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 Nurse Suzie is administering 12:000PM medication in

Ward 4. Two patients have to receive Lanoxin. What  Baby Liza, 3 months old, with a congenital heart
should Nurse Suzie do when one of the clients does deformity, has an order from her physician: “Give
NOT have a readable identification band? 3.00 cc of Lanoxin today for one dose only”. Which
o Ask the client his name of the following is the most appropriate action by
the nurse?
 Wilfred, 30 years old male, was brought to the o Clarify the order with the attending
hospital due to the hospital dues to injuries physician
sustained from a vehicular accident. While being
transported to the X-ray department, the straps  Which of the following nursing intervention should
accidentally broke and the client fell to the floor be given the highest priority when receiving a client
hitting his head. In this situation, the nurse is: in the OR?
o Liable along with the employer for the use o Verify the identification and informed
of a defective equipment that harms the consent
client
 Situation – In the OR, there are safety protocols that
 While going on evening round, Nurse Edna saw Mrs. should be followed. The OR nurse should be well
Pascual meditating and afterwards started singing versed with all these to safeguard the safety and
prayerful hymns. What is the BEST response of quality of patient delivery outcome.
Edna?
o Respect the client’s actions as this provides  Which of the following should be given highest
structure and support the client priority when receiving patient in the OR?
o Verify patient identification and informed
 Which of the following situations would possibly consent
cause a nurse to be sued due to negligence?
o Nurse gave a client wrong medication and  Surgeries like I and D (incision and drainage) and
an hour later, client complained of debridement are relatively short procedures but
dyspnea considered ‘dirty cases.’ When are these procedures
best scheduled?
 The nurse is in the hospital canteen and hears two o Last case
staff nurses talking about the client confined in room
612. They mentioned his name and discussed details  OR nurses should be aware that maintaining the
of his condition. Which of the following actions client’s safety is the overall goal of nursing care
should the nurse take? during the intraoperative phase. As the circulating
o Approach the two nurses and tell them nurse, you make certain that throughout the
that their actions are inappropriate procedure…
especially in a public place. o strap made of strong non-abrasive
material are fastened securely around the
 When the nurse breaches the duty of confidentiality, joints of the knees and ankles and around
he or she can be disciplined by both employer and the 2 hands around an arm board
the Board of Nursing. In addition to this discipline,
he or she can:  Another nursing check that should not be missed
o Be held responsible or any damages that before the induction of general anesthesia is:
result o check baseline vital signs

 Which of the following best describes acquaintance  Some lifetime habits and hobbies affect
rape? postoperative respiratory function. If your client
o Sexual intercourse committed with force smokes 3 packs of cigarettes a day for the past 10
or with the threat of force without a years, you will anticipate increased risk for:
person’s consent o postoperative respiratory function

 You are the nurse in an Adult Care Unit. You over-  Situation – One of the realities that we are
hear one of your co-staff nurse assigned to Aling confronted with is our mortality. It is important for
Josie who is 78 years old say, that if she refuses to us nurses to be aware of how we view suffering,
take her medications she will not be given her pain, illness, and even our death as well as its
favorite dessert. You report your co-staff’s behavior meaning. That way we can help our patients cope
as: with death and dying.
o Assault  Irma is terminally ill, she speaks to you in
confidence. You now feel that Irma’s family could be
 When a nurse volunteers to work in a hospital helpful if they knew what Irma has told you. What
setting and she commits a mistake, who is legally should you do first?
responsible?
o Volunteer nurse, hospital and the nurse in  Obtain Irma’s permission to share the information
charge with the family

 As a nurse, you accidentally administer 40 mg of  Ruby who has been told she has terminal cancer,
propranolol (Inderal) to a client instead of 10 mg. turns away and refuses to respond to you. You can
although client exhibits no adverse reactions to the best help her by:
larger dose. You should:  Coming back periodically and indicating your
o Complete an incident report availability if she would like you to sit with her
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recurrent pain at the upper right quadrant of the

 Leo, who is terminally ill and recognizes that he is in abdomen 1-2 hours after ingestion of fatty food. She
the process of losing everything and everybody he also had frequent bouts of dizziness, blood pressure
loves, is depressed. Which of the following would of 170/100, hot flashes. Which of the above
best help him during his depression? symptoms would be an objective cue?
o Blood pressure measurement of 170/100
o Sit down and talk with him for a while
 While talking with Mrs. Amado, it is most important
 Situation: The nurse supervisor is observing the staff for the nurse to:
nurses in her hospital to see how quality of care o Do an assessment of the client to
provided for client can be improved. determine priority needs
 The nurse supervisor is not satisfied with the bed
bath that is provided by Nurse Arthur. To improve  Situation – Errors while providing nursing care to
the care provided to the patients in the unit by patients must be avoided and minimized at all times.
Nurse Arthur, the nurse supervisor should: Effective management of available resources enables
o Bring the staff nurse to a client’s room and the nurse to provide safe quality patient care.
demonstrate a cleansing bath
 In a hospital were you work, increased incident of
 The staff nurse discusses with the novice nurse the medication error was identified as the number one
type of wound dressing that is best to use for a problem in the unit. During the brain storming
client. Together, they observe how well the session of the nursing service department, probable
dressings absorb the drainage. In what step of the causes were identified. Which of the following is
decision making process are they? process related?
o Testing options o failure to identify client

 To check if the nurses under her supervision use  Miscommunication of drug orders was identified as a
critical thinking, Mrs. David observes if the nurses probable cause of medication error. Which of the
act responsibly when at work. Which of the following is a safe medication practice related to
following actions of a nurse demonstrates the this?
attitude of responsibility? o Only officially approved abbreviations may
o Following standards of practice be used in the prescription orders

