Nursing Practice
Nursing Practice
Nursing Practice
1. His arterial blood gas results are PO2 of 85, PCO2 of 40 and HCO3 of 24. Which
of the following should be initiated? (3)
3. To encourage proper breathing exercises, which of the following should the nurse
teach? (1)
a. 24 gtt/min
b. 12 gtt/min
c. 21 gtt/min
d. 30 gtt/min
Situation 2: Nurse Jeddah is the staff nurse assigned in the Medical Ward of a
secondary hospital.
6. The physician ordered reverse isolation for Mr. Perez with second degree burns.
While performing reverse isolation technique, Nurse Freud should understand that:
(2)
a. it is not necessary to use sterile linen if the linen has been properly washed.
b. only some persons who come in direct contact with the client need to wear gloves
andmask
c. sterile gown and gloves must be worn while caring for Mr. Perez
d. it is not necessary to wear a mask
7. During the stage of diuresis, there is resorption of fluid into the intravascular
compartment and increase urinary output. Which electrolyte imbalance is most
frequently associated with this stage? (3)
8. The priority nursing care for patient suffering from stroke during acute phase is
to: (3)
a. maintain respiratory and cardiac functions
b. prevent contracture and deformities
c. maintain optimal nutrition
d. provide sensory stimulation
9. The nurse in the clinic would assess a 4-month-old who is in acute respiratory
distress when which of the following is observed? (2)
10. In assessing patient for signs of impending respiratory failure, an early symptom
that the nurse should look for is: (1)
a. Kussmaul’s respiration
b. cyanosis
c. tachypnea
d. bradypnea
11. Which of the following symptoms is common in clients with tuberculsosis? (1)
12. Nurse Kitchie obtains a sputum specimen from a client for laboratory study.
Which of he following laboratory techniques is most commonly used to identify
tubercle bacilli in sputum? (1)
a. Dark-field illumination
b. Sensitivity Testing
c. Acid – fast staining
d. Agglutination
13. A client has a positive Mantoux test. Nurse Kitchie correctly interprets this
reaction to mean that the client has: (2)
a. active tuberculosis
b. had contact with Mycobacterium tuberculosis
c. developed a resistance to tubercle bacilli
d. developed passive immunity to tuberculosis
14. Nurse Kitchie should teach clients that the most common route of transmitting
tubercle bacilli from person to person is through contaminated: (1)
a. dust particles
b. droplet nuclei
c. water
d. eating utensils
15. The client is to be discharged home with a community health nursing follow –
up. Of the following interventions, which would have the highest priority? (2)
Situation 5
Mang Tomas with advanced chronic obstructive pulmonary disease (COPD)
reports steady weight loss and being “is too tired from just breathing to eat, is
admitted in the hospital.
16. Which of the following physical assessment findings would Nurse Pepsi expect to
find for Mang Tomas? (2)
17. Which of the following nursing diagnoses would be most appropriate when
planning nutritional interventions? (1)
18. Nurse Pepsi’s priority goal for Mang Tomas is: (2)
19. Which of the following diets would be most appropriate for Mang Tomas? (2)
Situation 5: Tuberculosis (TB) has been declared a global emergency in 1993 by the
WHO.
21. TB ranks sixth in the leading causes of morbidity. Nurse Miranda recognizes
that the most hazardous periods for development of clinical disease is: (1)
a. 1 year
b. 2 ½ years
c. 3 months
d. 6 months
22. Which of the following statements is the primary preventive measure for PTB?
(2)
23. The source of infection in PTB is through which of the following? (1)
25. BCG is given to protect the baby from infection at what age? (1)
a. At birth
b. At 1 month
c. At 2 month
d. At 9 month
Situation 6: The national objectives for maintaining the health of all Filipinos is a
primary responsibility of the Department of Health.
