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Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie does when one of the clients does NOT have a readable identification band? A. Ask the client if she is Mrs. Santos B. Ask the client his name C. Ask the room mate if the client is Mrs. Santos D. Compare the ID band with the bed tag Lizette, a head nurse in a surgical unit, hears one of the staff nurses say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide staff nurse in the use of touch, which of the following would be the BEST response of Lizette? A. "Use touch when the situation calls for it". B. Touch serves as a connection between the nurse and the patient." C. "Use touch with discretion." D. Touch is used in physical assessment." You are asked to teach the client, Mr. Lapuz who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly? A. The cane and one foot or both feet are on the floor at all times B. He advances the cane followed by the left leg C. Client keeps the cane on the right side along the weak leg D. Client leans to the left side which is stronger George, a 43 year old executive, is scheduled for cardiac bypass surgery. While being prepared for surgery, he says to the nurse "I am not going to have the surgery. I may die because of the risk". Which response by the nurse is most appropriate? A. "Without the surgery you will most likely die sooner." B. There are always risks involved with surgery." C. There is a client in the other room who had successful surgery and you can talk to him". D. "This must be very frightening for you. Tell me how you feel about the surgery." 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? A. Report to the physician the effects of the medication on urination B. Take the medicine early in the morning C. Take a full glass of water with the medicine D. Measure frequency of urination in 24 hours Nurse Glenda gets a call from a neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? A. Observe the child for an hour if the child does not improve, refer to the physician in the neighborhood B. Recommend to bring the child immediately to the hospital C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to the hospital Wilfred, 30 years old male, was brought to the hospital due to injuries sustained from a vehicular accident. While being transported to the X-ray department, the straps accidentally broke and the client fell to the floor hitting his head. In this situation, the nurse is: A. Not responsible because of the doctrine of respondent superior B. Free from any negligence that caused harm to the patient C. Liable along with the employer for the use of a detective equipment that harms the client D. Totally responsible for the negligence While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna? A. Ignore the incidence B. Report the incidence to the head nurse C. Respect the client's actions as this provides structure and support to the client D. Call her attention so she can go to sleep A client asks for advice on low cholesterol food. You advise the client to eat the following:

A. B. C. D. 10.

Chicken liver, cow liver, eggs Lean beef and pork, egg white, fish Balut, salted eggs, duck and chicken egg Pork liempo, cow brain, lungs and kidney

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The code of ethics for nurses has an interpretive statement that provides: A. Continuity of care for the improvement of the client B. Guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the profession C. Standards of care in carrying out nursing responsibilities D. Identical care to all clients in any setting Which of the following situations would possibly cause a nurse to be sued due to negligence? A. Nurse gave a client wrong medication and an hour later, client complained of dyspnea B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the client's medicine cup C. As the nurse was about to administer medication, the client questioned why the medication is still given when in fact the physician discontinued it D. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Patient noticed the error and complained. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital: A. Diabetic client type 2 B. Client with chronic obstructive pulmonary disease (COPD) C. Client with second degree burns D. Client with psoriasis Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he has observed her to be too involved in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse? A. "Dont worry. I will call the attention of your wife." B. "Your wife is just trying to help because she is worried about you." C. "What are your thoughts about your wife's involvement in your care?" D. Your wife can assist you well in your care and recovery." The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take? A. Approach the two nurses and tell them that their actions are inappropriate especially in a public place B. Wait till the nurses finish the discussion and report the situation to the supervisor C. Say nothing to avoid embarrassing the staff nurses D. Remain quiet and ignore the discussion The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father has been getting out of bed at night and walks around the house in the early hours of the morning causing him to fail and injure himself. Which instruction would you give? A. Apply restraints during the night hours only B. Advise hospitalization to prevent future accidents C. Keep a radio or TV for company and to orient the client D. Have someone check on the client frequently at night

