RECALLS 6: NURSING PRACTICE 3

7. Maggie, a newly hired nurse, was pulled out from the Pediatric
Situation: A nasogastric tube (NGT) was ordered by the
Unit by the Supervisor and assigned to the Surgical ward
Emergency physician to a male patient suffering from head
temporarily for the shift at four o'clock in the afternoon. She has
trauma after undergoing thorough physical examinations and
to feed a post—operative patient who had a tracheostomy and
diagnostic tests. The physician diagnosed him to have a
nasogastric tube (NGT) as well. The feeding was mistakenly
basilar skull fracture.
infused to the tracheostomy instead of -infusing it to the NGT.
Helen can be liable for .
1. What PRIORITY nursing action should be done to the patient A. assault
considering his present condition? B. malpractice
A. Test the gastric content for blood. C. tort
B. Attempt to place the tube into the. duodenums. D. negligence
C. Check patency of airway before nasogastric tube insertion.
D. Use extra lubrication when inserting the nasogastric tube. 8. Rene is a staff nurse who was assigned to the medical ward.
The physician ordered 20 units of insulin injection to a client with
Rationale: NGT for basilar skull fracture is still okay but there diabetes. Nurse Rene administered 20 cc. of insulin instead.
should be “extras” to be done After 30 minutes the client developed hypoglycemia and died.
Nurse is liable for
A. negligence
2. Another patient is in need of a nasogastric tube. The nurse, B. tort
while inserting the tube, observes that the patient started to C. malpractice
cough and showed difficulty breathing. Which of the -following D. assault
is the BEST nursing action to be done in this situation?
A. Quickly remove the tube and let the patient rest.
B. Remove the tube and reinsert when difficulty of Rationale: 100 units = 1 cc of insulin
breathing subsides.
C. Notify the doctor at once and inform him of your observation 9. A staff nurse was caught by her supervisor administering high
D. Pull back the tube and wait for further order. doses of morphine to a patient with leukemia for a fee of 25,000
thousand pesos given by the mother. The nurse is liable for?
Rationale: ideally, removal is not done but only to pull back A. assault
slightly; DOB could be d/t placement in the wrong area B. tort
(trachea) C. bribery - is more on the act of the nurse
D. malpractice

3. Nurse Barbara is assessing the correct placement of the tube,

aspiration of the stomach contents as well as checking for PH. Rationale: liability is being asked
Which PH value result confirms the placement of the tube is in
place? 10. Nurse Cleo is assigned to a cranky and demanding patient
A. 6.0 suffering from peripheral neuropathy. One day the patient was
B. 7.35 chilling and needed blankets and a hot water bag (HWB). Nurse
C. 6.50 Cleo placed the HWB without cover and placed it directly to the
D. 5.2 patient' s foot. The patient suffered 2nd degree burns. Nurse
Cleo may be sued by relatives for .
Rationale: normal gastric pH should be acidic (pH 1-5.5); if A. breach of duty
pH reaches 6, this might be dislodged in the trachea B. negligence
C. justice
D. Malpractice
4. What is the recommended position during NGT insertion?
A. Supine position
B. High Fowler's Rationale: nursing action resulted to injury
C. Semi-Fowler position
D. LOW Fowler's
Situation: To ensure continuity of care, the nurse should be
able to document relevant baseline information about patient
Rationale: According to Lipincott, easier insertion because condition.
the epiglottis does not flap
11. Which assessment findings will the nurse record to be
5. Nurse Barbara is preparing to remove the NGT from the consistent in a client with respiratory failure?
patient. Which of the following PRIORITY instructions should be A. Hypoxemia, hypercapnia - low O2 in the blood; high CO2
given to the patient before she removes the tube? levels in the body
A. exhale and for a while. B. Hyperventilation
B. inhale and exhale quickly. C. Respiratory alkalosis
C. take and hold a deep breath. D. Hypoxia, hypocapnia

Situation: Nurse Olivia is on a 7-3 shift in the ER. The unit is Rationale: low O2 d/t malfunctioning of the lungs; lungs
crowded with patients and relatives. She is attending to two cannot push out the byproducts which is CO2 resulting to
patients, Marky having chest pains and Pablo with severe accumulation in the body
Nurse Olivia is on 7-3 shift in the ER. The unit is crowded with
patients and relatives. She is attending to two patients, Marky
12. Oxygen therapy is the administration of oxygen at a
having chest pains and Pablo with severe
concentration greater than that found in the environmental
atmosphere. The goal of oxygen therapy is to .
6. The nurse is liable to be charged with A. provide adequate transport of oxygen in the blood while
A. Tort decreasing the work of breathing and reducing stress on
B. negligence the myocardium
C. maleficence B. reverse the effects of hypoxemia in a patient
D. non—maleficence C. none of these
D. deliver a high concentration of oxygen in the blood
while decreasing the work of breathing and reducing
hypoxemia on the myocardium