 The hospital has an ongoing quality assurance

 The nurse who makes clinical judgment can be program. Which of the following indicates
dependent upon to improve the quality of care implementation of process standards?
clients. Nurse Julie uses such good clinical judgment o The nurses check client’s identification
when she gives priority care to this client: band before giving medications
o A post-operative client, Rey, who has a
blood pressure of 90/50 mmHg  Which of the following actions indicate that Nurse
Jerome is performing outcome evaluation of quality
 A good nursing care plan is dependent on a correctly care?
written nursing diagnosis. It defines a client’s o Interviews nurses for comments regarding
problem and its possible cause. The following is an staffing
example of a well written nursing diagnosis:
o Electrolyte imbalance related  An order for a client was given and the nurse in
hypocalcemia charge of the client reports that she has no
experience of doing the procedure before. Which of
 Situation - The practice of nursing goes with the following is the most appropriate action of the
responsibilities and accountability whether you work nurse supervisor?
in a hospital or in the community setting your main o Assign another nurse to perform the
objective is to provide safe nursing to your clients? procedure
 To provide safe quality nursing care to various clients
in any setting, the most important tool of the nurse  Nursing audit aims to:
is: o Compare actual nursing done to
o Critical thinking to decide appropriate established standards
nursing actions
 In Community Health Nursing, despite the
 You ensure the appropriateness and safety of your availability and use of many equipment and devices
nursing interventions while caring for various client to facilitate the job of the community health nurse,
groups by: the best tool any nurse should well be prepared to
o Using standards of nursing care as your apply is a scientific approach. This approach ensures
criteria for evaluation quality of care even at the community setting. This in
nursing parlance is nothing less than the:
 The effectiveness of your nursing care plan for your o nursing process
clients is determined by
o the outcome of nursing interventions  Evidence-based care started in medicine as a way to:
based on plan care o Integrate individual experience with
clinical research
 You are assigned to Mrs. Amado, age 49, who was
admitted for possible surgery. She complained of
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 Situation - The psychiatric mental health nurse  Situation – Your director of nursing wants to
adheres to standards that ensure quality improve the quality of health care offered in the
improvement. The following situations and hospital. As a staff nurse in that hospital you know
behaviors are means to achieve this goal. that this entails quality assurance programs.
 This is a process wherein the client’s chart is  The following mechanisms can be utilized as part of
reviewed to compare criteria for quality care with the quality assurance program of your hospital
actual practice EXCEPT:
o Psychiatric audit  ANS: Use of the Nursing
Interventions Classification
 In order to assess “Reliability” as a behavioral
characteristic, the nurse would ask herself which of  The use of the Standards of Nursing Practice is
the following questions regarding her recording: important in the hospital. Which of the following
o Did the history of the present problem statements best describes what it is?
correlate with the review of growth and  ANS: The Standards of care
development includes the various steps of the
nursing process and the standards
 All of these are advantages of peer review EXCEPT: of professional performance
o It requires the development of standards
for quality care  You are taking care of critically ill client and the
doctor in charge calls to order a DNR (do-not-
 The nursing team leader wants to involve all the resuscitate) for the client. Which of the following is
nurses in participating in their own personal and the appropriate action when getting DNR order over
professional growth through a brainstorming the phone?
session. One of the most important ground rules is: o Have 2 nurses validate the phone order,
o Follow the problem solving approach both nurses sign the order and the doctor
should sign his order within 24 hours
 “Did the nurse perform in the best possible manner
without waste?” aims to describe the nurse’s:  To ensure client safety before starting blood
 ANS: efficiency transfusion the following are needed before the
procedure can be done EXCEPT:
 You are the nurse manager of the Medical Unit. o blood should be warmed to room
Which of the following is a priority for you to temperature for 30 minutes before blood
consider when planning for the care of group of transfusion is administered
clients utilizing evidence-based practice?
ANS: Clients’ needs are assessed  Part of standards of care has to do with the use of
and individualized care plan are restraints. Which of the following statements is NOT
developed for each client true?
o Check client’s pulse, blood pressure and
 Situation - The purpose of the nursing care plan is to circulation every 4 hours
identify the care for an individual patient based on
his problem should be included if it is known. The  Situation – Joint Commission on Accreditation of
nurse writes a nursing care plan for a patient based Hospital Organization (JCAHO) patient safety goals
on nursing care standards. and requirements include the care and efficient use
 Given the example of a problem: “Anxiety due to a of technology in the OR and elsewhere in the
job interview”. Then “due to” or the reason for the healthcare facility.
problem should be included if it is known. The initial  As the head nurse in the OR, how can you improve
step in identifying problem is: the effectiveness of clinical alarm systems?
 ANS: Gather the data about the o Implement a regular maintenance and
patient testing of alarm systems

 Given the example of an expected outcome: “Openly  Overdosage of medication or anesthetic can happen
verbalize anxiety about job interview. Identify how even with the aid of technology like infusion pumps,
he can prepare for the job interview. “Which of sphygmomanometer, and similar devices/machines.
these is not a criterion of expected outcomes? As a staff, how can you improve the safety of using
o ANS: An expected outcome is stated in infusion pumps?
terms of what the nurse will do o Check the functionality of the pump before
use
 The following are reasons for setting deadlines
within which to achieve outcomes of care EXCEPT:  JCAHOs universal protocol for surgical and invasive
 ANS: Does not allow plans to be procedures to prevent wrong site, wrong person,
changed and wrong procedure/surgery includes the following
EXCEPT:
 Which of these is not a relevant nursing order? o Take a video of the entire intra-operative
 ANS: Discuss with a patient with procedure
specific means he might prepare
for the job interview  You identified a potential risk of pre and
postoperative clients. To reduce the risk of patient
 Which of these practices on evaluation support harm resulting from fall, you can implement the
nursing care? Review of care plan is: following, EXCEPT:
o A nursing team responsibility o Allow client to walk with relative to the OR
 Page 4 of 16

following should NOT be included in the patient’s

 As a nurse, you know you can improve on accuracy chart?
the of patient’s identification by 2 patient identifiers, o Arguments between nurses and residents
EXCEPT: regarding treatments
o call the client by his/her case and bed
number  During your morning rounds, Mr. Tipol, 60 year old
widower, tried to sit up and instead of holding to the
 Which of the following statements would best side rail held the IV stand causing the IV bottle to fall
indicate that Ruffy, who is dying, has accepted his and break. You wrote an incident report to show:
impending death? o Document the incident
o “I’m ready to go.”
 Erasures, alterations, and additions in medical
 Marla, 90 years old has planned ahead for her death- records and the nurse’s notes can be avoided. The
philosophically, socially, financially, and emotionally. following are some tips on how to do corrections,
This is recognized as: EXCEPT:
 Acceptance that death is inevitable o State the reason for any deviation from
normal procedure/practice
 Situation – You are now working as a staff nurse in a
general hospital. You have to be prepared to handle  Kathy is one of the patient’s. Her uncle, who is a
situations with ethico-legal and moral implications. doctor, wants to read her chart. Your appropriate
 You are on night duty in the surgical ward. One of action would be:
your patients Martin is a prisoner who sustained an o Instruct Kathy’s uncle to present a written
abdominal gunshot wound. He is being guarded by authorization signed by the patient
policemen from the local police unit. During your
rounds you heard a commotion. You saw the  Situation 11 – Mr. Jose’s chart is the permanent legal
policeman trying to hit Martin. You asked why he recording of all information that relate to his health
was trying to hurt Martin. He denied the matter. care management. As such, the entries in the chart
Which among the following activities will you do must have accurate data.
first?  Mr. Jose’s chart contains all information about his
 Make an incident report health care. The functions of records include on
following EXCEPT:
 You are on morning duty in the medical ward. You o Recording of actions in advance to save
have 10 patients assigned to you. During your time
endorsement rounds, you found out that one of your
patients was not in bed. The patient next to him  An advantage of automated or computerized client
informed you that he went home without notifying care system is:
the nurses. Which among the following will you do o Information concerning the client can be
first? easily updated
 Make an incident report
 Information in the patient’s chart is inadmissible in
 You are on duty in the medical ward. You were asked court as evidence when:
to check the narcotics cabinet. You found out that o The handwriting is not legible
what is on record does not tally with the drugs used.
Which among the following will you do first?  A telephone order is given to for a client in your
 Find out from the endorsement any patient who ward. What is your most appropriate action?
might have been given narcotics o Repeat the order back to the physician,
copy onto the order sheet and indicate
 You are on duty in the medical ward. The mother of that it is a telephone order
your patient who is also a nurse, came running to
the nurses’ station and informed you that Fiolo went  Because of increase incidents of medication error
into cardiopulmonary arrest. Which among the due to wrong transcription of physician medication
following will you do first? orders by nurses, a tertiary hospital utilized a
 Go to see Fiolo and assess for airway patency and computerized medication order system. Which of
breathing problems the following procedures may be done through the
said system?
 You are admitting Jorge to the ward and you found o Provide a list of drugs with their generic
out that he is positive for HIV. Which among the name
following will you do first?
 Take note of it and plan to endorse this to next shift  Situation – Records contain those comprehensive
descriptions of patient’s health conditions and needs
 Situation - RN’s should always be conscious that the and at the same serve as evidences of every nurse’s
contents in charting are admissible in court as accountability in the care giving process. Nursing
evidence. records normally differ from the institution to
 If there is any deviation from normal practice or institution nonetheless they follow similar patterns
procedure e.g. streptomycin was given by IV not IM, of meeting needs for specific types of information.
this should documented in the: The following pertains to documentation/records
o Incident report management.
 This special form is used when the patient is
 Documentation of all nursing activities performed is admitted to the unit. The nurse completes the
legally and professionally vital. Which of the information in this record particularly his/her basic
 Page 5 of 16