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SITUATIONAL Situation 1 - Preparation and administration of medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save patients' lives 16. You are to administer an intramuscular injection to Dulce, 1 1/2 year old girl. The most appropriate site to administer the drug is: A. dorso gluteal region B. ventrogluteal region C. vastus lateralis D. gluteal region An infant is ordered to receive 500 ml of D5NSS for 24 hours. The Intravenous infusion set is at 60 drops/ml. How many drops per minute should the flow rate be? A. 60 drops per minute B. 21 drops per minute C. 30 drops per minute D. 15 drops per minute

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Following surgery, Henry is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? A. 42 drops B. 20 drops C. 60 drops D. 32 drops Mr. Lagrito is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per ml. Approximately how many drops per minutes should the IV be regulated? A. 13 14 drops B. 17 18 drops C. 10 12 drops D. 15 16 drops The Physician ordered Nembutal Na gr. XX. The bottle contains 100 mg/capsule. How many capsules will be administered to the client? A. 11 capsule B. 12 capsules C. 15 capsule D. 10 capsule

funeral to look like and what dress she will use. This client is in the stage of: A. acceptance B. resolution C. denial D. bargaining 28. The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM to Mrs. Leyba. Demerol is available in a mutidose vial labeled 100mg/ml while Vistaril comes in an ampule labeled 50 mg/ml. You are to give both medications in one injection. You will: A. withdraw the medication from the vial first then from the ampule B. inject air into the vial, then into the ampule C. Inject air into the ampule, aspirate desired dose, then into the vial D. withdraw medication from the ampule then from the vial When giving Demerol 50 mg from a multidose vial labeled 100 mg/ml and Vistaril 50 mg from an ampule labeled 50 mg/ml. What is the total volume that you will inject to the client? A. 2 ml B. I ml C. 1.5 ml D. 1.75 ml Mrs. Bernas is emaciated and is at risk for developing which problem in skin integrity? A. Blisters B. Reddening of the skin C. Pressure sores D. Pustules

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Situation 2 - The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved. 21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should: A. tell the nurse how to give bed baths correctly B. ask another staff nurse to do the bed baths instead C. provide a manual to be read on giving bed baths D. bring the staff nurse to a client's room and demonstrate a cleansing bath The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client. Together, they observe how well the dressings absorb the drainage. In what-step of the decision making process are they? A. Testing options B. Considering effects on results C. Defining the problem D. Making final decisions

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Situation 4 - You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility. 31. Ramils right leg is injured and Nurse Karen has to move him from the bed to a wheel chair. Which of the following is the appropriate nursing action of Nurse Karen? A. Put the client on the edge of the bed and place the wheelchair at her back B. Face the client and place the wheelchair on her left side C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed D. Put the client on the edge of the bed and place the wheelchair on the client's left side Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented? A. Adduction of the shoulder B. Lateral flexion of the sternocleidosmastoid muscle C. Hyperextension of the knees D. Anterior flexion of lumbar curvature Joseph prefers to be in high fowler's position most of the time. The nurse should prevent which of the following? A. Posterior flexion of the lumbar curvature B. Internal rotation of the shoulder C. External rotation of the hip D. Adduction of the shoulder Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first? A. Move the patient to the edge of the bed near the nurse B. Adjust the bed to a flat position C. Lock the wheels of the bed D. Raise the bed rails opposite the nurse Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg? A. Sandbags B. Firm mattress C. Pillow D. High foot board

22.

32. 23. To check if the nurses under her supervision use critical thinking, Mrs. David observers if the nurses act responsibly when at work. Which of the following actions of a nurse demonstrates the attitude of responsibility? A. Thinking of alternative methods of nursing care B. Sharing ideas regarding patient care C. Following standards of practice D. Planning other approaches for patient care The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client: A. Roman, a client who is ambulatory and for surgery tomorrow B. A post-operative client, Rey, who has a blood pressure of 90/50 mmHg C. Mr. Abad, a client who needs instructions for home medications D. Fred, a client who received pain medication 5 minutes ago A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a clients problem and its possible cause. The following is an example of a well written nursing diagnosis: A. Acute pain related to altered skin integrity secondary to hysterectomy B. Electrolyte imbalance related to hypocalcemia C. Altered nutrition related to high fat intake secondary to obesity D. Knowledge deficit related to proctosigmoidoscopy

