NURSING PRACTICE IV

CARE OF CLIENTS WITH PHYSIOLOGIC AND

PSYCHSOCIAL ALTERATIONS (PART B)

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test items
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
3. AVOID ERASURES.
4. Write the subject title “NURSING PRACTICE IV” on the box provided.

SITUATION 1- Juanchito, 5 yrs. old, has idiopathic nephrotic syndrome. He has generalized edema with puffy face, distended
abdomen and edematous legs. Blood pressure is normal, Blood test show hypoalbuminemia.

1. The nurse is aware that generalized edema is due to hypoalbuminemia which lead primarily to which of the following?

a. Increased secretion of antidiuretic hormone c. Decrease plasma osmotic pressure

b. Reduced intravascular volume d. Stimulation of the rennin-angiotensin system

2. The nurse closely monitor the urine output of the patient. Which of the following characteristic pf a urine sample will the
nurse expect?

a. Fruity odor b. Increased amount c. Urine is frothy d. Blood in urine

3. The attending physician of Juanchito prescribed renal biopsy. When the nurse plans for the nursing care of juanchito
after the biopsy, which of the following will be a PRIORITY intervention to prevent bleeding?

a. Observe for abdominal pain and tenderness c. Place on complete bedrest

b. Monitor vital signs d. Closely watch urine output

4. Corticosteroid therapy was prescribed. Which of the following is the MOST relevant nursing intervention to address
complication of the therapy?

a. Weigh daily to monitor fluid balance c. Maintain on a salt restricted diet

b. Closely monitor for changes in body temperature d. Offer small frequent meals

5. When the nurse prepares her health instruction for the mother of juanchito, which of the following side effects of the
drug will the nurse include in her plan?

1. Diuresis 2. Hirsutism 3. Abdominal distention 4. Loss of appetite 5. Rounding of the face

a. 3,4,5 b. 2,3,5 c. 1,2,5 d. 1,2,3

SITUATION 2- As an ED nurse you should always be ready for any kind of emergency situation.

2. Peter, a 30 year old factory worker is brought to emergency department with multiple lacerations and tissue avulsion of
the right hand after catching the hand in a produce conveyor belt. When asked about tetanus immunization, he says,
“I’ve never had any vaccinations”, you will anticipate administration of:
a. Tetanus toxoid c. Immunoglobulin
b. Immunoglobulin and tetanux-diptheria toxoid d. Immunoglobulin, tetanus diptheria toxoid and pertussis vaccine
3. Paul is brought to the ED by his co-worker after suffering from amputation of a left middle finger. As his nurse which of
the following should you AVOID to do?
a. Placing the wrapped finger in a plastic bag c. Wrapping the amputated finger in sterile gauze
moistened with saline
b. Cleansing the stump area with normal saline d. Placing the amputated finger directly on ice
4. Josh, a 7 year old child is brought to the ED by his mother complaining of arm pain after falling off a swing at school.
After assessing Josh’ pain as 8 on a scale of 1-10. What will be your PRIORITY activity?
a. Assume that josh is too young to verbalize how much pain he is experiencing
b. Obtain further information about his pain using age-appropriate tool
c. Give josh a narcotic pain medication
d. Ask his mother to wait in the waiting room to find out if josh gets better without his mother
5. During the primary assessment of Bernie, who has sustained multiple trauma, you observe that his right pedal pulse are
absent and the leg is swollen. Your PRIORITY action is:
a. Initiate isotonic fluid through to large-bore IV lines c. Send blood to the laboratory for a complete
blood count (CBC)
b. Finish the airway, breathing ,circulation, disability survey d. Assess further for a cause of the decreased circulation
6. Anthony, 20 years old college student, unconscious, is admitted to the ED about 45 minutes after ingesting
approximately 30 diazepam (Valium) tablets. The physician prescribes gastric lavage. As a nurse, you FIRST action when
implementing the order is to:

a. Insert a large bore nasogastric tube c. Assist the physician to intubate Anthony
b. Position Anthony on his side d. Prepare a 50ml syringe with saline

SITUATION 3- Alicia, a newly hired staff nurse is assigned to a patient diagnosed with diabetic ketoacidosis with urosepsis in
the intensive care unit

7. Physician prescribed that capillary blood glucose (CBG) be monitored every 1 hour. Alicia missed to check the patient’s
capillary blood glucose at 1000H. Which of the following decisions of Alicia regarding documentation of hourly CBG is
MOST appropriate?
a. Sign the space for the data to indicate CBG reading not done c. Document per hospital protocol
b. State reason for not having taken the CBG reading d. Leave the space that corresponds to 1000H
blank
8. Alicia was taught on electronic record keeping and became aware that the following are the benefits of electronic record
keeping EXCEPT:

a. Prevents tampering with patients record c. Eliminates problem of illegible handwriting

b. Password secures accessing the system d. Increases time requires for documenting

