NURSING PRACTICE 1

Situation 1 - Mr. Ibarra is assigned to the triage area and while on duty, he
assesses the condition of Mrs. Simon who came in with asthma. She has difficulty
breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject
the client epinephrine 0.3mg subcutaneously

1. The indication for epinephrine injection for Mrs. Simon is to:

a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respiratory distress due to bronchial spasm
d. Restore client's cardiac rhythm

CORRECT ANSWER: C
RATIONALE: Asthma is a chronic inflammatory disorder of the airways resulting in
reversible bronchoconstriction and air hunger in response to triggers from a
variety of sources. When exposed to a trigger, the hyperactivity of the medium-
sized bronchi causes the release of leukotrienes, histamine and other substances
from the mast cells of the lung; these agents intensify the inflammatory process
and cause bronchospasm. When inhaled in small doses, epinephrine causes short-term
relief from the symptoms by widening the bronchial tubes allowing air to pass
through. Once again epinephrine is not the best cure, but a temporary relief when
an asthma inhaler is not present.
OPTIONS A & D are incorrect
OPTION B: Epinephrine does have a direct effect to relieve hypersensitivity to
allergen
SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales
series for nursing. Pathophysiology.pp.4-5;
http://www.udel.edu/chem/C465/senior/fall00/Performance1/epinephrine.htm.html

2. When preparing the epinephrine injection from an ampule, the nurse

initially:
a. Taps the ampule at the top to allow fluid to flow to the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to expel air
d. Breaks the neck of the ampule with a gauze wrapped around it

CORRECT ANSWER: B
RATIONALE: In preparing medications in ampule or any form of medications, always
check first the expiration date and discard outdated medication. Check the label
on the ampule carefully to make sure that the correct medication is being
prepared.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 816

3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese

patient. It is best for the nurse to:
a. Inject needle at a 15 degree angle over the stretched skin of the client
b. Pinch skin at the injection site and use airlock technique
c. Pull skin of patient down to administer the drug in a Z track
d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree
angle

CORRECT ANSWER: D
RATIONALE:To determine the angle of insertion , a general rule to follow relates
to the amount of tissue that can be grasped at the site. A 45-degree angle is used
when 1 inch of tissue can be grasped at the site; a 90-degree angle is used when 2
inches of tissue can be grasped.
OPTION A: Skin Test
OPTION C: IM
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 822

4. When preparing for a subcutaneous injection, the proper size of syringe

and needle would be:
Syringe 3ml and needle gauge 21 to 23
Tuberculin syringe 1 ml with needle gauge 26 or 27
Syringe 2ml and needle gauge 22
Syringe l-3ml and needle gauge 25 to 27

CORRECT ANSWER: D
RATIONALE: The type of syringe used for subcutaneous injections depends on the
medication given. Generally a 2-ml syringe is used for most SC injections.
However, if insulin is being administered, an insulin syringe is used; and if
heparin is being administered, a tuberculin syringe or prefilled cartridge may be
used. Needle sizes and lengths are selected based on the clients body mass,the
intended angle of insertion and the planned site. Generally a #25-gauge, 5/8-inch
needle is used for adults.
OPTIONS A, B & C are incorrect
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 822

5. The rationale for giving medications through the subcutaneous route is;
There are many alternative sites for subcutaneous injection
Absorption time of the medicine is slower
There are less pain receptors in this area
The medication can be injected while the client is in any position

CORRECT ANSWER: B
RATIONALE: Subcutaneous injections are given because there is little blood flow to
fatty tissue and the injected medication is generally absorbed more slowly,
sometimes over 24 hours. Some medications injected subcutaneously are growth
hormone, insulin, epinephrine and other substances.
OPTIONS A, C & D are all secondary reasons.
SOURCE: http://www.cc.nih.gov/ccc/patient_education/pepubs/subq.pdf

Situation 2 - The use of massage and meditation to help decrease stress and pain
have been strongly recommended based on documented testimonials.

6. Martha wants to do a study on the topic. "Effects of massage and meditation

on stress and pain." The type of
research that best suits this topic is:
Applied research
Qualitative research
Basic research
Quantitative research

CORRECT ANSWER: B
RATIONALE: Qualitative research is the investigation of phenomena, typically in an
in depth and holistic fashion, through the collection of rich narrative materials
using a flexible design.
Qualitative research relies on reasons behind various aspects of behavior. Simply
put, it investigates the why and how of decision making, not just what, where, and
when. Hence, the need is for smaller but focused samples rather than large random
samples, which qualitative research categorizes data into patterns as the primary
basis for organizing and reporting results. Qualitative researchers typically rely
on four methods for gathering information: (1) participation in the setting, (2)
direct observation, (3) in depth interviews, and (4) analysis of documents and
materials
OPTION A: Applied research focuses on finding solutions to existing problems. For
example, a study to determine the effectiveness of a nursing intervention to ease
grieving would be applied reaserch.
OPTION C: Basic research is undertaken to extend the base of knowledge in a
discipline, or to formulate or refine theory.
OPTION D: Quantitative research is the investigation of phenomena that lend
themselves to precise measurement and quantification, often involving rigorous and
controlled design.
SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and
Methods. 7th Edition.pp 18, 729; http://en.wikipedia.org/wiki/Qualitative_research

7. The type of research design that does not manipulate independent variable is:
Experimental design
Quasi-experimental design
Non-experimental design
Quantitative design

CORRECT ANSWER: C
RATIONALE: Non-experimental research- studies in which the researcher collects
data without introducing an intervention.
OPTION A: In experiment, the researcher controls the independent variable and
randomly assigns subjects to different conditions.
OPTION B: Quasi-experiment is an intervention study in which subjects are not
randomly assigned to treatment conditions, but the researcher exercises certain
controls to enhance the study’s internal validity.
SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and
Methods. 7th Edition.pp. 718,725,729

