Nursing Practice I

Situation: Loss and grief affect not only the clients and their families but also the nurses who
care for them. It is essential for the nurse to have a thorough understanding of a clients loss and
meaning of loss to the client.

A 55 year old client is terminally ill with advanced cancer of the ovary. To assist and
comfort her the nurse should:
o Provide support to the client
Upon learning about her condition, the client says to the nurse Why me? I did not do
anything wrong. What response of the nurse is most appropriate?
o This must be very difficult for you.
The client is in severe pain and manifest signs of impending death. The husband asks the
nurse if his wife is going to die soon. Which of the following is the most appropriate
response of the nurse?
o You are concerned that your wife will die?
The client has just died with her family around her. What appropriate nursing action
should the nurse make?
o Allow the family time with the deceased client.
The body is being prepared for transfer to the mortuary. Which of the following is the
most appropriate action of the nurse?
o Record the time of death

Situation : in teaching good sleep hygiene to adult clients, the nurse encounters clients in a
variety of situations that need some guidance and assistance.

When talking to a client to assess her sleeping difficulties, the nurses most therapeutic
communication would be:
o Do you take naps during the day?
To promote good sleep hygiene, the nurse teaches the client to doo the following
EXCEPT :
o Limit the use of bedroom for intensive work, studying, eating or watching t.v.
The client is concerned that sleeping during the day and being awake at night is abnormal
and unhealthy. The nurses most therapeutic response is:
o What makes you think that your habit sleeping during the day and being up at
night is unhealthy or abnormal?
Which of the following questions by the nurse will help identify possible causes of
clients sleep problems?
o What time do you usually sleep?

The client has obstructive sleep apnea (OSA) and has disrupted sleep. He asks the nurse
about the possible serious consequence of OSA. The nurses most appropriate response
would be the following EXCEPT:
o Alzheimers Disease

Situation: Total quality improvement is based on the premise that the process is ongoing and that
quality can always be improved.

While giving care to the client in Medical Unit, the nurse observes that a 65 year old male
bedridden client has been put over the site in order to:
o Protect the area from injury.
A bedridden client has a nasogastric tube and an intravenous line. The client appears
disoriented and attempts to remove both contraptions. What action of the nurse should be
done to protect the client from injuring himself?
o Ask the physician for an order for wrist restraints.
The nurse is taking care of a client receiving chemotherapy. She is concerned about the
clients nutritional status and aims to improve the appetite of the client. The nurse would:
o Administer medications before meals.
The nurse is evaluating the nutritional status of the client. Which of the following
parameters should be observed by the nurse?
o Stable weight
While completing the final preparations for a 12 year old child who is scheduled for
appendectomy, the nurse sees the mother applying hot water bag in the childs abdomen
for relief of pain. The nurse should tell the mother that the hot water bag may:
o Cause the appendix to rupture.

Situation 4: The nure has been assigned to take care of a client who has an endotracheal tube.
She noted thickening secretions.

Which of the following is the MOST appropriate nursing intervention to loosen the
secretions?
o Perform chest physiotherapy and assess the respiratory rate status
In performing endotracheal suctioning, the nurse should apply suction while:
o Rotating the catheter gently for not more than 10 seconds
The nurse is monitory the cuff pressure. To minimize the risk of tracheal tissue necrosis
the nurse should maintain the pressure to:
o 30-35 mmHg
The nurse is providing oral and nasal care every 2 to 4 hours to the client. As
precautionary measure for possible biting down of the oral endotracheal tube, the nurse
should:
o Have an assistant to hold the client

The head nurse reminds the staff nurse about measures that must be strictly observed
when suctioning the client with endotrahceal tube. Which of the following is the MOST
appropriate measure during?
o Hyperoxygenating the client before and after the procedure.

Situation5: The following situations are opportunities for the nurse to give health teachings.