personal data, current illness, previous health

history, health history of the family, emotional  You readmitted a client who was in another
profile, environmental history as well as physical department a month ago. Since you will need the
assessment together with nursing diagnosis on previous chart, from whom do you request the old
admission. What do you call this record? chart?
o Nursing Health History and Assessment o Medical records section
Worksheet
 Records Management and Archives Offices of the
 These are sheets/forms which provide an efficient DOH is responsible for implementing its policies on
and time saving way to record information that must record disposal. You know that your institution is
be obtained repeatedly at regular and/or short covered by this policy if:
intervals of time. This does not replace the progress o It obtained permit to operate from DOH
notes; instead this record of information on vital
signs, intake and output, treatment, postoperative  The nurse notes effectiveness of interventions in
care, post partum care, and diabetic regimen, etc. using subjective and objective data in the:
This is used whenever specific measurements or  progress notes
observations are needed to be documented
repeatedly. What is this?  The following are SOAP (subjective – Objective –
o Graphic Flow Sheets Analysis – Plan) statements on a problem: Anxiety
about diagnosis. What is the objective data?
 These records show all medications and treatment o Has periods of crying; frequently verbalizes
provided on a repeated basis. What do you call this fear of what diagnostic tests will reveal
record?
o Medicine and Treatment Record  Nursing care plans provide very meaningful data for
the patient profile and initial plan because the focus
 This flip-over card is usually kept in a portable file at is on the:
the Nurses Station. It has 2-parts: the activity and o Patient’s responses to health and illness as
treatment section and a nursing care plan section. a total person in interaction with the
This carries information about basic demographic environment
data, primary medical diagnosis, current orders of
the physician to be carried out by the nurse, written  The use of interpersonal decision making,
nursing care plan, nursing orders, scheduled tests psychomotor skills, and application of knowledge
and procedures, safety precautions in patient care expected in a role of a licensed health care
and factors related to daily living activities. This professional in the context of public health welfare
record is used in the change-of-shift reports or and safety is an example of:
during the bedside rounds or walking rounds. What  ANS. Competence
record is this?
o Nursing Kardex  Which of these feedbacks from individual
participants indicate maximum gain from the staff
 Most nurses regard this as conventional recording of development program?
the date, time, and mode by which the patient  ANS: I have a “Do it now” project
leaves a healthcare unit but this record includes for myself. i.e., to approach my
importantly, directs of planning for discharge that clinical supervisor regularly to
starts soon after the person is admitted to a discuss nursing care of our clients
healthcare institution. It is accepted that
collaboration or multidisciplinary involvement (of all  Registered nurses can be identified as a:
members of the health team) in discharge results in  ANS: Organization
comprehensive care. What do you call this?
o Discharge Summary  a strategy for change that focuses on teaching
workers new technology is:
 Situation – Records are vital tools in any institution  ANS: training
and should be properly maintained for specific use
and time.
 The patient’s medical record can work as a double  Some strategies to maintain professional health are
edged sword. When can the medical record become listed below. Which is NOT necessarily correct?
the doctor’s/nurse’s worst enemy?  ANS: Read fiction and nonfiction
o When the medical record is inaccurate, materials
incomplete, and inadequate
 a means of facilitating professional staff
 Disposal of medical records in government development is by building upon skills, abilities, and
hospitals/institutions must be done in close experience of each practitioner is called:
coordination with what agency? o the novice to expert model
o Records Management Archives Office
(RMAO)  Situation– You are a newly hired nurse in a tertiary
hospital. You have finished your orientation program
recently and you are beginning to assimilate the
 In the hospital, when you need the medical record of culture of the profession.
a discharged patient for research, you will request
permission through:
o Medical records section
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 Using Benner’s stages of nursing expertise, you are a  The least satisfactory method to evaluate the
beginning nurse practitioner. You will rank yourself effectiveness of the program is through:
as a/an: o Attendance
o Novice nurse
 Benner’s “Proficient” nurse level is different from  situation - The supervising nurse received report that
the other levels in nursing expertise in the context of a staff nurse is displaying frequent irritation, anger
having: and even indifference toward client and co-workers.
o A holistic understanding and perception of
the client  The initial action of the supervisor would be to:
o Call the nurse for a one on one conference
 As you become socialized into the nursing “culture”
you become a patient advocate. Advocacy is  The nurse expressed increasing feelings of
explained by the following EXCEPT: dissatisfaction. The supervising nurse intervenes
o Demonstrating loyalty to the institution’s therapeutically by taking on the role of:
rights o Counselor by actively listening

 Modern day nursing has led to the development of

the expanded role of the nurse as seen in the  Coupled with poor work performance, mental and
function of a: physical fatigue and actual withdrawal from client
o Clinical nurse specialist contact and nursing duties, the nurse can be said to
be suffering from:
 You join a continuing education program to help o Personality maladjustment
you:
o Update your knowledge and skills related  A priority in the nurse’s personal development
to field of interest program would be to:
o Help her find value and meaning in her
 Situation - The PRC regulates the practice of 42 work
professions in the Philippines.
 The most relevant professional program for her
 What is the basic requirement of the state for a would be:
nurse to practice her profession? o Behavior modification
o A nursing licensure
 Situation – The staff nurse supervisor requests all
 The Code of Good Governance for the profession in the staff nurses to “brainstorm” and learn ways to
the Philippines shall be adapted by: instruct diabetic clients on self-administration of
o All Filipino professionals insulin. She wants to ensure that there are nurses
available daily to do health education classes.
 The standardized guidelines and procedures for the  The plan of the nurse supervisor is an example of
implementation of Continuing Professional o primary prevention
Education (CPE) for all professional. Resolution
Numbers 2004-179 provides that the total CPE credit  When Mrs. Guerrero, a nurse, delegates aspects of
units for registered professionals with baccalaureate the clients care to the nurse-aide who is an
degree should be: unlicensed staff, Mrs. Guerrero
o 60 credit units for 3 years o is assigning the responsibility to the aide
but not the accountability for those tasks
 The Board of Nursing is vested with power to issue,
suspend, or revoke for cause, the:  Kokey, the new nurse, appears tired and sluggish
o Certificate of Registration and lacks the enthusiasm she had six weeks ago
when she started the job. The nurse supervisor
 RA 9173 stipulates the removal examination of the should
nurse licensure examination shall be taken: o empathize with the nurse and listen to her
o Within the same year after the last failed
examination  Process of formal negotiations of working conditions
between a group registered nurses and employer is
 Situation - For personal and professional o collective bargaining
development, the nursing staff decided to hold a
staff development program, “Self enhancement
through Assertiveness”.  You are attending a certification program on
 An appropriate assessment tool to maximize cardiopulmonary resuscitation (CPR) offered and
gathering of needs of nurses is through: required by the hospital employing you. This is
o Survey o inservice education

 A priority objective of the program is:  Situation – Management of nurse practitioners is

o Develop art and skills of therapeutic use of done by qualified nursing leaders who have had
self clinical experience and management experience.
 An example of a management function of a nurse is:
 The most effective way to practice assertiveness o Directing and evaluating the staff nurses
skills is through:
o role play  Your head nurse in the unit believes that the staff
nurses are not capable of decision making so she
 Page 7 of 16

makes the decisions for everyone without consulting enhancing the quality of nursing
anybody. This type of leadership is: care.
o Autocratic leadership
 ANS: a & d are strong justifications
 When the head nurse in your ward plots and
approves your work schedules and directs your  Which of the following IS NOT a correct statement as
work, she is demonstrating: regards Specialty Certification?
o Authority o The Board of Nursing intended to create
the Nursing Specialty Certification Program
 The following tasks can be safely delegated by a as a means of perpetuating the creation of
nurse to a non-nurse health worker EXCEPT: an elite force of Filipino Nurse
o Change IV infusions Professionals.