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Situation 5 - As you begin work in the hospital where you are on probation, you are tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them. 36. An ambulatory client, Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client? A. Turning off the lights to promote sleep and rest B. Instructing the client about the use of the call system C. Raising the side rails D. Placing the bed in high position Mikka, a 25 year old female client, is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following

Situation 3 - You are taking care of Mrs. Bernas, 66 years old, who is terminally ill with ovarian cancer stage IV. 26. When caring for a dying client you will perform which of the following activities? A. Encourage the client to reach optimal health B. Assist client perform activities of daily living C. Assist the client towards a peaceful death D. Motivate client to gain independence

37. 27. The client prepares for her eventual death and discusses with the nurse and her family how she would like her

surgery, the patient complained of pain. Which of the following is the most appropriate nursing diagnosis? A. Impaired mobility related to pain secondary to an abdominal incision B. Impaired movements related to pain due to surgery C. Impaired mobility related to surgery D. Severe pain related to surgery 38. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? A. Encourage the client to log roll when turning B. Encourage the client to do self-care C. Instruct the client to do deep breathing exercises D. Ambulate the client in that ward premises every twenty minutes Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozano's hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for Mr. Lozano? A. Involving family members in meeting client's personal needs B. Meeting his needs till he is ready to perform selfcare C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care Mr. Ernest Lopez is terminally ill and he chose to be at home with his family. What nursing actions are best initiated to prepare the family of Mr. Lopez? A. Talk with the family members about the advantage of staying in the hospital for proper care B. Provide support to the family members by teaching ways to care for their loved one C. Convince the client to stay in the hospital for professional care D. Tell the client to be with his family

46.

Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a: A. nurse supervisor B. social worker C. bookkeeping department D. physician Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to: A. receive emotional support B. to be part of a research study C. provide financial assistance D. assist with chemotherapy A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a: A. nutritionist B. dietitian C. physician D. medical pathologist When collaborating with other health team members, the best description of Nurse Rita's role is: A. encourages the client's involvement in his care B. shares and implements orders of the health team to ensure quality care C. she listens to the individual views of the team members D. helps client set goals of care and discharge Nurse Rita is successful in collaborating with health learn members about the care of Mr. Linao. This is because she has the following competencies: A. Communication, trust, and decision making B. Conflict management, trust, negotiation C. Negotiation, decision making D. Mutual respect, negotiation, trust

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Situation 8 - The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in the community setting your main objective is to provide safe nursing to your clients? 51. To provide safe quality nursing care to various clients in any setting, the most important tool of the nurse so is: A. critical thinking to decide appropriate nursing actions B. understanding of various nursing diagnoses C. observation skills for data collection D. possession of in scientific knowledge about client needs You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: A. Creating plans of care for particular clientele B. Identifying the correct nursing diagnoses for clients C. Making a thorough assessment of client needs and problems D. Using standards of nursing care as your criteria for evaluation The effectiveness of your nursing care plan for your clients is determined by: A. The number of nursing procedures performed to comfort the client B. The amount of-medications administered to the client as ordered C. The number of times the client calls the nurse D. The outcome of nursing interventions based on plan of care You are assigned to Mrs. Amado, age 49, who was admitted for possible surgery. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100 hot flashes. Which of the above symptoms would be an objective cue? A. Blood pressure measurement of 170/100 B. Complaint of hot flashes C. Report of pain after ingestion of fatty food D. Complaint of frequent bouts of dizziness While talking with Mrs. Amado, it is most important for the nurse to: A. Schedule the laboratory exams ordered for her B. Do an assessment of the client to determine priority needs C. Tell the client that your shift ends after eight hours D. Have the client sign an informed consent

