1. 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 CORRECT ANSWER: B RATIONALE: Before administering a medication, identify the client correctly using the appropriate means of identification, such as checking the identification bracelet, asking the client to state his/her name or, both. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 802 2. 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." CORRECT ANSWER: B RATIONALE: The therapeutic use of touch is a basic aspect of the nurse-client relationship and is normally perceived as a gesture of warmth and friendship. Elizabeth M. Varcarolis. Foundations of psychiatric and Mental Nursing.4 th ed.pp. 251 3. 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 CORRECT ANSWER: D RATIONALE: Lean your weight through the arm holding the cane as needed (left side) OPTION B: Advance the cane simultaneously with the opposite affected lower limb( less support) or advance the affected leg forward to the cane while the weight is borne by the cane and the stronger leg (maximum support). OPTION C: Client should use the cane on his stronger side. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1102 4. 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." CORRECT ANSWER: D RATIONALE: The nurse is acknowledging the patients feelings and allows him to express it. OPTION A: threatening to the patient OPTION B: though presenting the reality but not addressing the clients feelings OPTION C: belittling the clients feelings 5. 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 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 Reproduction is strictly prohibited RN International Review Center 1

6. 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 CORRECT ANSWER: C RATIONALE: Complete nursing action OPTION A: observing will not have any change in patients condition OPTION B: have you done any nursing intervention? OPTION D: leaving the child to the neighbor without performing your nursing intervention 7. 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 CORRECT ANSWER: C RATIONALE: The employer is liable because of respondeat superior principle. The nurse is liable for negligence. 8. 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 CORRECT ANSWER: C RATIONALE: It is important for nurses to develop a broad concept of spirituality. Many clients have spiritual strengths that the nurse can nurture to help them attain or maintain a feeling of spiritual well-being, to recover from illness and to face a peaceful death. OPTION A: In holistic nursing, the nurse provides care not only for the physical body and mind but also for the clients spirit. OPTION B: need not to be reported OPTION D: Allow time and privacy for and provide comfort measures prior to private worship, prayer, meditation, reading or other spiritual activities. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 995,1004 9. A client asks for advice on low cholesterol food. You advise the client to eat the following: A. Chicken liver, cow liver, eggs B. Lean beef and pork, egg white, fish C. Balut, salted eggs, duck and chicken egg D. Pork liempo, cow brain, lungs and kidney CORRECT ANSWER: B RATIONALE: lean meats and pork are low in saturated fat; egg white and fish are protein rich foods. All other choices are high in cholesterol. Foods high in cholesterol include meats, egg yolks, organ meats, whole milk and milk products. 10. 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 CORRECT ANSWER: B RATIONALE: A code of ethics is a formal statement of a groups ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral judgments over time. And (c) serve as a standard for their professional actions. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 73 11. 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 Reproduction is strictly prohibited RN International Review Center 2

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. CORRECT ANSWER: A RATIONALE: The term negligence refers to the commission or omission of an act, pursuant to a duty, that a a reasonably prudent person in the same or similar circumstance would or would not do and acting or the nonacting of which is the proximate cause of injury to another person or his property. The elements of professional negligence therefore are: 1. existence of a duty on the part of the person charged to use due care under circumstances 2. failure to meet the standard of due care 3. the forseeability of harm resulting from failure to meet the standard and 4. the fact that the breach of this standard resulted in an injury to the plaintiff Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp.160-161 12. 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 CORRECT ANSWER: C RATIONALE: Burns are exceedingly challenging due to the high risk of infection since the skin is no longer a barrier to bacteria. Infection is the most common complication of burns and is the major cause of death in burn victims. http://www.umm.edu/altmed/articles/burns-000021.htm OPTION A: susceptible to infection with open wounds but with proper care, less susceptible than burn patient OPTION B and D: are the least susceptible 13. 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." CORRECT ANSWER: C RATIONALE: Therapeutic and allows expression of feeling and thoughts OPTION A: False reassurance OPTION B: disagreeing OPTION D: not addressing the patients feelings 14. 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 CORRECT ANSWER: A RATIONALE: The nurse maintains patient confidentiality within legal and regulatory parameters. The nurse should approach his/her fellow nurses provided it is in a nice way not to embarrass them. OPTION B: In some cases it is appropriate to report it to the supervisor but you should not wait them to finish the discussion because more information will be divulge. OPTION C and D are inappropriate because we have also our moral responsibility with our co-worker as mention in the Code of Ethics. 15. 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 Reproduction is strictly prohibited RN International Review Center 3

