Professional Documents
Culture Documents
Situation 1: Loss and grief affect not only the clients and their families but
also the nurses who care for them. It is essential for the nurse to have a
thorough understanding of a clients loss and the meaning of the loss to the
client.
1. A 55-year-old client is terminally ill with advanced cancer of the
ovary. To assist and comfort her, the nurse should
A.
B.
C.
D.
2.
3.
Upon learning about her condition, the client says to the nurse,
Why me? I did not do anything wrong. What response of the
nurse is most appropriate?
A. You will be fine.
B. Death is a normal part of life.
C. This must be very difficult for you.
D. Everyone has to die sooner or later.
The client is in severe pain and manifests signs of impending
death. The husband asks the nurse if his wife is going to die soon.
Which of he following is the most appropriate response of the
nurse?
A. The signs do not predict the exact time frame of
death.
B. You are concerned that your wife will die?
C. Death is inevitable.
D. Are you worried that your wife will die?
4.
The client has just died with her family around her. What
appropriate nursing action should the nurse make?
A. Allow the family time to be with the deceased client
B. Allow the family to grieve
C. Give the personal belongings of the client to her family
D. Reassure the family that the body will be cared of
5.
7.
8.
The client is concerned that sleeping during the day and being
awake at night is abnormal and unhealthy. The nurses most
therapeutic response is
A. Many people who work at call centers have the same
habits and they are alright.
B. People have different biological clocks. As long as you
sleep and function well, your habit is not abnormal and
unhealthy
C. Would you like to change your sleeping habits at this
time?
D. What makes you think that your habit of sleeping
during the day and being up at night is unhealthy and
abnormal?
9.
10. The client has obstructive sleep apnea (OSA) and has disrupted
sleep. He asks the nurse about the possible serious
consequences of OSA. The nurses most appropriate response
would be the following except
A. Alzheimers disease
B. Cerebrovascular accident
C. Cardiac dysrhythmias
D. Hypertension
Situation 3: Total quality improvement is based on the premise that the
process is ongoing and that quality can be always improved.
11. While giving care to a client in a medical unit, the nurse observes
that a 65-year-old male bedridden client has a reddened area with
no break in the skin in his coccyx. A clean dressing has been put
over the site in order to
A.
B.
C.
D.
25. A mother calls the emergency unit to ask for advice after she
found her child seated on the bathroom floor with cleanser around
her mouth and tongue. The appropriate advice given to the
mother would be to
A. Check if the child is breathing and if the airway is open
B. Give the child syrup of Ipecac to induce vomiting
C. Call the poison control of a general hospital
D. Remove cleanser from the mouth and tongue
Situation 6: A 21-year-old female is admitted to the Surgery Ward and is
placed in traction. She has been very frustrated because she cannot do her
usual daily activities.
26. The nursing diagnosis that is most appropriate for this client is
A. Potential for immobility
B. Impaired physical mobility
C. Activity intolerance
D. Risk for injury and pathologic fractures
27. Limitations in the activity exercise routine of a client affect her
self esteem. To help increase the clients self esteem, the
nurse understands that
A.
B.
C.
D.
28. The nurse maintains the clients good body alignment while she is
in traction in order to
A. Promote proper body balance and optimal brain
functioning
B. Maintain body posture and strength
C. Promote efficient circulation and enhance lung
expansion
D. Decrease workload of the heart
29. The nurse considers the following statements when taking care of
a client with traction except
A. Steady pull from both directions keep the fractured
bone in place
B. Weights should be kept resting on the floor
C. Clients on traction need adequate skin care and proper
positioning
D. Traction can be used to correct or prevent deformities
30. Part of nursing care for a client on traction is giving instructions for
isometric exercises in order to
A. Prevent decubitus ulcers
B. Improve lung capacity
C. Normalize blood pressure
D. Maintain muscle strength
Situation 7: An understanding of the infectious process and appropriate
methods to protect the health workers and client from disease is important.
The following questions pertain to preventing transmission of infection.
31. The nurse is explaining standard precaution to the client. This
includes which of the following actions?
A. Wearing protective equipment when doing any nursing
procedures
B. Handwashing using antimicrobial soap and water
C. Recapping of used needles with both hands then place
in puncture-resistance container
D. Using clean gloves to handle contaminated items,
blood and excretions
32. The nurse is changing the wound dressing of a client. The most
appropriate action of the nurse would be to
A.
B.
C.
D.
33. The client has an order for contact precaution. The nurse is to
give her a bath. The precautionary measure that the nurse
observes is to use
A. Face mask and gloves
B. Sterile gloves and cap
C. Gloves and gown
D. Cap and face mask
34. The clinical instructor in the surgical unit is teaching the nursing
students about the prevention of spread of diseases in the health
care environment. Which of the following is the most important
practical way to prevent the spread of diseases?
A.
B.
C.
D.
D.
A.
B.
C.
Warning
Suspension
Dismissal
Verbal admonishment
1, 2, 3, and 4
1 and 3
2 and 4
1, 2, and 3
44. Which of the following should the nurse take into consideration
when the client has a DNR order?
A.
B.
C.
D.
C.
D.
Nurse-initiated
Collaborative
Support system
Doctor-initiated
1, 2, and 3
2 and 3
1 only
2, 3, and 4
53. You are taking care of a client with fecal incontinence. You are
aware that this client has a risk for injury due to
A.
B.
C.
D.
Paralytic ileus
Tolerance for solid food immediately after surgery
Immediate return of gastrointestinal motility
Excessive flatus
Qualitative research
Applied research
Quantitative research
Basic research
Full disclosure
Informed consent
Human dignity
Self-determination
58. The research question for this study may be stated as follows:
A.