 You made a mistake in giving the medicine to the  The NSCC was created for the purpose of
wrong client. You notify the client’s doctor and write implementing the Nursing Specialty policy under the
an incident report. You are demonstrating: direct supervision and stewardship of the Board of
o Accountability Nursing. Who shall comprise the NSCC?
o A Chairperson, chosen from among the
 Situation – As the CPE is applicable for all Regulatory Board Members; a Vice
professional nurse, the professional growth and Chairperson appointed by the BON at
development of Nurses with specialties shall be large; two other members also chosen at-
addressed by a Specialty Certification Council. The large; and one representing the consumer
following questions apply to these special groups of group;
nurses.
 Which of the following serves as the legal basis and  Situation – As a Nurse, you have specific
statute authority for the Board of Nursing to responsibilities as professional. You have to
promulgate measures to effect the creation of a demonstrate specific competencies.
Specialty Certification Council and promulgate
professional development programs for this group of  The essential components of professional nursing
nurse-professionals? practice are all the following EXCEPT:
o R.A. 7164  Culture
 You are assigned to care for four (4) patients. Which
 By force of law, therefore, the PRC-Board of Nursing of the following patients should you give first
release Resolution No. 14 Series of 1999 entitled: priority?
“Adoption of a Nursing Specialty Certification  Emy, who was previously lucid but is now
Program and Creation of Nursing Specialty unarousable
Certification Council.” This rule-making power is
called:  Brenda, the Nursing Supervisor of the intensive care
o Quasi-Legislative Power unit (ICU) is not on duty when a staff nurse
committed a serious medication error. Which
 Under the PRC-Board of Nursing Resolution statement accurately reflects the accountability of
promulgating the adoption of a Nursing Specialty the nursing supervisor?
Certification Program and Council, which two (2) of  Brenda should be informed when she goes back on
the following serves as the strongest justification for duty
its enforcement?
 Advances made in science and  Which barrier should you avoid, to manage your
technology have provided the time wisely?
climate for specialization in almost  Procrastination
all aspects of human endeavor;
and  You are caring for Vincent who has just been
 As necessary consequence, there transferred to the private room. He is anxious
has emerged a new concept known because he fears he won’t be monitored as closely
as globalization which seeks to as he was in the Coronary Care Unit. How can you
remove barriers in trade, industry allay his fear?
and services imposed by the  Assign the same nurse to him when possible
national laws of countries all over
the world; and  Situation 18 – There are various developments in
 Awareness of this development health education that the nurse should know about:
should impel the nursing sector to
prepare our people in the services  The provision of health information in the rural areas
sector to meet the above nationwide through television and radio programs
challenge; and and video conferencing is referred to as:
 Current trends of specialization in o Telehealth program
nursing practice recognized by the
International Council of Nurses  A nearby community provides blood pressure
(ICN) of which the Philippines is a screening, height and weight measurement, smoking
member for the benefit of the cessation classes and aerobics class services. This
Filipino in terms of deepening and type of program is referred to as
refining nursing practice and o outreach program
 Page 8 of 16

 Part of teaching client in health promotion is  As a nurse, you know that the intact skin acts as an
responsibility for one’s health. When Ciara states she effective barrier to most microorganisms. Therefore,
needs to improve her nutritional status this means: items that come in contact with the intact skin
o Client will decide the goals and should be:
interventions required to meet her goals o Disinfected
 Situation 6- The OR is divided into three zones to
 Nurse Eunice is providing tertiary prevention to Mrs. control traffic flow and contamination.
Vento. An example of tertiary prevention is  What OR attires are worn in the restricted area?
o Identifying complication of diabetes o Head cap, scrub suit, mask, OR shoes

 Mrs. Olivia has schedule for Pap Smear. She has a  Which of the following nursing intervention should
strong family history of cervical cancer. This is an be given the highest priority when receiving a client
example of in the OR?
o secondary prevention o Verify the identification and informed
consent
 Situation – Ensuring safety is one of your most
important responsibilities. You will need to provide  Conversation while in the operation is ongoing is
instructions and information to your clients to minimized because:
prevent complications. o It enhances the spread of microorganism
to the incision site
 Randy has chest tubes attached to a pleural drainage
system. When caring for him you should:  Spaulding categorized instruments according to use.
 change the dressing daily using aseptic techniques Where do you classify endoscopic instrument?
o High level disinfected instruments
 Fanny, came in from PACU after pelvic surgery. As
Fanny’s nurse you know that the sign that would be  In the OR, “Surgical Conscience” means:
indicative of a developing thrombophlebitis would o Honest adherence to surgical aseptic
be: techniques all the time
 a tender, painful area on the leg
 Medical gases are used a lot in the OR. Some gases
 To prevent recurrent attacks on Terry who has acute are used to operate equipment and some are used
glomerulonephritis, you should instruct her to: to administer genral anesthesia through inhalation.
 seek early treatment for respiratory infections What is the identifying color of the tank which
contains “laughing gals”?
 Herbert had a laryngectomy and he is now for o Blue
discharge. He verbalized his concern regarding his
laryngectomy tube being dislodged. What should  On a traffic light, yellow means “proceed with
you teach him first? caution”. In the field of healthcare, where do you
 Notify the physician at once discard your used tissue papers?
o Green bin
 When caring for Larry after an exploratory chest
surgery and pneumonectomy, your priority would be  An instrument tray with black striped
to maintain: autoclave/steam chemical indicator tape
 ventilation exchange communicates that the instrument tray.
o Is sterile

 Situation - As a perioperative nurse, you are aware

of the correct processing methods for preparing  During a meal, a client with hepatitis B dislodges her
instruments and other devices for patient use to IV line and bleeds on the surface of the over-the-bed
prevent infection. table. It would be most appropriate for the nurse to
 Items that enter sterile tissue or vascular system are instruct a housekeeper to clean the table with:
categorized as critical items and should be: o bleach
o Sterilized
 Situation – In the hospital, you aware that we are
helped by the use of a variety of equipment/devices
 As an OR nurse, what are your foremost to enhance quality patient care delivery.
considerations for selecting chemical agents for  You are to initiate an IV line to your patient, Ken, 5,
disinfection? who is febrile. What IV administration set will you
o Material compatibility and efficiency prepare?
o Microset
 Before you use a disinfected instrument, it is
essential that you:  Ken is diagnosed to have measles. What will your
o Wrap the instrument with sterile towel protective personal attire include?
o . Face mask
 You have a critical heat labile instrument to sterilize
and are considering to use a high level disinfectant.  What will you do to ensure that Ken, who is febrile,
What should you do? will have a liberal oral fluid intake?
o Prolong the exposure time according to o Provide a calibrated pitcher of drinking
manufaturer’s direction water and juice at the bedside and monitor
 Page 9 of 16

 Before bedtime, you went to ensure Ken’s safety in

bed. You will do which of the following:  Which of the following is the best example of the
o Put the side rails up ethical principle of fidelity?
 Ken’s room is fully mechanized. What do you teach o Keeping a promise to return to the client’s
the watcher and Ken to alert the nurses for help? room at a given time
o C. Call system
 The Code of Nurses
 Situation – Infection can cause debilitating o Delineates all obligations and responsibility
consequences when host resistance is compromised of the nurse
and virulence of microorganisms and environmental
factors are favorable. Infection control is one  The obligation to correctly perform one’s assigned
important responsibility of the nurse to ensure duties is:
quality of care. o Responsibility