26. The Department of Health Program has a mission which includes all of the
following, except: (1)
a. Ensure accessibility
b. Quality of health care
c. Improve quality of life
d. Health for all Filipinos in the year 2020
27. Which of the following are primary strategies to achieve health goals? (1)
a. Ensure accessibility
b. Achievement of quality health care for all
c. Health for all Filipinos
d. Promotion of health education
30. Which of the following is not a primary strategy to achieve health goals? (1)
31. As a nurse you know that there are many elements that provoke the attack.
Which among the elements is a common allergen to both the children and adult
patients? (1)
a. Cigarette smoke
b. Dust – mite
c. Perfume
d. Flowers
32. If a child has asthma, what nursing diagnosis can you make that will direct your
nursing intervention? (2)
33. As a nurse, what body organs and sense can you utilize in rural areas that can
crudely assess presence of asthma in children? (2)
34. In case of asthmatic attack, what position can a nurse advise patients to take? (1)
a. Semi – fowler’s
b. Sitting
c. Lying down in bed
d. Prone lying
35. Of what use is the Peak Expiratory Low Rate (PEFR) as a monitoring device for
nurses? (3)
Situation 8: Fear and anxiety are conditions that bring about acid-base imbalances.
36. What is the primary nursing responsibility when a patient presents respiratory
distress? (2)
37. When a patient is fearful and anxious, what is the condition indicative of? (3)
a. Respiratory alkalosis
b. Metabolic acidosis
c. Metabolic alkalosis
d. Respiratory acidosis
39. Chow, 2-year-old has difficulty of breathing without any previous cause. What
can a nurse do at this very moment? (2)
40. If Chow asks for food and drink, which among the following will you give him?
(3)
a. Soft drinks
b. Ice cream
c. Hot milk and crackers
d. Warm congee
41. Which of the following is the main factor that contributes to the problem of
getting sick of pneumonia among children below 5 years old? (3)
43. Which classification of pneumonia has the child if 3 or more danger signs are
present? (2)
a. Severe
b. Pneumonia
c. No Pneumonia
d. Very severe
44. When the child is to receive antibiotic, where should the first dose be given? (1)
a. In the school
b. In the health center
c. In the home
d. In the referral system
45. Which of the following is your topic for health teaching to mothers of children
with pneumonia? (2)
a. Breastfeeding
b. Family planning
c. Use of Assess Card
d. Play therapy
Situation 10: The Tochan family is in crisis situation. Mr. Tochan, 60-year-old has
emphysema and is in ZMDH. He was admitted last September 5, 2006. His wife
Vina, 50-year-old is taking care of her husband in the hospital. He is under close
observation with O2 inh/NC @ 2LPM.
46. Upon auscultation, rales are heard in Mr. Tochan’s left lower lung segment. One
of the orders in the care and treatment of Mr. Tochan was postural drainage once a
day. To perform the procedure it would involve placing Mr. Tochan on: (2)
47. Mr. Tochan’s condition resulted in COPD. His blood pH is 7.33 and he is
restless. Accordingly, her nursing care plan should include: (3)
48. Most of the time Mr. Tochan is allowed to rest. At 12 noon CBC & ABG were
done. The results showed PaO2 - 92%, PCO2 - 46, RBC- 4.8 mx10, WBC - 11000,
Hgb.-12g/dl. The best nursing action would be: (2)
Situation 11: At around 7:30 am the following day, Nurse Pia endorsed Mr. Tochan
to Nurse Vega as having a temperature reading of 38.8ºC/ax. She also endorsed that
he’d been restless during the night.
52. One of the nurses came at the bedside of Mr. Tochan and states: “You look like
you are having difficulty of breathing.” The nurse’s statement is: (3)
53. Later that day, Mr. Tochan had bouts of productive cough. The most effective
infection control is for the nurse to: (1)
a. portal of entry
b. infectious agent
c. reservoir
d. portal of exit
55. The following conversation took place at Mr. Tochan’s bedside while the
morning shift nurse was making her rounds:
Nurse: “Mr. Tochan, I will be teaching you deep breathing exercises.”
Tochan: “I would prefer that we wait for my wife. She knows what to do.”
