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FREE NLE REVIEW QUESTIONS: NP 1- Fundies & Other Related Stuf

( Taken from sample questions posted on april & late march)

The nurse must know that the most accurate oxygen delivery system available is,,,,

a. venturi mask
b. nasal cannula
c. partial non re-breather mask
d. simple face mask

Answer c.
Partial non-re breather mask delivers the highest oxygen concentration from 95% to 100% by means
of other mechanical ventilation. The venturi mask delivers oxygen concentrations varying from 24%
to 40% or 4 to 6 liters per minute.Nasal cannula delivers oxygen concentrations varying from 2 to 6
liters per minuteSimple face mask delivers oxygen concentration from 5 to 8 liters per minute.

With a title "Effects of aromatherapy on the stress levels of businesswomen in an urban community",
the reader would know that this is a/an:
A. descriptive research
B. quantitative research
C. applied research
D. basic research
APPLIED RESEARCH focuses on finding solutions to existing problems while
BASIC RESEARCH is done to expand knowledge in a discipline or to formulate or modify a theory.
DESCRIPTIVE RESEARCH is a non-experimental study done to observe, describe and document
naturally occurring situations.
QUANTITATIVE RESEARCH is the study of phenomena using precise measurement and

The primary purpose for regulating nursing practice is to protect:

A. the public
B Practicing nurses
C The employing agency
D. Professional standards

correct answer A Each state or province is charged with the responsibility of protecting the health
and welfare of its populace, which it does by regulating nursing practice.

Which of these does NOT occur in a descriptive study?

A. manipulation of variable
B. explanation of relationships between two or more phenomena
C. investigation of a phenomena in real life context
D. exploration of relationships between two or more phenomena
The principle of a descriptive study is to examine, explain, and document a situation as it naturally

A research group studied the trend in junk food consumption of a group of females over a 10-year
period using data they collected annually. This is an example of a/an:
A, case study
B. evaluative study
C. longitudinal study
D. cross-sectional study

a LONGITUDINAL STUDY involves data gathering at more than one point in time.
CROSS-SECTIONAL STUDY involves gathering of data at one point in time.
An in-depth analysis or exploration of an individual is called CASE STUDY

In the research "The effect of listening to a relaxation tape on the anxiety levels of preoperative
patients," the independent variable is:
A. anxiety levels
B. preoperative patients
C. listening to a relaxation tape
D. relaxation tape
The independent variable is the presumed cause. In this case, "anxiety levels" is the dependent

What is the nursing action if patient has pneumothorax during the Postoperative Care? SATA
A.High Fowlers Position
B.Assist Thoracentesis
C.Chest Xray
D.Assist with chest insertion
E.Flat in bed
F.Vital Signs

Correct Answer ABCDF

What is the minimum number of yrs. in practice, required for deanship in a college of nursing?
a. 5 yrs.
b. 6 yrs.
c. 7 yrs.
d. 8 yrs.
The salary of a PHN shall not be lower than:
a. SG 12
b. SG 15
c. SG 20
d. SG 25
8. Your professional license may be revoked in which of the ff. circumstances?
a. violation of Nursing ethics
b. practice of nursing under supervision
c. gross competence
d. professional conduct
9. Nursing Service Supervisors must have how many MA units in management and administration?
a. 12
b. 6
c. 9
d. 15

correct answer ABAC

A well written plan would include the following, EXCEPT
A.Research problem
B Review of Related Literature and Theoretical/Conceptual Framework
C.Methods and Procedures
D.Research Findings

Correct ans D. Pag proposal plng wala pang findings

Shock and dismay are felt by the client at what stage of death and dying?
A. Denial
B. Anger
C. Acceptance
D. Depression
ANSWER: A - Denial
Denial is refusal to believe existing loss and may be manifested by shock and dismay or prolonged

A colostomy was created in a client who was diagnosed with colon cancer. During the first day post-
op, the nurse does not find any measurable fecal drainage from the patients's colostomy. What
should the nurse do?
A. continue the current plan of care
B. call the doctor immediately
C. irrigate the stoma
D. encourage the patient to increase fluid intake

The normal plan of care should be continued because the colostomy is expected not to function for 2 days or more
(48 to 72 hours) after surgery. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous
and serosanguineous drainage), the physician need not be notified and the stoma should not be irrigated at this time.

The primary critical observation for apgar scoring is

A. Respiratory rate
B.Heart rate
C Presence of meconium
D.eval of moro reflex
Correct Answer B. HR is vital and most critical observation in Apgar scoring at birth. Respi effort
rather than rate is included in in the APgar,the rate is very erratic

DOUBLE BLIND RESEARCH no bias or prejudice on treatment blind folded

- gives accuracy due not conscious & biased

If a researcher studies the effect of a scheduling assignment on nurses morale, the scheduling
assignment would be referred to as the:
a. Independent variable
b. dependent variable
c. population

Correct answer A. Ang dependent ay on Nurses morale

Epispadias- urinary meatus located

dorsal or above glans penispenis (EDA)

Hypospadias- urinary meauts loc ventral or below glans penis (HVB)

Hypospadias with chordee- fibrous band causing penis to curb downward

Patient reacted to meds given, allergy. Inform MD he will give anti-histamine.

Incident report for purpose of risk management
Report of sudden occurrence
Go to Head nurse

Pt has appendicitis. Pain in RLQ who is primarily responsible for patient Head nurse.
HN can delegate to staff nurse pt died. Head Nurse is liable.

2 main problems in colleting data:

1.Hawthornes effect problem in experimental design inaccurate due toconsciously being observed
(PAASCU accreditation management keepsschool clean before PAASCUA comes to school.

2.Halo Effect special relationship inaccurate due bia

Purpose: for proper formulation of conceptual & theoretical framework.

Theory relationship bet concepts

Conceptual framework-Illustration showing relationship between variables

Paradigm- diagrammatic presentation / illustration of conceptual framework

The nurse is planning interventions beneficial to a client with chronic illness.The nurse should focus
on Except :
A. reducing health care cost
B.Pain Management
C. Promoting independence
D.Improving quality of life

Correct Answer B.. Simply because pain management para sa acute illness

The nurse suspect DHN in erderly client. The nurse assess for skin turgor. EXCEPT:
A. Forehead
B.upper extremities

Correct Answer B. . A and C are most reliable..