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D. Aromatherapy
Rationale: heart should be well oxygenated, otherwise, this
could result to MI, O2 therapy is deemed important in this
case Rationale: decreased sensory perception especially for touch
→ high risk for burns; skin is also fragile
13. The nurse is aware of the differences between hypoxia and
hypoxemia. Hypoxemia is characterized by 20. You assess a patient with complex regional pain syndrome.
A. a deficiency of oxygen and the biotic environment The nurse is concerned about the patient's depressed mood,
B. a decrease in oxygen supply to the tissues because she or he has said “I can't live with this pain.’' You
C. an insufficient amount of oxygen in the body and, if severe further assess for suicide risk, because.
enough, can be life-threatening A. suicidal thoughts are common in patients with chronic
D. a decrease in the arterial oxygen tension in the blood pain
and is manifested by changes in mental status B. decreased pain thresholds lead to suicidal thoughts
(progressing through impaired judgment, agitation, C. verbalization of suicidal thoughts is a way for patients to get
disorientation, confusion, lethargy, and coma) attention
D. suicidal thoughts are often expressed by patients with acute
14. A nurse suspects a diabetic patient: to have hypokalemia pain
when she observed which of the following symptoms to be
documented?
Rationale: complex regional pain syndrome is chronic pain
A. Sunken eyeballs, Kussmaul breathing, hunger
that can be felt in the extremities; patients with chronic pain
B. Apathy, weakness, abdominal distention
wants to end this and thereby develops suicidal thoughts
C. Edema, bounding pulse, confusion
D. Spasms, hypotension, convulsions
Situation: Mr. Eduardo, 76-year-old, a former chairman of the
Rationale: hypoK- low K in the blood: for nerve impulse and board of trustees of an academic institution had a severe
muscle contraction → if low, metabolism is also low; abdomen chest pain and was rushed to the Medical Center by the
distends d/t slow GIT process (constipation) members of the family. He was seen at the ER and was
advised by the physician to be admitted.
15. . In the initial presentation of type I diabetes mellitus in a
patient, which symptoms would the nurse expect to assess and 21. After a comprehensive assessment and diagnostic tests, he
document? was found out to have blockage of 2 coronary arteries. The wife
A. Polydipsia and polyphagia and his 2 children, a nurse and a doctor were trying to convince
B. Short attention span and hyperactivity their father to undergo open heart surgery to relieve his
C. Blurred vision and weight gain discomfort. In this ethical decision, who should be followed?
D. Weight loss and hypotonic reflexes A. wife
B. children
C. Patient
Rationale: Polydipsia, Polyphagia, and Polyuria
D. doctor

16. You assessed a 67-year-old patient for reports of episodic,

Rationale: patient is still conscious and able to decide for
sudden—onset, right—sided facial pain. The patient describes
himself
the pain as fleeting, electric—like and triggered by light touch
and brushing of the teeth. You suspect
A. temporomandibular disorder. 22. When Mr. Eduardo decides not to go for surgery and is
B. trigeminal neuralgia. respected by the physician, which ethical principle is being
C. myofascial pain syndrome observed?
D. facet syndrome. A. Justice
B. Beneficence
C. Autonomy
Rationale: CN 5 (facial nerve) is affected
D. Non-maleficence

17. Which of the following is the recommended protocol for

Rationale: able to decide for himself; self-governance
preventing constipation when starting a patient on opioids?
A. Increasing fluids and fiber
B. Using a bowel stimulant and stool softener 23. While in the hospital, Mr. Eduardo keeps on asking for pain
C. Adding bulk fiber to the diet. medications. Then the Nurse of Mr. Eduardo offers his pain
D. Giving the patient enemas as needed. medication when needed, she is applying the ethical principle of
.
A. Fidelity
Rationale: fiber retains fluid
B. Beneficence
C. Advocacy
18. A 12—year—old patient who is receiving in—home care D. Justice
without IV access needs medication for breakthrough pain.
Which of the following is the most effective route of
Rationale: to do good; nurse wanted for the patient’s pain to
administration?
go away
A. Nebulized
B. Oral—transmucosal
C. Intranasal 24. The Nurse observed that the dose of the PRN pain
D. Transdermal medication ordered by the physician to Mr Eduardo is quite high
for his age, so she suggested a lower- dose. What ethical
behavior is being manifested by the nurse with this action?
Rationale: because it is highly vascularized → direct to the
A. Fidelity
bloodstream → goes to the target organ
B. Non-maleficence
C. Advocacy
19. You have some older patients in your department. Which D. Justice
nonpharmacologic intervention is difficult to use with older
adults who are cognitively impaired?
Rationale: if the dose is too high, this might cause harm to the
A. Distraction
patient
B. Heat application
C. Guided imagery

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25.. Mr. Eduardo is on bed rest. When he uses the call bell for 31. As a nurse, the responsibility for your pre—operative care
the nurse to assist him to be transferred to the commode and for patient Mina includes which of the following EXCEPT
answers him to wait for 5 minutes and the nurse comes on time A. providing adequate. nutrition and elimination.
is an example of what ethical principle? B. preparing the operative site of the abdominal region.
A. Maleficence C. explaining the surgical procedure while admitting the
B. Non—maleficence patient.
C. Fidelity D. ensuring the patient is psychologically ready for the
D. Advocacy surgery.