9. To maintain confidentiality of patient’s record, Alicia recommended which of the following practices needs improvement?

a. Screen visible to passersby c. Access code are not shared by the nurses
b. Computer log off automatically when not in use d. Printouts are retrieved immediately

10. Alicia looked for a manual which could facilitate her orientation regarding documentation. The manual is not available.
This observation reflects management inadequacy in which of the following?

a. Controlling b. Planning c. Directing d. Organizing

11. Standards of documentation require that a system is in place regarding corrective actions related to errors in charting.
Which of the following observations in the patient’s record indicates that the standards is implemented?
a. Updated information with notation marked as late entry c. Corrected information written in the next available space
b. Correction of the erroneous entry written above d. A straight line drawn across a phrase in the nurses notes, dated
and initialed

SIITUATION 4- Domedes, a 56 year old farmer, was admitted in the emergency department(ED) because of hematemesis is
accompanied by hematochezia. Diomedes is an alcoholic and is under treatment for cirrhosis of the liver. His abdomen is
enlarged and his lower extremities are edematous. Admitting physician’s initial diagnosis is ruptured esophageal varices.

12. Assessment reveals signs and symptoms of early compensatory hemorrhagic shock. If you were the nurse who admitted
Diomedes, which of the following will you consider as the compensatory mechanism responsible for the increased heart
rate and respiratory rate?
a. Stimulation of the sympathetic nervous system c. Renin-angiotensin response
b. Increase in size of the vascular bed due to peripheral vasodilation d. Release of adrenocortropic hormone from the
hypothalamus
13. To restore hemodynamic stability on the client, which of the following will the nurse expect to be done FIRST?

a. Insertion of central arterial and venous catheters c. Blood transfusion for blood replacement
b. Endoscopic ligation of rupture varices d. Administration of vasoactive and inotropic drugs

14. Hemodynamics means measurement revealed stable vital signs and increased cardiac output. The physician ordered
treatment of the esophageal varices. Which of the following procedures will the nurse expect to be done?

a. Upper endoscopy c. Exploratory laparotomy

b. Intrahepatic portal systemic shunt d. Coagulation therapy

15. In the intensive care unit nursing orders required all nurse to assess regularly for early manifestations of portal systemic
encephalopathy. Which of the following will the nurse note during her observation?

a. Occurrence of asterexis c. Signs and symptoms of increased intracranial pressure

b. Development of disorientation and incoherence d. Presence of papilledema

16. Serum ammonia level of the client remained to be elevated. The following may be considered by the nurse to be TRUE
regarding this observations EXCEPT:
a. Ammonia is formed as proteins and amino acids are broken down by intestinal bacteria
b. Ammonia accumulates in the blood due to in ability of the kidney to excrete ammonia
 c. Due to bleeding, blood in the intestinal tract is digested as protein, thereby increasing serum ammonia
d. Since liver function is destroyed ammonia can no longer be converted to a less toxic form

SITUATION 5- The declining level of patient satisfaction related to nursing service per survey results as well as increased
incidences of hospital acquired infection during the past 6 months caused the nursing service division to push the nursing
units to explore quality improvement projects.
17. The intensive care unit (ICU) quality Improvement team decide to gather data to determine probable causes of central
line infection among the ICU patients. If you were the member of the quality improvement team, which of the following
data will you consider as MOST appropriate to yield the most probable cause of central line infection?
a. Nurses notes on hourly assessment of sites of central line
b. Performed central line care interventions as observed
c. Daily every shift report of central line care measures from bedside nurses
d. Incidence of central line infection as reported by infection control nurse
18. The highest incidence of fall among the hospitalized patients is in the medical unit. The medical unit quality improvement
team has identified the probable cause of the incidences of fall among their hospitalized patients. With the data analyzed
and findings organized, which of the following should the quality improvement team do FIRST?
a. Implement fall prevention measures identified to be effective
b. Propose a list of nursing actions intended to identify fall risks and preventive measures
c. Do a pilot study of the fall prevention measures to a small group of patients
d. Brainstorm for a plan for an appropriate action for change
19. Another group of quality improvement team in the ICU conducted a project on ventilator associated pneumonia
incidences among ICU patients. If you are a member of his team, which of the following measures will you consider as
the MOST appropriate to be implemented in collaboration with the respiratory therapist?
a. Perform regularly assessment of the client’s readiness to be extubated
b. Consider or tracheal as a preferred route of endotracheal intubation
c. Maintain head elevation at 30-45 degrees
d. Suction endotracheal tube as prescribed in the manual of procedures
20. Noise level in the ICU has always been a complaint in the patient satisfaction survey. Which of the following tools can be
recommended to the quality improvement team as most appropriate to determine level of noise in the ICU.
a. Questionnaire with clients and patients as respondents c. Measurement device
b. Observation checklist d. Interview schedule form with nurses, clients and relatives as interviewees
21. During a group discussion, probable factors responsible for urinary infection incidences among hospitalized clients in the
medical unit were being expired. Which of the following will you consider as the group of data which would be LEAST
helpful?
1. Diameter and length of Foley catheter 4. Daily physical activities of the client
2. Length of time Foley catheter has been kept indwelling 5. Relevant data regarding need for continuing
indwelling catheter 3. Age and sex of client
a. 1,2,4 b. 3,4,5 c. 1,2,3 d. 2,3,4
SITUATION 6- Kiko, 8 years old has two chest tubes connected to a disposable water sealed drainage system because of
chest injuries from a vehicular accident.
22. The nurse observed that the drainage from the chest tubes have not increased from the previous shift report. Which of
the following is the PRIORITY action of the nurse?