Situation 6 - Myrna a researcher proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 41. In both quantitative and qualitative research, the use of a frame of reference is required. Which of the following items serves as the purpose of a framework? A. Incorporates theories into nursing's body of knowledge B. Organizes the development of study and links the findings to nursing's body of knowledge C. Provides logical structure of the research findings D. Identifies concepts and relationships between concepts Myrna needs to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT: A. Locating and identifying resources B. Reading and recording notes C. Clarifying a research topic D. Using the library The primary purpose for reviewing literature is to : A. organize materials related to the problem of interest B. generate broad background and understanding of information related to the research problem of interest C. select topics related to the problem of interest D. gather current knowledge of the problem of interest

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54. 44. In formulating the research hypotheses, researcher Myrna should state the research question as: A. What is the response of the staff nurses to the health values? B. How is variable health value" perceived in a population? C. Is there a significant relationship between health values and health promotion activities of the staff nurses? D. How do health values affect health promotion activities of the staff nurses? 55. 45. The proposed study shows the relationship between the variables. Which of the following is the independent variable? A. Staff nurses in a selected college of nursing B. Health values C. Health promotion activities D. Relationship between health values and health promotion activities

Situation 9 - Oral care is an important part of hygienic practices and promoting client comfort. 56. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and

Situation 7 - White working in a tertiary hospital, you are assigned to the medical ward.

presence of sores. Which of the following is BEST to use for oral care? A. Lemon glycerine B. Hydrogen peroxide C. Mineral oil D. Normal saline solution 57. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a sidelying position with head of bed lowered B. Keep the client dry by placing towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and an orderly progression The advantages of oral care for a client include all of the following, EXCEPT : A. decreases bacteria in the mouth and teeth B. reduces need to use commercial mouthwash which irritate the buccal mucosa C. improves client's appearance and self-confidence D. improves appetite and taste of food A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouth wash to avoid rinsing the buccal cavity B. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs C. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums D. Suctioning as needed while cleaning the buccal cavity Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment

B. C. D.

Ask the nurse to find a way to learn the procedure Tell the nurse to read the procedure manual Do the procedure with the nurse

Situation 11 - Mr. Jose's chart is the permanent legal recording of all information that relates lo his health care management. As such, the entries in the chart must have accurate data. 66. Mr. Jose's chart contains all information about his health care. The functions of records include all following EXCEPT: A. Means of communication that health team members use to communicate their contributions to the client's health care B. The client's record also shows a document of how much health care agencies will be reimbursed for their services C. Educational resource for student of nursing and medicine D. Recording of actions in advance to save time An advantage of automated or computerized client care system is: A. the nursing diagnosis for a client's data can be accurately determined B. cost of confinement will be reduced C. information concerning the client can be easily updated D. the number of people to take care of the client will be reduced Information in the patient's chart is inadmissible in court as evidence when: A. the client's family refuses to have it used B. the client objects to its use C. the handwriting is not legible D. it has too many abbreviations that are "unofficial Nursing audit aims to: A. provide research data to hospital personnel B. study client's illness and treatment regimen closely C. compare actual nursing done to established standards D. provide information to health-care providers A telephone order is given for a client in your ward. What is your most appropriate action? A. Copy the order on to the chart and sign the physician's name as close to his original signature as possible B. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order C. Write the order in the client's chart and have the head nurse co-sign it D. Tell the physician that you can not take the order but you will call the nurse supervisor

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Situation 10 - Errors while providing nursing care to patients must be avoided and minimized at all times. Effective management of available resources enables the nurse to provide safe quality patient care. 61. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related? A. Interruptions B. Use of unofficial abbreviations C. Lack of knowledge D. Failure to identify client Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication practice related to this? A. Maintain medication in its unit dose package until point of actual administration B. Note both generic and brand name of the medication in the Medication Administration Record C. Only officially approved abbreviations maybe used in the prescription orders D. Encourage clients to ask question about their medications 72. 63. The hospital has an ongoing quality assurance program. Which of the following indicates implementation of process standards? A. The nurses check client's identification band before giving medications B. The nurse reports adverse reaction to drugs C. Average waiting time for medication administration is measured D. The unit has well ventilated medication room Which of the following actions indicate that Nurse Jerome is performing outcome evaluation of quality care? A. Interviews nurses for comments regarding staffing B. Measures waiting time for clients per nurse's call C. Checks equipment for its calibration schedule D. Determines how many clients post surgery have experienced infection An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor? A. Assign another nurse to perform the procedure 73.