Rationale: the nurse kept his promise to the patient; loyalty to Rationale: procedure is to be explained by the surgeon and
the profession should be done after the patient has decided

26. Nurse Daisy selects only patients who have suffered stroke 32. Which of the following pre—operative medications do you
admitted and discharged from the hospital as participants of the expect to be ordered by the surgeon the night before surgery?
study. Which of the following describes the selection of A. morphine sulfate
participants of Nurse Daisy in her study? B. Phenergan - antihistamine for allergies
A. Random sampling - equal chance of getting picked C. Valium - Diazepam
B. Experimental sampling - non existent D. Demerol
C. Purposive sampling
D. Stratified sampling - there should be a characteristic
Rationale: Anxiolytics - lowers anxiety, muscle relaxant, and
included; systemized
light sedation; Options AD are analgesics and is used for pain

Rationale: participants of the study are selected by the

33. The patient is scheduled for operation at 8 o’clock. In the
researcher; handpicked
morning, the pre—operative medications were administered an
hour before the surgery. What PRIORITY nursing measures
27. Nurse Daisy' respondents were asked to sign consent before should you perform before transferring the patient to the
the conduct of the study. Three (3) participants were forced to operating room?
join the study. Which right is violated when they are forced to A. Ask her to sign the consent.
become research respondents? B. Check if she is using her identification bracelet.
A. Right to full disclosure C. Assist the patient to urinate.
B. Right to self determination D. Determine what type of anesthesia will be done - surgeon’s
C. Right of privacy and confidentiality responsibility
D. Right not to be harmed
Rationale: to ensure correct wheeling in of the patient into the
Rationale: violation of the respondents autonomy OR suite; Options AC are performed before administration of
preop meds
28. One respondent wants to withdraw from the study. Which
ethical principle in research should Nurse Daisy observe? 34. What medicines are ordered by the surgeon to reduce
A. Refuse request to withdraw as participant. salivation & bronchial secretions before the operation?
B. Allow participants to withdraw anytime. A. Benadryl
C. Provide incentive not to withdraw. B. Atropine S04
D. Remind him of his duty as participant. C. Magnesium S04
D. Codeine
Rationale: right to withdraw is still part of the participants
autonomy Rationale: to prevent aspiration

29. Nurse Daisy conducted a series of interviews with 35. After 36 hours post exploratory laparotomy, which of the
respondents on different times and occasions. This is to following PRIORITY physical findings should be reported
determine their experiences and differentiate responses to immediately to the attending physician?
questions. This method is done in which of the following types of A. Presence of flatus
research? B. No bowel sounds
A. Experimental study - cause and effects C. Rigid abdomen
B. qualitative study - experiences D. Nausea & vomiting
C. Historical study - past issues
D. Quantitative study - numerical data; those that can be
Rationale: might be indicative of peritonitis or inflammation in
measured
the peritoneum
30. Before Nurse Daisy analyzes the time, budget, and materials
needed to complete the research project. This undertaking in Situation: Nurse Maggie is assigned in the medical unit and
research is a component of caring for patients mostly affected by Endocrine disorders. As
A. research ability a professional nurse, she is expected to be competent in
B. reliability taking care of them.
C. feasibility
D. validity
36. Nurse Maggie is taking care of Ms. Risa, 32-year-old who has
a tentative diagnosis of thyrotoxicosis. With the increased
Rationale: if the study is realistic regarding to budget, thyroid hormone that stimulates metabolic rate in this condition,
resources; if attainable; feasibility AKA research ability which of the following is NOT expected by the patient to
manifest?
A. Increase cardiac output
Situation: Mina, a cashier in a bookstore consulted the ER
B. Hypermotile bowels and diarrhea
because of abdominal cramps, nausea and vomiting and
C. Palpitation
slight fever. She has been experiencing these for almost 3
D. Cold intolerance
days now. After a complete physical examination, laboratory
and diagnostic tests, the physician ordered her to be admitted
for Exploratory laparotomy. You are the Nurse—in—charge of Rationale: should be heat intolerance; increased body
this patient. temperature; thyrotoxicosis has increased RR, PR, diarrhea,

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fever Refeeding syndrome: potentially fatal shifting of fluids and