CORRECT ANSWER: D RATIONALE: The older adult sleeps about 6 hours a night. About 20% to 25% is REM sleep. Stage IV sleep is markedly decreased and some instances absent. The first REM period is longer. Many elders awaken more often during the night and it often takes them longer to go back to sleep. At this case, enhance the sense of safety and security by checking on clients and making sure that the call lights is within reach. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1116-1117 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 CORRECT ANSWER: B RATIONALE: The ventrogluteal region is the preferred site for intramuscular injection because: Contains no large nerves or blood vessels Provides the greatest thickness of gluteal muscle consisting of both the gluteus and medius and gluteus minimus Is seald off with bone Contains consistently less fat than the buttocks area, thus eliminating the need to determine the depth of subcutaneous fat. OPTION A: can be used in children and adult with full developed gluteal muscles, should not be used for children under 3 years old unless the child has been walking for at least 1 year. OPTION C: Recommended for infants 7 months and younger OPTION D: very general option Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 826-827 17. 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 CORRECT ANSWER: B RATIONALE: Drops per minute= Total infusion volume x drop factor Total of infusion in minutes = 500 ml x 60 drops/ml 24 hrs x 60 min = 20.8333333 drops/min = 20-21 Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1391 18. 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 CORRECT ANSWER: A RATIONALE: Drops per minute= Total infusion volume x drop factor Total of infusion in minutes = 1000 ml x 20 drops/ml 8 hrs x 60 min = 41. 6666667 drops/min = 41-42 Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1391 19. 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 Reproduction is strictly prohibited RN International Review Center 4

B. 17 18 drops C. 10 12 drops D. 15 16 drops CORRECT ANSWER: A RATIONALE: Drops per minute= Total infusion volume x drop factor Total of infusion in minutes = 1000 ml x 10 drops/ml 12hr x 60min = 13.89 drops Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1391 20. 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 CORRECT ANSWER: B RATIONALE: 1 grain= 60 mg mg = 20 grain x 60 mg/ 1 gr = 120 mg/100mg/capsule = 12 capsules 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 CORRECT ANSWER: D RATIONALE: A staff members inexperience can be hindrance to delegation; an institution can minimize this through competency-based orientation and testing; the nurse delegating the task sometimes must teach the novice the necessary skills to complete the task; with proper guidance, delegating can improve the novices skills. Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 94 22. 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 CORRECT ANSWER: A RATIONALE:Decision making is a critical thinking process for choosing the best actions to meet a desired goal. The steps include: Identify the purpose Set the criteria Weigh the criteria Seek alternatives Examine the alternatives Project Implement Evaluation Examining alternatives- the nurse analyzes the alternatives to ensure that there is an objective rationale in relatiion to the established criteria for choosing one strategy over another. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 252 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 Reproduction is strictly prohibited RN International Review Center 5

D. Planning other approaches for patient care CORRECT ANSWER: A RATIONALE: Responsibility denotes obligation. It refers to what must to be done to complete a task and the obligation created by the assignment. Tomey, Ann Marriner. Guide to Nursing Management and Leadership. 7th Edition. Pp. 47 24. 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 CORRECT ANSWER: B RATIONALE: The patient is hypotensive and might be an indication of an early shock. OPTION A: 3RD OPTION C: 4TH OPTION D: 2ND 25. 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 CORRECT ANSWER: C RATIONALE: A nursing diagnosis has three components: (a) the problem and its definition (b) the etiology and (c) defining characteristics. It describes the clients health status clearly and concisely in a few words. To be clinically useful, diagnostic labels need to specific; when the word specify follows a NANDA label, the nurse states the area in which the problem occurs. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 279 OPTION A: double diagnosis OPTION B and D: used a medical term on the etiology 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 CORRECT ANSWER: C RATIONALE: Nurses need to ensure that the client is treated with dignity, that is with honor and respect. Dying clients often feel they have lost control over their lives and over life itself. Helping clients die with dignity involves maintaining their humanity, consistent with their values, beliefs and culture. Clients want to be able to manage the events preceding death so they can die peacefully. Nurses can help clients to determine their own physical, psychologic and social priorities. OPTIONS A, B and D are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 1050 27. The client prepares for her eventual death and discusses with the nurse and her family how she would like her 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 CORRECT ANSWER: A RATIONALE: The model was introduced by Elizabeth Kbler-Ross in her 1969 book "On Death and Dying". The stages have become well-known as the "Five Stages of Grief". The stages are: 1. Denial: "It can't be happening." 2. Anger: "Why me? It's not fair." 3. Bargaining: "Just let me live to see my children graduate." 4. Depression: "I'm so sad, why bother with anything?" 5. Acceptance: "It's going to be OK." Reproduction is strictly prohibited RN International Review Center 6