When doing a physical assessment of an Old-old client the nurse expect to see which of the ff:
A.decrease pubic hair
B.increase tear production
C.thick,brittle nail
D.pupils are constricted

Correct Answer B. In age-related physical changes include decrease scalp,auxillary,pubic hair,pupils

are smaller,thick brittle nail and decrease tear production

During the assessment the client tell to the nurse that he has pain in left knee. The information is
A.objective data
B.subjective data
C.historical data

Correct Answer B

When caring a client with a chronic illness the nurse aware that client will have Except:
A.Impaired function
C.irriversible condition

Correct Answer B. Dahil ang Pain fall into Acute illness hehe..

leukocytosis may indicative of which of the ff: EXCEPT:

A.Viral infection
B. Fungal infection
C.Bacterial Infection

Correct Answer A.. sa Leukopenia sya

Before administering an intermittent tube feeding the nurse aspirates 40ml of undigested formula
from the clients nasogastric tube. Which should the nurse implement as a result of this finding?

A. Discard the aspirate and record as pt. output

B. Mix with new formula to administer the feeding

C. Dilute with water and inject into the nasogastric tube

D. Reinstill the aspirate through the nasogastric tube via gravity using a syringe


AFTER checking residual feeding contents the nurse reinstills the gastric contents into the stomach
by removing the syringe bulb of plunger and pouring the gastric contents via the syringe into the
nasogastric tube. Gastric contents should be reinstilled(unless they exceed an amount of 100ml or
as defined by agency policy) in order to maintain the clients fluid and electrolyte balance. The nurse
avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric
aspirate is a small volume it should be reinstilled. However mixing the formula with water

Test taking strategy --> use the process of elimination. Eliminate A because it increases the risk of
dehydration. Remembering that the removal of gastric contents can disturb the clients fluid and
electrolyte balance will assist in eliminating B C. Also recalling that aspirated gastric contents are not
mixed with formula .

Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines
that which of the following nursing actions is the priority?
a. monitoring weight
b.assessing edema
c. monitoring apical pulse
d. monitoring temperature

ANSWER C. Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying
hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

Patient receiving BT whole Blood, you are the nurse on duty, while observing the patient, the patient
complains of difficulty in breathing,You auscultate, you heared rales both lungs, px V/S ARE:
BP140/90 with bounded pulse,RR= 30 and PR = 99. As a Nurse ON duty, what will you do first?
a. stop the infusion
b. decrease/slowdown the rate of the blood, High fowlers position and give O2
C. giVE o2 and run PNSS
D. gIVE antihistamine and run PNSS

B is the answer.ky thats a sign of fluid over load...e decrease lng ang rate..kasi...eninfused yan...kasi kailangan...wala
namang allergic reaction na nangyayari dyan...baka na nassobrahan lng sa rate nya or sa dropping..so e slowdown
mo lang...tas mag bigay ka ng o2 yes pag book yang pag babasihan natin need yan ng orders ang oxygen..pero sa
setting natin we knew naman kung kailan needed ng patient ang o2..d naman siguro tau mag bigay pag d kailangan
dba?so SOP na yan ..e stop mu lng yung trasfusion pag my allergic reactions like febrile reactions,hemolytic reactions
as evedence by dysrythmia probobly due to sudden hyper K or flanck pain..or rashes or wheezing

1. Using the principles of standard precautions, the nurse would wear gloves in what nursing

A. Providing a back massage

B. Feeding a client
C. Providing hair care
D. Providing oral hygiene

2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration
secondary to vomiting and diarrhea. What is the best method used to assess the clients
A. Oral
B. Axillary
D. Heat sensitive tape

Correct Answer- DB

Nursing Practice 1: Professional Adjustments, Jurisprudence and Nursing Ethics

Situation: It is important for nurses to recognize that nursing practice is guided by the professional
obligation and bioethics. Nurses need to be aware of these standards since nurses are accountable
for their action in all these areas in their professional role.

15. What is the principle to hold on when an adult has signed the consent form of a research study
but has changed his mind?
A. Autonomy B. Confidentiality C. Beneficence D. Justice

16. The principle that tells, such as clients right to refuse treatment maybe in conflict with nurses
obligation to benefit client and carry out treatment is
A. Beneficence B. Justice C. Confidentiality D. Ethical dilemma

17. When all patients in the ward receive the same quality care, the bioethical to be used is
A. Confidentiality
B. Ethical dilemma
C. Justice
D. Double Effect

18. The principle that tells older persons to be treated accordingly as a person is
A. Beneficence B. Respect C. Nonmaleficence D. Autonomy

19. When the nurse administered morphine for clients in pain but some expected harm such as
respiratory depression and effects of medication occur, you are thinking the particular principle of
A. Respect B. Beneficence C. Autonomy D. Double Effect

Reference Book: Comprehensive Review of PNLE and NCLEX-RN for Nurses

Author/Owner: Erickson E. Marquez, RN, RPT, RN-PMH, MAN, MAED

****No answer: but 15.A 16.D 17.C 18.B 19.D

1. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer
the formula
A. Every four to six hours
B. Continuously
C. In a bolus
D. Every hour
2. Which bed position is preferred for use with a client in an extended care facility on falls risk
prevention protocol?
A. All 4 side rails up, wheels locked, bed closest to door
B. Lower side rails up, bed facing doorway
C. Knees bent, head slightly elevated, bed in lowest position
D. Bed in lowest position, wheels locked, place bed against wall
1) B: Continuously
Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption.
However, initial feedings may be given by bolus to assess the client''s tolerance to formula.

2) D: Bed in lowest position, wheels locked, place bed against wall

No longer is it advisable to use the lower side rails. With all 4 side rails used it reflects inappropriate
use of protective restraints without an order. Placing the bed against the wall permits getting out of
bed on only 1 side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest
position (without bending limbs to restrict movement) provides a shorter distance to the ground if the
client chooses to get out of bed. If the side rails are used 3 pulled up are acceptable. If 4 are pulled
up an order for protective restraints is needed and has to usually be renewed in 48 to 72 hours along
with more frequent documentation.

Writing goals/desired outcomes is part of the 3rd phase of the nursing process. Nurse Lemuel is
writing desired outcomes for his patient. Which of the following desired outcomes indicate that Nurse
Lemuel has a correct understanding of formulating desired outcomes?
A. Enable the client to drink at least 200ml of fluid per hour until skin turgor goes back to normal
B. Facilitate patients understanding of his disease
C. Allow the patient to do a 30-minute light intensity exercise 4-5 times a week as tolerated
D. The patient will be able to recall 5 symptoms of diabetes before discharge
Desired outcomes should focus on the clients response and behavior. Each desired outcome should
start with the words the patient or the client to help make the desired outcome client-centered. Avoid
using statements that start with enable, facilitate, allow, permit, let or other similar verbs because
these denote what the nurse hopes to accomplish, not what the client should do.