electrolytes that may occur in malnourished; if too much food
is introduced, baka malunod ung patient dahil may tubig na
37. The endocrine system is a glandular tissue that produces,
nga sa lungs
stores and secretes hormones. Which of the following is the
UNIQUE characteristic of all hormones?
A. Circulate into the blood for metabolic processes. 42. What is the PRIMARY collaborative goal of treatment for Ms.
B. Enter cells to alter genetic development. Wendy?
C. Accelerate the anabolism and catabolism regulation. A. Resolve possible dysfunctional family roles as an adolescent.
D. Influence cellular activity of specific target tissues. B. Increase strong desire to eat.
C. Restore normal nutrition and weight.
D. Assist. her to increase feelings of control overeating.
Rationale: E.g., FSH secreted by Pituitary Gland going to the
follicle to be stimulated
43. For Ms. Wendy, which route for delivery of nutrition and fluids
will the health care team try FIRST?
38. When conducting a physical assessment of patients with A. Gastrostomy tube
endocrine disorders, the nurse guided that the ONLY endocrine B. Oral route
organ that can be done by palpation is the . C. Nasogastric route
A. parathyroid gland D. Intravenous route
B. adrenal gland
C. pituitary gland
Rationale: less invasive first; there are no any other
D. thyroid gland
contraindications for oral route not to use
39. The attending physician of Ms. Risa ordered several
laboratories and diagnostic tests. She was ordered to undergo 44. In caring for this patient suffering from anorexia nervosa,
thyroid scanning. Which of the following data should be obtained which task can be delegated to the nursing assistant?
by Nurse Maggie PRIOR to the procedure? Check if patient is A. Obtaining special food for the patient when she requests -
. dietician
1. allergic to iodine B. Sitting with the patient during meals and for about an
2. allergic to shellfish hour after meals.
3. Pregnancy - teratogenic C. Weighing the patient daily and reinforcing that she is
4. taking anti—thyroid drug - thyroid would not absorbed underweight.
the iodine D. Observing for and reporting ritualistic behaviors related to
A. 1, 2, 3 & 4 food.
B. 1 & 3
C. 1, 2 & 4 45. You find Ms. Wendy in her room running and trotting around
D. 1 & 2 for about the last 30 minutes. What is the BEST response to give
her at this time?
A. "Tell me why you are running and trotting around the
Rationale: thyroid scanning → pill is ingested and would go
room?"
to the thyroid → thyroid will absorb radioactive agent
B. "Stop running right now. Otherwise, we will change your
exercise program. "
40. Patient Risa is for discharge in 3 days’ time. In the discharge C. "We have talked about exercise and agreed to reach
plan of Nurse Maggie, she has identified a priority nursing your weight goal first. "
diagnosis which is, 'Risk to Impaired vision related to inability to D. "If you continue to exercise like this you are going to eat
close the eyelids completely". Which of the following more."
interventions is NOT APPROPRIATE to protect the eye of the
patient from Injury and maintain visual acuity? Use .
Rationale: Patients with anorexia should be stopped when
A. tinted eyeglasses as protective mechanism to bright light
seen exercising
B. artificial tears as need to moisten the dry eyes
C. clear eyeglasses when doing outdoor activities
D. report to the health care professionals any pain or visual
Situation: You are assigned to the PACU and are currently
changes
caring for patients undergoing different types of surgical
operations.
Rationale: eyes are already prone to drying, use of clear
eyeglasses does not do anything to protect the eyes
46. Post—operative nausea and vomiting presents the greatest
risk for?
A. an 81 year—old, 55 kg. woman following cystoscopy under
Situation: Ms. Wendy, 15 years old, 100lbs, 5 ft. tall, admitted
local anesthesia.
to you for diagnostic evaluation and nutritional support. She is
B. a 45 year—old; 70 kg. mar. following an arthroscopy under
moderately dehydrated with potassium level of 2.3mg/L. She
epidural anesthesia
has experienced weight loss of more than 15 percent within
C. a 23 year—old, 125 kg woman following a diagnostic
the past 3 months.
laparoscopy under general anesthesia
D. a 14 year—old, 40 kg. boy following an orchiopexy under
41. Ms. Wendy is at risk for refeeding syndrome that is caused general anesthesia
by rapid feeding. What should be the PRIORITY action of the
health care team to prevent complications associated with this
Rationale: Option C is more at risk because she is obese;
syndrome?
they are also prone to apnea
A. Assess for signs of pallor of the extremities and sluggish
capillary refill.
B. Monitor for decreased bowel sounds, nausea, bloating, and 47. Nursing interventions indicated during the patient's recovery
abdominal distention. from the general anesthesia in the PACU includes which of the
C. Observe for signs of secret purging and ingestion of water following?
to increase weight. A. Encouraging deep breathing and coughing
D. Monitor for peripheral edema, crackles in the lungs, and B. Withholding analgesics until the patient is discharged from
jugular vein distention. the PACU
C. Placing the patient in supine position
D. Restraining patients during episodes of emergence delirium
Rationale:
Normal K: 3.5-5.5; Wendy is already hypokalemia

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53. Nurse supervisor who is retiring is helping the new

Rationale: Instruct client to perform DBE to open up alveoli
supervisor learn about the position. As part of this education, the
and to prevent atelectasis/lung collapse and pneumonia
current supervisor makes all the decisions that can be made
under certainty. What conditions will these decisions have in
48. In preparation for discharge after surgery, which of the common?
following should the nurse advise the patient? 1. There is risk associated with the decision. (-)
A. The rationale for abstinence from sexual intercourse for 4 2. The alternatives are known. (+)
to 6 weeks 3. The conditions of each alternative are clear. (+)
B. A timeframe for when various physical activities can be 4. The decision is complex and dynamic. (-)
required A. 1 and 4
C. The necessity of a referral to a nutritional center for B. 1 and 2
management of dietary restrictions C. 2 and 3
D. The need to call the hospital clinical unit to report any D. 3 and 4
abnormal signs and symptoms
54. A disagreement has arisen between two staff nurses. Both
Rationale: signs and symptoms might be fatal if the patient have discussed the situation with the head nurse. The head
did not report it immediately nurse feels that the problem is likely self-solving. How should the
head nurse approach this situation?
1. Allow some time to pass to see if the situation resolves.
49. An informed consent is required for EXCEPT. 2. Support both nurses as they work through this issue.
A. Irrigation of the external ear canal 3. Provide any resources the nurses may need to help
B. Closed reduction of a fracture solve the problem.
C. Urethral catheterization 4. Intervene if the problem begins to affect client care.
D. Insertion an intravenous catheter A. 1, 2, 3, 4
B. 1, 2, 3
Rationale: Option A is not invasive and therefore does not C. 1 and 2
require informed consent D. 2, 3, 4