8. This research topic has the potential to contribute to nursing because it

seeks to:
Include new modalities of care
Resolve a clinical problem
Clarify an ambiguous modality of care
Enhance client care

CORRECT ANSWER: D
Rationale: Nursing research is systematic inquiry designed to develop knowledge
about issues of importance to the nursing profession, including nursing practice,
education administration, and informatics. Research designed to generate knowledge
and to improve the health and quality of life of nurse’s clients. Nurses
increasingly are expected to adopt an evidenced-based practice, which is broadly
defined as the use of best clinical evidence in making patient care decisions.
OPTIONS A,B and C are also correct but the best is option D
SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and
Methods. 7th Edition.pp. 3-4

9. Martha does review of related literature for the purpose of:

Determine statistical treatment of data research
Orientation to what is already known or unknown
To identify if problem can be replicated
Answering the research question

CORRECT ANSWER: D
RATIONALE: All of the choices are correct except D. Answer to the research
question may be found after conducting the study.
The following are purposes of a literature review:
Identification of a research problem and development or refinement of research
questions or hypothesis
Orientation to what is known and not known about an area of inquiry, to ascertain
what research can best make a contribution to the existing base of evidence
Determination of any gaps or inconsistencies in abody of research
Determination of a need to replicate a prior study in a different setting or with
a different study population
Identification or development of new or reined clinical interventions to test
through empirical research
Identification of relevant theoretical or conceptual frameworks for a research
problem
Identification of suitable designs and data collection methods for a study
For those developing research proposals for finding, identification of experts in
the fields who could be used as consultants
Assistance in interpreting study findings and in developing implications and
recommendations
SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and
Methods. 7th Edition.pp. 5

10. Client's rights should be protected when doing research using human subjects.
Martha identifies these rights as
follows EXCEPT:
right of self-determination
right to compensation
right of privacy
right not to be harmed

CORRECT ANSWER: B
RATIONALE: All are the client’s rights for being the subject in a research except
option B.
The following are the basic human rights of research subjects:
Right to informed consent
The right to refuse and/or withdraw from participation
Right to privacy
Right to confidentiality or anonymity of data
Right to be protected from harm
SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the
Philippines.10th Edition.pp.110-111

Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance

related to excessive secretions and is at risk for infection because of retained
secretions. Part of Nurse Mario's nursing care plan is to loosen and remove
excessive secretions in the airway,

11. Mario listens to Richard's bilateral sounds and finds that congestion is in
the upper lobes of the lungs. The
appropriate position to drain the anterior and posterior apical segments of
the lungs when Mario does percussion
would be:
Client lying on his back then flat on his abdomen on Trendelenburg position
Client seated upright in bed or on a chair then leaning forward in sitting
position
Client lying flat on his back and then flat on his abdomen
Client lying on his right then left side on Trendelenburg position

CORRECT ANSWER: B
RATIONALE: Postural Drainage involves a patient assuming various positions to
facilitate the flow of secretions from various parts of the lung into the bronchi,
trachea and throat so that they can be cleared and expelled from the lungs more
easily. The diagram below shows the correct positions to assume for draining
different parts of the lung.
OPTIONS A and C are inappropriate
OPTION D will drain the lower lobes of the lung
SOURCE: http://www.huff-n-puff.net/posturaldrainage.htm

12. When documenting outcome of Richard's treatment, Mario should include the
following in his recording EXCEPT:
Color, amount and consistent of sputum
Character of breath sounds and respiratory rate before and after procedure
Amount of fluid intake of client before and after the procedure
Significant changes in vital signs

CORRECT ANSWER: C
RATIONALE: The nurse needs to evaluate the client’s tolerance of postural drainage
by assessing the stability of the clients vital signs, particularly the pulse and
respiratory rates and by noting signs of intolerance, such as pallor, diaphoresis,
dyspnea and fatigue.Following Postural drainage, the nurse should auscultates the
client’s lungs, compare the findings to the baseline data, and document the
amount, color, and character of expectorated secretions.
OPTION C is not part of the documentation.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305

13. When assessing Richard for chest percussion or chest vibration and postural
drainage Mario would focus on the
following EXCEPT:
Amount of food and fluid taken during the last meal before treatment
Respiratory rate, breath sounds and location of congestion
Teaching the client's relatives to perform 'the procedure
Doctor's order regarding position restriction and client's tolerance for lying
flat

CORRECT ANSWER: C
RATIONALE: Option C, though is part of nursing interventions but it is not the
focus during this time.
OPTION A is important to prevent vomiting and aspiration
OPTION B will give the nurse baseline data
OPTION D is important because certain position is contraindicated to the client
that may further lead to dyspnea
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305
14. Mario prepares Richard for postural drainage and percussion. Which of the
flowing is a special consideration
when doing the procedure?
Respiratory rate of 16 to 20 per minute
Client can tolerate sitting and lying position
Client has no signs of infection
Time of last food and fluid intake of the client

CORRECT ANSWER:D
RATIONALE: Postural drainage treatments are scheduled two or three times daily,
depending on the degree of lung congestion. The best times include before
breakfast, before lunch, in the late afternoon and before bedtime. It is best to
avoid hours shortly after meals because postural drainage at these times can be
tiring and can induce vomiting.
OPTION A has no special consideration since it is normal
OPTIONS B & C don’t have any special considerations
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305

15. The purpose of chest percussion and vibration is to loosen secretions in the
lungs. The difference between the
procedure is;
Percussion uses only one hand white vibration uses both hands
Percussion delivers cushioned blows to the chest with cupped palms while vibration
gently shakes
secretion loose on the exhalation cycle
In both percussion and vibration the hands are on top of each other and hand
action is in tune with
client's breath rhythm
Percussion slaps the chest to loosen secretions while vibration shakes the
secretions along with the
inhalation of air

CORRECT ANSWER: A
RATIONALE: Percussion sometimes called clapping is forceful striking of the skin
with cupped hands. Vibration is a series of vigorous quiverings produced by hands
that are placed flat against the client’s chest wall. Option A is true to both
percussion and vibration.
OPTION B is not the correct way
OPTION C: percussion can be done with one hand
OPTION D: percussion is not slapping
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.1303,1305

Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for
observation; after complaints of severe chest pain. You are assigned to take care
of the client.