Wearing of personal protective equipments (PPE) is an effective method of infection control. PPE
typically consist of gloves, gown, mask and eyewear. Which of the following principles regarding
donning and removing of PPEs is incorrect?
A. After washing the hands, the gown is put on first, then the mask, eyewear and lastly, gloves
B. In removing soiled PPE, the gloves are removed first, then the eyewear, gown and lastly, the
C. The mask is removed at the doorway to the patients room
D. In donning clean disposable gloves, the open method of gloving should be followed at all times
In donning clean gloves, no special technique is required. Only sterile gloves require a special
All other choices are correct.

Which of the ff statements is best describes charting by exception?

A. A chronological account of the clients status and treatments, written in paragraphs.
B. A narrative recording on separate sheets by each member of the health team.
C. Detailed flow charts and emphasis on the changes in the clients condition.
D. Documentation that is limited only to significant findings.

Answer: D
Rationale: option A refers to narrative charting option b pertains to source oriented charting ; option
C refers to focus problem-charting.

An ileostomy is a stoma that has been constructed by bringing the loop of the small intestine out on
the surface of the skin.When assessing the client with a new ileostomy,the Nurse knows that the
effluent from the ileostomy should be: A. Soft stool B.Pasty to soft stool C.Liquid to pasty stool D.
well-formed stool

Ans:C liquid to pasty stool.The effluent should be liquid because the water will not be removed from the stook as with
an intact colon.The fecal material becomes more formed and solid as it moves through the colon.

The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most
effective to promote healing?
A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soaks
C) Leaving the area open to dry
D)Applying a hydrocolloid or foam dressing

The correct answer is D: Applying a hydrocolloid or foam dressingWhile the previously accepted treatment was a
transparent cover, evidence now indicates that the foam (DuoDerm) dressings work best..

A 75 year old woman comes to the emergency care unit. Upon initial assessment, you noticed her
face, lips, and tongue are so swollen that she can hardly talk. She also exhibits difficulty breathing
with inspiratory wheezing. As the nurse attending to the patient, what is your first action?
A. Administer oxygen support via non-rebreather mask
B. Administer Epinephrine immediately as ordered by physician
C. Administer oxygen support via face mask
D. Assess patient for signs of hypoxemia
ANSWER: B. Administer Epinephrine immediately as ordered by physician
Immediate action for patient exhibiting anaphylaxis is to counter the inflammatory response by giving
sympathomimetics such as Epinephrine to induce bronchodilation and vasoconstriction.

Situation: A cardiac surgeon at Iloilo Mission Hospital is undergoing surgery after being shot twice
inside the hospital by Michael Cruz, 41, of Roxas, Capiz. Mr. Cruz then shot himself. In a press
conference in the afternoon following the incident, hospital and law enforcement officials said that no
one else was injured. Officials said that hospital staff barricaded themselves in separate rooms until
the hospital was deemed safe. Staff were said to have responded quickly and in an appropriate
manner to protect themselves and patients. This wasn't by accident.

The nurse is aware that the main reason for accidents in hospital is:

A. People sneak in cigarettes

B. Equipment breaks unexpectedly
C. Patients do not recognize hazards
D. Safety precautions always take extra time


Test Taking Tip: Identify the key word in the stem that sets a priority. Identify the option that contains
a specific determiner.
The word "main" in the stem is a keyword that sets a priority. The word "always" in option D is a
specific determiner.

Correct Answer: C

Patients can be cognitively impaired, deny their physical impairments, or have limited perception,
which impedes their ability to recognize hazards. Usually it takes the same amount of time to do
something correctly as it does to do it incorrectly in letter D.

Accidents are not accidents but precise arrivals at the wrong right time

The primary nurse assigns a staff nurse to insert an indwelling urinary (Foley) catheter. What is the
first thing the staff nurse should do?

A. Explain the procedure to the patient

B. Gather equipment at the bedside
C. Check the physician's order
D. Wash hands thoroughly


Test Taking Tip: This question is designed to test your ability to recognize that the insertion of a
urinary catheter is a DEPENDENT nursing intervention that requires physician/doctor's order.

Correct Answer: C

Rationale: Inserting an indwelling urinary catheter is a dependent nursing intervention and requires
a physician's order that first must BE VERIFIED by the nurse implementing the order. Washing the
hands is not the first step in this procedure. Gathering equipment for this procedure is premature.
You can't directly explain the procedure to your patient, there are other things the nurse must do first.

In order proper sequence for this procedure would be:

1st - Check the doctor's order (C)
2nd - Explain the procedure to the patient (A)
3rd - Gather equipment at the bedsides (B)
4th - Wash hands thoroughly (D)
A client has a left pleural effusion that has not yet been treated. The nurse plans to have which of the
ff items available for immediate use?

A. Intubation tray
B. Paracentesis tray
C. Thoracentesis tray
D. Central venous line insertion tray

The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows
drainage of the fluid which may then be analyzed to determine the precise cause of the effusion.

Test taking -> use the process of elimination and knowledge regarding the usual treatment for pleural
effusion. Note the relationship between the word PLEURAL in the and THORACENTESIS.

Phantom limb pain is considered as:

A. Superficial pain
B. Visual pain
C. Somatic pain
D. Neuropathic pain

Which of the ff cultural characteristic defines a chinese clients response of pain?

A. Liberalism
B. Scientology
C. Stoicism
D. Hedonism

1. Answer: D
Rationale: neuropathic pain is due to damage to the central and peripheral nervous system.
Anticinvulsants like phenytoin (Dilantin) may help decrease pain. Opiods are almost ineffective for
this type of pain.

2. Answer: C
Rationale : chinese clients usually display an indeference to pain. This phenomenom is known as

A complete blood count is commonly performed before a petient goes into surgery. What does this
test seek to identify?
A. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
B. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine
C. Electrolyte imbalance that could affect the blood's ability to coagulate properly
D. Low levels of urine constituents normally excreted in the urine
Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before
surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need
for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood. Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.

