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PRE-BOARD EXAMINATION V NURSING PRACTICE V Care of Clients (Part C) GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions. 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. INSTRUCTIONS: 1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 2. Write the subject title Nursing Practice V on the box provided. 3. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set B. SITUATION 1: Mr. Lee is admitted to have his pacemaker inserted. The nurse explains that the catheter will be inserted into the subclavian view. 1) The nurse should explained further that the electrode is to be positioned in the: a) SA node b) Left atrium c) Right ventricle d) Superior Vena cava 2) Mr. Lee has a permanent demand pacemaker demand pacemaker. The nurse teaching should. a) Inform Mr. Dee that the pacemaker will function continuously at a set rate. b) Instruct Mr. Lee to take the pulse daily & keep accurate records c) Encourage Mr. Lee to reduce the former level of activity d) Instruct Mr. Dee to sleep on pillows 3) To evaluate the effectiveness of Mr. Lees pacemaker, the nurse ensure that pulse remains at least: a) Regular rhythm b) Above the demand c) Equal to the pacemaker d) Palpable at distant sites 4) An abdominal condition is which a person must sit, stand or used multiple pillows to breath when lying down is: a) Orthopnea c) Eupnea b) Dyspnea d) Apnea

5) Cardioversion is most effective when the client demonstrates: a) Ventricular standstill b) Ventricular Fibrillation c) Ventricular tachycardia d) Premature ventricular beats SITUATION 2: Mrs. Rosa has had three abortions. Presently she is pregnant and is being admitted for vaginal bleeding. 6) Mrs. Rosa asked you, to tell her more about abortion. You started by defining abortion as. a) An exaggeration of normal menses b) Loss of the fetus after viability c) Loss of the fetus before viability d) Loss of fetus after 28 weeks


7) In contrast to threatened abortion, inevitable abortion is characterized by: a) Fever, signifying an infection b) A dilated cervix c) A lesser amount of vaginal bleeding d) A closed cervix 8) She was told she might have a threatened abortion. This characterized by. a) Profuse bleeding & an incompetent cervix b) The retention of some of the products of conception c) Uterine cramping, vaginal spotting & a closed cervix d) Uterine cramping, vaginal bleeding & an close cervix 9) Mrs. Rosa has another abortion this could be a. a) Habitual abortion c) Excessive abortion b) Missed abortion d) Complete Abortion 10)You are caring for a woman who is having threatening spontaneous abortion includes the following EXCEPT: a) Allowing her a walk around & take a light exercise b) Strict bed rest c) Careful determination of presence & amount of vaginal bleeding d) Observe her uterine contraction SITUATION 3: Gary, 18 years old has been a marihuana use, since he was in 12 y/o. 11)Manifestation of marijuana intoxication is/are. a) Drowsiness b) Constricted pupil c) Hypertension d) Conjunctival redness 12)During visiting hours, Gary says, I hate Mom I dont like to see her, the best response of the nurse would be: a) It seems you dont really like to see her b) Go to your room & stay there until visiting time is over c) Why do you not like to see her d) Tell me more about your mother 13)Marijuana is a: a) CNS stimulant b) Sedative-hypnotic c) Mind alternating substance d) CNS depressant 14)Joshua prefers to keep himself inside his room is drawn. The most appropriate strategy to deal with this behavior is for the nurse to: a) Hold one on one counseling session b) Avoid establishing a relationship c) Make group interactions frequent, short & undemanding d) Keep interaction the main focus of therapy 15)Health teaching plan for Gary, would include informing him of the possible physical complication of marijuana use which is: a) Performing of nasal septum b) Respiratory paralysis c) Cardiovascular collapse d) Impaired lung structure SITUATION 4: Miss Matok Tan is a new registered nurse assigned at the fertility clinic. 16)All of the following are physiologic effects of progesterone, EXCEPT:

a) b) c) d)

Movement of zygote through the oviduct Slightly basal body temperature Formation of corpus luteum Inhibition of uterine contractility during pregnancy