55. Which statement by a formal leader of a surgical unit reflects

50. Which of the following nursing actions during the immediate the personality required to energize the staff and promote
postoperative period has the HIGHEST priority? creativity?
A. Observing for hemorrhage 1. "This is the decision I have made and there is no room
B. Maintaining a patent airway for discussion” - dismissive
C. Recording intake and output 2. "I would like to thank everyone for your hard work and
D. Checking vital signs every 15 minutes dedication while we have been short staffed.
3. “I am certain that our new assignment system is going
Rationale: priority is AIRWAY! to make workload more equitable.
4. "I know this week has been rough.” - validation
A. 3 and 4
Situation: According to Peter Drucker Management Is doing B. 2, 3, 4
things right Resource management is the process by which C. 1 and 2
managers manage their resources effectively. These D. 1, 2, 3
resources can be intangible (people and time) and tangible
(equipment, materials, and finances). It involves planning so Rationale: should motivate and give supportive messages
that the right resources are assigned to the right tasks.

51. Currently patients in the unit are bathed in the morning Situation: Nurse Lory is assigned in the oncology unit of x
between 8 to 11 in the morning. The nursing staff is considering hospital. She assists in the care of a 40-year-old female with
changing the schedule to bathing the patients in the evening bone cancer.
between 7 to 9 p. m. Which statement reflects an assumption
that might affect the nursing staff's ability to think critically 56. The patient complains of pain. Nurse Lory assesses the
about the change? patient. Which of the following statements is a MOST important
1. "The day shift just wants to shift work onto the evening information nurse Lory gathers during the initial assessment?
shift. (-) The .
2. "Everyone Likes to bathe right before bed (-). A. patient's self—reporting of her pain experience
3. “Il If we let them change this, they will want to make lots B. results of assessment of the physical examination
of other changes. (-) C. amount of pain medication the patient is taking.
4. "I read a research article that reported that clients D. response of the family toward the illness of the patient
sleep better when they have been bathed right before
bedtime.” (+); evidence-based
A. 3 and 4 Rationale: best indicator of pain is self- report; pain is
B. 2, 3, 4 subjective
C. 1, 2, 3
D. 1 and 2 57. The patient informs nurse Lory that she is taking medications
to control the pain. Which of the following statements verbalized
52. A serious disagreement has arisen between two staff nurses. by the patient indicates that the patient needs further teachings
The head nurse chooses not to make a decision regarding the about medications to control pain.
disagreement until more evidence is collected. Which part of A. It is okay take my pain medication even if I am not having
the nursing process does this head nurse's critical thinking any pain” - pain medications are nephrotoxic/ hepatotoxic
reflect? B. "I should take my pain Medication periodically, so I don’t get
A. planning addicted to the drug.”
B. diagnosis C. "l should contact the nurse if the pain is not effectively
C. evaluation controlled by my Medication.”
D. assessment - data collection D. "I should take my medications around-the-clock to control
the pain.”

Additional Notes: abortive therapy - prevention of pain

(anticipation; prophylaxis)

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58. The patient receives chemotherapy. Nurse Lory writes a 63. Which of the following is the most common cause of
nursing diagnosis for the patient. Which of the following nursing Mastoiditis?
diagnoses is MOST appropriate? A. Bone tumor
A. Altered body image B. Untreated Otitis Media
B. Pain related to treatment C. Meningitis
C. Impaired physical mobility D. Mastoid diseases
D. Risk for infection
Rationale: infection in the middle ear; if this is not treated
Rationale: bone marrow suppression occurs during immediately, it can spread to the mastoid ear cells
chemotherapy → immunocompromised → nadir: lowest level
of immunity
64. Antibiotics have limited use in the actual treatment of
Mastoiditis because________.
NC: neutropenic precautions
A. Tissue destruction is extensive
→ Reverse isolation
B. It is a long-term treatment
→ Cooked foods; fresh, uncooked foods (e.g., lettuce) is
C. Antibiotics do not easily penetrate the infected bony
contraindicated
structure of the mastoid
D. Culture has to be done to identify which antibiotic is most
59. Nurse Lory is aware that a patient receiving chemotherapy effective for the treatment of Mastoiditis
is at risk for bone marrow depression. She instructs the patient
on how to prevent infection at home when she is discharged. 65. Which of the following is the most common treatment for
Which of the following should nurse Lory communicate to the Mastoiditis?
patient? A. Mastoidectomy only
A. "Wash your hands frequently and maintain good B. Mastoidectomy with tympanoplasty
hygiene." C. Antibiotics with tympanoplasty
B. Avoid physical contact with other people while receiving D. Antibiotics
chemotherapy
C. "Do not share the bathroom with young children or with any
Rationale: eliminate the options with antibiotics because it is
pregnant member of the family.
stated from the previous question (#64) that antibiotics does
D. "Visit the laboratory every week for a WBC analysis
not work in mastoiditis
→ Mastoidectomy - removal of mastoid
Rationale: handwashing is the single, most effective method → Tympanoplasty - repair of tympanic membrane
of infection prevention (eardrum)