Acceptance-there is a difference between resignation and acceptance. You have to accept the loss, not just try to bear it quietly. Realization that it takes two to make or break a marriage. Realization that the person is gone (in death) that it is not their fault, they didn't leave you on purpose. (even in cases of suicide, often the deceased person, was not in their right frame of mind) Finding the good that can come out of the pain of loss, finding comfort and healing. Our goals turn toward personal growth. Stay with fond memories of person. SOURCE: http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model 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 CORRECT ANSWER: A RATIONALE: When mixing medications from one vial and one ampule, first prepare and withdraw the medication from the vial (Ampules do not require the addition of air prior to withdrawal of drug). Then withdraw the required amount of medication from the ampule. OPTIONS B,C and D are incorrect Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 819 29. 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 CORRECT ANSWER: C RATIONALE: Demerol: dose in hand = Quantity on hand 100mg = 1 ml 100mgx = 1ml (50 mg) X= 50mg/ml 100 mg = 0.5 ml Vistaril: 50mg/ml = 50mg/x = 1 ml Demerol (0.5ml) + Vistaril (1ml) = 1.5 ml 30. 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 CORRECT ANSWER: C RATIONALE: Emaciation occurs when a human loses substantial amounts of much needed fat and often muscle tissue, making that human look extremely thin. The cause of emaciation is a lack of nutrients from starvation or disease. The shape of the bones in a severely-emaciated person is distinguishable, the shoulder blades are prominently sharp, and the ribs and spine can be clearly seen, while the arms and legs are not significantly wider than the bones that support them. Death may occur. Risk for pressure sores increases due to the fact that patient is terminally ill so she is immobile. http://en.wikipedia.org/wiki/Emaciated OPTION A: caused by constant friction OPTION B: reddening of the skin is may be a manifestation of other problem OPTION D may be caused by infection 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 Reproduction is strictly prohibited RN International Review Center 7 desired dose quantity desired 50mg x

CORRECT ANSWER: D RATIONALE: Lower the bed to its lowest position so the clients feet will rest flat on the floor. Lock the wheels of the bed. Place the wheelchair parallel to the bed as close to the bed as possible. Put the wheelchair on the side of the bed that allows the client to move toward his or her stronger side. Lock the wheels of the wheelchair and raise the footplate. Give explicit instructions to the client. Ask the client to move forward and sit at the edge of the bed. This brings the clients center of gravity closer to the nurse. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1092 OPTION A: wheelchair should be at the clients stronger side OPTION C: wheelchair should be parallel to the bed and as close to the bed as possible 32. 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 CORRECT ANSWER: C RATIONALE: Problems to be prevented in dorsal recumbent position includes: Hyperextension of neck in thick-chested person Posterior flexion of lumbar curvature External rotation of the legs Hyperextension of knees (Put small pillow under the thigh to slightly flex the knee) Plantar flexion (foot drop) Pressure on heels Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1082 33. 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 CORRECT ANSWER: A RATIONALE: Problems to be prevented in Fowlers Position includes: Posterior flexion of lumbar curvature (Provide pillow at lower back or lumbar region to support lumbar region) Hyperextension of neck Shoulder muscle strain, possible dislocation of shoulders, edema of hands and arms with flaccid paralysis, flexion contracture of the wrist Hyperextension of knees Pressure on heels Plantar flexion of feet (foot drop) Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1081 34. 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 CORRECT ANSWER: C RATIONALE: Lock the wheels on the bed and raise the rail on the side of the bed opposite the nurse to ensure client safety. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1084 All options are correct but the nurse should first do option C to ensure clients safety, all the rest will follow as part of the procedure in moving your client up in bed. 35. 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 CORRECT ANSWER: A RATIONALE: Roll or sandbag is placed laterally to trochanter of femur to prevent external rotation of legs. OPTION B: Firm mattress provides good body support at natural body curvatures Reproduction is strictly prohibited RN International Review Center 8

OPTIONC: Pillows used or support or elevation of a body part OPTION D: prevent foot drop Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1080 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 CORRECT ANSWER: C RATIONALE: Raising the side rails promotes safety by preventing falls that may lead to injury or fracture. OPTION A: does address the safety needs but rather on the patients comfort OPTION B: more on emergency needs of patient OPTION D: the bed should be in lowest position as possible. 37. 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 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 CORRECT ANSWER: A RATIONALE: Nursing diagnosis should be concise, related to only one problem and written clearly. Noticed that OPTION C and D have the same etiology which is a surgical intervention; the diagnosis according to NANDA is Impaired mobility and not Impaired movements 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 CORRECT ANSWER: C RATIONALE: Walking is encouraged hours after surgery and breathing exercises may be performed to avoid loss of air in a lung or pneumonia. It is advised to bend at the hip, not at the waist, and to avoid twisting at the shoulders or hips. However at this time, options A, B and D can aggravate the pain experienced by the patient. Deep breathing exercise is one form of relaxation techniques. http://www.answers.com/topic/laminectomy?cat=health 39. 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 self-care C. Preparing a day to day activity list to be followed by client D. Involving Mr. Lozano in his care CORRECT ANSWER: C RATIONALE: During this time, they will gradually increase their activities to the point where they are doing all of their own self-care such as bathing and eating, as well as beginning a walking program as part of their rehabilitation program. OPTION A: we are developing independence to the client OPTION B: the nurse should gradually increase the activity OPTION D: may be correct but the best is Option C http://www.heartpoint.com/mimore.html#anchor87783 40. 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 Reproduction is strictly prohibited RN International Review Center 9