Situation 12 - Nurse Roque, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of clients with various conditions 71. Which of the following client conditions should be Miss Roque's priority in the pediatric unit? A. The baby whose fontanel is bulging and firm while asleep B. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated C. A baby who is wailing after being awakened by the banging of the door D. A baby boy whose circumcision has yellowish exudate When suctioning the endotracheal tube, the nurse should: A. explain procedure to patient, insert catheter gently applying suction, withdrawn using twisting motion B. insert catheter until resistance is met then withdraw slightly, applying suction intermittently as catheter is withdrawn C. Hyperoxygenate client then insert catheter using back and forth motion D. Insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn Nurse Roque is giving instructions to Doris, the daughter of a comatose patient, to give a sponge bath. While Doris is doing the sponge bath, what action of Doris needs correction? A. Answering the phone while wearing gloves used for sponge bath B. Rolling the patient like a log to do back rub C. Lining the rubber mat with bed sheet as incontinence pad for the patient D. Turning the patient on the left side with head slightly elevated

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Dina sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application is most important for Nurse Roque to do? A. Use baby powder to reduce irritation under the cast B. Assess sensation of each arm C. Evaluate skin temperature in the area D. Check radial pulses bilaterally and compare To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? A. Upon waking up, cough deeply and expectorate into container B. Cough after pursed lip breathing C. Save sputum for two days in covered container D. After respiratory treatment, expectorate into a container

D. 85.

Rogers

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Nursing care becomes necessary when clients is unable to fulfill biological, physiological development or social needs explains which of the following theories: A. Adaptation theory B. Self-care deficit theory C. Theory of the Unity of Man D. Transcultural care theory

Situation 15 - When creating your lesson plan for cerebrosvascular disease or STROKE, it is important to include the risk factors of stroke. 86. The most important risk factor is: A. cigarette smoking B. hypertension C. binge drinking D. heredity Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: A. embolic stroke B. hemorrhagic stroke C. diabetic stroke D. thrombotic stroke Hemorrhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: A. phlebitis B. trauma C. damage to blood vessel D. aneurysm The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? A. Amphetamines B. Cocaine C. Shabu D. Demerol A participant in the STROKE class asks what is a risk factor of stroke. Your best response Is: A. "More red blood cells thicken blood and make clots more possible." B. "Increased RBC count is linked to high cholesterol." C. "More red blood cells increase hemoglobin content." D. "High RBC count increases blood pressure."

Situation 13 - Infections are quite commonly the reasons for a client's hospitalization. Appropriate interpretation of diagnostic tests and measures for infection control are helpful in the management of patient care. 76. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? A. Neutrophils 60% B. White blood cells (WBC) 90007mm C. Erythrocyte sedimentation (ESR) is 39 mm/hr D. Iron 75 mg/100 ml Surgical sepsis is observed when: A. inserting an intravenous catheter B. disposing of syringes and needles in puncture proof containers C. washing hands before changing wound dressing D. placing dirty soiled linen in moisture resistant bags A client with viral infection will most likely manifest which of the following during the illness stage of the infection? A. Client was exposed to the infection 2 days ago but without any symptoms B. Oral temperature shows fever C. Acute symptoms are no longer visible D. Client "feels sick" but can do normal activities Which of the following laboratory test results indicate presence of an infectious process? A. Erythrocyte sedimentation rate (ESR) 12 mm/hr B. White blood cells (WBC) 18.000/mm3 C. Iron 90g/100ml D. Neutrophils 67% Among the clients you are assigned to take care of, who is most susceptible to infection? A. Diabetic client B. Client with burns C. Client with pulmonary emphysema D. Client with myocardial infarction