17)There are many functions of estrogen, one of which is: a) Elevates basal body temperature during ovulation b) Inhibits uterine contractility c) Promotes lactation d) Promotes female secondary sex characteristics 18)Which of the following is a diagnostic test for fertility? a) Paps smear b) Coombs test c) Culdocentesis d) Hysterodalpingogram 19)Following ovulation, the ovum is normally viable for how many hours? a) 8 b) 24 c) 10 d) 12 20)Within the female reproductive tract, the sperm remains viable for how many days? a) 5 b) 4 c) 1 d) 3 SITUATION 5: Nursing Care after delivery is an important as any stage of delivery. 21)The cord of the baby must be between 2 clamps and tied using sterile scissors or blade. Then where is the baby place? a) Breast of mothers b) Side of mothers c) Give to grandmother d) Babys own mat on bed 22)The first two hours after delivery the mother should be watched for bleeding. What should be the most important parameter to check? a) Vital sign c) Placenta b) Uterus d) Laceration 23)What should be inspected on the baby? a) Breast circumference b) APGAR and Defects c) Height in centimeters d) Weight in kilograms 24)Home deliveries should be visited at postpartum. How many hours after delivery is first home visit? a) 36 b) 12 c) 24 d) 48 25)What is most important to check during home visit? a) Breastfeeding practices b) Babys milk formula c) Nutrition of mothers d) Bleeding in kilograms SITUATION 6: One of the things that a nurse must do to ensure quality-nursing care is to formulate a nursing goal for clients based on some theoretical nursing model that she could adopt in planning nursing care. 26)One example of a nursing model id the self-deficit theory. In this model, nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. This model was popularized by: a) Dorothea Orem b) Hildegard Peplau c) Faye Abdellah

d) Virginia Henderson


27)Another nursing model professes that the foal of nursing to work independently with other health care workers assisting client to gain independence as quickly as possible. The theorist in this nursing model is: a) Virginia Henderson b) Hildegard Peplau c) Faye Abdellah d) Dorothea Orem 28)The goal of nursing according to the nursing theory of Florence Nightingale is to: a) Develop interaction between nurse and client b) Care for a help clients retain total care c) Facilitate the bodys reparative processes by manipulating clients environment d) Reduce stress so that client can move more easily through recover process 29)In interacting with patients, a nurse can be governed by Travelbees nursing model. The framework for practice in this model is that: a) Interpersonal process is process is viewed as human relationship b) Client continuously changes & co-exists with environment c) Caring is central and unifying domain for nursing knowledge and practice d) Nursing process is defined as dynamic interpersonal process between nurse, client and health care system 30)Which of the following statements best support the concept that nursing is dynamic? a) Every patient is a unique physical, emotional, social and spiritual being. b) It is important that the patient participate in the over all nursing knowledge and practice. c) Caring is central and unifying domain for nursing knowledge and practice. d) Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. SITUATION 7: Mrs. Pala 38 years of age complaints of chest pain and was admitted to the hospital. 31)How would you assess whether she has angina pectoris? There is: a) Substernal chest pain b) Crushing chest pain c) Stabbing chest pain d) Vertigo upon standing 32)If it is angina pectoris, which drug will she respond to relieve her from chest pain? a) Marijuana c) Demerol b) Nitroglycerine d) Morphine sulfate 33)If she is having MI what would be the characteristics of the chest pain? a) Crushing c) Excruciating b) Stabbing d) Rubbing 34)Diagnosed as MI, what drug is best to relieve her from chest pain? a) Ponstan c) Nitroglycerine b) Marijuana d) Demerol 35)If PRN drug is not administered in case of severe chest pain. She can have: a) Apnea c) Tachycardia b) Cardiac arrest d) Hyperventilation SITUATION 8: Glen Sy is a 16-year-old son of a rich Chinese baker. He met a vehicular accident with his friends at the Skyway while they were driving beyond the speed limit. 36)What is the BEST position to transport Glen to the nearest health care facility? a) Position is insignificant because he can no longer move his legs b) Supine and protected from flexion and hyperextension c) Trendelenburg position d) Sitting position to secure immediate medical care

37)He was diagnosed to be paraplegic. His family want to know what this means. The nurse explains that Glen is paralyzed on his a) Right side of the body b) Lower extremities c) Both lower and upper extremities d) Upper extremities 38)The family was advised to give fluids liberally to Glen, what is the rationale for this? a) Maintain fluid and electrolyte balance b) Prevent temperature elevation c) Promotes faster recovery d) Prevent urinary tract infection 39)What factor contributes to the calcium loss in a paraplegic patient like Glen? a) Altered kidney function b) Decreased calcium intake c) Inadequate fluid intake d) Decreased activity 40)Which statement BEST indicates that Glen is about ready to learn how to take care of himself? a) What activities will I be allowed to perform? b) My mother will hire a private duty nurse to take care of my needs at home. c) Will I never be able to walk again? d) My Parents will bring me to the US for therapy


