abiding to this principle if: a. you provide good for yourself c. you provide common good for just people b. you provide the greatest good for a greater number of people d. you provide greatest good to the victims ANSWER: B Utilitarianism is defined as providing the greatest good for a greater number of people. Reference: Marquis BL and Huston CJ. 2009. Leadership Roles and Management Functions in Nursing / Theory and Application. Wolters Kluwer / Lippincott Williams and Wilkins. p.72. 79. A client tells the nurse not to inform family members about her medical diagnosis. In meeting this request, the nurse is upholding which of the following? a. Confidentiality b. Living Will c. Advance Directive d. Informed consent ANSWER: A

Confidential information is also termed as privileged communication because it is given based on trust. Any information gathered by the nurse during the course of caring for the patient should always be treated confidential. This duty extends even after the patients death. Confidential information may be revealed only when: a.) the patient himself permits such revelation as in the case of claim for hospitalization, insurance benefits, among others; b.) the case is medico-legal such as attempted suicide, gunshot wounds which have to be reported to the local police or NBI or constabulary; c.) the patient is ill of communicable disease and public safety may be jeopardized; and d.) given to members of the health team if information is relevant to his care. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Page 106. 80. Mr. Madrigal was brought home with an advance directive, but the nurse is not sure that she can follow his wishes. The nurse should: a. Follow the directive even though the nurse is uncomfortable with the directives. b. Call Mr. Madrigals lawyer. c. Discuss with the interdisciplinary team in charge of Mr. Madrigal and the organizational ethics committee. d. Ignore the advance directive ANSWER: C There is a growing trend for hospitals to have formal ethics committees. These may be composed of philosophers, doctors, nurses, lawyers, clergy or social workers. They discuss sensitive issues such as when to withdraw or withhold treatment for an adult and the treatment of a severely handicapped newborn. Some may include topics such as right to die, informed consent, right to choose or refuse treatment, right to know who is treating the patient. Reference: Lydia M. Venzon, Professional Nursing in the Philippines 10th edition, Page 104. 81. Mrs. Mayen, 77-years-old, has been admitted with pneumonia. Her husband asks the nurse about the living will. As a licensed nurse, you correctly response by saying which of the following with regards to the living will? a. A living will is legally binding in all states. b. A living will allows the court to decide when is the care can be given. c. A living will allows the individual to express his or her wishes regarding care. d. A living will allows a health worker to withhold fluids and medications. ANSWER: C The living will provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions. Reference: Barbara Kozier, Fundamentals of Nursing 8th edition, Page 64. 82. In developing managers, it is important to emphasize knowledge, attitude, and ability factors. Ms. Mendoza to be a chief nurse here in the Philippines, is required to have: a. At least 9 units of Graduate studies in Nursing.

b. Academic preparation in Nursing administration. c. Doctoral degree in Nursing with a major in Nursing Administration. d. Masters degree in Nursing with a major in Nursing Administration. ANSWER: D In the Philippines, Chief Nurses or Nursing Service Directors of hospitals with 100 bed-capacities are required to have a Masters Degree in Nursing with a major in Nursing Administration, while Supervising Nurses should have at least nine (9) units of Graduate Studies in Nursing. Nursing Service Administrators are required to be academically prepared; therefore all those who wanted to be in administration should have good education but specific to chief nurse requirement will direct you to option D. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 5 83. Ms. Marqueza knows that management processes are composed of four major functions. Its functions are: i. Planning ii. Directing iii. Coordinating iv. Organizing v. budgeting vi. Controlling vii. Scheduling viii. Supervision a. i, ii, iv, vi b. i, ii, iii, iv c. i, iii, iv, viii d. i, vi, vii, viii ANSWER: A Management process includes planning, organizing, directing, and controlling. Supervising and coordinating are under the directing function. Scheduling and budgeting are under the planning function. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 5 84. The Nurse Manager set the objectives, developed programs, and prepared the budget, tools and resources. She is on what stage of management process? a. Planning b. Controlling c. Budgeting d. Directing ANSWER: A Planning is the first function which includes setting objectives; developing and scheduling programs; and preparing budget. It is important to recognize that planning permeates the other functions which are dependent on it. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 5 85. Before the management decides as to the amount of budget must be allotted for the current year, primarily, it would be best to: a. Develop a plan for area of responsibility. c. Determine what is needed. b. Set-up first the control system to ensure good budgeting. d. All of the above ANSWER: D All of the above statements are necessary before allotting a budget. A budget committee must be well defined to assure an orderly and timely development of the budget like in option B. Estimations of what are needed and who will be responsible to it as well as the involvement on staff in budget preparation and control leads to cost consciousness, awareness of activities, and increased cost-effectiveness. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 29