60. Nurse Lory observes that the patient gets irritable and
Situation: In the PGH Ear Unit, the staff nurse is attending to
angry with the medical/ nursing staff whenever a procedure or
several outpatient clients seeking follow-up care.
treatment is done on her. Which of the following approaches
would be BEST to diffuse the anger of the patient?
A. Let the patient and family members have time for each 66. The nurse assists in ear irrigation. Which of the following
other. statements by the nurse is correct?
B. Direct the discussion and allow the patient to express A. “Tilt the head towards the unaffected ear.”
her feelings. B. “Direct the stream of irrigate at the sides of the ear
C. Arrange a meeting between the patient and another person canal.” - if at the middle, the irrigate would hit the eardrum
with bone cancer. directly and cause damage
D. Request the social worker of the psychiatrist in the hospital C. “After the procedure, lie on the unaffected side to allow the
to talk to the patient. irrigate to soften any hardened mass.” - the irrigate should
not be retained in the ear
D. “This procedure is allowed for otitis media to clean the
Rationale: encourage verbalization
canal.” - can cause spread of infection

67. In administering ear drops, the nurse observes which of the

Situation: Nelson, a 26-year-old construction worker, arrives
following principles?
in the Ear Clinic riding a Honda Motorcycle. He is wearing a
A. In a child, pull pinna upward and backward.
headset with an Mp3 player hooked to his belt. Nelson is for
B. Let the ear drops fall on the middle space of the canal.
hearing assessment.
C. Lie on the unaffected side to facilitate absorption.
D. Position unaffected ear uppermost. - affected ear should be
61. Pure Tone Audiometry is ordered for Nelson. Which of the positioned uppermost to facilitate absorption
following does this procedure measure?
A. Vestibular portion of the auditory nerve
Rationale:
B. Ear canal volume
→ chilD: downward and backward
C. Structure of the cars
→ adUlt: upward and backward
D. Hearing acuity

62. Nelson was found to have Mastoiditis. Which of the 68. Otosclerosis, a disorder of labyrinth function, constitutes
following ear structures is affected? which type of hearing loss?
A. Tympanic membrane A. Perceptive loss
B. Pinna B. Conductive loss
C. Eustachian tube c. Sensorineural loss
D. Mastoid air cells - located at the back of the ear d. Mixed loss

Rationale: otosclerosis is the thickening of auditory ossicles;

middle ear

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C. Nausea and vomiting

D. Muscle pain

Rationale: withdrawal occurs when there is an abrupt

stopping of taking substances

75. The following are the reasons why many people abuse
caffeine. Choose the exception.
A. Relieve fatigue
B. Increase mental alertness
C. Both A and B
D. Neither A nor B

Situation: Nurse Fe had been working as a head nurse in the

Mental Health pavilion of Davao City. For the past years she
had been challenged to cater to the needs of different
→ Middle ear: conductive hearing loss mentally ill patients across the continuum of care.
→ Inner ear, CN VIII (vestibulocochlear nerve):
sensorineural hearing loss/perceptive hearing loss 76. A staff nurse in the psychiatric ward is upset about the new
• Options A and C are the same female charge nurse who just sits in her office all day. One of the
→ Mixed: both conductive and sensorineural hearing loss staff members informs Nurse Fe about the situation. Which
statement by Nurse Fe indicates a laissez faire leadership
style?
69. Which of the following is a characteristic sign of acute otitis
A. “I will schedule a meeting to discuss the concern of the
media in children?
charge nurse”
A. Jumping in pain
B. “I hired the new charge nurse and she is doing what I told
B. Ear tugging
her to do”
c. Painless inflammation
C. “I will talk to the charge nurse about your concerns and get
d. Difficulty awakening
back to you”
D. “You and the staff really should take care of this
Rationale: children cannot express themselves well. They do situation on your own”
gestures instead; they won’t tug their ear if there is no pain
Rationale: laissez faire - little to no control; doesn't apply to
70. What makes children more predisposed to chronic otitis everybody; members should be highly motivated, expert, and
media? independent
A. Shorter Eustachian tube
B. Horizontal orientation of the ear canal
77. A volunteer nurse on the ward tells the nurse that one of the
C. Primary diaphragmatic breathing - children are mouth
patients on the ward is a neighbor and asks about the patient’s
breathers
condition. Which information should the nurse discuss with the
D. Both A and B
volunteer?
A. Determine how well she knows the patient before talking
Situation: Addiction disorders are unnecessarily common in with the volunteer
the modern lifestyle of Filipinos, especially with the rise of B. Tell the volunteer the patient’s condition in layman’s term
establishments selling products with caffeine. Because of the C. Ask the patient if it is all right to talk with the volunteer
various “improvements” in performance, this industry is still D. Explain that patient information is on the need-to-know
unwavering. basis only