CORRECT ANSWER: B RATIONALE: As death approaches, the nurse assists the family and other significant people to prepare. The nurse asks questions that help identify ways to provide support during the period before and after death. The most important aspects of providing support to the family members of the dying client involve using therapeutic communication to facilitate their expression of feelings. The nurse also serves as a teacher, explaining what is happening and what the family can expect. Family members should be encouraged to participate in the physical care of the dying person as much as they wish to and are able. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1048,1052 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 CORRECT ANSWER: B RATIONALE: Framework is the underpinnings of a study; often called a theoretical framework in studies based on a theory, or a conceptual framework in studies rooted in a specific conceptual model. Their overall purpose is to make research findings meaningful and generalizable. Theories allow researchers to knit together observations and facts into orderly scheme. The linkage of findings into a coherent structure can make the body of accumulated evidence more accessible and, thus, more useful. Theories and conceptual models help to stimulate research and the extension of knowledge by providing both direction and impetus. OPTION A: describes only theoretical framework OPTION D: only for conceptual models Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 119-120 42. 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 CORRECT ANSWER: D RATIONALE: The following are purposes of review of related literature: 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 a body 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 OPTION D: There are variety of resources in the review of literature Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 5 43. 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 CORRECT ANSWER: A RATIONALE: Literature review is a critical summary of research on a topic of interest, often prepared to put a research problem in context. It is an umbrella effect, the main purpose of review of literature is to organize materials related to your topic. Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 722 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? Reproduction is strictly prohibited RN International Review Center 10

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? CORRECT ANSWER: D RATIONALE: Research questions are the specific queries researchers want to answer in addressing the research problem. Research questions guide the type of data collected in a study. Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 65 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 CORRECT ANSWER: B RATIONALE: Independent variable is the variable that is believed to cause or influence the dependent variable. Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 720 Situation 7 - White working in a tertiary hospital, you are assigned to the medical ward. 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 CORRECT ANSWER: B RATIONALE: A social worker counsels clients and support persons regarding social problems, such as finances, marital difficulties and adoption of children. Option D: responsible for medical diagnosis and for determining the therapy required by a person who has a disease or injury. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 94-95 47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a selfhelp 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 CORRECT ANSWER: A RATIONALE: A self-help group is a small, voluntary organization composed of individuals who share a similar health, social or daily living problem. One of the central beliefs of the self-help movement is that people who experience a particular social or health problem have an understanding of that condition which those without it do not. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 436 48. 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 CORRECT ANSWER: B RATIONALE: Anyone can use the term nutritionist , even without any formal education or training. It's not a professionally regulated term which means that there are no minimum qualifications for a person to call himself or herself a nutritionist. Technically, only registered dietitians can use the term dietitian , which is a professionally regulated term. A registered dietitian is required to meet specific educational and professional standards. http://www.riverside-online.com/health_reference/Diet-Nutrition/AN00987.cfm Dietitians in hospitals generally are concerned with therapeutic diets, may design special diets to meet the nutritional needs of individual clients and supervise the preparation of meals to ensure that clients receive the proper diet. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 94 49. 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 Reproduction is strictly prohibited RN International Review Center 11

C. she listens to the individual views of the team members D. helps client set goals of care and discharge CORRECT ANSWER: B RATIONALE: Collaboration among health care professionals becomes increasingly important as more practitioners specialize in progressively more narrow areas of expertise while others take on generalist role. The nurse as a collaborator: With Nurse colleagues: Shares personal expertise with other nurses and elicits the expertise of others to ensure quality client care Develops a sense of trust and mutual respect with peers that recognizes their unique contributions With other health care professionals: Recognizes the contribution that each member of the interdisciplinary team can make by virtue of his or her expertise and view of the situation. Listens to each individual views Shares health care responsibilities in exploring options, setting goals and making decisions with clients and families Participates in collaborative interdisciplinary research to increase knowledge of a clinical problem or situation With professional nursing organizations: Seeks opportunities to collaborates with and within professional organizations Serves on committees in state (provincial) and national nursing organizations or special groups. Supports professional organizations in political actions to create solutions for professional and health concerns. With legislator: Offers expert opinions on legislative initiatives related to health care Collaborates with other hea;th care providers and consumers on health care legislation to best serve the needs of the public. OPTION B is the best answer. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 111-112 OPTION A and D are inappropriate OPTION C is only part of collaboration with other health care professionals. 50. 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 CORRECT ANSWER: A RATIONALE: The key elements necessary for collaboration include effective communication skills, mutual respect, trust and a decision making process. Effective communication can occur only if the involved parties are committed to understanding each others professional roles and appreciate each other as an individual. Mutual respect occurs when two or ko0re people show or feel honor or esteem toward one another. Trust occurs when a person is confident in the actions of another person. The decision making process at the team level involves shared responsibility for the outcome. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 112-113 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 CORRECT ANSWER: B RATIONALE: Diagnosis is a reasoning process that uses critical thinking. A nursing diagnosis provides the basis for selecting independent nursing interventions to achieve outcomes for which the nurse is accountable. Nursing diagnosis is a judgement made after thorough systematic data collection. The diagnostic process is used continuously by most nurses. As a result of attaining knowledge, skills and expertise , the expert nurse may seem to perform these mental process automatically. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 281-282, 290 52. 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 Reproduction is strictly prohibited RN International Review Center 12