A nurse is caring for the client with acute glomerulonephritis.the nurse instructs the nursing assistant
to do which of the following in the care of the client?
A.monitor the client temp q 2 hrs
B.remove the water pitch from the bed side
C.ambulate the client frequently
D.encourage a diet that is high in protein

- B daw ?

a patient receives 500mg of bid in 7 days. In the 4th day he consume 1 tablet of the drug about 8am
in the morning. How many tablets that he consumed and the maximum mg he takes in the past 4
A. 4000 total mg / 8 tablets
B. 6000 total mg / 10 tablets
C. Neither of the two
here is how it done colonthree emoticon
BID is twice a day so it will be given 8am and 6pm only
1st day : 8 am: 1 tab 500mg 6pm: 1 tab 500mg
2nd day : 8 am: 1 tab 500mg 6pm: 1 tab 500mg
3rd day: 8 am: 1 tab 500mg 6pm: 1 tab 500mg
4th day: 8am : 1 tab 500mg 6pm: 1 tab 500mg
total all of it is 3500/7tablets but what i ask here maximum mg he take in the past 4 days so he
already consumed the 6pm drug smile emoticon

After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina
suspects the client is experiencing anaphylactic shock. What should the nurse do first?
A. Page an anesthesiologist immediately and prepare to intubate the client.
B. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital
C. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
D. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator
as prescribed. The physician is likely to order additional medications, such as antihistamines and
corticosteroids; if these medications don't relieve the respiratory compromise associated with
anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists;
however, the nurse should continue to monitor the client's vital signs. A client who remains
hypotensive may need fluid resuscitation and fluid intake and output monitoring; however,
administering epinephrine is the first priority.

QUESTION: 1.which nursing action regarding intubation equiptment/supplies is most appropriate

following intubation of a post operative client who had a respiratory arrest?. A.soak the intubation
equiptment in concentrated betadine solution B.place intubation blade in bag and solution arrange
for gas sterilization C.soak intubation blade in cidex solution D.wash with soap and water and allow
to air dry Correct answer
>>>>>>>>>>>>>>>>>>>>>>>:RATIONALE:sterilization of equiptment after exposure to body fluids
of a client is protocol.all other options are incorrect because they do not provide sterility.

The nurse prepares to teach, a client to ambulate with a cane. Before teaching cane assisted
ambulation, the priority nursing assessment is to determine that the client has

A. Self consciousness about using a cane

B. Full range of motion in lower extremities

C. An adequate level of stamina and energy

D. Balance muscle strength and confidence

Assessing the clients balance strength and confidence helps determine if the cane is a suitable
assistive device for the client. Self consciousness is a component of the assessment, it is not the
priority. Full range of motion and high level of stamina are not needed for walking with a cane.

1. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR, ENABLING and

A. Benner
B. Watson
C. Leininger
D. Swanson

2. The unique function of the nurse is to assist the individual, sick or well, in the performance of
those activities contributing to health that he would perform unaided if he has the necessary
strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly
as possible.

A. Henderson
B. Abdellah
C. Levin
D. Peplau



1. D. Caring according to Swanson involves 5 processes. Knowing means understanding the client.
Being with emphasizes the Physical presence of the nurse for the patient. Doing for means doing
things for the patient when he is incapable of doing it for himself. Enabling means helping client
transcend maturational and developmental stressors in life while Maintaining belief is the ability of
the Nurse to inculcate meaning to these events.

2 .A. This was an actual board question. Remember this definition and associate it with Virginia
Henderson. Henderson also describes the NATURE OF NURSING theory. She identified 14 basic
needs of the client. She describes nursing roles as SUBSTITUTIVE : Doing everything for the client,
SUPPLEMENTARY : Helping the client and COMPLEMENTARY : Working with the client. Breathing
normally, Eliminating waste, Eating and drinking adquately, Worship and Play are some of the basic
needs according to her.
1. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal?

a. Dullness over the liver.

b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries...

1. Answer: (C) Shifting dullness over the abdomen.

Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other
options are normal abdominal findings.

A clear liquid diet has been prescribed

for a client. The nurse should offer which
item to the client?
A.Apple juice
B. Orange juice
C.Tomato juice
D Ice cream without nuts

Rationale: A clear liquid diet consists of foods that are relatively
transparent. The food items in options B, C, and D would be included
in a full liquid diet

Captain of the ship doctrine applies on what area of the hospital?

A. Emergency room
B. Operating room
C. Pediatric ward
D. Out-Patient Department

Ans: B- Respondent Superior

PROPOSED the GRAND theory of NURSING as CARING A.erickson,tomlin,swain

B.peterson,zderad C.benner,wrubel D.boykin,schoenhofer Correct answer D

A nurse is caring for an immobile patient.the most appropriate nursing intervention to implement is:
a.turning the patient evry 4hrs. b.applying an abdominal binder while the patient is lying in bed
c.encouraging the use of incentive spirometry hourly d.maintaining the patient maximum fluid intake
of 1000ml daily CORRECT ANSWER:C GENERAL FEEDBACK:patient need to repositioned every
2hrs to reduce stagnation of secretions.an application of an abdominal binder will restrict chest
expansion.patient need a minimum of 2000 ml everyday to adequately and keep pulmonary
secretions thin,watery,and clear.

According to them,morality is measured of how people treat human being and that a moral child
strives to be kind and just A.zderad and peterson B.benner and wrubel C.fowler and westerhoff
D.schulman and mekler CORRECT ANSWER D

Clamping allows urine to collect in the tubing at the location where the specimen is obtained.
Nurse Joseph is caring for a client with a urinary catheter, he is planning to clamp the catheter for
specimen collection later. Which of the following catheters should Nurse Joseph clamp?
A. Ureteral catheter
B. Suprapubic catheter
C. Foley catheter
D. Nephrostomy catheter
Foley catheters may be clamped. Care must be taken to avoid kinking, clamping, or obstructing a
ureteral, suprapubic or nephrostomy catheter.
Obstructing a ureteral or nephrostomy catheter will result in increased pressure in the renal pelvis,
causing tissue damage. Suprapubic catheters will not drain well if mechanically obstructed

What best describes nurse as a CARE PROVIDER? A.determine clients need B.provide direct
nursing care C.help client recognize and cope with stressful psychological situation D.works in
combined effort with all those involved in patients care CORRECT
ANSWER:ARATIONALE:>>>>>>>>>you can never provide nursing care if you dont know what are
the needs of the client.how can you provide an effective drainage if you dont know where is the bulk
of the clients secretion.therefore the best description of a care provider is the accurate and prompt
determination of the clients need to be able to render an apptopriate nrsg.care

Changing a positions should be done in a consistent manner, usually every two hours in most
hospitals. When a client is placed in a Fowler's position, which of the following problems will be
1. Posterior flexion of lumbar curvature
2. Hyper extension of knees
3. Plantar flexion
4. Hyper extension of lumbar curvature
5. Pressure on heels

A. All except 1
B. All except 2
C. All except 3
D. All except 4

Answer: D
Rationale: statement numbers 1,2,3 and 5 are accurate fowler's position, or a semi-sitting position, is
a bed position in which the head and trunk are raised 45 to 90 degrees.
Reference: kozier and Erb's Fundamental of Nursing, 8th Edition, (2008), volume 2, pp. 1132 & 1133

The rigthful owner of the chart or clients record or patiens chart is ? ___________

*** The institution or agency is the Rightful Owner of the chart / clients record. This does not,
however, exclude the cl's right to the same records. Accdg. To Guido 2001, the client has the right to
access all info. Contained w/in his or her own record and to have a copy of the original record
ref: fundamental of nursing (concepts,process and practice) by zofier, erb, berman, snyder page;329

It is the Nurse's error that lead to the patient's injury and is proved by the nurses negligence, this is
pertained to as:

A. Dura lex sed lex

B. Fueste Mia,solo Mia
C.Res Ipsa loquitor
D. Respondeat superior

Correct answer po si C. Kc the things speak for it self may evidence.