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Situation 16 - Accurate computation prior to drug administration is a basic skill all nurses must have. 91. Ronald 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? A. 1,000 mg tid B. 500 mg tid C. 1,500 mg tid D. 250 mg tid Riza, 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? A. 0.5 ml B. 1.25 ml C. 2.5 ml D. 1.0 ml The physician ordered Potassium Chloride (KCl) in D 5W 1 liter to be infused In 24 hours for Mrs. Gomez. Since Potassium Chloride is a high risk drug. Nurse Robert used an intravenous pump. Which of the following should Nurse Robert do to safely administer this drug? A. Check the pump setting every 2 hours B. Teach the client how the infusion pump operates C. Have another nurse check the infusion pump setting D. Set the alarm of the pump loud enough to be heard Baby Liza, 3 months old, with a congenital heart deformity, has an order from her physician; "give 3.00 cc of Lanoxin today for 1 dose only". Which of the following is the most appropriate action by the nurse? A. Clarify order with the attending physician B. Discuss the order with the pediatric heart specialist in the unit C. Administer Lanoxin intravenously as it is the usual route of administration D. Refer to the medication administration record for previous administration of Lanoxin When Nurse Norma was about to administer the medications of client Lennie, the relative of Lennie told the nurse that they buy her medicines and showed the

Situation 14 - A significant milestone influencing the development of nursing concepts and theories was the establishment of journal of nursing research. Several nursing theorist have published the framework for practice according to their respective nursing theory. 81. Which of the following theorists consider and utilize nature and environment in the healing process? A. Julia Sotejo B. Ida Jean Orlando C. Florence Nightingale D. Imogene King In her theory, Imogene King defined nursing process as a dynamic interpersonal process between nurse, client and health care system. In this theory, which of the following nursing skills is most important to help client establish positive adaptation to environment? A. Assessment skills B. Communication skills C. Environment management skills D. Technical skills Who among the following theorists has identified twenty one specific client needs or problems in the area of comfort, hygiene, safety, physiologic balance, psychologic and social factors and sociological and community factors? A. Faye Abdellah B. Dorothy Johnson C. Sister Callista Roy D. Virginia Henderson Which of the following nurse theorists has stated that the goals of nursing is to maintain and promote health, prevent illness and care for and rehabilitate ill and disabled client through humanistic science and nursing. A. Orem B. Abdellah C. Nightingale 92.

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container of medications of the client. Which of the following is the most appropriate action by the nursed? A. Hold the administration of the client's medication and refer to the head nurse B. Put aside the medications she prepared and instead administer the client's medications C. Tell the client that she will inform the physician about this D. Bring the medications of the client to the nurse's station and prepare accordingly Situation 17 - You are taking care of Mrs. Santillan, a 48 year old woman who is unconscious after a cerebrovascular accident. You are aware that there are many physical complications due to immobility. 96. You should be alert for the following complications she may experience EXCEPT: A. Impaired mobility B. Contractures and muscle atrophy C. Hypostatic pneumonia D. Pressure sores Proper positioning of an immobilized unconsciousness client is important for the following reasons EXCEPT: A. Maintain skin integrity B. Promotes optimal lung expansion C. Prevent injuries and deformities of the musculoskeletal system D. Facilitates rest and sleep When positioning your client, you should observe good body mechanics for yourself and the client. This means that the nurse: A. Uses back muscles B. Assumes correct body alignment and efficient use of muscles to avoid injury C. Observes rhythmic movements when moving about D. Uses large muscles only You are going to move Mrs. Santillan, a 150 lbs. unconscious woman. Some principles to use when moving the client include the following EXCEPT: A. Prepare to move client by taking a deep breath and tightening abdominal and gluteal muscles B. Maintain wide base of support With feet and with knees flexed C. Push and pull using arms and legs instead of lifting D. Move close to the object to be moved leaning cm bending at the waist

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100. After moving Mrs. Santillan to the desired position, which action will you avoid? A. Avoid friction between bony prominences B. Place pillows to position client's extremities C. Apply restraints D. Raise bed rails