16. When doing an initial assessment, the best way for you to identify the
client's priority problem is to:
Interview the client for chief complaints and other symptoms
Talk to the relatives to gather data about history of illness
Do auscultation to check for chest congestion
Do a physical examination white asking the client relevant questions

CORRECT ANSWER: A
RATIONALE: An interview is a planned communication or a conversation with a
purpose, for example, to get or give information, identify problems of mutual
concern, evaluating change, teach, provide support or provide counseling or
therapy. Initially during an assessment, the nurse first asks the complaints of
the client and the associated symptoms so that initial intervention can be done.
OPTION B: the client is the primary source of data
OPTIONS C and D: may follow after
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265

17. Upon establishing Mr. Regalado's nursing needs, the next nursing approach
would be to:
Introduce the client to the ward staff to put the client and family at ease
Give client and relatives a brief tour of the physical set up the unit
Take his vital signs for a baseline assessment
Establish priority needs and implement appropriate interventions

CORRECT ANSWER: C
RATIONALE: Assessment is always done first before anything else.
OPTION A and B are interventions
OPTION D is diagnosing, planning and interventions

18. Mr. Regalado says he has "trouble going to sleep". In order to plan your
nursing intervention you will.
Observe his sleeping patterns in the next few days
Ask him what he means by this statement
Check his physical environment to decrease noise level
Take his blood pressure before sleeping and upon waking up

CORRECT ANSWER: B
RATIONALE: It is another question for prioritization. Clarifying what the patient
mean of “trouble going to sleep” enable the nurse to plan for the appropriate
intervention.
OPTION A is inappropriate, may require some time before the intervention
OPTIONS C is judgmental that the noise is the cause of trouble in sleeping
OPTION D is inappropriate without further assessment

19. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal
edema. When taking care of Mr.
Regalado, which of the following intervention would be the most appropriate
immediate nursing approach.
Moisturize lower extremities to prevent skin irritation
Measure fluid intake and output to decrease edema
Elevate lower extremities for postural drainage
Provide the client a list of food low in sodium

CORRECT ANSWER: A
RATIONALE: All of the options are interventions for edema but option A is the
immediate intervention.
SOURCE: Black and Hawks. Medical Surgical Nursing.Vol. 1.7th Edition.pp. 217-218

20. Mr. Regalado will be discharged from your unit within the hour. Nursing
actions when preparing a client for
discharge include all EXCEPT:
Teaching the factors that may trigger chest pain
Giving instructions about his medication regimen
Telling the patient to see the doctor for the final instruction
Proper recording of pertinent data

CORRECT ANSWER: C
RATIONALE: Nurse preparing to send clients home needs to assess the following
parameters in their clients: personal and health data, abilities to perform the
activities of daily living (ADLs), any physical, cognitive or other functional
limitations, caregiver’s responses and abilities, adequacy of financial resources,
community supports, hazards or barriers that the home environment presents and
need for health care assistance in the home. Essential information before
discharge includes information about medications, dietary, and activity
restrictions, signs of complications that need to be reported to the physician,
follow-up appointments an telephone numbers, and where supplies can be obtained.
OPTION C is inappropriate. The nurse is giving the patient discharge instruction
before leaving the hospital.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 114

Situation 5 - Accurate computation prior to drug administration is a basic skill

all nurses must have.

21. Rudolf is diagnosed with amoebiasis and is to receive metronidazole (Flagyl)

tablets 1.5 gm daily in 3 divided
doses for 7 consecutive days. Which of the following is the correct dose of
the drug that the client will receive per
oral administration?
1,000 mg tid
500 mg tid
1,500 mg tid
250 mg tid

CORRECT ANSWER: B
RATIONALE: 1gram=1,000 milligram
1.5 gm x 1,000 mg = 1,500 mg
1,500 /3doses= 500 per oral administration

22. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three
times a day. The available dose
is 125 mg/ml. Which of the following should Nurse Paulo prepare for each
oral dose?
.5 ml
1.25 ml
2.5 ml
1 ml

CORRECT ANSWER: A
RATIONALE: Q= Drug prescribed/ drug available or stock
= 62.5 mg/125mg/ml
= 0.5 ml

23. A client is ordered to take Lasix, a diuretic, to be taken orally daily.

Which of the following is an appropriate
instruction by the nurse?
Report to the physician the effects of the medication on urination
Take the medication early in the morning
Take a full glass of water with the medication
Measure frequency of urination in 24 hours.

CORRECT ANSWER: B
RATIONALE: furosemide (Lasix) is a diuretic that will increase urination so it is
important to instruct patient to take the drug early in the morning to prevent
problems in sleep because when taken at night, it will produced urinary frequency.
OPTION A: Effects on urination is normal since it is a diuretics
OPTION C: is not that important
OPTION D: measuring the total amount of output is more important than the
frequency

Situation 6 - Mrs. Seva, 32 years old, asks you about possible problems regarding
her elimination now that she is in the menopausal stage.