Which of the ff nursing theorist introduced transcultural nursing model?

A. Imogene king

B. Myra levine
C. Ida jean orlando

D. Madeliene leininger


The most important communication skill to be developed by the nurse manager is

A. Firmness

B. Assertiveness

C. Questioning

D. Attentive listening

attentive or active listening is the most important communication skills to be developed by the nurse

All of the ff are primary responsibilities of the nurse manager except

A. Performing bedside nursing

B. Coordinating and delegating patient care

C. Setting standards of performance

D. Designating staff schedules


The nurse provides care for a client newly admitted with severe right flank pain, temperature of
101F (38.3C), chills, and dysuria. Which action should the nurse take NEXT?

A. Obtain a urine sample.

B. Assess for pain at the right costovertebral angle.
C. Start the ordered antibiotics.
D. Encourage fluid intake of at least 3000 mL.


Strategy: "NEXT" indicates priority.

(1.) urine needs to be collected for verification of any organisms; most frequent offender is
Escherichia coli

(2.) client admitted with severe right flank pain

(3.) priority is to collect urine for urinalysis before starting antibiotic therapy

(4.) fluids are important, but not the priority

The manager role of the nurse is best demonstrated when she

A. Plans nursing care with the patient

B. Works together with the nursing team

C. Initiates nursing action with co workers

D. Speaks in behalf of her patient

the case manager role is demonstrated when the nurse works together with the health team

What equiptment would be necessary to complete an evaluation of CN 9 and 10 during a physical

assesment a.opthalmoscope b.tongue depressor and flashlight c.cotton ball d.penlight CORRECT

As a part of a disaster drill,the nurse reacts to an announcement that a dirty bomb exploded 4 miles
away.according to the disaster plan,which of the following actions should the nurse take FIRST?.
A.contact parents to immediately pick up their children B.turn off the airconditioners and forced air
heating units C.encourage the staff and children to remain calm D.move food and water to an interior
area in the school CORRECT ANSWER is B:turn off all units bring fresh air in from the outside;close
the lock all doors and windows;move to an inner room or basement.
A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and
determines that the client is expiriencing respiratory acidosis. Which of the following validates the
nurses findings?

A. pH 7.25, PCO2 50mmHg

B. pH 7.35, PCO2 40mmHg
C. pH 7.50, PCO2 52mmHg
D. pH 7.52 PC02 28mmHg

Answer: A, PH = 7.25 indicates acidosis and PCO2 more on respiratory and it is increased

Nurse Kris is administering TPN through peripheral IV.line to a school age child.whats the smallest
amount of glucose thats considered safe and not caustic to small veins,while also providing
adequate TPN a.15 PERCENT GLUCOSE b.17 percent glucose c.10 percent glucose d.5 percent

Which of the ff nursing theorist conceptualizes that all persons strive to

achieve self care?
A. Sister callista roy
B. Dorothea orem
C. Dorothy jonson
D. Jean watson
The nurse cares for clients in the LONG TERM FACILITY.a client is diagnose with
LEGIONNAIREs dse.which of the following actions by the nurse is MOST appropriate?
A.place filters on the air ducts of the client room B.sterilize the untensils used by the
client C.place the client on droplet precautions D.ask for maintenance on the
institutions hot water tank CORRECT ANSWER D:caused by legionella
pneumophilia,which is found in warm stagnant water such as hot water tanks,is
spread by aerosolized route from the environmental source to the patient

Situation: Mrs. Mejia lost her PNP - Special Action Force (SAF) trooper husband PO2
Ephraim Mejia in a Mamasapano Clash at Maguindanao. She is brought to the
Pangasinan Provincial Hospital (PPH) one month after the January 25, 2015 incident
for loss of appetite and difficulty of sleeping. On admission, she states "Bakit ito
kailangang mangyari sa akin? Hindi ko na talaga kaya. Miss na miss ko na ang aking
Question: The first step in crisis intervention for Mrs. Mejia is which one of the
A. Suggesting available community resources, which can help her
B. Assessing the situation thoroughly
C. Teaching Mrs. Mejia relaxation technique
D. Helping Mrs. Mejia identify the sources of her stress
There are Six-Steps model of Crisis Intervention
1. Defining the problem
2. Ensuring client safety
3. Providing support
4. Examining alternatives
5. Making Plans
6. Obtaining commitment
The six-step model of crisis intervention focuses on the immediate process of
actively, assertively, intentionally, and continuously assessing, listening and acting
to systemically assist the client to regain as much of the pre-crisis equilibrium,
mobility and autonomy as possible.
Read here: http://goo.gl/HiFNgx
Correct answer is B
Rationale: ASSESSING is under in the ensuring safety since the question is asking
for "First Step" (nothing more). Ensuring safety means constantly assessing the
possibility of physical and psychological danger to the client as well as to others and
the internal impact of environmental situation. Teaching Mrs. Mejia about relaxation
technique is the 5th step on crisis intervention. Why? Because it provides COPING
MECHANISM and action steps which are concrete and positive for the client to do in
the present with COLLABORATION also. Like relaxation technique, helping Mrs. Mejia
identify the sources of stress and suggesting available community resources can
also be seen at the PLANNING.
That's why only letter B belongs to assessment, the rest are planning. And by virtue
of nursing process (ADOPIE) still, assessment should be done first obviously, pwera
lang po kung nag over analyzed kayo sa tanong smile emoticon since wala naman
pong LISTENING (w/c is the first/top step in crisis intervention) then we will choose
The first three steps of the six-step model are:
1) Defining the problem:
- Use active LISTENING, including open-ended questions.
2) Ensuring client safety:
- ASSESS internal impact as well as environmental situation.
3) Providing support:
- It is important that you communicate to the client that you care about her.
Steps 4, 5, and 6 involve ACTING strategies.
4) Examining alternatives:
- Assist in brainstorming choices available now. Search for immediate supports.
5) Making Plans:
- Provides something concrete and positive for the patient to do now with definite
action steps which the patient can own and comprehend.
6) Obtaining commitment:
- Help the patient commit to a definite action step. This step involves asking the
client to verbally summarize the plan.
Observing, understanding and responding with empathy, genuineness, respect,
concreteness, acceptance, non-judgment and caring. Psychological First Aid
Evaluating the patient's present and past situational crises in terms of coping
ability, mobility, lethality and need for your aid.
Your involvement in the crisis is non-directive, collaborative or directive, according
to the assessed needs of the patient and
the availability of environmental supports.
Summary: The first three steps of this model are usually more passive listening
activities than actions. The final three steps are largely action behaviors on your
part even though listening is always present along with assessment as an
overarching theme.
Gets nyo po? wink emoticon
An order for a client was given and the nurse in charge of the client reports that she has no
experience of doing the procedure before. Which of the following is the most appropriate action of
the nurse supervisor?