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 CORRECT ANSWER: B RATIONALE: A nursing diagnosis provides the basis for selecting independent nursing interventions to achieveoutcomes for which the nurse is accountable. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.290 53. 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 CORRECT ANSWER: D RATIONALE: Desired outcome or goal serves as criteria for evaluating client progress. Although developed in the planning step of the nursing process, desired outcome serves as criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 301 54. 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 CORRECT ANSWER: A RATIONALE: Objective data, also referred to as sign or overt data, are detectable by an observer or can be measured or tested against an accepted standard. Subjective data, also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 262 OPTIONS B,C and D are subjective cues 55. 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 CORRECT ANSWER: B RATIONALE: All phases of nursing process rely on accurate and complete data. OPTION B is nurse centered OPTION D: signing of consent is the doctors responsibility Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 5 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 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 CORRECT ANSWER: D RATIONALE: Mouth care for unconscious or debilitated people is important because their mouths tend to dry and consequently predisposed to infections. The nurse can use commercially prepared applicators or foam swabs to clean the mucous membranes. Normal saline solution is recommended for oral hygiene for the dependent client. OPTION A: long term use of lemon glycerine swabs can lead to further dryness of mucosa and changes in tooth enamel. OPTION B: Hydrogen peroxide is not recommended for use in oral car because it irritates healthy oral mucosa and may alter the microflora of the mouth. OPTION C: Mineral oil is contraindicated because aspiration of it can initiate an infection (lipid pneumonia). Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 727 Reproduction is strictly prohibited RN International Review Center 13

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 CORRECT ANSWER: A RATIONALE: Position the unconscious client in a side-lying position with the head of bed lowered. In this position, the saliva automatically runs out by gravity rather than being aspirated into the lungs. OPTIONS B, C and D did not address the question Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 730 58. 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 CORRECT ANSWER: B RATIONALE: The purpose of oral care are to remove food particles from around and between teeth; to remove dental plaque; to enhance the clients feelings of well-being; to prevent sores and infection of the oral tissues. OPTION B: part of maintaining oral hygiene is the use of appropriate commercial mouthwash. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 727 59. 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 CORRECT ANSWER: D RATIONALE: The clients mouth is rinsed by drawing about 10 ml of water or alcohol-free mouthwash into the syringe and injecting it gently into each side of the mouth. Watch carefully to make sure that all the rinsing solution has run out of the mouth into the basin. If not, suction the fluid from the mouth. Fluid remaining in the mouth maybe aspirated into the lungs. OPTION C: done when no foam swabs are available Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 730 60. 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 CORRECT ANSWER: D RATIONALE: The mentholated ointment such as lip balm has a primary purpose which is to provide an occlusive layer on the lip surface to seal moisture in lips and protect them from external exposure. Dry air, cold temperatures and wind all have a drying effect on skin by drawing moisture away from the body. Lips are particularly vulnerable because the skin is so thin, and thus they are often the first to present signs of dryness. The patient has difficulty of breathing, anticipate that the patient might have O2 treatment so petroleum jelly is contraindicated because it can burn the lips and mouth. http://en.wikipedia.org/wiki/Lip_balm 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 CORRECT ANSWER: D RATIONALE: Errors can and do occur usually because one client gets a drug intended for another. Reproduction is strictly prohibited RN International Review Center 14

Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 804 62. 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 CORRECT ANSWER: C RATIONALE: A physician usually determines the clients medication needs and orders medications. Most agencies also have lists of abbreviations officially accepted for use in agency. Both nurses and physicians may need to refer to these lists. These abbreviations can be used on legal documents, such as clients charts. OPTION B: The name of the drug to be administered must be clearly written. In some settings only generic names are permitted; however, trade names are widely used in hospitals and health agencies. OPTION A and D does not address the question Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 794, 796 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 CORRECT ANSWER: A RATIONALE: Quality Assurance program is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. Quality assurance requires evaluation of three components: Structure evaluation focuses on the setting in which care is given. It answers question: What effect does the setting have on the quality of care? Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. Process evaluation focuses on how the care was given. It answers questions such as these: Is the care relevant to the clients need? Is the care appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Some examples of process criteria are Check clients identification band before giving medication and Performs and records chest assessment, including auscultation, once per shift. Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care. Outcome criteria are written in terms of client responses or health status, just as they are for evaluation within the nursing process. For example: How many clients undergoing hip repairs develop pneumonia? or How many clients who have a colostomy experience an infection that delays discharge? Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 322-323 64. 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 CORRECT ANSWER: D RATIONALE: refer to rationale of # 63 OPTION A and C: structure evaluation OPTION B: process evaluation 65. 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 B. Ask the nurse to find a way to learn the procedure C. Tell the nurse to read the procedure manual D. Do the procedure with the nurse CORRECT ANSWER: D RATIONALE: A staff members inexperience can be hindrance to delegation; an institution can minimize this through competency-based orientation and testing; the nurse delegating the task sometimes must teach the novice the necessary skills to complete the task; with proper guidance, delegating can improve the novices skills. Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 94 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. Reproduction is strictly prohibited RN International Review Center 15