71. Which of the following do not have the potential of addiction, Rationale: consider the principle of confidentiality
if consumed frequently and in large amounts?
A. Chocolate-flavored Cola
78. The psychiatric ward is governed by a system of shared
B. Apple juice
governance. Which statement best describes an advantage of
c. Green tea - contains caffeine
this system?
d. Common cold preparations
A. It guarantees that union will not be able to come into the
hospital
72. Caffeine greatly affects which part of the heart, as reflected
B. It makes the manager responsible for sharing information
in an ECG?
with the staff
A. Atrium
C. It involves staff nurses in the decision-making process
B. Ventricles
of the unit - democratic
c. Purkinje fibers
D. It is a system used to represent the nurses in labor disputes
d. Interventricular septum
79. A nurse is able to assess that a depressed patient is bleeding
Rationale: caffeine increases amplitude (P wave - atrial from a wrist cut. She immediately directs another staff nurse
depolarization) to call the doctor and send the nurse aide to gather specific
materials to implement measures to control bleeding. Which
73. The nurse suspects caffeine intoxication in a young style of leadership did the nurse use in this situation?
professional if he notes which finding? A. Autocratic
A. Decreased flow of thought and speech - increased B. Democratic
B. Psychomotor agitation C. Facilitative
C. Urinary retention - diuresis D. Laissez-faire
D. Pale face - flushed
Rationale: autocratic - strong control through commands;
74. In the previous situation of the young professional done in emergencies
intoxicated with caffeine, he suddenly was unable to take any
caffeine source for 24 hours already. The nurse expects to note
the following findings, except?
A. Headache
B. Difficulty in stimulating - agitation

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 RECALLS 6: NURSING PRACTICE 3

80. Which strategy should the nurse leader use to facilitate the
Rationale: the nerve endings are not identical with the natural
performance appraisal conference?
genitalia after gender reassignment surgery resulting to
A. Interview with other staff about the employee’s
decreased pleasure → depression
performance - nurse-centered
B. Begin the evaluation interview with an open-ended
question Situation: In the Psychiatric ward nurses are discussing the
C. Include personal feelings in the comment sections of the other factors that caused Alzheimer's disease (AD). And they
tool for clarity - should be objective all agree that it is a degenerative disease of the brain caused
D. Refrain from adding comments to the evaluation form - by gradual death and loss of brain cells resulting to
should add objective comments (strengths and weakness) progressive and irreversible Dementia.

Additional Notes: performance appraisal conference is done 86. Which of the following nursing intervention is most helpful in
depending on the hospital’s policy meeting the needs of an older adult hospitalized with the
diagnosis of Dementia of the Alzheimer’s type?
A. providing a nutritious diet high in carbohydrates and protein
Situation: The nurse is caring for patients with issues in
B. simplifying the environment as much as possible while
gender and sexuality. The following situations will apply.
eliminating the need for choices
C. developing a consistent nursing plan with fixed time
schedules to provide for emotional needs
81. A nurse was approached by a 23-year-old male who D. providing an opportunity for many alternative choices in the
confessed that he has romantic and sexual affinity towards daily schedule to stimulate interest
lesbians, gays, transsexuals, bisexuals, a straight male and
a straight female. The nurse will help the man identify himself Rationale: clients with Alzheimer’s have disturbed executive
as a? functioning: cannot decide of plan → limit choices as much as
A. Transsexual possible
B. Asexual
c. Pansexual - pan means all
d. Polysexual 87. The nurse recognizes that Dementia of the Alzheimer’s type
is characterized by:
82. Chester, a 25-year-old male, has decided that he wants A. aggressive acting-out behavior
gender reassignment surgery. He asks the nurse as to whom B. periodic remissions and exacerbations
he should ask help regarding his concern. The nurse will help C. hypoxia of selected areas of brain tissue
the client correctly if the nurse refers him to a? D. areas of brain destruction called senile plaques
A. Endocrinologist
B. Psychologist Rationale: organic - an organ of the body is affected that
c. Psychiatrist caused the disease
d. Surgeon
88. A 75-year-old man with the diagnosis of Dementia has been
Rationale: the testicles are gonads which is responsible for cared for by his wife for 5 years. For the past 2 years he has not
the release of testosterone; if removed, it will cause hormonal spoken and incontinent of urine and feces. During the last
imbalances month he has changed from being placid and easygoing to
agitated and aggressive. He is admitted to a Psychiatric
83. Which among the following individuals is characterized by hospital for treatment with Psychopharmacology. Which is
either a male or a female who dresses like a male or a female? the priority nursing care while this client is in the psychiatric
A. Transvestite - medical term facility?
B. Transgender A. managing his behavior
c. Cross-dresser B. preventing further deterioration - address incontinence
d. Transsexual C. focusing on the needs of the wife
D. establishing on the needs of the wife

Additional Notes: transvestic fetish - pleasure from cross-

dressing Rationale: agitation and aggressiveness are behavioral
problems and it is vital to address this