 Honrad, who has been complaining of anorexia and

feeling tired, develops jaundice. After a workup he is  Among children candidates for organ transplant,
diagnosed of having Hepatitis A. His wife asks you when all selected children have appropriate tissue
about gamma globulin for herself and her household matches for the same donated organ, the basis for
help. Your most appropriate response would be: the decision as to which child gets the organ is that
 “You should contact your physician immediately the organ is given to the child who:
about getting gammaglobulin.” o Will receive the most benefit from the new
organ
 Voltaire develops a nosocomial respiratory tract
infection. He asks you what that means? Your best  Situation - any hospitals form bioethical review
response would be: committees to ensure better quality of life of
 “You acquired the infection after you have been patients. You are invited by the nursing service
admitted to the hospital.” department to participate in their bioethical review
committee. You are expected to know the purpose
 As a nurse you know that one of the complications and apply bioethical principles.
that you have to watch out for when caring for Omar  Which of the following is the purpose of the ethical
who is receiving total parenteral nutrition is: review committee?
 infection o Promote implementation of general
standards
 A solution used to treat Pseudomonas wound
infection is:  Daria who is admitted to the hospital with
 Dakin’s solution autoimmune thrombocytopenia and a platelet count
of 20,000/æL develops epistaxis and melena.
 Which of the following is most reliable in diagnosing Treatment with corticosteroids and immunoglobulin
a wound infection? has not been successful. Her physician
 Culture and sensitivity recommended splenectomy. Daria state “I don’t
 Situation – NURSES are involved in maintaining a need surgery. This will go away on its own.” In
safe and healthy environment. This is part of quality considering your response
care management. o Advocacy
 The first step in decontamination is:
 removal of the patients clothing and jewelry and  Zorayda is terminally ill and is experiencing severe
then rinsing the patient with water pain. She as bone and liver metastasis. She has been
on morphine for several months now. Zorayda is
 For a patient experiencing pruritus, you recommend aware that they are having financial problem. She
which type of bath decides to sign a DNR form. What ethical form did
ANS: colloidal (oatmeal) Zorayda and her family utilize as basis for their
 Induction of vomiting is indicated for the accidental decision to sign a DNR.
poisoning patient who has ingested.  Advocacy
 aspirin
 Tricia, a staff nurse in a cancer unit, is considered a
 Which of the following term most precisely refer to role model not only by her colleagues, but also by
an infection acquired in the hospital that was not her patients. She goes out of her way to help other.
present or incubating at the time of hospital She is very active in their professional organization
admission? and she practices what she teaches. What ethical
 Nosocomial infection principle is she practicing?
o Justice
 Which of the following guidelines is not appropriate
to helping family members cope with sudden death?  You are commuting to work riding the LRT. An older
 Obtain orders for sedation of family members person collapsed and nobody seems to notice her.
The security guard tried to make her sit down but
 The code of ethics for nurses has an interpretive she remained unconscious. You saw what happened
statement that provides: and you decided to help. With help, you brought the
o Guide for carrying out nursing patient to the nearest hospital. You learned later
responsibilities that provide quality care that woman was diabetic. She was on her way to the
and for the ethical obligation of the diabetes clinic to have her fasting blood sugar
profession tested. She developed hypoglycemia. You were able
 Page 10 of 16

to save a life. You felt good. What principle was Code of Ethics for Nurses which the Board
applied? of Nursing promulgated.
o Beneficence
 Situation - Ninety year old Purita is confined at the  Based on the Code of Ethics for Filipino Nurses, what
medical unit for respiratory ailment for which a is regarded as the hallmark of nursing responsibility
breathing apparatus is prescribed for her to use and accountability?
while she sleeps. She refuses to wear it continuously o Health, being a fundamental right of every
though she fully understands the medical indication individual
for it
 Which of these ethical principles can guide the nurse
in her action?  Which of the following nurses’ behavior is regarded
o Nonmaleficence as a violation of the Code of Ethics of Filipino
Nurses?
 Purita has six children who are already adults. They o A nurse endorsing a person running for
differ in their opinion whether or not to allow their congress.
mother to decide for herself. The nurse would
encourage family conference for:  A nurse should be cognizant that professional
o Consensus building programs for specialty certification by the Board of
Nursing are accredited through the:
 Breathing treatments are to be given to Purita. In o Nursing Specialty Certification Council
anticipation that Purita might refuse, Dinio, one of
the children requests that he be the one to sign  Mr. Jimmy, R.N. works in a nursing home, and he
consent in behalf of their mother. The nurse explains knows that one of his duties is to be an advocate for
that Purita is rational in her thinking and which of his patients. Mr. Santos knows a primary duty of an
these clients’ right must be regarded? advocate is to:
o Right to refuse treatment o safeguard the well being of every patient

 Which of these would be the nurse’s priority  Lizette, a head nurse in a surgical unit, hears one of
following the treatment principle of least restrictive the staff nurse say that she does not touch any client
alternative? assigned to her unless she performs nursing
o One to one staffing procedures or conducts physical assessment. To
 Purita talks about her joy in having responsible and guide the staff nurse in the use of touch, which of
accomplished children and recalls challenging career the following would be the BEST response of Lizette?
as a lawyer. She is demonstrating a sense of: o “Touch serves as a connection between
o Ego integrity the nurse and the patient”
 Situation – The nurse’s understanding of ethico-legal
responsibilities will guide his/her nursing practice.
 The principles that govern right and proper conduct  George, a 43 year old executive is scheduled for
of a person regarding life, biology and the health cardiac bypass surgery. While being prepared of
professions is referred to as: surgery, he says to the nurse “I am not going to have
o Bioethics the surgery. I may die because of the risk”. Which
response by the nurse is most appropriate?
 The purpose of having a nurses’ code of ethics is: o “This must be very frightening for you. Tell
o To help the public understand professional me how you feel about the surgery”
conduct expected of nurses
 Mr. Chris Martinez has been confined for three days.
 The most important nursing responsibility where His wife helped take care of him and he has
ethical situations emerge in patient observed her to be “too involved” in his care. He
o Be accountable for his or her own actions complained to the head nurse about this. Which of
the following would be the BEST response of the
 You inform the patient about his rights which include nurse.
the following EXCEPT: o “What are your thoughts about your
o Right to obtain information about another wife’s involvement in your care?”
patient
 The major components of the communication
process are:
 This principle states that a person has unconditional o Message, sender, channel, receiver and
worth and has the capacity to determine his own feedback
destiny:
o Autonomy  Informal communication takes place when
individuals talk and is best described by saying the
 Situation – As Filipino Professional Nurses we must participants:
be knowledgeable about the Code of Ethics for o have no particular agenda or protocol
Filipino Nurses and practice these by heart. The next
questions pertain to this Code of Ethics.
 Which of the following is TRUE about the Code of  The mother of a 9-month old infant is concerned
Ethics of Filipino Nurses? that the head circumference of her baby is greater
o The Philippine Nurses Association for being than the chest circumference. The BEST response by
the accredited professional organization nurse is:
was given the privilege to formulate a
 Page 11 of 16

o “This is normal until the age of 1 year,  Soledad is terminally ill of cancer. Looking sad she
when the chest will be greater.” expresses. “Wala na yata akong pag-asang mabuhay
pa.” A response which fosters hope is:
 Which of the following will work best when the o “Mukhang napakabigat ang dinaramdam
nurse is communicating with an infant? ninyo. Andito po ako at puwede tayong
o Use an adult voice just as you would for mag-usap.”
anyone
 Camilia verbalizes, “Pinaguusapan nila ako. Ayaw nila
 The tone and pitch of the voice, volume, inflection, ako.” A therapeutic response is:
speed, grunts and other vocalization are preferred to o “Nalulungkot ba ang pakiramdam mo?”
by which of the following terms?
o Paraverbal clues  During socialization Nicanor was provoked, became
furious and started shouting “Walang hiya kayo! Ako
 Which of the following remark indicates that the ang bida ditto!” The nurse’s action is:
client’s relative understood the discharge instruction o Take him away from the group until he
for wound care? manages to have control of himself
o “I will report any redness or swelling of the
wound”  Nicanor become verbally assaultive to the nurse. He
says, “Ikaw, nurse, wala kanga lam! Marunong pa
 After cystoscopy, Mr. Santos asked you to explain ako saiyo, e. Ano ba ang pinagmamalaki mo!” The
why there is no incision of any kind. What do you tell nurse responds therapeutically by:
him? o Acknowledging his behavior, put him in his
o “Cystoscopy is an endoscopic procedure of right senses; respond with, “Oo nga, galit
the urinary tract” ka sa nurse pero hindi tama na naninigaw
ka.”
 Situation - The nurse visited the Reyes family to
check on their two growing children, aged 7 and 4  Situation – As a nurse, you should be aware and
years. Upon her visit she observed that common prepared of the different roles you play.
areas of arguments between Mr. and Mrs. Reyes are  What role do you play when you hold all client’s
about conflicting ways of bringing up their children. information entrusted to you in the strictest
Mrs. Reyes is lax and tolerant while Mr. Reyes often confidence?
insists strict ways to a point of over protectiveness o Patient’s advocate
from what he perceives as unsafe i.e., community
and neighbours that cannot be trusted.  As a nurse, you can help improve the effectiveness
 Mr. Reyes remarked “I am way about visiting- with of communication among healthcare givers by:
all the media news about child kidnapping and o One-on-one oral endorsement
robberies.” – The Nurse’s BEST response would be:
o “I acknowledge what you are saying. My
concern is the health care of your family  As a nurse, your primary focus in the workplace is
and information are strictly confidential.” the client’s safety. However, personal safety is also a
concern. You can communicate hazards to your co-
 Mrs. Reyes expressed that her socializing with workers through the use of the following EXCEPT:
neighbors is limited because her husband thinks she o Posting IR in the bulletin board
is getting overly friendly with a guy next door. Which
of the following would the nurse emphasize as  As a nurse, what is one of the best way to reconcile
basic? medications across the continuum of care?
o Keeping trust in the relationship o Communicate a complete list of the
patient’s medication to the next provider
 For the nurse to be effective in developing rapport of service
with the family it is essential that she keeps her
appointment on time and stick to a care plan. She is  As a nurse, you protect yourself and co-workers
applying the principle of: from misinformation and misrepresentations
o Consistency and predictability through the following EXCEPT:
o Endorsement thru trimedia to advertise
 Which of these communicate unconditional your favorite disinfectant solution
acceptance of Anita and her situation?
o “You are safe here and I am ready to  Situation – The nurse engages the client in a nurse-
listen” patient interaction