A client who had a cerebrovascular accident resulted in right sided weakness of the
extremities and mild slurring of speech. The nurse is assisting the client to ambulate. To
prevent the client from falling, the nurse should stand at the:
o C. Right side with one arm around the clients arm
The use of principles of body mechanics is important when taking care of clients. To
prevent injury to self and other, the nurse teaches the family members to do which of the
following?
o B. Form a broad base of support, flex the knees and keep the feet wide apart.
The clinic nurse in a large factory, teaches some exercise to some office workers, which
of the following statements is the most appropriate?
o B. The best cardiovascular activity is walking on a treadmill
An elderly client has been taught how to use crutches in going up and down the stairway.
You observe that the clients use of crutches is appropriate when he:
o B. Advances the crutches first to go up the stairs then the affected leg.
A mother calls the emergency Unit to ask for advice after she founf her child seated in
the bathroom floor with cleanser around her mouth and tongue. The appropriate advice
given to the mother would be:
o C. Call the poison control of a general hospital

Situation 6: A 21 years old female is admitted in the Surgical Ward and is placed in traction. She
has been in bed and is very frustrated because she cannot do her usual daily activities

The nursing diagnosis that is most appropriate for the client is

o C. Activity intolerance
Limitations in the activity-exercise routine of a client affect her self-esteem. To help
increase the clients self-esteem, the nurse understands that:
o B. Being confined in bed with no productive activity causes depression
The nurse maintains the clients good body alignment while she is on traction in order to:
o B. Maintain body posture and strength
The nurse considers the following statements when taking care of a client with traction
EXCEPT:
o B. Weights should be kept resting on the floor
Part of nursing care for the client on traction is giving instructions for isometric exercises

o D. Maintain muscle strength

Situation 7: An understanding of the infectious process and appropriate methods to protect the
health workers and client from disease is important. The following questions pertain to
preventing transmission of infection.

The nurse is explaining standard precaution to the client. This includes which of the
following actions?
o S. Wearing protective equipment when doing any nursing procedures
The nurse is changing the wound dressing of the client. The MOST appropriate action od
the nurse would be to :
o C. Open the sterile dressings with the sterile gloves.
The client has an order for contact precaution. The nurse is to give her a bath. The
precautionary measure that the nurse observes is to use:
o C. Gloves and gown.
The clinical instructor in the Surgical Unit is teaching the nursing students about the
prevention of spread of diseases in the health care environment. Which of the following
is the MOST important practical way to prevent the spread of disease?
o A. Consistently washing hands
The nurse is to perform a sterile procedure while assisting in minor surgery. Which of the
following actions of the nurse maintain aseptic technique?
o A. Keeping the sterile field within the view
A staff nurse in the emergency room is well-like by her colleagues because she could
easily relate well with the co-workers. For the past 2 months she has been absent 4-5
times. She has been given a written admonishment for unexcused absence. Which of the
following is the best course of action of the head nurse.
o B. Dismissal

Situation 9: A nurse in the Medical Unit suspects that a colleague is abusing chemical while on
duty. Irregular reports in narcotics medication sheet are noted when she is on duty

Which of the following should be appropriate action of the nurse?

o D. Write an incident report and submit to administration
To be vigilant when a co-worker is suspected of abusing chemicals, it is imperative for
the nurse to assess which of the following substances abuse indications
o Defensive when questions on the discrepancies in the narcotic control
o Excessive work related tardiness, absence and accidents
o Accurate but sloppy documentation
o Social isolation
o A. 123

Health care agencies have policies in place for Do Not Resuscitate(DNR) decisions
when the client is either comatose or near death. In this situation, which of the following
should be the responsibility of the nurse?
o B. Ascertain that a written order DNR from the physician is in place
Which of the following should the nurse take into consideration, when the client has
DNR order?
o A. The DNR order is not separate from other aspects of clients care
A nurse in the Cancer Unit is in a quandary in carrying out a DNR order due to personal
beliefs. Which of the following should be the appropriate action of the nurse in this
situation?
o A. Seek counselling session with the nurse supervisor on duty
o B. Seek comfort and allay ones fears through stress management
o C. Ignore personal beliefs and feelings in the situation
o D. Consider a change of assignment

Situation 10: A nurse is a member of the multidisciplinary health team. In working with the
team, client and family are important considerations in the formulation of goals and planning of
care.