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 CORRECT ANSWER: D RATIONALE: Charting should be timely, complete, accurate, confidential and client specific. Documentation should be done as soon as care is provided whenever possible and should reflect the clients present condition; late entries must be so noted. Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 76 67. 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 CORRECT ANSWER: A RATIONALE: With the Computerized clinical documentation system CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. http://www.biomedcentral.com/content/pdf/1472-6947-1-3.pdf Though almost all of the choices are advantages of using computerized client care system but the best is OPTION A. 68. 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 CORRECT ANSWER: D RATIONALE: Medical records are usually used to give important evidence in legal proceedings such as police investigations, determining cause of death, extent of injury incurred by the patient, among others. It is usually the medical records librarian, by virtue of subpoena duces tecum, who testifies that the patients records are kept and protected from unauthorized handling and change. Only complete accurate records are accepted in court. Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp.177-178 According to Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 330: The record is considered inadmissible as evidence when the client objects, because information the client gives to the physician is confidential. However, in Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp.106, Confidential information may also be revealed as provided for by the law in Article IV, Section 4 (1) of the New Constitution, which states that: The privacy of communication and correspondence shall be inviolable except upon lawful order of the court or when public safety and order require otherwise. 69. 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 CORRECT ANSWER: C RATIONALE: Audit means the examination of records.These auditing procedures are completed to ensure continuity of care and that health care standards are being met by the institution. Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 75 70. 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 Reproduction is strictly prohibited RN International Review Center 16

CORRECT ANSWER: B RATIONALE: According to the 7th and 8th Guidelines for telephone orders: Read the order back to the prescriber at the end. Use words instead of abbreviations. Write the order on the physicians order sheet. Record date and time and indicate I was a telephone order (TO). Sign name and credentials. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 346 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 CORRECT ANSWER: B RATIONALE: it needs immediate intervention since it is a respiratory problem and elevation of temperature may indicate infection which may alter the respiratory function of the infant. OPTION A is the case of hydrocephalus but the patient is calm so there is less risk of increasing the intracranial pressure. OPTION C is a normal response of the baby OPTION D may be a sign of infection but is less threatening than OPTION B 72. 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 CORRECT ANSWER: B RATIONALE: Resistance usually means that the catheter tip has reached the bifurcation of the trachea. To prevent damaging the mucous membranes at the bifurcation, withdraw the catheter about 1 to 2 cm before applying the suction. Apply intermittent suction for 5 to 10 seconds. Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. OPTION A: incorrect, catheter is inserted without applying suction to prevent tissue trauma and oxygen loss OPTION C: you dont insert catheter using back an forth motion OPTION D: suctioning is only for 5 to 10 seconds Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1324 73. 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 CORRECT ANSWER: A RATIONALE: The action promotes transfer of microorganism to the telephone which may also be transferred to others. 74. 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 CORRECT ANSWER: B RATIONALE: Assess sensation of each arm to detect any damage to nerve function or if there is any nerve compression. It is necessary because during the application of the cast, the most common complication is the compartment syndrome which may be caused by decreased blood supply due to increased pressure in the area. Compartment syndrome without prompt treatment lead to nerve damage and muscle death. 75. 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 Reproduction is strictly prohibited RN International Review Center 17

CORRECT ANSWER: A RATIONALE: Sputum specimens are often collected in the morning. Upon awakening, the client can cough up secretions that have accumulated during the night. Ask the client to expectorate the sputum into the specimen container. OPTION B: Collected after postural drainage OPTION C: Specimen is sent immediately to the laboratory before any contaminating organism can grow. OPTION D: treatment alters the result Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 771 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 CORRECT ANSWER: C RATIONALE: The normal ESR for women is 20-30 mm/hr; for men 15-20 mm/hr OPTION A, B and D are all normal Normal values Neutrophil 50%-70% WBC 4,500-10,000/mm Iron 60-170 mg/100ml 77. 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 CORRECT ANSWER: A RATIONALE: An object is sterile only when it is free of all microorganisms. Sterile technique is indicated for procedures that require penetration of clients skin such as with injections and IV catheter insertion. Sterile technique is also employed for many procedures in general care areas (such as administering injections, changing wound dressings, performing urinary catheterizations and administering intravenous therapy. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 655 Prentice Hall Reviews and Rationales series for nursing. Fundamentals of Nursing.copyright 2005.pp. 144 78. 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 CORRECT ANSWER: B RATIONALE: Prodromal or illness stage is the presence of signs and symptoms of the disease. OPTION A: incubation period OPTION C: recovery period 79. 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% CORRECT ANSWER: B RATIONALE: Its beyond the normal value of 4,500 to 10,000/mm3. WBC of 10,000 to 15, 000 is an indicative of inflammation. A more than 15, 000 is an indication of infection. OPTION A: below normal but Lower-than-normal levels occur with: Congestive heart failure Hyperviscosity Hypofibrinogenemia (decreased fibrinogen levels) Low plasma protein (due to liver or kidney disease) Polycythemia Sickle cell anemia Reproduction is strictly prohibited RN International Review Center 18