SITUATION 9: Streptococcal diseases are caused by Group A Streptococci. Persons infected with this beta-hemolytic disease present sore throat. 41)Marta came to the doctors clinic with her Grade 6 daughter who complained of fever, exudative tonsils and tender lymph nodes. What is the serious complication to watch? a) Peritonillas abscess b) Rheumatic heart disease c) Sydenhams chorea d) Otitis media 42)Another complication streptococcal disease, which manifests upper respiratory infection, is which one of these below: a) Acute rheumatic fever b) Acute heart disease c) Erysipelas d) Impetigo 43)Mode of transmission of strep infection is direct contact with infected person. What is your health teaching to the family of Marta? a) Separate food utensils b) Disinfect all soiled linens c) Isolate infected member d) Cover nose and mouth when sneezing/ coughing

44)Which penicillin group is drug of choice the doctors order for you to carry out? a) Procaine Penicillin G IM b) Oral Penicillin c) Penicillin G IM Benzathine d) Oral Penicillin 45)What is the first thing that a nurse should do in giving antibiotics? a) Give histamine b) Sensitivity skin test c) Check wheal d) Report rashes

SITUATION 10: As a head nurse in the medical ward for two years, on of the things that you have observed that contributes to the quality of nursing care in your unit is the observance of accurate documentation and reporting by your staff? 46)Which of the following nursing activities does NOT need to be recorded immediately? a) Providing a back rub at bed time b) Carrying out the order for blood transfusion c) Applying a pressure dressing for bleeding d) Transporting a client to the x-ray department for upper GI series


47)Your unit has been constantly recognized for outstanding endorsement procedure in between shift and has served as a model to the other wards. The major purpose of endorsement report is to: a) Inform the physician of a clients progress b) Communicate to the other members of the team the care rendered to the clients c) Provide an opportunity for nurses to share common concerns d) Provide continuity of care 48)The basis for the endorsement report is the communication to the next shift of the: a) Prescribed medical regimen b) Clients health needs c) Routine nursing orders d) Information on the Kardex 49)Which of the following information may NOT be included in the verbal endorsement report? a) Mr. Vicente will be seen by the oncologist in the morning for the schedule biopsy b) Mr. Martin pulse rate was 85/min at 8:30 and 105/min at 1:00 PM. c) Mr. Ching has been started on Penadur 500 mgs every 4 hours d) Mr. San Jose has been uncooperative and overacting during the day 50)When a physician gives a telephone order, the only way for the order to be legal is: a) the physician must give his name over the phone b) the nurse must record the order in the treatment sheet c) the physician must sign the order within the prescribed time d) the supervisor must accept the phone order SITUATION 11: Malou Wang, 36 years old secundi, 34-35 weeks AOG was rushed to the ER due to sudden gush of painless vaginal bleeding. Admitting impression is placenta previa. 51)In taking care of patients with placenta previa, the health personnel should do the following, EXCEPT: a) Internal examination b) Inform relatives to prepare blood for possible transfusion c) Notify pediatrician for a possible admission of a pre-term baby. d) Prepare a double set-up delivery when labor is imminent 52)A type of placenta previa where the placenta is implanted in the lower uterine segment is: a) Partial c) Total b) Marginal d) Low-lying 53)The etiology of placenta previa includes all the following, EXCEPT: a) Advancing age b) Multiparity c) Heredity d) Previous Cesarean section 54)The most important sign of placenta previa is painless hemorrhage which: a) Does not appear until the near end of the second trimester b) Does not appear until labor begins c) Appears anytime during pregnancy d) Appears on the beginning of the second trimester 55)When placenta previa is controlled, the MOST important nursing intervention is to: a) Administer blood transfusion as ordered b) Place the patient on complete bed rest

c) Request for blood typing and cross matching of blood d) Infuse IV fluids to replace volume loss