a. Check the chest tube for kinks c. Document observation

b. Assess for breath sounds d. Change position of the patient

23. Frequent assessment of the closed drainage system is important to ensure appropriate functioning. The nurse observes
that the water level fluctuates with respiratory effort. The nurse consider this as sign of:

a. Trapped air b. An inefficient system c. Patent tubes d. Air leaks

24. The nurse works with a nursing aide. Which of the following is a CORRECT action of the nurse? The nurse directed the
nursing aide to:
a. Always check that clamp is available at the bedside
b. Observe regularly the amount and color of drainage from chest tubes
c. Report signs of patient’s discomforts at the site of the chest tubes
d. Turn the patient regularly and maintain connections of the tubes
25. While the nurse was turning the patient during bed bath, one of the chest tubes was pulled out from its site. Which of
the following will the nurse do FIRST?

a. Reinsert the chest tube c. Cover wound site occlusively

b. Disconnect chest tube from drainage system d. Clamp the chest tube
26. To determine if chest tube are in place and pneumothorax is corrected which of the following will the nurse expect the
a. Tidal
physician volume measurement
to order? c. Chest radiograph
b. Arterial blood gas analysis d. Thoracentesis

SITUATION 7- A group of intensive care unit nurses decide to conduct a research study to describe the relationship between
the frequency of endotracheal suctioning and the incidence of infection among ventilator assisted patients. The team
selected the non-experimental design specifically the prospective approach.

27. If you are a member of the research team, which of the following will you consider as the research study’s independent
variable when you formulate the research problem?
a. Incidence of infection c. Dependence of clients
b. Relationship of endotracheal suctioning and incidence of infection d. Frequency of endotracheal suctioning
28. Data regarding the study’s dependent variable will be collected by the research team through which of the following?

a. Self-report techniques c. Projective techniques

b. In vitro measures d. Available data in the patient’s chart

29. The research team is fully aware that measurement of variables is very important consideration in obtaining quality data
in the study. Which of the following statements will you accept as TRUE?
a. Reliability quality of an instrument is independent of its validity c. A measuring device which is unreliable can be valid
b. An instrument can be valid without being reliable d. High reliability of an instrument provides no evidence of
its validity
30. Taking into consideration the content of the written informed consent, which of the following reflects the research team’s
recognition of the participant’s right to privacy?

a. Right to withdraw and withhold information c. Voluntary consent

b. Confidentiality pledge d. Potential benefits and risks

31. The research team decided to conduct the study for 3 months. Utilizing the prospective approach, which of the following
will the researcher appropriately do?
a. Participants will be assigned to the experimental and control group and incidence of infection in the two groups will be
compared
b. During the period of 3 months, those ventilator assisted patients who developed infection will be include in the study
c. On the last day of the 3rd month, charts of participants will be reviewed and data collected regarding frequency of
endotracheal suction and incidence of infection
d. From day one to the last day of the 3rd month, data regarding frequency of endotracheal suctioning and incidence of
infection will be collected

SITUATION 8- A 69 year old female patient was admitted in the emergency department (ED) via ambulance from nearby
restaurant. Patient was drowsy and was unable to identify herself. Blood pressure was 150/90, tachycardic and respiration
shallow with a rate of 30/minute. Companion of the patient claimed that while laughing, the patient got choked with a piece
of pork meat and was unable to breathe for quite some time until somebody successfully got it out of her throat.