24. Instruction on health promotion regarding urinary elimination is important.

Which would you include?
Hold urine, as long as she can before emptying the bladder to strengthen her
sphincters muscles
If burning sensation is experienced while voiding, drink pineapple-juice
After urination, wipe from anal area up towards the pubis
Tell client to empty the bladder at each voiding

CORRECT ANSWER: D
RATIONALE:
Promoting Urinary Elimination
Instruct the client to respond to urge to void as soon as possible; avoid
voluntary urine retention
Teach the client to empty the bladder completely at each voiding
Emphasize the importance of drinking 9-10 glasses of water daily
Teach female clients about Kegel’s exercises to strengthen perineal muscles
Etc.
OPTION A is incorrect
OPTION B might not always be correct, pineapple juice increase the acidity of
urine but burning sensation may be an indication already of an existing disease.
OPTION C: wiping should be from front to back

25. Mrs. Seva also tells the nurse that she is often constipated. Because she is
aging, what physical changes
predispose her to constipation?
inhibition of the parasympathetic reflex
weakness of sphincter muscles of the anus
loss of tone of the smooth muscles of the colon
decreased ability to absorb fluids in the lower intestines

CORRECT ANSWER: C
RATIONALE: If the feces are very hard or if there is great difficulty in passing
it out, then it is constipation.
Causes of constipation
Peristalsis of the intestine in the elderly is usually weakened, hence they are
more prone to constipation. Aging may also affect bowel regularity because a
slower metabolism results in less intestinal activity and muscle tone.
Inadequate water or lack of fibre in food, leading to hard faeces.
Psychological factors, e.g. using bedpan or commode chair without privacy, a dirty
toilet, depression, etc.
Drugs such as morphine group pain killers, certain diuretics, calcium tablets.
Diseases, e.g. diabetic mellitus, hypothyroidism.
SOURCE:http://healthlink.mcw.edu/article/930592170.html;http://www.info.gov.hk/eld
erly/english/healthinfo/healthproblems/constipation.htm

26. The nurse understands that one of these factors contributes to constipation:
excessive exercise
high fiber diet
no regular time for defecation daily
prolonged use of laxatives

CORRECT ANSWER: D
Rationale: Laxatives contain chemicals that help increase stool motility, bulk,
and frequency -- thus relieving temporary constipation. But when misused or
overused, they can cause problems, including chronic constipation! A healthy diet
filled with fresh fruits, vegetables, and whole-grain products; regular exercise;
and drinking at least eight cups of water daily can help prevent constipation in
most people.
Still, 85% of doctor visits for constipation result in a prescription for a
laxative. So it's important to understand how laxatives work and how to use them
safely.
OPTION A&B will not cause constipation
OPTION C: Some people think they are constipated if they do not have a bowel
movement every day. However, normal stool elimination may be three times a day or
three times a week, depending on the person.
SOURCE: http://www.webmd.com/digestive-disorders/laxatives-for-constipation-using-
them-safely?src=RSS_PUBLIC

27. Mrs. Seva talks about her being incontinent due to a prior experience of
dribbling urine when laughing or
sneezing and when she has a full bladder. Your most appropriate
.instruction would be to:
tell client to drink less fluids to avoid accidents
instruct client to start wearing thin adult diapers
ask the client to bring change of underwear "just in case"
teach client pelvic exercise to strengthen perineal muscles

CORRECT ANSWER: D
RATIONALE: It is important to remember that urinary incontinence is not part of
normal aging and often treatable. Independent nursing interventions for clients
with urinary incontinence include (a)a behavior-oriented continence training
program that may consist of bladder training, habit training, prompted voiding,
pelvic muscle exercises and positive reinforcement; (b) meticulous skin care and
(c) for males, application of an external drainage device (condom-type catheter
device).
Pelvic muscle exercises (also known as Kegel exercises) work the muscles that you
use to stop urinating. Making these muscles stronger helps you hold urine in your
bladder longer. These exercises are easy to do. They can lessen or get rid of
stress and urge incontinence.
Kegel Exercises
The muscles you want to exercise are your pelvic floor muscles. These are the ones
you use to stop the flow of urine or to keep from passing gas. Often doctors
suggest that you squeeze and hold these muscles for a certain count, and then
relax them. Then you repeat this a number of times. You will probably do this
several times a day. Your doctor will give you exact directions.
OPTIONS A,B and C are inappropriate
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1270;
http://www.niapublications.org/agepages/urinary.asp

28. Mrs. Seva asked for instructions for skin care for her mother who has urinary
incontinence and is almost always
in bed. Your instruction would focus on prevention of skin irritation and
breakdown by
Using thick diapers to absorb urine well
Drying the skin with baby powder to prevent or mask the smell of ammonia
Thorough washing, rinsing and drying of skin area that get wet with urine
Making sure that linen are smooth and dry at all times

CORRECT ANSWER: C
RATIONALE: Skin that is continually moist becomes macerated (softened). Urine that
accumulates on the skin is converted to ammonia, which is very irritating to the
skin. Because both skin irritation and maceration predispose the client to skin
breakdown and ulceration, the incontinent person requires meticulous skin care. To
maintain skin integrity, the nurse washes the client’s perineal area with soap and
water after episodes of incontinence, rinses it thoroughly, dries it gently and
thoroughly and provides clean, dry clothing or bed linen. If the skin is
irritated, the nurse applies barrier creams such as zinc oxide ointment to protect
it from contact with urine. If it is necessary to pad the client’s clothes for
protection, the nurse should use products that absorb wetness and leave a dry
surface in contact with the skin.
OPTION A and B: Use of diapers and other containment devices may prevent the
bedding and clothing from getting soiled, however they tend to keep the urine or
stool in constant contact with the skin. Within a short period of time, the skin
can become damaged. Special care must be taken to prevent skin breakdown by
keeping the skin clean and dry.
OPTION D is also correct but the best is option C
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1271;
http://www.healthcentral.com/ency/408/003976.html

Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are
the physiological needs vital to life. The nurse's knowledge and ability to
identify and immediately intervene to meet these needs is important to save lives.