Nurse: “You should not rely on your wife. I will show you how to do it effectively.”
The nurse’s last statement is: (2)
Situation 12: The Department of Health promotes use of herbal drugs. As a public
health nurse, you implement the program on traditional medicine in the community.
56. To promote the use of herbal medicines, which of the following projects would
you encourage the people in the community to do? (1)
57. Which of the following herbal plants is used for respiratory problems such as
asthma, cough and fever? (1)
a. Lagundi
b. Sambong
c. Niyog-niyogan
d. Yerba Buena
58. Which of the following aromatic herbs for body pain, rheumatism and arthritis
is used by older persons? (1)
a. Sambong
b. Yerba Buena
c. Carmona-rosa
d. Alusimang Bato
59. Which of the following herbal plants is used for mild non-insulin dependent
diabetes mellitus? (1)
a. Alusimang Bato
b. Bawang
c. Carmona-rosa
d. Ampalaya
60. In the use of herbal medicines, which of the following statement is incorrect? (2)
Situation 13: Mr. Ang Lee has chronic cough and dyspnea. Her physician made a
diagnosis of Acute Pulmonary Emphysema.
61. He has dyspnea with mild exertion. What is the probable cause of this? (2)
63. While waiting for the resident-on-duty to perform the physical examination, Mr.
Lee would be most comfortable in which position? (1)
64. The primary objective of your nursing care management for him is to improve
her quality of life. Which of the following would not be included in your therapeutic
approach? (3)
a. Prevention of infection
b. Prompt treatment of infection
c. Providing supportive care
d. Maintenance of a conducive environment
65. Which of the following hygienic care would be most appropriate for Mr. Lee?
(2)
5Situation 14: Mrs. Meow, 46-year-old with asthmatic attack is admitted in the
medical ward of Rico Hospital.
66. Your finding in your assessment would include the following, except: (1)
a. Ability only to speak a few words without taking a deep breath
b. Tachycardia, cool and moist skin
c. Air hunger and presence of wheezing sounds
d. Tachycardia, warm and moist skin
67. With your assessment, which of these symptoms would you expect to develop
later? (2)
a. Nasal flaring
b. Lips pursed in an effort to exhale
c. Cyanosis
d. Use of accessory muscles for breathing
68. Which has the fewer tendencies to precipitate or trigger asthmatic attack? (1)
a. Air pollution
b. Cold weather
c. Changes in climate
d. Mold, house dust
69. The least of nursing care that you would do with Mrs. Meow is to: (2)
70. The most comfortable position for Mrs. Meow to assume during asthmatic
attack is: (1)
a. Sitting
b. Orthopneic
c. Fowler’s
d. Supine
Situation 15: Mr. Kaldero, age 38, is referred to the local hospital clinic after his
tuberculin skin test was found to be positive. He is admitted for further diagnosis
and evaluation. Medications ordered for Mr. Cordero are 300 mg Isoniazid (INH)
p.o. daily, 300 mg Rifampicin p.o. daily, 100 mg Pyridoxine (Vitamin B6) p.o. daily,
regular diet and bed rest.
71. Which would most likely confirm Mr. Kaldero’s diagnosis of tuberculosis? (1)
a. Creatinine kinase test
b. Chest x-ray
c. Sputum smear and culture
d. White blood cell count
72. Which clinical manifestations would the nurse expect in a patient with TB? (2)
73. Which nursing activity would be most therapeutic while Mr. Kaldero is on bed
rest? (2)
75. After a week in the hospital, Mr. Kaldero is ready for discharge. When
providing discharge instructions, the nurse should discuss all of the following,
except:
Situation 16: Reason Blade, R.N., is the staff nurse on duty at the Medical Ward of
Aquinas University Hospital.