Doctors orders are medical interventions that the nurse is expected to implement. By
education and training the nurse may choose not to follow doctors order. Which of the
following statement is NOT true?
o A. The nurse has less training than the doctor and clarifying an order is against
hospital protocol
The nurse carries out nurse-initiated interventions which are referred to as independent
functions. These functions are:
o A. Actions based on nursing diagnoses for the benefit of the client and not under
supervision from other health team members.
A client sustained multiple injuries from a vehicular accident. To maintain his level of
health, he will need the health team. Which of the following illustrate this kind of
interventions?
o Collaborative
A new staff nurse is attending an orientation program. The supervisor emphasizes close
collaboration with the health team as an important function of the nurse. The nurse
demonstrate this when she:
o A. Identifies the community health centers that the client can visit when
discharged.
A client is admitted with a medical diagnosis of acute gastroenteritis with severe
dehydration. The nurse recognizes that when caring for this client, she will be doing
mostly:
o Dependent nursing functions

o
o
o
o

Independent nursing interventions

Discharge planning with the physician in charge
Delegation of nursing functions to the nursing aide
A. 1,2,3

Situation 11 Problems with bowel movement may be experienced by people of different ages. It
can cause enough discomfort or health problems to individuals that require nursing interventions.

An active woman in her mid-twenties has been on weight loss diet of low carbohydrates
and high protein diet. She is successful on losing weight but is experiencing constipation.
Which of the following should the nurse advice the client to AVOID constipation?
o C. Eat nutrient dense food that are low calorie but have high nutrient value and
fiber like broccoli, berries
You are administering soapsuds enema to a client. During the procedure, the cleient
complains of abdominal cramping. Your most appropriate initial nursing approach would
be to :
o A. Clamp the enema tubing to stop flow of the fluids
You are taking care of a client with fecal incontinence. You are aware that this client has
a risk for injury due to:
o A. Falls when trying to go to the bathroom
A client is brought to the hospital due to severe diarrhea. Which of the following is a
major problem of the client requiring immediate management by the health team?
o D. Sever fluid electrolyte imbalance
A client had abdominal surgery under general anesthesia, would most likely experience.
o B. Tolerance for solid food immediately after surgery

Situation12: A researcher investigated the effect of crossing of a leg at the knee during blood
pressure measurement on the clients blood pressure. Participants were recruited from the
outpatients of a government training hospital consisting of 50 males and 50 females,21to70 years
of age with a diagnosis of hypertension.

Which of the following describes this type of research?

o C. Quantitative research
The researcher explains to the participants the nature of the study. Which of the following
describes the action of the researcher?
o A. Full disclosure
The researcher question for this study may be stated as follows:
o B. What is the effect of crossing a leg at the knee on the blood pressure of the
participants
Which of the following is appropriate instrument in measuring the dependent variable?
o D. Observational rating instrument

The researcher found out that the blood pressure measurements are higher when a leg is
crossed at the knee and that the probability is less than 1 in 10,000. With these findings
the researcher concludes that:
o A. There is an increase in blood pressure when a leg is crossed at the knee

Situation 13: Teaching clients about healthy food intake for health promotion and disease
prevention is an important function of the nurse. Nutritional deficiency is preventable if
individuals and families have adequate knowledge about normal nutrition