29. Which of these clients has a problem with the transport of oxygen from the
lungs to the tissues?
Carol with a tumor in the brain
Theresa with anemia
Sonny Boy with a fracture in the femur
Brigette with diarrhea

CORRECT ANSWER: B
RATIONALE: Anemia is a condition characterized by abnormally low levels of healthy
red blood cells or hemoglobin (the component of red blood cells that delivers
oxygen to tissues throughout the body).
The tissues of the human body need a regular supply of oxygen to stay healthy. Red
blood cells, which contain hemoglobin that allows them to deliver oxygen
throughout the body, live for only about 120 days. When they die, the iron they
contain is returned to the bone marrow and used to create new red blood cells.
Anemia develops when heavy bleeding causes significant iron loss or when something
happens to slow down the production of red blood cells or to increase the rate at
which they are destroyed.
OPTIONS A, C and D has no direct effect in the oxygenation of tissues.
SOURCE: http://www.answers.com/topic/anemia?cat=health

30. You noted from the lab exams in the chart of Mr. Santos that he has reduced
oxygen in the blood. This
condition is called:
Cyanosis
Hypoxia
Hypoxemia
Anemia

CORRECT ANSWER: C
RATIONALE: Hypoxemia is an abnormal deficiency in the concentration of oxygen in
arterial blood (Mosby's Medical Dictionary).
OPTION A: Cyanosis-a bluish discoloration of the skin and mucous membranes
resulting from inadequate oxygenation of the blood
OPTION B: Hypoxia -a condition in which there is a decrease in the oxygen supply
to a tissue.
OPTION D: Anemia is having less than the normal number of red blood cells or less
hemoglobin than normal in the blood.

31. You will do nasopharyngeal suctioning to Mr. Abad. Your guide for the length
of insertion of the tubing
for an adult would be:
tip of the nose to the base of the neck
the distance from the tip of the nose to the middle of the cheek
the distance from the tip of the nose to the tip of the ear lobe
eight to ten inches

CORRECT ANSWER: C
RATIONALE: Oropharyngeal or nasopharyngeal suctioning removes secretions from the
upper respiratory tract. Make an appropriate measure of the depth of the catheter
by measuring the distance between the tip of the client’s nose and the earlobe, or
about 13 cm (5 inches) for an adult.
OPTIONS A, B and D are inappropriate
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1318, 1320

32. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma
to the area by:
Applying suction for at least 20-30 seconds each time to ensure that all
secretions are removed
Using gloves to prevent introduction of pathogens to the respiratory system
Applying no suction while inserting the catheter
Rotating catheter as it is inserted with gentle suction

CORRECT ANSWER: C
RATIONALE: For nasopharyngeal suctioning, without applying the suction, insert the
catheter premeasured or recommended distance into either nares and advance it
along the floor of the nasal cavity. This avoids the nasal turbinates. Never force
the catheter against an obstruction. If one nostril is obstructed, try another.
OPTION A: Suction is applied for 5 to 10 seconds while slowly withdrawing the
catheter. A suction attempt should last only 10 to 15 seconds.
OPTION B is true to prevent infection but not avoiding trauma
OPTION D: The catheter is rotated during suction not during the insertion of
catheter and no suction is applied during the insertion of the catheter.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1320

33. Myrna has difficulty breathing when on her back and must sit upright in bed
to breath, effectively and
comfortably. The nurse documents this condition as:
Apnea
Orthopnea
Dyspnea
Tachypnea

CORRECT ANSWER: B
RATIONALE: Orthopnea: The inability to breathe easily unless one is sitting up
straight or standing erect.
OPTION A: Apnea is the temporary cessation of breathing
OPTION C: Dyspnea: Difficult or labored breathing; shortness of breath.
OPTION D: Abnormally fast breathing. A respiratory rate that is too rapid.
SOURCE: http://www.medterms.com/script/main/art.asp?articlekey=5702

Situation 8 - You are assigned to screen for hypertension: Your task is to take
blood pressure readings and you are informed about avoiding the common mistakes in
BP taking that lead to 'false or inaccurate blood pressure readings.
34. When taking blood pressure reading the cuff should be:
deflated fully then immediately start second reading for same client
deflated quickly after inflating up to 180 mmHg
large enough to wrap around upper arm of the adult client 1 cm above brachial
artery
inflated to 30 mmHg above the estimated systolic BP based on palpation of radial
or brachial artery

CORRECT ANSWER: D
RATIONALE: Pump up the cuff until the sphygmomanometer reads 30 mmHg above the
point where the brachial pulse disappeared.
OPTION A: Wait 1 to 2 minutes before making further measurements. A waiting period
gives the blood trapped in the veins time to be released. Otherwise, false high
systolic readings will occur.
OPTION C: Wrap the deflated cuff evenly around the upper arm. Locate the brachial
artery. Apply the center of the bladder directly over the artery. The bladder
inside the cuff must be directly over the artery to be compressed if the reading
is to be accurate. For an adult, place the lower border of the cuff approximately
2.5 cm or 1 inch above the antecubital space.
OPTION D is inappropriate
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 515-516

35. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of
death worldwide and
is a preventable disease. The primary cause of COPD is:
tobacco hack
bronchitis
asthma
cigarette smoking

CORRECT ANSWER: D
RATIONALE: COPD is a chronic lung disease. It has its own symptoms. The most
common cause of COPD is known. And it's preventable.
Smoking is the primary cause of COPD.
It is 10 times more likely that a smoker will get COPD than a nonsmoker. Exposure
to secondhand tobacco
Cigarette smoke causes COPD by irritating the airways and creating inflammation
that narrows the airways, making it more difficult to breathe. Cigarette smoke
also causes the cilia to stop working properly so mucus and trapped particles are
not cleaned from the airways. As a result, chronic cough and excess mucus
production develop, leading to chronic bronchitis.
OPTION B: is one of the diseases in COPD
OPTION A and C:incorrect
SOURCE: http://www.clevelandclinic.org/health/health-
info/docs/2400/2416.asp?index=8709
http://www.copdguide.com/copd-is-different.jsp

36. In your health education class for clients with diabetes you teach, them the
areas for control Diabetes
which include all EXCEPT:
regular physical activity
thorough knowledge of foot care
prevention of infection
proper nutrition

CORRECT ANSWER: B
RATIONALE: Option D: In order to maintain a constant blood sugar level, diabetics
should ideally eat approximately the same amount of food per day, with a set
number of calories at around the same time of day so that blood sugar levels don’t
fluctuate too much. In addition, healthy snacks should be enjoyed to stop the
blood glucose levels from dropping too much in between meals. Meals should never
be skipped and the day’s food should contain a mixture of whole grains, fruits,
lean meat or meat substitutes i.e. corn, vegetables and low fat dairy products.
OPTION A: In conjunction with a healthy low fat diet, moderate exercise should be
taken at least five times a week for around 30 minutes each session. How a
diabetic person chooses to exercise will depend to some extent on their initial
level of fitness i.e. obese people will not go jogging or cycling for miles at a
time, and any exercise routine should only be performed after consulting a doctor.
As an individual starts to lose weight then the level of physical activity can be
increased accordingly but overdoing it to begin will undoubtedly lead to even
bigger problems.
OPTION C: Infection may result to hyperglycemia because the body requires more
glucose for energy. Thus preventing infection also control diabetes
OPTION B: A knowledge on foot care prevents complication of diabetic foot but does
not control diabetes itself.
SOURCE: http://www.diabeticlive.com/articles/17/1/Controlling-Diabetes-With-Diet-
And-Exercise/Page1.html

37. You teach your clients the difference between, Type I (IDDM) and Type II
(NDDM) Diabetes.
Which of the following is true?
both types of diabetes mellitus clients are all prone to develop ketosis
Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM)
diabetes which is genetic in etiology
Type I (IDDM) is characterized by fasting hyperglycemia
Type II (IDDM) is characterized by abnormal immune response

CORRECT ANSWER: B
RATIONALE: While it is said that type 2 diabetes occurs mostly in individuals over
30 years old and the incidence increases with age, we are seeing an alarming
number patients with type 2 diabetes who are barely in their teen years. In fact,
for the first time in the history of humans, type 2 diabetes is now more common
than type 1 diabetes in childhood. Most of these cases are a direct result of poor
eating habits, higher body weight, and lack of exercise.Type 1 diabetes was also
called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes
mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the
body itself, and is rendered incapable of making insulin. Abnormal antibodies have
been found in the majority of patients with type 1 diabetes. Antibodies are
proteins in the blood that are part of the body's immune system. The patient with
type 1 diabetes must rely on insulin medication for survival. In autoimmune
diseases, such as type 1 diabetes, the immune system mistakenly manufactures
antibodies and inflammatory cells that are directed against and cause damage to
patients' own body tissues. In persons with type 1 diabetes, the beta cells of the
pancreas, which are responsible for insulin production, are attacked by the
misdirected immune system. It is believed that the tendency to develop abnormal
antibodies in type 1 diabetes is, in part, genetically inherited, though the
details are not fully understood.
OPTION A: ketoacidosis -- mostly in people with type 1 diabetes -- and
hyperglycemic hyperosmolar nonketotic syndrome (HHNS) in people with type 2
diabetes or in people at risk for type 2 diabetes.
OPTION C:There is no such thing as fasting hyperglycemia
OPTION D: Type I is characterized by abnormal immune response
SOURCE: http://www.medicinenet.com/diabetes_mellitus/page3.htm

38. Lifestyle-related diseases in general share common risk factors. These are
the following except
physical activity
smoking
genetics
nutrition

CORRECT ANSWER: C
RATIONALE: A way of life or style of living that reflects the attitudes and values
of a person or group. Lifestyle assessment focuses on the personal lifestyle and
habits of the client as they affect health. Categories of lifestyle generally
assessed are physical activity, nutritional practices, stress management and such
habits as smoking, alcohol consumption and drug use.
OPTION C genetics is the scientific study of heredity. Genetics pertains to humans
and all other organisms.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 128

Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where
she works. She decides to get involved and help the victims of the accident.