SITUATION 12: Mr. Rocky, 50 years old, a radio announcer was brought to the ER by his coworker. He has excruciating pain, dyspnea, cyanosis and symptoms of shock. Diagnosis was hypertension and arteriosclerotic disease with myocardial infractions. 56)Considering the signs and symptoms manifested by Mr. Rocky, would you expect Demerol to be ordered by the physician? a) Yes, because it depresses the respiratory center in the medulla. b) Yes, because this drug would help reduce the patients anxiety and relieve the pain. c) No, because Demerol must be used sparingly to prevent addiction d) Yes, because it acts as a vasodilator thus establishing collateral circulation 57)Mr. Rocky has been receiving digitalis drug, which of these is a digitalis? a) Meperidine HCL c) Eltroxin b) Lugols solution d) Lanoxin 58)Which of these is NOT a symptom of digitalis poisoning that the nurse should observe? a) Increased appetite b) Slowing of the pulse c) Mental confusion d) Irregular 59)The nurse understands that the slightly elevated temperature of Mr. Rocky at his early stage of his ailment, suggests: a) Need for oxygen b) Accompanying infection c) Severe heart damage d) Normal body response 60)Which of these diagnostic examinations is indicated for heart disease? a) SGOT c) BUN b) BSP d) SGPT SITUATION 13: Mrs. Bada, sustained trauma on the lower lumbar region of her spinal cord. 61)Mrs. Bada develop an epidural hematoma, as a result, she is likely to experience: a) Persistent headache b) Loss of consciousness within one week after the accident. c) Increase intracranial pressure immediately after the accident d) No signs and symptoms for several hours 62)Nursing care should include determination of his level of consciousness. Minimal consciousness impairment would be indicated by: a) Stupor b) Excessive drowsiness c) Lack of response to pain d) Inability to be aroused 63)Drug that is usually prescribed to lower his increased intracranial pressure is: a) Mannitol c) Mercuhydrin b) Lasix d) Aldactone 64)The rationale for doing craniotomy to Mrs. Gato is to: a) Drain and ligate bleeding coming from the arteries b) Drain and ligate bleeding vessels c) Reduce the hematoma d) Absorb the hematoma 65)Nursing measures to prevent accident post craniotomy: a) Provide hand restrain b) Provide Posey restrain c) Provide siderails

d) Provide tongue depressor


SITUATION 14: A six year old child, Manolito, has been diagnosed as having attention deficit disorder: 66)The common manifestation of this disorder are: a) Easily distracted, can not sit still, frequently interrupts others b) Often initiates physical fights, stealing and truancy c) Truancy, lying, easily distracted d) Head banging body rocking and intense desire for inanimate objects. 67)An appropriate nursing diagnosis is: a) Sensory perceptual alteration b) Ineffective individual coping c) Impaired adjustment d) Impaired verbal communication 68)Manolito is at the phallic stage of development which is best described in one of the following statements: a) Experiences gratification of basic needs b) Derives pleasure both from elimination of feces and their retention c) Experiences both pleasurable and conflicting feelings associated with genital organs d) Learns to hide their sexuality from disapproving adults 69)An important consideration in the care of a child like Manolito is: a) Promote orientation and appropriate independence b) Reinforce reality focusing on real people and events c) Reinforce acceptable behavior immediately d) Setting limits in his behavior 70)The physician may order this medication for Manolito: a) Chlorpromazine (Thorazine) b) Imipramine HC1 (Tofranil) c) Diazepam (Valium) d) Methylphenidate (Bitalin) SITUATION 15: Substance abuse is one of the common health problems now-a-days that has a great impact on the lives of our people, sociological and economically. 71)The following is not appropriate as a goal of care for clients with chemical and or/ drug dependency: a) Experience increasing comfort and safety b) Identifying community resources to support client and family c) Experience loss of weight during rehabilitation d) Develop stress-management technique 72)A condition in which and individual experiences withdrawal when a substance is abruptly stopped: a) Physiological dependency b) Drug misuse c) Psychological dependency d) Drug abuse 73)The primary defense mechanism used by chemical dependents is: a) Suppression c) Projection b) Denial d) Rationalization

74)When a nurse participate in information dissemination regarding the problems of drug addiction and initiates group discussion among the young people to draw from them their problems and coping responses, she is demonstrating what levels of care? a) Secondary care b) Quarterly interventions

c) Tertiary care d) Primary intervention


75)Which of the following statements is not correct regarding alcohol withdrawal? a) Delirium tremens may occur about 2nd and 4th day after drinking has stooped. b) Respiratory depression and hypertension are common during withdrawal c) Withdrawal signs and symptoms may occur within 6-12 hours after drinking has ceased d) Seizures and hallucinations during withdrawal SITUATION 16: Mara, a 6-month-old girl is admitted due to acute gastroenteritis with mild dehydration. 76)An IVF of D5 0.9% 500ml. was ordered to run for 12 hours. How many cc will you run per hour? a) 41-42 c) 31-32 b) 50-51 d) 62-63 77)Upon examination of her anterior fontanel, you noted that it is: a) Slightly depressed c) Firm and closed b) Bulging d) Soft 78)Normally at age 6 mos. Mara would have weighed how many kilograms if her birth weight is 4000 grams? a) 8 b) 6 c) 10 d) 12 79)When teaching the mother what food to give Mara, she can liberally give the following EXCEPT: a) Mashed sweet potato b) Oresol c) Gatorade d) Diluted milk formula 80)Which of the following is NOT an antidiarrheal drug? a) Loperaminde HCL b) Succinyl sulfathiazole c) Kaopectate d) Metronidazol SITUATION 17: Endemic malaria occurs in the tropic and subtropic areas where socioeconomic condition is very poor. 81)Which among the infectious agents of malaria is most serious to affect man? a) Plasmodium brasilianum b) Plasmodium malariae c) Plasmodium Vivax d) Plasmodium falcifarum 82)During your assessment, which among the signs and symptoms need referral to a secondary of tertiary care facility? a) Sweating and headache b) Icterus and shock c) Fever and chills d) Renal or liver failure 83)Laboratory confirmation of malaria is done in blood film. what do you expect to see in the film? a) Antibodies c) Malaria purinates b) Malarial parasites d) Antigen 84)The mode of transmission of this disease is through the bite of an infected female mosquito. What do you call this female aggressive mosquito? a) Aminophylline c) Anophiles b) Spirozoites d) Hepatocytes 85)What drug of choice is ordered for Malaria taken for 4-6 weeks? a) Chloroquine c) Phosphates b) Primaquine d) Sulfates