86. As the chief nurse establishes formal authority and sets up the organizational structure by identifying groupings, the nurse is in what stage of management process? a. Planning b. Organizing c. Supervising d. Directing ANSWER: B In organizing, establishments of formal authority are the main activity. The process covers recruiting, selecting, orienting, and developing personnel to accomplish the goals of the organization. Supervising is an activity under the process of directing. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 6 87. Organizational structure is depicted in an organizational chart. As the chief nurse sets an organizational structure and identifies groupings, roles and relationships, she gives attention to qualifications and scopes of responsibilities as well as the relationship and authorities of personnel. Qualifications and scope of responsibility refers to: a. Staffing b. Job description c. Recruiting d. Organizing ANSWER: B Job descriptions, one of the activities in organizing, refer to specification of ones responsibility and qualifying characteristic in a specific or designated position. Staffing, one of the activity under organizing, refers to determining the staff needed and its pattern. Under staffing, recruiting, selecting, orienting, and developing personnel is accomplished to achieve the organizations goal. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 6 88. As the head nurse in the ward you disseminate the new information about the care of client in the pediatric ward. Instead of using alcohol in cleaning the cord, it is now considered that sterile water is more effective since it does not irritate the skin and the cord. Head Nurse applies which of the basic roles of a manager? a. Informational role b. Decisional role c. Liaison role d. Interpersonal role ANSWER: A Informational role refers to activities such as reviewing, disseminating, and monitoring information from both internal and external sources. Decisional role refers to activities such as innovating, trouble shooting and negotiating when conflicts arise. Option C is under the interpersonal role where a manager should act as a liaison between the external and internal sources. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 4 89. To which of the following functions of management does setting objectives of care belong? a. Planning b. Controlling c. Directing d. Organizing ANSWER: A Planning is a four-stage process to: Establish objectives and goals Evaluate the present situation and predict future events Formulate a planning statement

 Convert the plan action into a statement Reference: Venzon, L.M. & Nagtalon, J.M.V. (2006) Nursing Management towards Quality Care. 3rd Ed. Page 6 90. Mrs. Dizon, chief nurse, called for a meeting with the supervisors to discuss understaffing and the need to hire new nurses. They are engaging in which process? a. Planning b. Organizing c. Directing d. Controlling ANSWER: B In organizing, the staff needed determined. Develop and maintained staffing patterns, distributive in areas as needed. Under this also is the development of job descriptions, define qualifications and functions of personnel. Reference: Venzon, L.M. & Nagtalon, J.M.V. (2006) Nursing Management towards Quality Care. 3rd Ed. Page 6 91. Ms. Dina, head nurse, is responsible to the number of personnel reporting to her. This principle refers to: a. Span of control b. Unity of command c. Carrot and stick principle d. Esprit d corps ANSWER: A Span of control refers to the number of workers who report directly to a manager. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p.43 92. She decides to illustrate the organizational structure. Which of the following elements is NOT included? a. Level of authority b. Lines of communication c. Span of control d. Unity of direction ANSWER: D Unity of direction is a management principle, not an element of an organizational structure. Span of control or the number of workers that a supervisor can effectively manage. Esprit de corps is an intangible term used for the capacity of people to maintain belief in an institution or a goal, or even in oneself and others. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p.43 93. The management is planning for the amount of budget that must be allotted for the current year, primarily, it would be best not to do which of the following? a. Develop a plan for area of responsibility. c. Determine what is needed. b. Set-up first the control system to ensure good budgeting. d. none of the above ANSWER: D All of the above statements are necessary before allotting a budget. A budget committee must be well defined to assure an orderly and timely development of the budget like in option B. Estimations of what are needed and who will be responsible to it as well as the involvement on staff in budget preparation and control leads to cost consciousness, awareness of activities, and increased cost-effectiveness. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 29