The nurse is teaching a family to take food with high protein content. She discovers that
the familys consideration is the high cost of food. Which of the following affordable
high protein food should the nurse recommend?
o C. Fried rice and dried fish
During the follow up visit the client ask the nurse foods that are complete in protein
which of the following should the nurse recommend?
o C. Eggs cooked in any style
A mother asks the nurse what finger food is safe for her toddler. Knowing that children
can easily choke on food, the nurse should advice the mother to feed the toddler which of
the following foods?
o B. Cereal like cheerio
A client diagnosed with peptic ulcer asks you what food is best to add to his diet so as not
to exacerbate his symptoms. Which of the following is the most appropriate food for the
client?
o D. Frequent intake of milk
A mother asks if teenagers require special diet since teenagers rapidly grow at this time.
The nurse informs the mother that:
o C. Boys and girls should have food low in calories to prevent adolescent obesity

Situation 14: physical examination is performed to gather comprehensive pertinent assessment

data. Health history ascertains the clients complaints and directs the focus of physical
examination.

While taking the health history of the client, she tells the nurse that she has occasional
episodes of palpitation that would last for about 45 minutes to an hour. To further explore
this information, the BEST question that the nurse would ask the client would be:
o D. How frequently does this episode of palpitation happen to you?
A female client is in the Emergency Unit with chief complaints of difficulty of breathing
and is receiving oxygen inhalation. To obtain a complete health history of the client, the
BEST nursing approach is to:
o A. Focus on the physical examination and obtain data from the chart

A client has just been transferred to the Surgical Unit after knee surgery. The nurse needs
to assess the circulation of the right lower leg. Which of the following is the INITIAL
approach of the nurse?
o B. Inspect the color of the foot
While performing a physical examination to an 82 year old male client, the nurse
modifies her examination to consider the clients general weakness and reduce ability to
move in bed. Which of the following is the MOST appropriate nursing action?
o A. Sequencing the examination to minimize changing clients position
The nurse is auscultating the clients heart. Which of the following is the BEST position
for the client to enable the nurse to hear all areas and high-pitched murmurs?
o Sitting and leaning forward

Situation 15: A male nurse meets a 55 year old client in his room. During interaction, the nurse
feels drawn to the client and later looks forward to seeing the client daily as he does his round.
The nurse realizes that the client looks and acts like his grade school teacher who was kind and
fatherly towards him.

Which of the following best describe the feelings that the nurse experience towards the
client?
o A. Counter transference
The nurse uses the concept of the therapeutic use of self when she:
o A. Becomes self- aware and manages his feeling for the client
The client is informed that he has a stage IV colon cancer, he realizes he is dying and his
family has difficulty with his impending death. The nurse deals with his own personal
feeling about death and grieving in order to:
o B. Assist client and family express feelings on their impending loss
One afternoon, the nurse enters the room and the client tells the nurse Stop bothering
me, leave me alone. I dont want anyones pity. The most appropriate response of the
nurse is to say:
o B. Alright, I understand and will leave you for a while.
A therapeutic relationship exists when the:
o A. Nurse and client work together to talk about how clients needs may be met.

Situation 16: Continuous personal and professional development of the nurse is expected to
provide safe quality care to clients

A post surgical client is assigned to the nurse has an order of pain medication through a
patient controlled analgesia (PCA). The nurse has no prior experience in the use of PA
with clients. Considering the time frame, which of the following is the MOST appropriate
action of the nurse?
o B. Secure assistance before implementation

The focus of care is to shorten hospital stay by moving clients from acute care setting to a
community based care setting which of the following are the components of health care
delivery that are important to improve the health of the general public?
o B. Acute care and community health care setting
When a nurse acts professionally it implies that she:
o C.Is knowledgeable, conscientious and responsible to self and others.
Nursing as a profession requires its member to possess a significant amount of education.
The route for an individual to become an RN in the Philippines is through completion of:
o B. Degree of Bachelor of Science in Nursing and eligible to take the Nurse
Licensure Examination
To remain current un nursing skills knowledge and theory, a nurse who works in a
geriatric unit plans to attend a continuing education program (CPE) in the care of elderly
clients. The following about CPE are true EXCEPT:
o C. It is a response to scientific and technological advances to make nurses
globally competitive.

Situation 17: The Medical Ward have clients with various disease conditions. As newly hired
nurse, you are challenged to update knowledge and skills in the provision of nursing care.