A. Assign another nurse to perform the procedure.

B. Ask the nurse to find way to learn procedure
C. Tell the nurse to read the procedure manual.
D. Do the procedure with the nurse.

Ans: D Eliminate B at C long term kasi yun di naman agad pag inaral o binasa alam na, kaya nga my return demo
nun college days sa nursing:) i think d is the best way,

Which type of white blood cells release histamine during an anaphylactic reaction?

A. Neutrophils
B. Lymphocytes
C. Eosinophils
D. Basophils

Answer is D


During an allergic or anaphylactic reaction, basophils release histamine, leading to vasodilation, increased capillary
permeability, and bronchospam.

Neutrophils defend against bacteria and fungi and produce relatively small inflammatory responses as first

Lymphocytes defend against viral infections and do not release histamine during an allergic reaction.

Eosinophils primarily defend against parasitic infections and are important in allergic responses. However, they
primarily release interleukin, not histamine.

Acute bacterial infection

Chronic bacterial infection

External inflammation
Internal inflammation

A client will be receiving long-term,continuous parenteral nutrition (PN)

at home. The nurse should incorporate which priority client problem in the
plan of care?

A. Lack of hope

B. Being socially isolated

C. Inability to cope effectively

D. Low self-esteem related to current



Rationale: The client will be receiving long-term, continuous PN
at home. Therefore, the client will be socially isolated from stimuli
outside the home. No data in the question support options A, C,
or D.

A registered nurse is documenting her patient assesment.which of the following examples of

docmentation is most clear?. 1.seems comfortable at this time 2.is asleep,appears not to be
experiencing pain 3.apparently is not in pain bcoz he didnt rate it hign on the scale 4.states pain is a
2 on a 0 to 10 scale CORRECT ANSWER:4---to be factual,avoid words such as
appears,seems,apparently because they are vague and lead to conclusions that cannot be
supportes by objectibe information.

In order to increase medication effectiveness the nurse should instruct the client taking oral bisacodyl
to take the medication

A. At bedtime
B. With a large meal
C. With a glass of milk
D. On an empty stomach
The most rapid effect from bisacodyl occurs when it is taken on an empty stomach. It will not have a
rapid effect if taken with a large meal. If it is taken at bedtime the client will have a bowel movement
in the morning. Taking the medication with a glass of milk will not speed up its effect.

Test taking--> focus on subject achieving a rapid effect. Recalling that medications generally are
more effective if taken on an empty stomach.

Which of the following must a dean of the college of nursing possess to qualify for the position?
A. Doctoral degree
B. Master's degree in nursing
C. Nine units in nursing administration
D. Master's degree in allied health sciences
ANSWER: B Master's degree in nursing
A dean in a college of nursing should possess a master's degree in nursing and must have at least 5
years of experience in teaching and supervision.
Those teaching at the graduate programs for nurses must possess post master''s degree or a
doctoral degree in nursing (option A).
A Faculty must possess a master's degree in nursing or other allied medical and health science
(option D).
Option C is a requirement for a nurse supervisor

Nursing Practice 1
Category: Chain of Infection

Which of the following is the exact order of the infection chain?

1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission
A. 1,4,5,2,6,3
B. 4,5,2,6,3,1
C. 4,5,3,6,2,1
D. 4,5,6,3,2,1

Correct Answer is Letter C (why not A,B nor D?)

1st: Etiologic agent

2nd: Reservoir
3rd: Portal of exit
4th: Mode of transmission
5th: Portal of entry
6th: Susceptible host

Chain of infection starts with the SOURCE : The etiologic agent itself. It will first proliferate on a
RESERVOIR and will need a PORTAL OF EXIT to be able to TRANSMIT itself using a PORTAL OF
A simple way to understand the process is by looking at the lives of a young queen ant that is
starting to build her colony. Imagine the QUEEN ANT as a SOURCE or the ETIOLOGIC AGENT.
She first need to build a COLONY, OR the RESERVOIR where she will start to lay the first eggs to be
able to produce her worker ants and soldier ants to be able to defend and sustain the new colony.
They need to EXIT [PORTAL OF EXIT] their colony and crawl [MODE OF TRANSMISSION] in
HOST]. By imagining the Ant's life cycle, we can easily arrange the chain of infection

Nursing Practice 1
Category: Nursing Theories
November 2014 Board Exam Question

Situation: Nursing theories affect everyday nursing practice. Most nurses employ a number of
theories in practice rather than using one theory exclusively. Using a variety of nursing theories
during a given day, allows the nurse to choose the best theory to fit the situation. In an ideal setting,
nursing theories serve to provide underpinnings to nursing care in every patient encounter. They help
nurses use critical thinking skills, analytical and improve concept comprehension. Nursing theories
improve patient care, patient outcomes, and nurse-patient communication. Through the use of
nursing theories in practice, new knowledge and data are gleaned that can influence the future of
nursing practice.

1) Which nursing theorist believes that most patients are capable of performing self care?
A. Sister Callista Roy
B. Madeleine Leininger
C. Martha Rogers
D. Dorothea Orem

2) The nursing theorist whose worked focused on twenty-one problems of nursing.

A. Faye Abdellah
B. Lydia E. Hall
C. Ida Jean Orlando
D. Virginia Henderson

3) Defined health as a dynamic state in the life cycle, and Illness as interference in the life cycle.
A. Betty Neuman
B. Imogene King
C. Martha Rogers
D. Dorothy Johnson

4) Which theorist can be defined as "The goal of nursing is to put the patient in best condition for
nature to act upon him, primarily by altering the environment."
A. Dorothea Orem
B. Madeleine Leininger
C. Joyce Travelbee
D. Florence Nightingale

5) For her, Nursing is a theoretical system of knowledge that prescribes a process of analysis and
action related to care of the ill person
A. Sister Callista Roy
B. Jean Watson
C. Imogene King
D. Lydia E. Hall

Correct answers: D A B D A


1. Dorothea Orem developed the Self Care theory or model. This theory maintains that some
patients are completely compensatory and totally dependent on the nurse for care, other patients are
partially compensatory and need only assistance by the nurse and others are totally independent in
terms of their self care needs.