76. In Bed No. 1 is Mr. Monterey, a 50-year-old client with asthma. Your nursing
management for him is: (2)
77. To ease his breathing, which position would make him most comfortable? (1)
a. Dorsal recumbent
b. Sim’s
c. Orthopneic
d. Fowler’s
78. Mr. Tatad, who is in Bed No. 3 is suffering from COPD. You informed him that
the most effective bronchodilator is: (2)
a. Lukewarm lemonade
b. Deep breathing
d. Steam inhalation
d. Mild mucolytic agent
79. What diet is best recommended for him considering his existing Valsalva
maneuver problem? (2)
80.Which of the following will not promote effective clearing of Mr. Tatad’s
tracheobronchial secretions? (2)
Situation 17: In a developing country like the Philippines, accumulation of fluid in the
pleural cavity commonly results from tuberculosis.
81. Anatomically, the inner part of the thoracic cavity is lined by the parietal
membrane, while the membrane that envelops the lung is called: (1)
a. visceral membrane
b. cell membrane
c. plasma membrane
d. pulmonary membrane
82. Mang Jose is prepared for CTT. Nurse A would know that CTT stands for: (2)
83. The correct position of Mang Jose to assume during CTT is: (1)
a. supine position
b. sitting on a chair, leaning on the back rest
c. high fowler’s with arm of affected side above the head
d. side lying on high fowler’s at the side of the bed
84. During the rounds, Nurse A noticed that the chest tube was accidentally
removed by the client. The best appropriate nursing action Nurse A should take is:
(3)
85. Nursing responsibilities in caring for patients with CTT are the following except:
(3)
a. ensure that the drainage bottle is at the level of the patient’s chest
b. monitor water-seal drainage bottle to ensure fluid level is above drain tube
c. coil tubing carefully to avoid kinking
d. prepare two clamps at bedside and take with patient when brought out of the room
86. Which of the following physiologic needs has the highest priority for Calamares?
(1)
a. Fluid
b. Nutrition
c. Oxygen
d. Low Temperature
87. A symptomatic patient like Calamares would consider which of the following as
her most important needs? (2)
88. Illness prevention activities are generally designed to help client attain which of
the following? (2)
Situation 19: Mr. Murdocks, a 65-year-old retired steel mill worker, is admitted to
the unit with dyspnea-upon-exertion. He has a long history of smoking. Initial
assessment findings include barrel chest, ankle edema, persistent cough with
copious sputum production and variable wheezing on expiration.
91. Mr. Murdocks’ ankle edema and respiratory problems should make the nurse
suspect hypertrophy of which heart chamber? (2)
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
92. The physician orders an Aminophylline IV drip for Mr. Murdocks. The nurse
should be alert for which sign of drug toxicity? (2)
a. Depression
b. Lethargy
c. Tachycardia
d. Cyanosis
93. ABG measurements reveal a ph of 7.25, PaCO2 of 52 mmHg and a HCO3 level
of 25 mEq/L. The result indicates what acid-base imbalance? (2)
95. The physician orders postural drainage. Which statement about postural
drainage is most accurate? (2)
a. Postural drainage uses gravity to augment mucociliary clearing mechanisms and drain
retained secretions
b. All patients with COPD are positioned the same way during postural drainage
c. Postural drainage involves rhythmic clapping of the chest wall with cupped hands
d. postural drainage is effective only when performed for 1 hour or longer
Situation 20: Marisse, a BSN student was assigned in the medical ward. She is to
administer medication under the supervision of her clinical instructor.
96. When administering drugs, the nurse compares the label of the drug container
with the medicine card correctly except: (2)
97. What is the best way of identifying the right client ideally? (1)
98. If the doctors orders q8h, what does this mean? (1)
99. The expectorant guiafenesin (Robitussin) 300 mg p.o. has been ordered. The
bottle is labeled 100mg/5mL. How many mL should be given? (2)
a. 13 mL
b. 14 mL
c. 15 mL
d. 16 mL
100. The physician orders: Administer Ampicillin 50 mg. oral suspension p.o q6
hours for 7 days. Stock dose is 125 mg/5mL in 30 mL bottle. How many bottles of
the medication will you request? (3)
a. 5 bottles
b. 4 bottles
c. 3 bottles
d. 2 bottles