32. Physician’s admitting diagnosis is acute respiratory acidosis. If you were the ED nurse who admitted the client, which of
the following will you expect?

a. A normal pH and a PaCO2 greater than 45mmHg c. A pH less than 7.35 and a PaCO2 greater than
b. A pH more than 7.35 and a PaCO2 lower than 45mmHg
45mmHg d. A pH less than 7.35 and a PaCO2 pf 45mmHg

33. The initial arterial blood gases results of the client revealed a normal bicarbonate level which of the following statements
will the nurse accept as TRUE that would explain this specific finding?
a. Serum bicarbonate will remain unchanged in all types of respiratory acidosis
b. The kidneys can modify only the excretion rate of acids
c. The compensatory response of the kidneys occurs only over hours to days
d. A change in serum bicarbonate is noted only in cases of respiratory acidosis
34. You understand that the alteration in the mental status of the client is primarily due to acute effects of which of the
following?

a. Hyperventilation b. Hypercapnia c. Tachypnea d. Hypoxemia

35. Related to temporary airway obstruction, the admitting nurse identified, “Impaired gas exchange” as a priority nursing
diagnosis. Which of the following interventions will you consider to be the MOST appropriate to determine if normal gas
exchange has been regained?

a. Administer prescribed bronchodilator c. Place on fowler’s position as tolerated

b. Maintain on oxygen inhalation as ordered d. Monitor arterial blood gases redrawn every 2 hours
36. The client is closely observed for signs of dysrhythmia. If you were the nurse at the bedside, which of the following
waves in the cardiac monitor will consider as the wave that represents the contraction of the ventricles?

a. QT interval b. QRS complex c. PR interval d. ST segment

SITUATION 9- Lito, 35 years old is HIV positive. Aside from fatigue, Lito has no other complaints.

37. The result of the enzyme-linked immunosolvent assay Test (ELISA) was positive. The nurse understands that this is a
test to determine the presence of:

a. HIV antibody c. HIV antigen-antibody response

b. Actively replicating HIV d. Increased CD4 cell count

38. Which of the following is NOT a primary tool for AIDS prevention?

a. Education c. Immunization
b. Counseling d. Behavior modification

39. Which of the following is an INAPPROPRIATE advice of the nurse for lito?

a. Do not engage in un protective sexual activity c. Inform all sexual partners of his health status
b. Inform all health care personnel; d. Do not become pregnant

40. From the list of nursing diagnosis prepared by the nurse for lito, which of the following is a PRIORITY nursing diagnosis?

a. Risk for impaired skin integrity c. Ineffective coping

b. Risk for injury d. Ineffective sexuality pattern

41. When the nurse interacts with the client, which of the following precautionary measures should she observe to prevent
contamination?

a. Avoid touching body fluids c. Maintain a 3 feet distance from the patient
b. Wear gloves d. Wear mask and gown

SITAUTION 10- Leon has been diagnosed with End-stage Renal Disease. The physician prescribed dietary teaching and
outpatient hemodialysis three times a week.

42. Leon ask the nurse to tell him the purpose of the treatment. Which of the following is the MOST appropriate response of
the nurse?
a. Hemodialysis removes excess fluids and waste products and restore electrolyte balance
b. Hemodialysis uses the principles of diffusion and ultrafiltration to remove electrolytes
c. Blood is pumped through a semipermeable capillary in a hemodialyzer
d. Hemodialysis is one of several renal replacement therapy
43. An arteriovenous fistula has been created. Postoperatively, which of the following will the nurse include as a PRIORITY
nursing intervention to promote circulation?

a. Auscultate for bruit every 4 hours c. Observe finger tips for cyanosis
b. Elevate the affected arm d. Keep dressing intact

44. Which of the following pre-dialysis care is done by the nurse to be able to determine effectiveness of treatment with
regards to excess fluid volume?

a. Assess integumentary status c. Have patient empty bladder prior to treatment

b. Assess vascular site d. Record weight and vital signs

45. Nutrition therapy of Leon includes control of protein. Dietary prescription states that Leon is allowed 0.8 gram of protein
per kg day. If Leon weighs 120 lbs., how much is his daily protein allowance?

a. 57.9 g b. 43.6 g c. 81.7 g d. 96 g

46. Leon claims he loves to eat raisins. The nurse instructs the patient to avoid this food because it is rich in which of the
following?

a. Sodium b. Potassium c. Magnesium d. Phosphorus

Situation 11 – Arnel 58 years old, post total thyroidectomy with modified neck dissection due to papillary carcinoma of the
thyroid gland with lymp node metastasis was admitted for radioactive iodine therapy.