http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm OPTION C: normal OPTION D: normal 80. 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 CORRECT ANSWER: B RATIONALE: Burns are exceedingly challenging due to the high risk of infection since the skin is no longer a barrier to bacteria. Infection is the most common complication of burns and is the major cause of death in burn victims. http://www.umm.edu/altmed/articles/burns-000021.htm OPTION A: susceptible to infection with open wounds but with proper care, less susceptible than burn patient OPTION C and D: are the least susceptible 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 CORRECT ANSWER: C RATIONALE: Florence Nightingale, often considered as the first nurse theorist, defined nursing more than 100 years ago as the act of utilizing the environment of the patient to assist him in his recovery. 82. 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 CORRECT ANSWER: B RATIONALE: Imogene M. King developed a general systems framework and a theory of goal attainment. The framework speaks to three levels of systemsindividual or personal, group or interpersonal, and society or social. The theory of goal attainment speaks to the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space. King emphasizes that both the nurse and the client bring important knowledge and information to the relationship and that they work together to achieve goals. Research has supported that when the nurse and client communicate and work together toward mutually selected goals, the goals are more likely to be attained. 83. 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 CORRECT ANSWER: A RATIONALE: Faye Abdellah developed a list of 21 unique nursing problems related to human needs in the 1960s. OPTION B: Behavioral Systems Model The person is a behavioral system comprised of a set of organized, interactive, interdependent, and integrated subsystems. OPTION C: Adaptation Model The person is an open adaptive system with input (stimuli), who adapts by processes or control mechanisms OPTION D: Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery". She categorized nursing activities into 14 components, based on human needs.
84. 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.

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A. B. C. D.

Orem Abdellah Nightingale Rogers

CORRECT ANSWER: D RATIONALE: Martha E. Rogers developed the Science of Unitary Human Beings as nursings unique body of knowledge. Human beings and their environments are infinite energy fields in continuous motion. They produce patterns and are unitary. OPTION A: Dorothea E. Orems general theory of nursing is made up of the three interrelated theories of selfcare, self-care deficit, and nursing systems. Self-care deficit exists when the therapeutic self-care demand exceeds self-care agency. OPTION B: Faye Abdellah developed a list of 21 unique nursing problems. OPTION C: Florence Nightingale is recognized as founder of modern-day nursing. Her environmental model is based on the idea that the impetus for healing lies within the individual human being and the focus of care is to place the individual in an environment that is supportive to that healing process.
85. Nursing care becomes necessary when clients is unable to fulfill biological, physiological development or social needs explains which of the following theories:

A. B. C. D.

Adaptation theory Self-care deficit theory Theory of the Unity of Man Transcultural care theory

CORRECT ANSWER: B RATIONALE: Dorothea E. Orems general theory of nursing is made up of the three interrelated theories of selfcare, self-care deficit, and nursing systems. Self-care deficit exists when the therapeutic self-care demand exceeds self-care agency. OPTION A: Roys Adaptation Model The person is an open adaptive system with input (stimuli), who adapts by processes or control mechanisms OPTION C: Martha E. Rogers developed the Science of Unitary Human Beings as nursings unique body of knowledge. Human beings and their environments are infinite energy fields in continuous motion. They produce patterns and are unitary. OPTION D: Since Madeline Leiningers work began in the 1950s with transcultural nursing, she has viewed the world as multicultural. Being a nurse and an anthropologist, she believed the individuality of the patient, as a cultural being is fundamental. A nurse must understand a patients heritage and traditions before a nurse can assist a patient with wellness and illness issues. Leininger established the Transcultural Nursing Society in 1989 to provide nurses with educational and certification opportunities. 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 CORRECT ANSWER: B RATIONALE: Hypertension-most important risk factor for all stroke types; no defined BP indicating increased stroke risk, but risk increases proportionately as BP increases. http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/CVD.html 87. 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 CORRECT ANSWER: C RATIONALE: Strokes can be classified into two main categories, including the following: ischemic strokes - strokes caused by blockage of an artery. hemorrhagic strokes - strokes caused by bleeding. An ischemic stroke occurs when a blood vessel that supplies the brain becomes blocked or "clogged" and impairs blood flow to part of the brain. Ischemic strokes are further divided into two groups, including the following: thrombotic strokes - caused by a blood clot that develops in the blood vessels inside the brain. embolic strokes - caused by a blood clot that develops elsewhere in the body and then travels to one of the blood vessels in the brain via the bloodstream. Reproduction is strictly prohibited RN International Review Center 20