2. Faye Glenn Abdellah also made a name in the nursing profession with the formulation of her 21
Nursing Problems Theory. Her theory changed the focus of nursing from disease-centered to
patient-centered, and began to include the care of families and the elderly in nursing care.

3. Imogene King states that health is a state in the life cycle and Illness is any interference on this
cycle. I enjoyed the Movie LION KING and like what Mufasa said that they are all part of the CIRCLE
OF LIFE or the Life cycle. Hehe! King has interrelated the concepts of interaction, perception,
communication, transaction, self, role, stress, growth and development, time, and space into a theory
of goal attainment. Her theory deals with a nurse-client dyad, a relationship to which each person
brings personal perceptions of self, role, and personal levels of growth and development.

4. Florence nightingale do not believe in the germ theory, and perhaps this was her biggest mistake.
Yet, her theory was the first in nursing. She believed that manipulation of environment that includes
appropriate noise, nutrition, hygiene, light,comfort, sanitation etc. could provide the clients body the
nurturance it needs for repair and recovery.

5. Remember the word THEOROYTICAL' For Callista Roy, Nursing is a theoretical body of
knowledge that prescribes analysis and action to care for an ill person. She introduced the
ADAPTATION MODEL and viewed person as a BIOSPSYCHOSOCIALBEING. She believed that by
adaptation, Man can maintain homeostasis.

Situation: Recognition of Normal values is vital in assessment of clients with various disorders

Question #1

A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is
3.2mEq/L.Which of the following would the nurse expect to note on the ECG as a result of this

A. U waves
B. Elevated T waves
C. Absent P waves
D. Elevated ST Segment

Correct answer : A - U wave

The nutritional needs and diet restrictions for the client with CRF vary according to the degree of
remaining renal function and the type of renal replacement therapy used. The purpose of nutrition
therapy is to provide the food and fluids needed to support the metabolism for a client who is at high
risk for becoming malnourished. Nurse Grace caring for a cleint with hyperphosphatemia and chronic
renal failure assists the client to make which of the following low phosphorus menu selections?
A. Milkshake
B. Scrambled eggs and whole wheat toast
C. Fresh fruit plate
D. Chicken sandwich
Fresh fruit plate is LOW in phosphorus. Eggs, poultry, whole grains, and dairy products are all foods
HIGH in phosphorus. The control of phosphate levels is started early in CRF to avoid
osteodystrophy. The nurse should monitor serum phosphate levels of the client. Dietary phosphorus
restrictions and drugs to assist with phosphate control may be prescribed. Phosphate binders must
be taken at mealtime.

1. The principles that govern right and proper conduct of a person regarding life, biology of the health
professionals is referred to as;
A. Morality
B. Religion
C. Values
D. Bioethics

2. A subjective feelings about what is Right or Wrong is said to:

A. Morality
B. Religion
C. Values
D. Bioethics

3. Values are said to be the enduring believe about a worth of a person, ideas, belief. If values are
going to be a part of a research, this is categorized under;
A. Qualitative
B. Experimental
C. Quantitative
D. Non Experimental


Mark has multiple abrasions and a laceration to the trunk and all four extremities says, I cant eat all
this food. The food that the nurse Loveshould suggest to be eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing

To promote good sleep hygiene, the nurse teaches the client to do tge following EXCEPT.

A. Avoid a heavy meal 3 hours before bedtime

B. use the bedroom only for resting and sleeping
C. Stay in bed, if sleep does not come in 30 mins
D. Limit the use of bedroom for intensive work, studying eating or watching tv

When talking to a client to assess her sleeping difficulties, the nurses most therapeutic

A. Do you take naps during the day?

B. is this room darkened at night?
C. Do you take snacks prior to going to bed?
D. What do you do just before going to bed?


Chest physiotherapy is a group of therapies used in combination to immobilize secretions.
Nurse Grace is to do Chest Physio therapy to a male patient,Mr. Jim, diagnosed with Pneumonia.
Which of the following is an important aspect of planning Mr. Jims care?
A. The order should be coughing, percussion, postural drainage and then suctioning
B. A good time to perform percussion and postural drainage is in the morning after breakfast.
C. Percussion and postural drainage should be done before lunch.
D. Hyperoxygenation of the patient with 100% oxygen should be done 10 minutes before CPT
This procedure should be done on an empty stomach to decrease clients discomfort which could
include vomiting and nausea. CPT should take place prior to coughing and suctioning of the client
who has decreased ability to cough. Hyperoxygenation is not needed prior to CPT.

Enema is the introduction of solution into the rectum for several purposes but mainly to evacuate
fecal material in preparation for diagnostic procedure or surgery. It is also administered to relieve
constipation and fecal impaction.
The doctor prescribed an enema for a client with a chief complaint of right lower abdominal pain. The
most appropriate action for the nurse to take is?
A. Assist the client in a lateral Sims position
B. Question the physician about the order
C.Prepare 750 ml of irrigating solution warmed to 100 degree Fahrenheit
D. Provide privacy and explain the prescribed procedure to the client
Enemas are contraindicated in an acute abdominal condition of unknown origin such as suspected
appendicitis as well as after recent colon or rectal surgery or myocardial infarction. Since a diagnosis
is not yet established, enema is ccontraindicated and should be questioned by the nurse.All the other
statements are true with regards ro enema

Nursing Leadership and Management (Nurse Hierarchy)

A. Nurse 2
B. Nurse 3
C. Nurse 4
D. Nurse 5
E. Nurse 6

____ 1. Head Nurse

____ 2. Chief Nurse
____ 3. Nursing Supervisor
____ 4. Officer-In-Charge Nurse
____ 5. Assistant Chief Nurse

Correct Answers:
__B__ 1. Head Nurse
__E__ 2. Chief Nurse
___C_ 3. Nursing Supervisor
___A_ 4. Officer-In-Charge Nurse
__D__ 5. Assistant Chief Nurse

A nurse is reinforcing teaching with a client about compromised host precautions. The client is
receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has
learned about necessary dietary changes?

A) grilled chicken sandwich and skim milk

B) roast beef, mashed potatoes, and green beans

C) peanut butter sandwich, banana, and iced tea

D) barbeque beef, baked beans, and cole slaw

The correct answer is B: roast beef, mashed potatoes, and green beans
The client has correctly selected an appropriate lunch and appears to have knowledge of restrictions.
Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions
require that foods are either cooked or canned. Options 1, 3 and 4 do not demonstrate learning, as
raw fruits, vegetables, and milk are to be avoided.