51. Prior to admission, the client underwent a scan with a test amount of radioactive iodine. If you were the nurse who
admitted the client, which of the following will you consider as the reason for this intervention?
 a. To determine existence of known distant metastatic tumor c. To explore the operative site for baseline data
b. To measure size of remaining thyroid tissue d. To mark the site where the radioactive iodine will
be administered
52. In the nursing care plan prepared for the client, which of the following interventions is LEAST relevant ensure a safe
environment code treatment has started?
a. Utilize preferably only disposable items for patient’s personal use
b. Provide hand sanitizers in the corridor outside the client’s room
c. Dispose appropriate garbage bags marked radioactive
d. Have all frequently handled items in the room covered with absorbent material
53. As the nurse assigned to the client, you understand that after radioactive iodine has been administered, excess iodine
not absorbed by the thyroid tissue will leave the body PRIMARILY through which of the following?
a. Sweat b. Urine c. Feces d. Saliva
54. To ensure effectiveness of radioactive iodine therapy, you expect the physician will prescribe low iodine diet during which
of the following?
a. Day of administration of the radioactive iodine until day of discharge
b. Two weeks before, during and 2 days after the treatment
c. The day before the scan until the day after treatment
d. Upon admission in the hospital until a week after the treatment\
55. When planning discharge, which of the following instructions will you consider for reduction of radioactive exposure to
others?
1. Use private toilet facilities and flush 2-3 times 4. Bathe daily and wash hands frequently
after use 5. Stay in isolation at home two weeks after the
2. Wash eating utensils separately treatment
3. Drink normal intake of fluids
a. All except 3 b. 2, 3 and 5 c. 2, 4, and 5 d. 1, 2 and 4

Situation 12 - Manuel 4 years old is positive for Bacterial Meningitis.

56. From the history obtained from the mother, which of the following could be the possible method by which the infection
was transmitted to the patient?
a. Drinking water in the community was contaminated c. Hand of caregiver was contaminated with fecal
b. Contact with respiratory secretions of an infected discharges
person d. Eating utensils with the child were contaminated
57. The physician prescribed lumbar tap. When the nurse reads the laboratory results, which of the following reflects positive
results indicative of Bacterial Meningitis?
a. Decreased white blood cells, decrease proteins, high glucose c. Increased white blood cell, increased proteins,
low glucose
b. Normal white blood cells count, increased proteins, high glucose d. Increased white blood cells, decrease proteins,
low glucose
58. Assessment findings reveal positive Brudzinki’s sign. When the nurse flexed the child’s neck forward, which of he
following behavior indicated a positive Brudzinki’s sign?
a. Hip flexed and knee extended c. Leg extended with resistance
b. Knee extended and ankle flexed d. Hip, knee and ankle flexed

59. In the nursing care plan prepared by the nurse, “ Pain related to Meningeal irritation” is a priority nursing diagnosis.
Which of the following should the nurse avoid to do to prevent pain when positioning the patient?
a. Extend leg c. Hyperextend the neck
b. Flex the neck forward d. Flex the hip
60. “Ineffective tissue perfusion related to increase intracranial pressure” is another nursing diagnosis formulated by the
nurse, which of the following assessment data specific to eye changes would the nurse interpret as normal intracranial
pressure?
a. Positive sunset eye signs c. Positive nystagmus
b. Positive strabismus d. Positive doll’s eye reflex

Situation 13 – You are assigned in the Nephrology Ward. One of your patient is Carlos with an admitting impression of right
renal calculi. Based on his story, Carlos was brought to the ED by his friend when he experienced severe excruciating right
flank pain, nausea and vomiting. This was relieved when the doctor gave him Buscopan. The doctor ordered several
diagnostic work up. Kidney urinary Bladder and Intravenous Pyelography (KUB-IVP) and ultra sound, Blood chemistry and 24
hour urine collection to measure calcium, uric acid, creatine, sodium, pH and total volume were likewise ordered.