39. Her priority nursing action would be to:

Assess damage to property
Assist in the police investigation since she is a witness
Report the incident immediately to the local police authorities
Assess the extent of injuries incurred by the victims, of the accident

CORRECT ANSWER: D
RATIONALE: The first priority whenever an accident occurs is to deal with the
emergency and ensure that any injuries or illnesses receive prompt medical
attention.
SOURCE: http://web.princeton.edu/sites/ehs/healthsafetyguide/A2.htm

40. Priority attention should be given to which of these clients?

Linda who shows severe anxiety due to trauma of the accident
Ryan who has chest injury, is pale and with difficulty of breathing
Noel who has lacerations on the arms with mild-bleeding
Andy whose left ankle swelled and has some abrasions

CORRECT ANSWER: B
RATIONALE: Respiratory problems and problem with the oxygenation should always be
the priority.
OPTION A is least priority because it is a psychological need
OPTION C is the second
OPTION D is the third

41. In the emergency room, Nurse Rivera is assigned to attend to the client with
lacerations on the arms,
while assessing the extent of the wound the nurse observes that the wound
is now starting to bleed profusely.
The most immediate nursing action would be to:
Apply antiseptic to prevent infection
Clean the wound vigorously of contaminants
Control and reduce bleeding of the wound
Bandage the wound and elevate the arm

CORRECT ANSWER: D
RATIONALE: Bleeding from any external wound sites on the victim's body should be
controlled to prevent the victim from going into shock which could lead to death
if not treated immediately.
Elevation - Keeping the wound above the level of the heart will decrease the
pressure at the point of injury, and will reduce the bleeding.
Direct Pressure - Placing pressure on the wound will constrict the blood vessels
manually. After applying pressure for sometime, you can make a pressure bandage
around the injury site. The key is to not make this too tight to cut all
circulation because this could have direct consequences later on. The bandage
should be tight enough to maintain pressure on the wound but not too tight to
impede any blood flow. If the skin turns purple-blue or if there is no pulse
present at the major pressure pints then the pressure bandage is on too tight.
OPTION A does not address the immediate need of the patient
OPTION B is incorrect because it may induce more bleeding
OPTION C is correct but option D is more specific
SOURCE: http://en.wikipedia.org/wiki/Emergency_bleeding_control

42. The nurse applies pressure dressing on the bleeding site. This intervention
is done to:
Reduce the need to change dressing frequently
Allow the pus to surface faster
Protect the wound from micro organisms in the air
Promote hemostasis

CORRECT ANSWER: D
RATIONALE: Hemostasis is the stoppage of bleeding or hemorrhage. Also, the
stoppage of blood flow through a blood vessel or organ of the body
Pressure dressing is a nonadherent bandage applied over the incision that is
covered by an absorbent layer and a stretchable adhesive. This application is
intended to compress dead space and prevent hematoma and seroma formation.
SOURCE: http://www.woundsresearch.com/Pressure-dressing

43. After the treatment, the client is sent home and asked to come back for
follow-up care. Your responsibilities
when the client is to be discharged include the following EXCEPT:
Encouraging the client to go to the, outpatient clinic for follow up care
Accurate recording, of treatment done and instructions given to client
Instructing the client to see you after discharge for further assistance
Providing instructions regarding wound care

CORRECT ANSWER: C
RATIONALE: Nurse preparing to send clients home needs to assess the following
parameters in their clients: personal and health data, abilities to perform the
activities of daily living (ADLs), any physical, cognitive or other functional
limitations, caregiver’s responses and abilities, adequacy of financial resources,
community supports, hazards or barriers that the home environment presents and
need for health care assistance in the home. Essential information before
discharge includes information about medications, dietary, and activity
restrictions, signs of complications that need to be reported to the physician,
follow-up appointments an telephone numbers, and where supplies can be obtained.
OPTION C: The client does not have the direct appointment with the nurse after the
discharge.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 114

Situation 10 - While working in the clinic, a new client, Geline, 35 years old,
arrives for her doctor's appointment. As the clinic nurse, you are to assist the
client fill up forms, gather data and make an assessment.

44. The nurse purpose of your initial nursing interview is to:

Record pertinent information in the client chart for health team to read
Assist the client find solutions to her health concerns
Understand her lifestyle, health needs and possible problems to develop a plan of
care
Make nursing diagnoses for identified health problems

CORRECT ANSWER: C
RATIONALE: An interview is a planned communication or a conversation with a
purpose, for example, to get or give information, identify problems of mutual
concern, evaluating change, teach, provide support or provide counseling or
therapy. Initially during an assessment, the nurse first ask the complaints of the
client and the associated symptoms so that initial intervention can be done.
It is an umbrella effect. Option C encompasses options A, B and D.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265

45. While interviewing Geline, she starts to moan and doubles up in pain, She
tells you that this pain occurs
about an hour after taking black coffee without breakfast for a few weeks
now. You will record this as follows:
Claims to have abdominal pains after intake of coffee unrelieved by analgesics
After drinking coffee, the client experienced severe abdominal pain
Client complained of intermittent abdominal pain an hour after drinking coffee
Client reported abdominal pain an hour after drinking black coffee for few weeks
now

CORRECT ANSWER: D
RATIONALE: To complete the assessment phase, the nurse records client data.
Accurate documentation is essential and should include all data collected about
the client’s health status. Data are recorded in a factual manner and not
interpreted by the nurse.
OPTION D is more complete recording of the patient’s complaints.
SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.274

46. Geline tells you that she drinks black coffee frequently within the day to
"have energy and be wide awake"
and she eats nothing for breakfast and eats strictly vegetable salads for
lunch and dinner to lose weight.
She has lost weight during the past two weeks, in planning a healthy
balanced diet with Geline, you will:
Start her off with a cleansing diet to free her body of toxins then change to a
vegetarian, diet and drink
plenty of fluids
Plan a high protein, diet; low carbohydrate diet for her considering her favorite
food
Instruct her to attend classes in nutrition to find food rich in complex
carbohydrates to maintain daily
high energy level
Discuss with her the importance of eating a variety of food from the major food
groups with plenty of fluids