B.
C.
D.
Self-report method
Participant observation
Biophysiologic measures
Observational rating instrument
60. The researcher found out that the blood pressure measurements
are higher when a leg is crossed at the knee and that the
C.
D.
A.
B.
C.
D.
Situation 13: Teaching clients about healthy food intake for health promotion
and disease prevention is an important function of the nurse. Nutritional
deficiency is preventable if individuals and families have adequate
knowledge about normal nutrition.
61. The nurse is teaching a family to take food with high protein
content. She discovers that the familys consideration is the high
cost of food. Which of the following affordable high protein foods
should the nurse recommend?
A.
B.
C.
D.
62. During the follow-up visit, the client asks the nurse foods that are
complete in protein. Which of the following should the nurse
recommend?
A.
B.
C.
D.
63. A mother asks the nurse what finger food is safe for her toddler.
Knowing that children can easily choke on food, the nurse should
advice the mother to feed the toddler which of the following
foods?
A.
B.
C.
D.
Caramelized popcorn
Cereals like cheerio
Grilled hotdog
Salted nuts
64. A client diagnosed with peptic ulcer asks you what food is best to
add to his diet so as not to exacerbate his symptoms. Which of
the following is the most appropriate food for this client?
A.
B.
C.
D.
66. While taking the health history of the client, she tells the nurse
that she has occasional episodes of palpitations that would last
for about 45 minutes to 1 hour. To further explore this information,
the best question that the nurse should ask would be
A.
B.
68. A client has just been transferred to the surgical unit after knee
surgery. The nurse needs to assess the circulation of the right
lower leg. Which of the following is the initial approach of the
nurse?
A.
B.
C.
D.
70. The nurse is auscultating the clients heart. Which of the following
is the best position of the client to enable the nurse all areas and
high-pitched murmurs?
A.
B.
C.
D.
Situation 15: A male nurse meets a 55-year-old client in his room. During
interaction, the nurse feels drawn to the client and later looks forward to
seeing the client daily as does his rounds. The nurse realizes that the client
looks and acts like his grade school teacher who was kind and fatherly
towards him.
71. Which of the following best describes the feelings that the nurse
experienced towards the client?
A.
B.
C.
D.
Counter-transference
Transference
Denial
Idealization
72. The nurse utilizes the concept of therapeutic use of self when she
A.
B.
C.
D.
C.
D.
A.
B.
C.
74. One afternoon the nurse enters the room and the client tells the
nurse, Stop bothering me. Leave me alone. I dont want anyones
pity. The most appropriate response of the nurse is to say
A.
B.
C.
D.
D.
Situation 17: The medical ward has clients with various disease conditions.
As a newly hired nurse, you are challenged to update knowledge and skills in
the provision of nursing care.
81. When administering oxygen therapy to a client, the least likely to
cause anxiety is the use of
A.
B.
C.
D.
A.
B.
C.
D.
Face mask
Oxygen tent
Nasal catheter
Nasal cannula
83. The nurse is assisting a client who has an order for postural
drainage. To help the client obtain maximum benefits after the
procedure, the nurse should
A.
B.
C.
D.
84. When doing postural drainage for the client, measures should be
taken to minimize which of the following conditions?
1.
2.
3.
4.
1 and 2
1, 2 and 3
1, 2, 3 and 4
1, 3 and 4
Grating sound
Coarse crackles or rales
High pitched musical sounds
Loud low pitched sounds
Talk to the client and family and inquire what their fears
are about blood transfusion
Reassure the client and family that blood transfusion is
a simple low risk procedure
Tell the client that he will be closely observed for the
first hour so he will be safe
Request the doctor to explain to the client why blood
transfusion is necessary
87. The nurse prepares the following equipment for blood transfusion
except
A.
B.
C.
D.
89. The nurse stays and observes closely the client after the start of
the blood transfusion for possible transfusion reaction which
includes the following except
A.
B.
C.
D.
Hypovolemic reaction
Febrile reaction
Hemolytic transfusion reaction
Allergic reaction
90. After starting blood transfusion, the nurse should make sure that
the blood is transfused to the client within how many hours from
the time it started?
A.
B.
C.
D.
12 hours
10 hours
8 hours
4 hours
Situation 19: The nurse is assigned to take care of elderly clients with
different needs while in the medical ward.
91. While examining an elderly female client, the nurse notes musky
sour body odor of the client indicating poor hygiene. Which of the
following is the most appropriate action of the nurse?
A.
B.
C.
D.
93. The client has been on bed rest and has reddening of the skin of
bony prominences. When moving the client up in bed, the nurse
places her arms across her chest. This is done to
A.
B.
C.
D.
94. The nurse reports that a client appears uncomfortable and covers
herself with bed sheets on a warm day. The nurse asks
permission to pull out the sheet but noted urine smell and wet bed
sheets. She persuades the client to get up and shower. The client
refuses and becomes teary-eyed. The most appropriate
therapeutic statement by the nurse would be:
A.
B.
C.
D.
95. The client agrees to take a shower. While the client is being
assisted to the bathroom, she begins to fall. Which of the
following should be the initial action of the nurse?
A.
B.
C.
D.
Situation 20: Understanding clients needs depends upon the ability of the
nurse to communicate therapeutically.
96. A client in her early 20s was recently diagnosed with breast
cancer. She says to the nurse, Why did this happen to me? Do I
deserve this when I have been very good to others? Which of the
following should be the appropriate action of the nurse?
A.
B.
C.
D.
98. The doctor orders the insertion of a nasogastric tube for a client
who refused to eat. She has severe weight loss. She removed the
tube and says, I dont need that thing. The most appropriate
nursing response is
A.
B.
C.
D.