 Situation - Through the nurse-patient relationship,  The best time to inform the client about terminating
the nurse intervenes utilizing effective the nurse-patient relationship is:
communication techniques. The following are varied o at the start of the relationship
situations in a psychiatry ward.
 The patient verbalizes, “Masama ang pakiramdam  The client says, “I want to tell you something but can
ko. Hindi ako nakatulog kagabi.” A therapeutic you promise that you will keep this a secret?” A
response of the nurse would be: therapeutic response of the nurse is:
o “Maari mo bang sabihin sa akin ang mga o “Yes, our interaction is confidential
naiisip at nararamdaman mo?” provided the information you tell me is not
detrimental to your safety.”
 Page 12 of 16

 When the nurse respects the client’s self-disclosure,

this is a gauge for the nurse’s”  When the nurse is asked a personal question, which
 ANS: professionalism of these reactions indicate a need for her to
introspect?
 Rapport has been established in the nurse-client o His/Her right to privacy is being intruded.
relationship. The client asks to visit the nurse after
his discharge. The appropriate response of the nurse  It is 10 o’clock on your watch. The client asks, “What
would be: time is it?” The nurse’s appropriate response is:
o “The best time to talk is during the nurse- o “It is 10 o’clock.”
client interaction time. I am committed to
have this time available for us while you
are at the hospital and ends after your  Situation – Cathy, mother of 2 young kids, 36 years
discharge.” old, had a mammogram and was told that she has
breast cysts and that she may need surgery. This
 The client has not been visited by relatives for causes her anxiety as shown by increase in her pulse
months. He gives a telephone number and requests and respiratory rate, sweating and feelings of
the nurse to call. An appropriate action of the nurse tension.
would be:  Considering her level of anxiety, the nurse can best
o Assist the client to bring his concern to the assist Cathy by:
attention of the social worker. o Giving her clear but brief information at
the level of her understanding

 Situation – The nurse is often met with the following  Cathy blames God for her situation. She is easily
situations when clients become angry and hostile. provoked to tears and wants to be left alone,
refusing to eat or talk to her family. A religious
 To maintain a therapeutic eye contact and body person before, she now refuses to pray or go to
posture while interacting with angry and aggressive church stating that God has abandoned her. The
individual, the nurse should: nurse understands that Cathy is grieving for her self
o keep an “open posture, e.g. Hands by sides and is in the stage of:
but palms turned outwards o anger

 During the pre-interaction phase of the N-P  The nurse visits Cathy and prods her to eat her food.
relationship, the nurse recognizes this normal Cathy replies, “What’s the use? My time is running
INITIAL reaction to an assaultive or potentially out.” The nurse’s best response would be:
assaultive person. o “You sound like you are giving up.”
o Display empathy towards the patient
 The nurse feels sad about Cathy’s illness and tells her
 Which of the following is an accurate way of head nurse during the end of shift endorsement
reporting and recording an incident? that, “it’s unfair for Cathy to have cancer when she is
o “When asked about his relationship with still so young and with two kids.” The best response
his father, client clenched his jaw/teeth, of the head nurse would be:
made a fist and turned away from the o Advise the nurse to “be strong and learn to
nurse.” control her feelings”

 To encourage thought, which of the following  Realizing that she feels angry about Cathy’s
approaches is NOT therapeutic? condition, the nurse learns that being self-aware is a
o “Why do you feel angry?” conscious process that she should do in any situation
like this because:
 A patient grabs a chair and about to throw it. The o The nurse has to be therapeutic at all times
nurse best responds saying, and should not be affected
o “Stop! Put that chair down.”
 Situation - while working in a tertiary hospital, you
 Situation – It is common that clients ask the nurse are assigned to the medical ward.
personal questions.  Your client, Mr. Diaz, is concerned that he cannot
pay his hospital bills and professional fees. You refer
 Anticipation of personal questions is given adequate him to a:
attention during which phase of the nurse patient o Social worker
relationship?
o Working phase  Mr. Magno has lung cancer and is going through
chemotherapy. He is referred by the oncology nurse
 If the client asks for the nurse’s telephone number, to a self-help group of clients with cancer to:
which of these responses is NOT appropriate? o Receive emotional support
o “It is confidential I just don’t give it to
anyone.”  A diabetic hypertensive client, Mrs. Linao, needs a
change in diet improve her health status. She should
 When the client asks about the family of the nurse, be referred to a:
the MOST appropriate response is: o Dietician

o Give a brief and simple response and focus  When collaborating with other health team
on the client. members, the best description of Nurse Rita’s role is:
 Page 13 of 16

o Shares and implements orders of the  Situation - The perioperative nurse collaborates with
health team to ensure quality care the client, significant others healthcare providers.
 Patient outcomes reflect the collaborative
 Nurse Rita is successful in collaborating with health interdisciplinary effort and independent nursing
team members about the care of Mr. Linao. This is activities. Who is the primary partner of the nurse in
because she has the following competencies: health care?
o Communication, trust, and decision  c. The client
making
 To control environmental hazards in the OR, the
 Situation - The following questions refers to nurse’s nurse collaborates with the following departments
efforts to do collaboration and teamwork. Select the EXCEPT:
best answer. o Chaplaincy services

 The most important role of the nurse as a member  Waste disposal poses a big problem for the hospital.
of the team is to: Biological wastes (i.e., amputated limbs) disposal
o Coordinate the physiological care and should be coordinated with the following agencies
management of clients EXCEPT:
o Crematorium . MMDA
 A biological/medical approach to patient care utilizes o DOH DILG
which of the following?
o Somatic therapy  Tess, the PACU nurse discovered that Malou, who
weighs 110lbs prior to surgery, is in severe pain 3
 Which of these nursing actions belong to the hours after cholecystectomy. Upon checking the
secondary level of preventive intervention? chart, Malou found out that she has an order of
o Providing emergency psychiatric services Demerol 100 mg I.M. pm for pain. Tess should verify
the order with:
 When the nurse identifies a client who has attempt  c. Surgeon
to commit suicide the nurse should:
o Refer the client to the psychiatrist  Rosie, 57, who is diabetic, is for debridement of
incision wound. When the circulating nurse checked
 The community health nurse was invited by the the present IV fluid, she found out that there is no
principal of an elementary school and was asked to insulin incorporated as ordered. What should be
give a task to parents. An appropriate topic would circulating nurse do?
be: o Communicate with the ward nurse to
o Disciplining children at home and in school verify if insulin was incorporated or not