CORRECT ANSWER: D
RATIONALE: Diet planning principles (ABCNMV)
1. Adequacy
-Provides sufficient energy and nutrients
2. Balance
- Consume a number of different foods in appropriate proportion to each other
3. kCalorie control
-Energy balance
4. Nutrient density
-Large amount of nutrients in a food with a small amount of calories
5. Moderation
-In consuming foods that are not nutrient dense
6. Variety
-Consume a variety of foods within and among the food groups
OPTION A is inappropriate because the patient is already in vegetable diet
OPTION B is limited only in protein and carbohydrates
OPTION C is limited to carbohydrates only
SOURCE: http://www.usm.edu/~nfs362/chap2.out.PDF

47. Geline tells you that she drinks 4-5 cups of black coffee and diet cola
drinks. She also smokes up to a
pack of cigarettes daily. She confesses that she is in her 2nd month of
pregnancy but she does not want
to become fat that is why she limits her food intake. You warn or caution
her about which of the following?
Caffeine products affect the central nervous system and may cause the mother to
have
a "nervous breakdown"
Malnutrition and its possible effects on growth and development problems in the
unborn fetus
Caffeine causes a stimulant effect on both the mother and the baby
Studies show conclusively that caffeine causes mental retardation

CORRECT ANSWER: B
RATIONALE: Maternal malnutrition impairs pregnancy outcome, increases maternal
mortality and retards early childhood development.
18 million low-birth weight babies are born to undernourished mothers each year.
This is a prime cause of infant mortality in developing countries
OPTION A, C and D are all limited to effects of caffeine
SOURCE: http://www.iaea.org/Publications/Booklets/Malnutrition/four.html

48. Your health education plan for Geline stresses proper diet for a pregnant
woman and the prevention of
non-communicable diseases that are influenced by her lifestyle these
include of the following EXCEPT:
Cardiovascular diseases
Cancer
Diabetes Mellitus
Osteoporosis

CORRECT ANSWER: D
RATIONALE: Your cardiovascular system consists of your heart and all blood vessels
throughout your body. Diseases ranging from aneurysms to valve disease are types
of cardiovascular disease. You may be born with some types of cardiovascular
disease (congenital) or acquire others later on, usually from a lifetime of
unhealthy habits, such as smoking, which can damage your arteries and cause
atherosclerosis
Cigarette smoking causes 87 percent of lung cancer deaths (1). Lung cancer is the
leading cause of cancer death in both men and women (3). Smoking is also
responsible for most cancers of the larynx, oral cavity and pharynx, esophagus,
and bladder. In addition, it is a cause of kidney, pancreatic, cervical, and
stomach cancers (2, 4), as well as acute myeloid leukemia (2).
OPTION D:Osteoporosis occurs when an imbalance occurs between new bone formation
and old bone resorption. The body may fail to form enough new bone, or too much
old bone may be reabsorbed, or both. Two essential minerals for normal bone
formation are calcium and phosphate. Throughout youth, the body uses these
minerals to produce bones. If calcium intake is not sufficient or if the body does
not absorb enough calcium from the diet, bone production and bone tissue may
suffer.
SOURCE: http://www.emedicinehealth.com/osteoporosis/page2_em.htm;
http://www.cancer.gov/cancertopics/factsheet/Tobacco/cancer
http://www.mayoclinic.com/health/cardiovascular-disease/HB00032/UPDATEAPP=0

Situation 11 - Management of nurse practitioners is done by qualified nursing

leaders who have had clinical experience and management experience.

49. An example of a management function of a nurse is:

Teaching patient do breathing and coughing exercises
Preparing for a surprise party for a client
Performing nursing procedures for clients
Directing and evaluating the staff nurses

CORRECT ANSWER: D
RATIONALE: Management has a unique purpose and outcome that is needed to maintain
a healthy organization. Management functions include planning, organizing,
staffing, directing and controlling. According to Kleinman,the basic components
of management functions include planning, organizing, delegating, problem solving,
evaluating and enforcing policies and procedures.
Other options are not correct
SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management
Functions in Nursing. Theory and applications. 5th Edition.pp. 39-41

50. Your head nurse in the unit believes that the staff nurses are not capable of
decision making so she makes
the decisions for everyone without consulting anybody. This type of
leadership is:
Laissez faire leadership
Democratic leadership
Autocratic leadership
Managerial leadership

CORRECT ANSWER: C
RATIONALE: Autocratic Leadership Style
This is often considered the classical approach. It is one in which the manager
retains as much power and decision-making authority as possible. The manager does
not consult employees, nor are they allowed to give any input. Employees are
expected to obey orders without receiving any explanations. The motivation
environment is produced by creating a structured set of rewards and punishments.
OPTION A:The laissez-faire leadership style is also known as the “hands-off¨
style. It is one in which the manager provides little or no direction and gives
employees as much freedom as possible. All authority or power is given to the
employees and they must determine goals, make decisions, and resolve problems on
their own.
OPTION B:The democratic leadership style is also called the participative style as
it encourages employees to be a part of the decision making. The democratic
manager keeps his or her employees informed about everything that affects their
work and shares decision making and problem solving responsibilities. This style
requires the leader to be a coach who has the final say, but gathers information
from staff members before making a decision
OPTION D:A manager’s style of managing has been a continuing cause of concern to
his manager's style is one of the major contributors to the performance and
effectiveness of his unit. The desire to define how a manager should conduct
himself while working with others has led to investigations into those variables
that may affect levels of managerial performance. This article examines, in
summary form, investigations by various management authorities on the subject of
managerial styles. These investigations have been developed into three theories of
managerial style: trait, behavior, and situation.
SOURCE: http://www.essortment.com/all/leadershipstyle_rrnq.htm
http://www.airpower.maxwell.af.mil/airchronicles/aureview/1976/mar-apr/dean.html