Professional Adjustments and Nursing Jurisprudence (Criminal Law)

(1) Isabel, a housemaid, broke into a pawnshop intent on stealing items of jewelry in it. She found,
however, that the jewelry were in a locked chest. Unable to open it, she took the chest out of the
shop. What crime did she commit?

(A) Robbery in an uninhabited place or in a private building

(B) Theft

(C) Robbery in an inhabited house or public building.

(D) Qualified theft

Correct Answer: A. Robbery in an uninhabited place or in a private building

Nursing Research (Statistics)

3. What statistical or descriptive measure is used to determine the level of performance of BSBA
students in business statistics class using scores in midterm exam?

A. Mode and range

B. Mean

C. Variance and range

D. Median and mean deviation

Correct Answer: B. Mean or average weighted mean

During blood transfusion, the nurse observes the following guidelines, except:
A. Using a gauge 18 needle
B. For the first 15 minutes of infusion, monitoring the client's vital signs every 5 minutes
C. Slowdown the infusion if the client experiences chilling, headache or flank pain
D. Blood should be transfused within 4 hours from receiving it from the laboratory
Answer C.
If the patient manifest the following, the transfusion of blood should be stopped immediately. The IV
line with plain NSS should be opened and regulated at KVO. Specimens (patient''s blood, transfused
blood and patient's urine) are sent to the laboratory immediately.

Nurse Mary, the outgoing nurse, has just endorsed to you a patient who has IV infiltration as
documented in his charting. Which of the following assessment findings on the patient would cause
you to question Nurse Marys documentation?
A. (+) blanching and swelling on the skin surrounding the IV site
B. there is discomfort in the IV site when palpated as verbalized by the patient
C. the IV site feels warm to touch
D.. the IV fluid is flowing very slowly
Answer C
Infiltration occurs when the IV cannula is dislodged from the vein which causes the IV fluid or
medication to be infused into the surrounding tissue.
The clinical manifestations of infiltration are the following: swelling, blanching and coolness of the
skin and surrounding tissues, discomfort, depending on the IV solution, the fluid is flowing more
slowly or stops flowing, and there is absence of blood backflow in the IV catheter and tubing.
(letter C warm to touch) is a symptom of Phlebitis (Infiltration - cold to touch)

Assessment of correct tube placement is essential in ensuring that the NGT has passed through the
esophagus and not the trachea into the lungs.
Nurse Grace has just inserted an NGT into his patient and wants to check for placement. Which of
the following assessment findings would indicate that the NGT is placed in the intestines and rather
than the stomach?
A. a whooshing sound is heard from the patients epigastrium using a stethoscope when 20 mL of air
is injected into the NGT
B. aspirated contents from NGT has a pH of 2
C. aspirated contents has a bilirubin level of 13 mg/dL
D. an opaque tube is seen through x-ray from the nose up to the stomach
ANSWER. C. aspirated contents has a bilirubin level of 13 mg/dL If the aspirate has a bilirubin level
of > 10 mg/dL, then it is from the intestines, not the stomach. Aspirate from the stomach usually has
a bilirubin level of 1.5 mg/dL, while those from the lungs have a bilirubin level of almost zero. An
acidic aspirate confirms that it is from the stomach, while a pH of 6 or greater indicates that the
aspirate is either from the intestinal or respiratory tract. Auscultation and x-ray are also correct
techniques of checking for NGT placement in the stomach.

As a manager, the nurse should:

A Initiates nursing action with co workers.
B Plans nursing care with the client.
C Speaks in behalf of the client.
D Works together with the team.

answer letter D Rationale : As a nurse manager, you should be able to work with the team..
he nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity.
Which choice indicates the client understands dietary needs?

A) Three apricots

B) Medium banana

C) Naval orange

D) Baked potato

The correct answer is D: Baked potato

The baked potato contains 610 milligrams of potassium.

As a counselor, the nurse performs which of the ff. Ask?

A Encourage client to express feelings and concerns.
B Helps client to learn a dance or song to enable her to participate in activities.
C Help the client prepare in group activities.
D Assist the client in setting limits on her behavior.

Answer letter A Rationale: A counselor is much more of a listener than a speaker. She encourage the client to express
feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments
and Frustrations..

As a care provider, The nurse should do first:

A Provide direct nursing care
B Participate with the team in performing nursing intervention.
C therapeutic use of self
D Early recognition of the client's needs..

nswer letter D Rationale: we are talking about what should the nurse do first.ASSESSMENT involves early recognition
of clients needs.

A diabetic patient was amputated following an unexpected necrosis on the right leg, he sustained
and undergone BKA.he then underwent therapy on how to use his new prosthetic leg.This is a type
of what level of prevention?
A Primary
B Secondary
C Tertiary
D Nota
Answer letter C Rationale: Tertiary prevention rehabilitation.Client is now being assisted tp perform ADLs at his
optimum functioning.Remember that all kinds of responsibility and palliative management is included in tertiary

Which of the following is correct when placing a professional title in the trodat?


B. PhD, RN
C. PhD, EdD, MAN

C is the answer, you have to start with the degrees na hindi na pwede matanggal sayo kahit kailan. Licenses may be

A student nurse is with a medical unit during this clinical rotation. She is administering an enema
with her instructor in the room. The patient states that they can no longer hold the enema solution.
The student nurse acknowledges the patients request and begins to tell the patient that he can go to
the bathroom to expel the enema. The instructor suggests that the patient wait a few minutes to give
the enema solution time to be absorbed into the bowel. In this situation the student nurse follows the
suggestion of the instructor, which demonstrates what level of critical thinking according to Kataoka-
Yahiro and Saylors model?

a. Level 1: Basic
b. Level 2: Complex
c. Level 3: Commitment
d. The student nurse is not demonstrating critical thinking. CORRECT ANSWER IS A:At the basic
level of critical thinking a learner trusts that experts have the right answers for every problem.
Thinking is concrete and based on a set of rules or principles.

A nurse is scheduling multiple diagnostic procedures for a client with activity intolerance. The
procedures ordered include an echocardiogram, chest x-ray examination, and a computed axial
tomography (CT) scan. The nurse schedules the procedure in which sequence to best meet the
needs of this client?
Chest x-ray examination in the morning ,echocardiogram in the afternoon, and the CT scan the
morning of the following day
Chest x-ray examination and echocardiogram together in the morning, and the CT scan in the
afternoon of the same day
Echocardiogram in the morning, and the chest x-ray examination and CT scan together in the
afternoon of the same day
CT scan in the morning, and the chest x-ray examination and echocardiogram on the following