 Situation - Collaborative planning is essential if  Situation – Concerted work efforts among members
nursing and health care are to be made available to of the surgical team is essential to the success of the
all people. surgical procedure.
 The sterile nurse or sterile personnel touch only
 Perioperative examples of collaboration are the sterile supplies and instruments. When there is a
following EXCEPT: need for sterile supply which is not in the sterile
o Collaboration with other OR personnel field, who hands out these items by opening its
regarding the practices of surgeons outer cover?
collecting exobirant professional fees.  ANS: Circulating nurse

 the nurses collaborate with other members of the  The OR team performs distinct roles for one surgical
health profession to improve the integrity of the procedure to be accomplished within a prescribed
hospital working environment through the following time frame and deliver a standard patient outcome.
ways EXCEPT: While the surgeon performs the surgical procedure,
o Joining the Mayo Uno Labor Union who monitors the status of the client like urine
output, blood loss?
 An example of a collaborating effort on public o ANS: Anesthesiologist
service particularly during summer is:  Surgery schedules are communicated to the OR
 c. Clean and Green usually a day prior to the procedure by the nurse of
the floor or ward where the patient is confined. For
 When does a nurse reject the interdependence of orthopedic cases, what department is usually
providers and patients in achieving access to health informed to be present in the OR?
care? o ANS Radiology department
o “Our hospital does not honor visiting  Minimally invasive surgery is very much into
doctors” technology. Aside from the usual surgical team, who
else has to be present when a client undergoes
 Individual patients and society as a whole benefit laparoscopic surgery?
from nursing participation in decisions made about o ANS: Laboratory technician
health care. This is exemplified in:
o Following the decision of CGFNS to retake
Test III and V to validate the visa screen for  In massive blood loss, prompt replacement of
the U.S. compatible blood is crucial. What department needs
to be alerted to coordinate closely with the patient’s
family for immediate blood component therapy?
 Page 14 of 16

o Pathology department  While eating his meal, Matthew accidentally

dislodges his IV line and bleeds. Blood oozes on the
surface of the over-bed table. It is most appropriate
 Situation – Nurses hold a variety of roles when that you instruct the housekeeper to clean the table
providing care to a perioperative patient. with
 Which of the following role would be the o Bleach
responsibility of the scrub nurse?
o Account for the number of sponges,  You are a member of the infection control team of
needles, supplies, used during the surgical the hospital. Based on a feedback during the
procedure meeting of the committee there is an increased
incidence of pseudomonas infection in the Burn Unit
 As a perioperative nurse, how can you best meet the (3 out of 10 patients had positive blood and wound
safety need of the client after administering culture). What is your priority activity?
preoperative narcotic? o Establish policies for surveillance and
o Put side rails up and ask client not to get monitoring.
out of bed
 Part of your responsibility as a member of the
 It is the responsibility of the pre-op nurse to do skin diabetes core group is to get referrals from the
prep for patients undergoing surgery. If hair at the various wards regarding diabetic patients needing
operative site is not shaved, what should be done to diabetes education. Prior to discharge today, 4
make suturing easy and lessen chance of incision patients are referred to you. How would you start
infection? prioritizing your activities?
 ANS. Clipped o Determine their learning needs then
prioritize
 It is also the nurse’s function to determine when
infection is developing in the surgical incision. The  You have been designated as a member of the task
perioperative nurse should observe for what signs of force to plan activities for the Cancer Consciousness
impending infection? Week. Your committee has 4 months to plan and
o Serosanguinous exudates and skin implement the plan. You are assigned to contact the
blanching various cancer support groups in your hospital. What
will be your priority activity?
 Which of the following nursing interventions is done o Clarify objectives of the activity with the
when examining the incision wound and changing task force before contacting the support
the dressing? groups
o Wash hands
 You are invited to participate in the medical mission
 Situation – Team efforts is best demonstrated in the activity of your alumni association. In the planning
OR stage everybody is expected to identify what they
 If you are the nurse in charge for scheduling surgical can do during the medical mission and what
cases, what important information do you need to resources are needed. You thought it is also your
ask the surgeon? chance to share what you can do for others. What
will be your most important role where you can
o Who is your assistant and anesthesiologist, demonstrate the impact of nursing in health?
and what is your preferred time and type o Conduct health education on healthy
of surgery lifestyle

 In the OR, the nursing tandem for every surgery is: BOARD EXAMINATION – NURSING PROCEDURES
o Scrub and circulating nurses COLOSTOMY CARE
1. Gather equipment.
 While team effort is needed in the OR for efficient 2. Place the patient in supine position.
and quality patient care delivery, we should limit the 3. Wash hands.
number of people in the room for infection control. 4. Don gloves.
Who comprise this team? 5. Remove old pouch by grasping pouch and gently
o Surgeon, assistants, scrub nurse, pulling away from skin. (You may use warm water
circulating nurse, anesthesiologist or an adhesive solvent to loosen the seal.)
6. Discard gloves.
 When surgery is on-going, who coordinates the 7. Wash hands and don new pair of gloves.
activities outside, including the family? 8. Gently wash stoma area with warm, soapy water.
o Nurse supervisor 9. Dry skin thoroughly.
10. Assess (and document after procedure):
 The breakdown in teamwork is often times a failure Stoma: Appearance
in: Peristomal skin: Condition
o Communication Feces: Amount, color, consistency, and presence of
unusual odor
 Situation – As a member of the health and nursing Emotional status
team you have a crucial role to play in ensuring that 11. Temporarily cover stoma with a gauze pad to
all the members participate actively is the various absorb drainage during ostomy care.
tasks agreed upon. 12. Apply skin prep in a circular motion. (Allow to air
dry for approximately 30 seconds.)
 Page 15 of 16