84. Lea, a 22-year-old lesbian, has decided to have a gender

reassignment surgery and is currently on hormone replacement 89. When attempting to understand the behavior of an older
therapy as she wait for her surgery. Which among the following adult diagnosed with Vascular Dementia, the nurse recognizes
features are noticeably the effect of hormone replacement that the client is probably:
therapy? A. not capable of using any defense mechanisms
A. Decreasing heart rate B. using one method of defense for every situation
B. Increased production of body hairs on areas with less C. making exaggerated use of old, familiar mechanism
body hairs than before D. attempting to develop new defense mechanisms to meet
C. Ovarian atrophy the current situation.
D. Linea nigra
Rationale: vascular dementia - presence of vascular lesions
in the brain → confabulation (making of stories as a defense
Additional Notes: bornique is to decrease the chafing
mechanism to protect ego)
of the skin since the buttocks are magkadikit (nagkikiskisan);
same with the axilla - this is not proven tho, sabi lang ni sir
90. The Nurse develops a nursing diagnosis of self-care deficit
for an older client with Dementia. Which of the following is the
85. After his gender reassignment surgery, Reston felt that he is
most appropriate goal for this client?
not as sexually satisfied as that of when he was still a male by
A. The client will be admitted to a long care facility to have
genitalia. Which among the following disorders have been noted
activities of daily living needs met
to be highest across males and females who had gender
B. The client will function at the highest level of
reassignment surgery?
independence possible - as much as possible
A. Manic Disorders
C. The client will complete all activities of daily living
B. Depression
independently within one (1 ) hour time frame
C. Schizophrenia
D. The Nursing staff will attend to all the client’s activities of
D. Bipolar Disorder
daily living needs during the hospitalizatio

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 RECALLS 6: NURSING PRACTICE 3

95. Which clinical indicator does Nurse Marco identify when

Rationale: goal - end-point
assessing a client with hemiplegia?
A. paresis of both lower extremities
Situation: The diverse Neurologic disorders present unique B. paralysis of one side of the body
challenges of nursing care. The Nurse must have a clear C. paralysis of both lower extremities
understanding of the pathologic processes for appropriate D. paresis of upper and lower extremities
nursing management. Nurse Marco is attending to clients in
the ward with Multiple Sclerosis. Situation: Sonia is a 28-year-old graduate school student in
a leading private university. She came to a psychiatric unit
91. Which statement by a client with Multiple Sclerosis due to sleeplessness but claiming she is still overactive. She
indicates to Nurse Marco that the client needs further revealed she has a history of depression when she was 18
teaching? years old and was into drugs. Further evaluation revealed
A. “I use a straw to drink liquids.” Sonia is suffering from a Bipolar disorder, rapid cycling
B. “I will take a hot bath to help relax my muscles.” mood disorder classification.
C. “I plan to use an incontinence pad when I go out.”
D. “I may be having a rough time now, but I hope tomorrow will 96. Which of the following characterizes Rapid Cycling Mood
be better.” disorder?
A. Exaggeratedly energetic behavior
Rationale: extreme temperatures (hot and cold) should be B. Depressive episodes alternating with at least one manic
avoided as this can aggravate the disease episode
C. Hypomanic episodes alternating with depressive episode of
MS - demyelination of the CNS → delayed conduction of two years duration
impulses D. Four or more mood episodes in 1 year duration

Charcot’s Triad (SIN) 97. In your interview with Sonia, she said "I have special power
→ Scanning speech that's why I was sent by God to make this world a better place."
This is a manifestation of:
→ Intentional tremors (during movement)
A. Paranoia
→ Nystagmus (oscillation of the eyeballs; motor)
B. Delusion of persecution
C. Delusion of grandeur - grandiose delusions: exaggerated
92. A recently hospitalized client with Multiple Sclerosis is self-importance
concerned about generalized weakness and a fluctuating D. Denial
physical status. What is the priority nursing intervention for this
client? 98. You heard Sonia telling another nurse, “there are people
A. encourage bed rest who want to harm me because I have special power." This is a
B. space activities throughout the day manifestation of what behavior?
C. teach the limitations imposed by the disease A. Mania
D. have one of the client’s relatives stay at the bedside B. Delusion of grandeur
C. Hallucination
Rationale: promote independence/activity; look for terms D. Delusion of persecution
such as “space”, “cluster”, “alternate”, “schedule”
Rationale: AKA persecutory delusions - false belief that
93. Marco is excited to be assigned to a Neuro –Ward after his someone intends to harm them
extensive training. He is preparing to conduct a Neurologic
examination. What nursing intervention is anticipated for a client 99. Which of the following is the first line treatment for acute
in the plateau phase of Guillain-Barre syndrome? mania?
A. providing a straw to stimulate the facial muscles A. Imipramine
B. inserting an indwelling catheter to monitor urinary output B. Sodium valproate
- d/t loss of bladder control C. Electro-convulsive therapy
C. encouraging aerobic exercises to avoid muscle atrophy D. Lithium carbonate - mood stabilizers
D. administering antibiotic medication to prevent pneumonia
Rationale: mania - bipolar I; bipolar II - hypomania
Rationale: plateau phase - active; symptoms are present
→ GBS (ascending paralysis; ground to brain)
100. Which of the following statements best describes severe
→ Compilation: respiratory failure.arrest since the diagram
depression?
is a muscle
A. Anxiety and panic attack are characteristics of other condition
B. Sonia wakes up early
94. Mr. Rod, a 48-year-old client carpenter, was admitted after a C. Agitation or Psychomotor retardation
spinal cord injury and the Physician indicates that a client is a D. Delusion and hallucinations do not occur
Paraplegic. The family asks Nurse Marco what this means. What
explanation should the nurse give to the family?
A. upper extremities are paralyzed
B. lower extremities are paralyzed
C. one side of the body is paralyzed
D. both lower and upper extremities are paralyzed

Rationale: paraplegic - lower

extremities are affected
(crosswise); caused by SCI
→ Hemiplegia is caused by
stroke/CVA (lengthwise)

RECALLS 6: NURSING PRACTICE 3