Hemorrhagic strokes occur when a blood vessel that supplies the brain ruptures and bleeds. Hemorrhagic strokes are divided into two main categories, including the following: intracerebral hemorrhage - bleeding from the blood vessels within the brain. subarachnoid hemorrhage - bleeding in the subarachnoid space (the space between the brain and the membranes that cover the brain). http://medicalcenter.osu.edu/patientcare/healthcare_services/stroke/types/ 88. 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 CORRECT ANSWER: A RATIONALE: Hemorrhage is any profuse internal or external bleeding from the blood vessels. The most obvious cause of hemorrhage is trauma or injury to a blood vessel. Hemorrhage can also be caused by aneurysms or weak spots in the artery wall that are often present at birth. Over time, the blood vessel walls at the site of an aneurysm tend to become thinner and bulge out like water balloons as blood passes through them, making them more likely to leak and rupture. Hypertension, or high blood pressure, is often a contributing factor in brain hemorrhage, which can cause a stroke. Other times, vessels simply wear out with age. Uncontrolled diabetes can also weaken blood vessels, especially in the eyes; this is called retinopathy (ret-i-NOP-a-thee). Use of medications that affect blood clotting, including aspirin, can make hemorrhage more likely to occur. Bleeding disorders can also spark hemorrhages. Among them are hemophilia (he-mo-FIL-e-a), an inherited disorder that prevents the blood from clotting. http://www.humanillnesses.com/original/Gas-Hep/Hemorrhage.html OPTION A: Phlebitis is an inflammation of vein 89. 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 CORRECT ANSWER: B RATIONALE: Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs. Stroke secondary to cocaine probably occurs because cocaine causes blood vessels to narrow (constrict) while also increasing blood pressure ( hypertension ). This vasoconstriction can be severe enough to reduce or block blood flow through the arteries in the brain. Stroke secondary to cocaine is most common in men under 40 years old. Risks include a history of recent cocaine use. In a few people who experience stroke after using cocaine, an underlying arteriovenous malformation is found, which may have predisposed them to developing a stroke. In these cases the stroke is due to bleeding in the brain as opposed to decreased blood flow. http://www.umm.edu/ency/article/000743.htm 90. 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." CORRECT ANSWER: A RATIONALE: High red blood cell count: Even a moderate elevation in red blood cell count can be a risk factor for stroke. A high number of red blood cells thickens the blood, leading to blood clots. http://www.texasheartinstitute.org/HIC/Topics/Cond/strokris.cfm 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 CORRECT ANSWER: B Reproduction is strictly prohibited RN International Review Center 21

RATIONALE: 1gram=1,000 milligram 1.5 gm x 1,000 mg = 1,500 mg 1,500 /3doses= 500 per oral administration 92. 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 CORRECT ANSWER: A RATIONALE: Q= Drug prescribed/ drug available or stock = 62.5 mg/125mg/ml = 0.5 ml 93. The physician ordered Potassium Chloride (KCl) in D5W 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 CORRECT ANSWER: A RATIONALE: The nurse must frequenty check the infusion pump. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1393 94. 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 CORRECT ANSWER: B RATIONALE: Dosage for infants ages 1 month to 2 years: For rapid digitalization, give 30 to 50 mcg/kg IV over 24 hours, divided as 0.1 mg/ml. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily. Option B is the best answer. Nursing 2008. Drug Handbook.26th edition.pp.230 95. 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 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 CORRECT ANSWER: D RATIONALE: medications are not left at the bedside except certain medication like nitroglycerine and cough syrup. Medications to be given to the patient must be prepared accordingly in the nurses station by the nurse. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 802 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 CORRECT ANSWER: D RATIONALE: Pressure sores is a result of impedes circulation and diminished supply of nutrients in the area. OPTION A: Clients experience a significant decrease in muscular strength and agility whenever they do not maintain a moderate amount of physical activity. OPTION B: Contractures are permanent shortening of the muscle limiting joint mobility. Atrophy is the decrease in size losing most of the strength and function of the muscle. Reproduction is strictly prohibited RN International Review Center 22

OPTION C: hypostatic pneumonia can cause severe infection that severely impairs oxygen-carbon dioxide exchange in the alveoli and is the common cause of death among weakened and immobile patients, especially heavy smokers. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1068-1017 97. 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 CORRECT ANSWER: D RATIONALE: Any position correct or incorrect, can be detrimental if maintained for a prolonged period. Frequent change of position helps prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels and contractures. Position changes also maintain muscle one and stimulate postural reflexes. Proper positioning allows greater chest expansion and lung ventilation. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1080-1081 98. 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 CORRECT ANSWER: B RATIONALE: The major purpose of body mechanics is to facilitate the safe and efficient use of appropriate muscle groups to maintain balance, reduce the energy required, reduce fatigue and decrease the risk of injury. OPTION A: use of leg and gluteal muscles rather than back muscles especially in lifting OPTION B: use of correct body alignment rather than rhythmic OPTION D: not relatively used of large muscles only. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1076 99. 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 CORRECT ANSWER: B RATIONALE: The base of support is easily widened by spreading the feet farther apart. The center of gravity is readily lowered by flexing the hips and knees until a squatting position is achieved. OPTION A: The greater the preparatory isometric tensing or contraction of muscles, before moving an object, the less energy required to move it, and less the likelihood of musculoskeletal strain and injury. OPTION C: When the arms are used in activity, dividing the work between arms and legs helps prevent back strain OPTION D: Objects that are close to the center of gravity are moved with the least effort. Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1077-1079 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 CORRECT ANSWER: C RATIONALE: Restraints is not indicated for the patient OPTION A: prevents the pressure sores OPTION B: prevents contractures OPTION D: prevent patient from falling

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