61. As the nurse of Carlos who is for KUB-IVP, which of the following will you include in your teaching plan?
1. What is an intravenous pyelography (IVP) 3. How is the procedure performed?
2. How should I prepare for this procedure
 4. What will I experience during and after the
procedure?
a. 3 and 4 b. All of the above c. 1 and 2 d. All except 3
62. One of the physician’s order is a 24 hour urine test. What instructions will you give Carlos if the collection will start
tomorrow at 7:00 AM (Day 1) and end at 7:00 AM the following day (Day 2)?
a. Discard your first urine sample at 7”00 AM tomorrow then start urine collection until 7:00 Am Day 2
b. Start urine collection at exactly 7:00 AM tomorrow up to day 2 but discard the last urine at 7:00 am of day 2
c. Discard your first urine sample tomorrow at 7:00 AM and your last urine sample collection on Day 2 at 7:00 AM and
collect all urine samples between those times
d. Start urine sample collection at exactly 7:00 AM tomorrow
63. The diagnostic examination confirmed the presence of renal calculi. A dietary medication and family history of renal stone
was part of the assessment that was done in order to:
a. Avoid taking drugs that could have contributed to stone formation c. Prescribed the type of diet that is needed to
prevent recurrence
b. Identify the factors predisposing Carlos to formation of stone d. Identify what type of stone was formed
64. To facilitate spontaneous passage of stone and dilute the urine, the following can be advised for Carlos EXCEPT;
a. Limit fluid intake to 1.5 liters per day to avoid fluid overload
b. Examine all urine output for presence of stone
c. Promote sufficient fluid intake to maintain a urine output of 3-4 liters/day
d. Record intake and output and daily weight to assess fluid status and renal function
65. Stone assay was done following its spontaneous passage. The result revealed uric acid stone. Prior to his discharged, you
made a teaching plan for Carlos on how he can prevent kidney stone formation. The following were included in your plan
EXCEPT:
a. Take allopurinol (Zylop
c. prim) that is prescribed by the doctor to reduce serum uric acid levels and urinary uric acid excretion
d. Avoid food high in purine like shellfish, anchovies, mushroom and organ meat
e. During the walking hours drink fluids every 1-2 hours and at bedtime take 2 glasses of water to prevent urine from
being too concentrated
f. Encourage activities leading to sudden increases in temperature of facilitate excretion of uric acid through sweating
Situation 14 – EMERGENCY – Triage Trauma to facilitate care of clients in the emergency room, various management
strategies have been devised to address the survival needs of patients. As an ER nurse you should be equipped with
knowledge, skills and attitude to cope with unexpected problems.
66. You are assigned as the triage nurse in the ER. Four patients injured in a vehicular accident were brought to the
Emergency Room at the same time. To whom will you assign the HIGHEST priority?
a. Rusty with maxillofacial injury and gurgling respiration
b. Zenia, with severe head injury but with no perceptible blood pressure
c. Harriet, with lumbar spinal cord injury with lower extremity paralysis
d. Bell, 8 months pregnant with premature labor contractions
67. Reynold was sideswiped by a motor cycle while he was waiting for a bus. His head hit the concrete pavement. According
to a witness Reynold was unconscious for a while but regained his consciousness as if nothing happened. However, after a
while he complained of severe headache and asked to be brought to the nearest Emergency Room. You are the nurse in the
Emergency Room, if increased intracranial pressure is suspected, what would be the sign?
a. Involuntary posturing c. Pupillary asymmetry
b. Irregular breathing pattern d. Alteration in level of consciousness
68. You are caring for Raymond who sustained multiple injuries following automobile accident. Your initial assessment
revealed that he is oriented to person and place but is rather confused as to time. He complains of severe headache and
drowsiness. His pupils are both equal reactive to light. Your critical nursing intervention would be:
a. Prevent unnecessary movement d. Monitor for signs of increased intracranial
b. Prefer to administer Mannitol pressure
c. Keep Raymond alert and responsive
69. Berne is admitted to the emergency room following an assault where she was beaten in the face and head. Based on
Berne’s history, which of the following interventions should be performed first?
a. Insert an oral or nasopharyngeal airway c. Insert an intravenous catheter
b. Give 100% oxygen by mask d. Obtain arterial blood gases
70. Marlou losses consciousness. You should prepare for which of the following FIRST?
a. Endotracheal intubation or surgical airway c. Place a nasogastric tube
placement d. Place a second IV line
b. CT scan on the head
Situation 15 – Lucila is an Emergency Department nurse working during the morning shift. A newly hired nurse was assigned
to work with her as part of orientation program.
71. A 41 year old victim of gunshot wound is being assessed closely for signs of hypovolemic shock. Which of the following
instructions of Lucila to the newly hired nurse is LEAST intended to obtain data regarding hypovolemic shock?
a. “Talk to the patient” b. “Note skin color of the patient”
 c. “Report to me changes in vital signs” d. “Maintain pressure on the wound”
72. The newly hires nurse observed Lucila perform assessment on a 50 year old female who sustained partial and full
thickness burns on both lower extremities due to fire. Which of the following questions asked by Lucila will the newly hired
nurse consider as an attempt to determine full thickness burns?
a. “Can you move both extremities?” c. “Did you cover your extremities with any material like
b. “How long were your extremities exposed to the a blanket?”
flames?” d. “Do you experience pain?”
73. Lucila administered as prescribed, antivenom and tetanus toxoid to a client admitted with history of snake bite. If you
were the newly nurse, which of the following statements will you consider INCORRECT?
a. Tetanus toxoid enhances effect of antivenom
b. Amount of antivenom is dependent on the severity of reaction than weight of the client
c. Complications induced may be prevented by tetanus toxoid
d. Antivenom is an antidote for snakebite
74. Lucila instructed the newly hired nurse to inform the client with congestive heart failure to avoid Valsalva-type
maneuvers. The newly hired nurse understands that these include the following EXCEPT:
a. Walking to and from the bathroom c. Moving from supine to lateral position
b. Coughing and straining d. Getting out of bed to a wheelchair
75. When appraising the performance of the newly hired nurse during the shift, which of the following behaviors will Lucila
consider as reflective of a responsibility to improve evaluation ability?
a. Seeks clarifications regarding deviations from c. Questions appropriately data obtained from the
standard procedures client
b. Organizes reference materials on medication d. Asks for supervision on performance of a new
prescriptions procedure