13. Apply skin barrier in a circular motion. Medical-Surgical

14. Measure stoma using a stoma guide. DRESSING CHANGE, STERILE
15. Cut ring to size. 1. Explain procedure to the patient.
16. Moisten ring with warm water and rub it until 2. Wash hands.
sticky, or remove paper backing from adhesivebacked 3. Place bedside table near the area to be dressed.
ring. 4. Gather supplies and place on bedside table.
17. Center ring over the stoma, gently pressing it to the 5. Place a disposable cuffed bag within reach of the
skin. (Smooth out any wrinkles to prevent seepage work area.
of effluent.) 6. Position and drape the patient in a comfortable
18. Center faceplate of bag over stoma and gently press position, exposing the area to be dressed.
down until completely closed. 7. Open sterile gloves and retain the inside of the
19. Document procedure and assessments from step 10 glove package for use as a sterile field.
(above): 8. Open sterile gauze pads and all supplies needed,
Example: Colostomy bag changed, stoma pink, peristomal and drop them onto the sterile field.
skin intact without signs of irritation. 70 mL of 9. Open the prescribed cleansing agents and pour onto
liquid greenish stool discarded with old colostomy at least two gauze pads.
bag. Patient looked away during procedure and 10. Don nonsterile gloves.
appeared to ignore nurse’s verbal communication. 11. Place a towel or waterproof pad under wound area.
12. Remove tape and soiled dressing (soak dressing in
sterile saline if it adheres to wound), noting the
COLOSTOMY IRRIGATION appearance of the wound, drain placement (if any),
1. Explain procedure to the patient and encourage suture or skin closure integrity; and amount, color,
participation. and consistency of the drainage on the dressing.
2. Position in a side-lying position or sitting on the 13. Discard the dressing in a cuffed trash bag.
toilet in bathroom if bed rest is not necessary. 14. Remove and place gloves into the trash bag.
3. Place bedpan on top of a disposable pad beneath 15. Wash hands.
stoma (if patient is in bed). 16. Don sterile gloves.
4. Fill solution bag with prescribed type and amount 17. Use gauze pads (which may be lifted with sterile
of irrigating solution, expelling air from irrigating forceps) to cleanse the wound with prescribed antiseptic
tube prior to insertion. solution. Cleanse the wound from the center
5. Hang solution bag 12 to 18 inches above the outward, using a new gauze pad for each outward
stoma. motion.
6. Don gloves. NOTE: Iodine solutions may cause skin irritation
7. Remove stoma appliance. if they are left on the skin between dressing
8. Place irrigation drainage sleeve over the stoma, changes.
attaching it snugly to prevent seepage of fluid onto 18. Discard used gauze pads into the cuffed bag, away
the skin. from the sterile field.
9. Place opposite end of drainage sleeve into bedpan 19. Apply sterile dressings to the incision or wound site
or toilet. one at a time. (If a drain is present, use a precut
dressing to fit around the drain.)
10. Dilate stoma, if ordered, by gently inserting the 20. Apply ABD pad if needed. (The blue line down the
lubricated tip of gloved fifth finger into stoma (use middle of the pad marks the outside surface.) the technique
a massaging motion to relax the intestinal muscle of applying several layers (the
until maximum dilation is accomplished). number of layers depends on the size of the
11. Lubricate tip of stoma cone or catheter. wound area and the patient) of saline-soaked
12. Insert stoma cone or catheter by using a rotating motion dressings next to the wound and covering these
until it fits snugly (about 3 inches). Do not with dry dressings.
insert against resistance. 21. Apply tape over the dressing or secure it with
13. Open tubing clamp, allowing irrigating solution to Montgomery ties.
flow into the bowel slowly. (If cramping occurs, 22. Discard supplies and used gloves into a trash bag.
stop flow until cramps subside.) 23. Wash hands.
14. After instillation of fluid, remove cone or catheter, 24. Document observations of the wound, dressing,
and allow colon to empty. drainage, dressing change, and patient response.
15. Gently massage the abdomen to encourage Example: Abdominal dressing changed. Small amount
emptying of colon (usually takes up to half an serosanguineous drainage on old dressing. Wound
hour). cleansed with H2O2. Wound edges approximated well.
16. Empty and remove irrigation sleeve.
17. Discard old gloves and don new pair. ENEMA ADMINISTRATION
18. Clean area around stoma. 1. Explain procedure to the patient.
19. Apply colostomy appliance. 2. Provide privacy.
20. Wash hands. 3. Gather all equipment.
21. Document type and amount of irrigation solution 4. Position the patient in left side-lying position with
instilled; size, color, and consistency of returned the right knee flexed (dorsal recumbent position for
solution; patient response; and complications. infants and small children).
Example: Colostomy irrigated with ——mL NS. 5. Place waterproof pad under the patient’s hips and
Solution returned with moderate amount loose, buttocks, and drape to expose anal area only.
greenish fecal material. No complaints during procedure. 6. Prepare the solution as ordered.
States she irrigates colostomy once a day at 7. Lubricate 2 inches of rectal tube to facilitate insertion.
home. 8. Open the clamp to allow solution to run through
and expel air from tubing. Reclamp tubing.
 Page 16 of 16

9. Place a bedpan near the bedside. 11. Check for proper tube placement in the stomach by
10. Don gloves. aspirating with a syringe for gastric drainage or by
11. Instruct the patient to take slow deep breaths to instilling about 20 mL of air into the NG tube while
facilitate relaxation. listening with a stethoscope for a gurgling sound
12. Separate the buttocks and insert rectal tube, directing over the stomach.
it toward the umbilicus about 3 to 4 inches. 12. Secure the tube after checking for proper placement
13. Raise the enema container about 12 to 18 inches by cutting a 3-inch strip of 1-inch tape and then
above the rectum and open the regulating clamp. splitting the tape lengthwise at one end, leaving 1
14. Administer the fluid slowly. inch intact at the opposite end
15. Lower the container or clamp the tubing if the 13. Place the intact end of the tape on top of the
patient experiences cramping.Medical-Surgical patient’s nose, and wrap one side of the split tape
16. After the solution is instilled, close the clamp and end around the tube and secure on a nostril. Repeat
remove the rectal tube. with the other split tape end.
17. Instruct the patient to retain solution as long as possible 14. Connect the NG tube to suction if ordered, or
(5 to 10 minutes for cleansing enema, 30 minutes clamp.Medical-Surgical
for retention enema). 15. Wrap adhesive tape around the distal end of the
18. Assist the patient to the bathroom or position him tubing and attach a safety pin through the tape tab
or her on the bedpan. to the patient’s gown.
19. Discard equipment. 16. Document the size and type of tube inserted. Note
20. Remove gloves and wash hands. the nostril used and the patient’s tolerance of the
21. Document the type and amount of enema solution procedure. Document how placement was validated
administered; approximate amount, color, and consistency and whether tubing was left clamped or attached to
of expelled material; and patient response. other equipment.
Example: Positioned on left side, NS enema, 500 mL Example: Number 10 NG tube placed per R naris and
given. Lg. amt. formed brown stool returned with secured with tape. Procedure tolerated well. Tube
enema solution. Complained of abdominal cramping placement validated by auscultation while instilling
during procedure. Quietly watching TV following procedure. air into stomach. Distal tubing clamped.
PEDIATRIC ADAPTATION PEDIATRIC ADAPTATION
The amount of enema solution used for infants and small Infant
children ideally is ordered by the physician. Caution should Follow adult procedure with these adaptations:
be used if it is necessary to give an enema to a premature 1. Sharply bend NG tube about 1/4 to 1/2 inch from tip.
or low-birth-weight infant. A 5- to 10-mL syringe attached (There is a sharp bend “downward” almost immediately
to a number 5 feeding tube can be used for the procedure. after insertion of tube into the nostril.)
Solutions may usually be given to other children as follows: 2. Flex the infant’s head gently onto the chest with your
Age Amount of Solution Tube Insertion nondominant hand. Nasogastric tube insertion; method of
Infant 100 mL 1 in securing tube with tape3. With the dominant hand, insert the
2–4 yr 200 mL 2 in tube using a
4–10 yr 200–400 mL 3 in downward motion almost immediately after the tube
Over 10 yr 500 mL 3 in enters the nostril.
4. Because the infant’s chest is small and sounds are
NASOGASTRIC TUBE INSERTION conducted throughout the chest and abdomen, auscultation
1. Gather the necessary equipment. of sounds may give a false impression of
2. Explain procedure to the patient. placement. Other standard methods of placement validation
3. Wash hands. may be used. A sensitive method of placement
4. Position the patient in a sitting position.Medical-Sur 5. validation for the infant is to place your hand
Check nostrils for patency by asking the patient to flat over the stomach area while forcing 2 to 3 mL of
breathe through one naris while occluding the air through the tube. Vibrations that reveal the location
other. of the tube tip can usually be felt through the
6. Measure length of NG tubing to be inserted by abdominal wall.
measuring the distance from tip of nose to ear-lobe Toddler or Preschooler
and from ear-lobe to about 1 inch beyond base of 1. Demonstrate the procedure on a doll.
xiphoid process. Use a small strip of adhesive tape 2. One or two additional people are usually needed to
to mark the measured distance on the tube. help restrain the child. The parent should not be
7. Don gloves and lubricate tube in water or a watersoluble asked to assist with child restraint.
lubricant. (Never use mineral oil or petroleum
jelly.)
8. Ask the patient to tilt his or her head backward, and
gently advance the NG tube into an unobstructed
nostril; direct tube toward back of throat and down.
9. As the tube approaches the nasopharynx, ask the
patient to flex head toward chest (to close the trachea)
and allow him or her to swallow sips of water
or ice chips as the tube is advanced into the esophagus
(about 3 to 5 inches each time the patient swallows).
NOTE: If the patient coughs or gags, check the
mouth and oropharynx. If the tube is curled in
the mouth or throat, withdraw the tube to the
pharynx and repeat attempt to insert the tube.
10. Ask the patient to continue swallowing until the
tube reaches the premeasured mark.