SITUATION 18: Kris, 50 years old, underwent total gastrectomy: 86)This operation involves the: a) Removal of microorganisms from the bladder b) Absorption of the bile pigment by the blood following obstruction of the bile from the jejunum. c) Removal of the stomach with anastomosis of the colon d) Removal of the stomach with anastomosis of the esophagus to the jejunum 87)You asses the operative site for excessive secretions, the rationale for too much fluid in the remaining gastric stump could cause. a) Dumping syndrome b) Increased pressure & injury c) Irritation d) Tympanism 88)Dumping syndrome is a postprandial problem that may occur post gastric resection. Intestinal manifestations of this syndrome are the following, EXCEPT: a) Gastric fullness b) Excessive vomiting c) Abdominal Cramping d) Borborygmi 89)Dietary management of this problem is: a) High protein, low carbohydrate, high fat, dry diet b) High protein, high carbohydrate, low fat, dry diet c) Dry bland diet d) Full diet

90)Which of the following nursing interventions would not cause delay of Kris gastric emptying? a) Giving fluids meals is prohibited b) Eating in recumbent position c) Eating high fowlers position d) Allowing her to lie down after meals SITUATION 19: During the orientation program for a new staff nurses, one of the first things emphasized is the application of nursing process in the management and care of thin patients: 91)The establishment of data base for a newly admitted patient forms which phase of the nursing process? a) Assessment c) Planning b) Implementation d) Nursing diagnosis 92)Assessment phase of the nursing process is completed a) At the beginning and end of each shift b) In the terminating phase of nursepatient relationships c) In the initial nursepatient relationship d) At the beginning and of each ship 93)A nurse who is taking care of a patient with severe dehydration due to loose bowel movement decided to first provide the patient with liquids and juices and give health instruction on sanitation and hygiene. The nurse in doing these activities is performing what element in the nursing process? a) Implementation c) Planning b) Evaluation d) Assessment 94)The comprehension and interpretation of the patients data to identify possible nursing problems id processed through. a) Assessment c) Analysis b) Evaluation d) Nursing diagnosis


95)In taking care of a patient for cardiac catherization, the nurse noted that the patient manifested fear related to cardiac catherization and its outcome. This statement is an example of: a) Nursing diagnosis c) Assessment b) Implementation d) Evaluation SITUATION 20: Occupation Health Nursing is the application of public health to conserve, restore and maintain health of workers in an industry. 96)Susan works in a garment factory. She is often invited by the industrial nurse in her promotive program of care. What included promotive care? a) Informing employee about insurance benefits b) Inviting worker to become members of the coop store c) Entertaining complaints of works d) Teaching of healthy and safe practices in the job. 97)Jackie is a union leader in the company. He is a friend of the nurse and helps her interpret health programs. What is the responsibility of the nurse? a) Assist in preparing complaints b) Accompany laborers to the DOLE c) Interprets provision of RA 1054 d) Prevention of accidents and promotion of good relationship 98)The health of the employees is wealth of a good company. The nurse acts a guide of workers in the provision of which program? a) Yearly picnics of families b) Annual medical checks up c) Scholarships of children d) Training of manpower resources 99)To involve the wives of laborers, the nurse can teach health habits. Which one is attractive to women to enjoin them? a) Teaching simple nursing care to the sick in the home b) Cooking lessons every Friday c) Fun for fitness d) Demonstration of nursing procedures 100) a) b) c) d) Which improvements of occupational health program could the PHN get involved? Medical Services for Works Industrial Toxicology Industrial Hygiene Program for Geothermal Works ***END***