94. Which phase of the employment process includes getting on the payroll and completing documentary requirements? a. Orientation b. Induction c. Selection d. Recruitment ANSWER: B Induction: This step in the recruitment process gives time for the staff to submit all the documentary requirements for employment. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p. 69 95. Nurse Mindy tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this? a. Centralized b. Decentralized c. Matrix d. Informal ANSWER: B Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow. Reference: Nursing Management towards Quality Care by Lydia Venzon and Nagtalon, 3rd edition p.66 96. An abstract is: a. A brief introduction to the study c. A brief summary of the contents of the entire report b. Another way to state the research problem d. A summary of the important findings ANSWER: C An abstract is a brief description/summary of a completed or a proposed research study. In research journals it is usually located at the beginning of an article. Reference: Nursing Research by Denise F. Polit, 8th edition, p. 698 97. The only research study where the researcher is opinion permitted is in: a. Recommendation b. Methodology c. Conclusions d. Review literature ANSWER: A Recommendation is part of the research where the researcher is allowed to discuss his/her opinions. Before the researcher gives his recommendations, he should once more go over the study and review the results, its shortcomings, for recommendations should be relevant and should flow from the findings. The researcher can state as many recommendations for future studies as many as possible as long as they are relevant to the findings and conclusions. Reference: Nursing Research by Denise F. Polit, 8th edition, p. 182 98. The purpose of research report is to: a. Proven hypothesis c. Suggests topics for further research b. Communicate what was done with the study d. Gain recognition as a scholar ANSWER: B The purpose of the research report is to communicate the findings of the study. No research is ever complete until a research report has been prepared. The research is of little value to the community unless that work is known. The

reporting of the results adds to knowledge on some issue and is the researchers responsibility. It is also to the researchers advantage to have research findings known by others because proper credit should be given to the work that has been completed. The other options are incorrect. Reference: Nursing Research by Denise F. Polit, 8th edition, p. 699-700 99. Since studying the entire population may not be possible because of certain factors, researchers can draw valid inferences from the population from a small portion of it. The process of drawing a small portion of the population is called what? a. Inferential statistics b. Operationalization c. Sampling d. Randomization ANSWER: C Sampling is the process of drawing a sample from the population being studied. Reference: Adanza, E.G. & Nazareno-Martinez, F.(2002) Methods Of Research For The Health Professions.1st ed. Manila. Rex Publishers Inc 100. Sample needed in every 10th name on the list, or patients in odd number rooms, or every 15th house on the blocks, this sampling is called: a. Stratified random sampling b. Cluster sampling c. Purposive sampling d. Systematic sampling ANSWER: D Systematic sampling is a method of selecting participants such that every kth person or element in a sampling frame or list is chosen. Stratified random sampling is the random selection of participants from two or more strata of the population. Cluster sampling is the form of sampling in which large groupings or clusters are selected first (example: nursing schools) with successive sampling of smaller units (nursing students). Purposive sampling a type of sampling method in which a researcher selects the participants from the study based on the personal judgment about which ones are the most representative of the study. It is also called judgmental sampling. Reference: Nursing Research by Denise F. Polit, 8th edition, p. 347