Situation 16 – Herminio, 70 years old, was admitted for operative repair of abdominal aortic aneurysm.
76. The nurse who admitted the patient recognizes that the development of abdominal aortic aneurysm in the patient could
be associated primarily with which of the following data obtained through nursing history.
a. He stopped smoking when he was 65 years old c. Patient is 70 years old
b. Patient is under treatment for hyperlipidemia d. Prolonged history of hypertension
77. When the nurse examines the patient’s abdomen, which of the following will she expect upon palpation?
a. Pulsating mass on the mid and upper abdomen c. Rebound tenderness on the mid abdomen
b. Bruit over a mass in the abdomen d. Rigid board like abdomen
78. Preoperatively, the priority nursing diagnosis in the nursing care plan is “Risk for ineffective tissue perfusion related to
aneurysm rupture resulting to hemorrhage.” Which of the following interventions is MOST appropriate to prevent rupture?
a. Apply cold compress on the abdomen c. Relieve pain immediately
b. Place patient on a Fowler’s position d. Maintain complete bed rest with legs flat on bed
79. Postoperatively, the nursing orders include monitoring patients closely for signs of graft leakage. Which of the following
signs of graft leakage will the nurse consider to be related to renal perfusion?
a. Decreasing hourly urinary output c. Increasing pelvic and groin pain
b. Increased abdominal girth d. Ecchymosis of scrotum
80. Second day postoperatively, the patient complained of absence of sensation in the lower extremities. Recognizing
manifestations of complications, the nurse attributes the complaint to which of the following?
a. Effect of anesthesia c. Electrolyte imbalance
b. Spinal cord ischemia d. Arterial occlusion
SITUATION 17- Victoria, the staff nurse is preparing a teaching plan for Mrs. Santos, a 75 year old who is recovering from an
episode of Acute Bronchitis which exacerbated her diabetes. Mrs. Santos is hard of hearing and arthritic but alert and
oriented.
81. In developing the teaching plan for Mrs. Santos, which of the following steps is done after Victoria has identified the
learning needs of her client?

a. Determine content c. Set learning outcomes

b. Set priorities for teaching d. Organize the learning experiences

82. Which of the following behavioral objectives is MOST appropriate before Mrs. Santos is expected to self-administer
medications prescribed by the physician?

a. Write the names of the drugs c. Select the prescribed medication

b. Identify all the medications d. Organize the medications

83. During assessment, which of the following is best for Victoria to do be able to determine the learning style preferred
by Mrs. Santos? Ask Mrs. Santos:

a. The things she usually do c. For changes she is willing to do

b. How she learned best in the past d. Who will be interested to learn with her
 84. Which of the following will be the MOST effective when Victoria uses the “one on one” discussion method of
teaching?
a. Frequently rephrase statements to facilitate understanding
b. Use printed materials with all capital letters for easy reading
c. Allow Mrs. Santos to recommend a schedule of drug administration
d. Limit to verbal instructions
85. During the discussion, Victoria asked Mrs. Santos to repeat what she just taught. Mrs. Santos did not respond. Which
of the following is BEST for Victoria to say?

a. Are there things which I did not say clearly? d. I asked you to repeat what I have just said, Mrs.
b. Mrs. Santos, did you hear what I asked you? Santos
c. Did you understand what I have just taught you?

SITUATION 18- You are assigned in the Cancer institute and caring for 5 patients with varying types of cancer
86. Hector, with non-Hodgkin’s lymphoma, develops a platelet count of 10,000/ul during chemotherapy. Based on these
findings, an appropriate nursing intervention is to:

a. Encourage fluids to 3000 ml/day c. Check the temperature q 4hr

b. Check all stools for occult blood d. Provide oral hygiene q 2hr

87. Fannie, a 26 year old teacher with stage II Hodgkin’s lymphoma asks you, “How long did I have to live?” your BEST
response is:
a. Most patients with your stage of Hodgkin’s disease are treated successfully
b. It will depend on how your disease responds to radiation, but most patients do well
c. You know, no one ca predict how long someone will live, so try to focus on the present
d. With ongoing maintenance chemotherapy, the 10-year old survival is very good
88. Debra, who has ovarian cancer tells you, “I don’t think my husband cares about me anymore. He rarely visits me.
“During the visit of Debra’s husband you greeted him and he told you “I just could not stand to see my wife so ill
and I don’t know what to say to her”. What will be your APPROPRIATE nursing diagnosis in this situation?
a. Interrupted family processes related to effect of illness on family members
b. Compromised family coping related to disruption in lifestyle and role changes
c. Risk for caregiver role strain related to burdens of care giving responsibilities
d. Impaired home maintenance related to perceived role changes
89. Jenny, a 40 year old single mother of two school age children is hospitalized with metastatic cancer of the ovary. You
find her crying, and she tells you that she does not know what will happen to her children when she dies. You MOST
appropriate response is:
a. For now you need to concentrate on getting well. Do not worry about your children
b. Why don’t we talk about the options you have for the care of your children?
c. Many patients with cancer live for a long time, so there is time to plan for your children
d. Perhaps your ex-husband will take the children when you can’t care for them

90. When assessing Lerma’s needs for psychologic support after she has been diagnosed with stage I cancer of the
colon, which questions will you ask to give you the MOST information?
a. Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon
b. How long ago were you diagnosed with this cancer?
c. How do you feel about having a possibly terminal illness?
d. Can you tell me what has been helpful to you in the past when coping with stressful events?

SITUATION 19- Luis, 56 years old was admitted for surgical repair of an aneurysm in the ascending aorta detected through
an annual physical examination required by the company where Luis is currently employed.
91. Which of the following questions should the nurse include when conducting a health history to identify a genetic risk
of aortic aneurysm?

a. Have you experience neck and back pain? c. Did any of your children have hypertension or any
b. How long have you been hypertensive? heart problem?
d. Has aneurysm ever been diagnosed in your family?

92. Physician confirmed his diagnosis that Luis’ aortic aneurysm is the fusiform type of true aneurysm. The nurse
recognizes that this type of aneurysm:
a. Is spindle shaped and involves three layers of the vessel well
b. Is characterized by a tear in the tunica intima with blood invading layers of the vessel wall
c. Involves the entire diameter of the ascending aorta
d. Is shaped like a sac involving only one layer of the vessel wall
 93. As the client is being prepared for surgery, which of the following assessment data should the nurse report
IMMEDIATELY to the physician?

a. Positive abdominal reflex c. Abdominal bruit

b. Increased while blood cell count d. Elevated blood pressure

94. Pot operatively, nursing orders include close observation for signs of arterial thrombosis. Which of the following
assessment data should you NOT consider as a manifestation of this complication?

a. Absence of peripheral pulses c. Increased abdominal pain

b. Increasing abdominal and scrotal pain d. Elevated body temperature

95. Protamine sulphate was prescribed by the physician as a PRN medication. The nurse understands that this
prescription is intended to:

a. Reverse effects of warfarin therapy c. Counteract adverse effects of beta blockers

b. Serve as an anticoagulant for arterial occlusion d. Treat excessive bleeding due to heparin therapy

SITUATION 20- As nurse perform their responsibilities in their job, they encounter situations which expose them to possible
lawsuits.
96. The nurse on night duty assumed that her patient is asleep. At the bedside, she discussed in detail the condition of
the patient with another nurse. Which of the following may be a possible legal complaint against the nurse?

a. Poor bedside behavior c. Breach of privacy

b. Breach of confidentiality d. Negligence

97. An 85 year old woman was diagnosed with Mestastic Breast Cancer. She has a colostomy and a fractured hip. The
night nurse documented that she became delusional and restraint was applied. No relative could stay with the
patient during the day. The incoming nurse recognizes possible liability in the application of the restraint. Which of
the following will she do FIRST?

a. Discuss concerns with relatives c. Consult attending physician

b. Obtain a medical order for a sedative d. Select a more appropriate and safe restraint

98. After cardiac catheterization, a female patient developed chest pain and died. The family sued the hospital
contending that it had a duty to inform the patient of the risk of the procedure. The court decided in favor of the
hospital. Which of the following is MOST likely the basis of the court’s decision?
a. The physician is the best person to inform the patient about the procedure
b. The re presentative of the hospital was not present during the procedure
c. The hospital practices quality control
d. The informed consent was signed by the patient
99. Elizabeth is a registered nurse who works in a call center. Because she is a nurse, her co-workers her to administer
their allergy and hormone medications. Which of the following actions is BEST to avoid liability?
a. Administer the medication after duty hours in the call center
b. Encourage co-workers to learn self-administration of drug
c. Administer the medication and dose correctly
d. Tell co-workers to secure a written medical prescription with physician’s license number
100. An elderly patient refused to take her cardiac medications. Thinking that she was dis oriented, the nurse crushed
the tablets and mixed them with the soup and fed the patient. The nurse may be liable for:
a. Negligence
b. Battery
c. Assault
d. Violation of privacy