When administering oxygen therapy to a client the LEAST likely to cause anxiety is the
use of:
o D. Nasal cannula
Which of the following is a major consideration in determining the method oof oxygen
administration to a specific client?
o A. Pathologic condition of the client
The nurse is assisting a client who has an order for postural drainage. To help the client
obtain maximum benefits after the procedure, the nurse should:
o C. Elevate the head of the bed to promote comfort.
When doing postural drainage for the client, measures should be taken to minimize which
of the following conditions?
o 1. Fatigue and pain
o 2. Dyspnea
o 3. Anxiety and discomfort
o 4. Coughing
o C. 1,2,3
The nurse is taking care of a client with asthma. During auscultation, she expects to hear
wheezing which would sounds like:
o C. High pitched musical sounds

Situation 18: A 7 year old client is brought to the emergency room for pas sing fresh blood upon
defecation. The client is actively bleeding and his blood pressure drops to 80/50. Fluids and
blood transfusion of packed RBC are ordered immediately

This is the first time the client will have a blood transfusion. He and his family are very
worried about the procedures. Your MOST appropriate nursing intervention would be:
o A. Talk to the client and family and inquire what their fears about blood
transfusion
The nurse prepares the following equipment for blood transfusion EXCEPT:
o B.IV infusion set with gauge 22 needle
The nurse understands that normal saline solution is used to initiate the intravenous
infusion rather than dextrose solution before blood transfusion to:
o D. Avoid hemolysis and clumping of red blood cells
The nurse stays and observes closely the client after the start of the blood transfusion for
possible transfusion reaction which includes the following except:
o A. Hypovolemic reaction
After starting blood transfusion , the nurse should make sure that the blood is transfused
to the patient within how many hours from the time it started?
o D. 4 hours

Situation 19: The nurse is assigned to take care of elderly female client with different needs
while in the Medical Ward

While examining an elderly female client , the nurse notes musky sour body odor of the
client indicating poor hygiene. Which of the following is the MOST appropriate action of
the nurse?
o D. Help the client bathe several times weekly
The client is weak and needs to be moved up in her bed. To reduce shearing force when
moving the client the nurse should:
o D. Use a draw sheet to put the client in correct position
The client has been on bed rest and has reddening of the skin at bony prominences. When
moving the client up in her bed the nurse places her arms across her chest. This is done
to:
o C. Reduce the surface that will come in contact with the bed.
The nurse reports that a client, appears uncomfortable and covers herself with bed sheets
on a warm day. The nurse asks permission to pill out the sheet but noted urine smell and
wet bed sheets. She persuades the client to get up and shower. The client refuses and
becomes teary eyed. The most appropriate therapeutic statement by the nurse would be:
o D. I understand how you feel but it is my responsibility to take care of you.
The client agrees to take a shower. While the client is being assisted to the bathroom she
begins to fall. Which of the following should be the initial action of the nurse

o A. Call for immediate help

Situation 20: Understanding clients needs depends upon the ability of the nurse to communicate
therapeutically

A client in her early twenties was recently diagnosed with breast cancer. She says to the
nurse, Why did this happen to me? Do I deserve this when I have been very good to
others?
o B. Provide reassurance by recognizing how difficult her situation must be.
The nurse found a 28 year old client who had hysterectomy crying while alone in her
room. What should be the nurses initial approach?
o A. Ask her what seems to be troubling her.
The doctor orders the insertion of nasogastric tube for the client who refused to eat. She
has severe weight loss. She remove the tube and says, I dont need that thing the most
appropriate nursing response is:
o D. Tell me what you dont like about the tube?
A client is admitted to the hospital for diabetes accompanied by her son. The son is
telling the nurse about his difficulty in taking care of his mother. The nurse is using nontherapeutic communication when she says:
o A. Maybe putting her in a home for elderly people will be best for her.
The nurse is establishing her presence to the client as part of her nursing care. This is best
interpreted as:
o A. Being with the client always