Board Examination

NURSING PRACTICE I Foundation of Nursing and Professional Nursing Practice

Situation 1 The physician prescribed 1 liter of Dextrose 5% in Water to be administered at 50ml per hour.
1. Considering the physicians order, the intravenous infusion should last?
D. 20 hours
2. The intravenous infusion was started at 10:00am. When the nurse checked the patient at 2:00pm, she noted the
level of the solution to be 850 ml. How much solution should have been infused at this time?
A. 200 ml
3. The nurse is analyzing the remaining fluid of 850 ml. Based from the amount to be consumed at 50 ml/hr, the
nurse assessed that the infusion is:
A. Delayed
4. Maintaining the prescribed flow rate of 50 ml/hr, in how many hours should the remaining 850 ml of 5% Dextrose
in Water be consumed?
A. 17 hours
5. At 10:00am, maintaining the prescribed flow rate of 50 ml/hr and considering the remaining 850 ml, how many
drops per minute should the nurse regulate the IV infusion if the drop factor is 15 drops/ml?
D. 13 drops/min
Situation 2 Recording is a vehicle of communication that provides critical information to other health care
professionals involved with the clients care. Failure to document not only renders other staffs potentially
liable but also renders the health care facility liable.
6. A nurse clinically assesses the client, states the nursing diagnosis and determines the appropriate intervention.
Which of the following procedures reflect the delivery of the nursing process?
A. Nursing Audit
Documentation is critical to determine if the standard of care was rendered to a patient to defend
nursing actions. Failure to chart, omissions and poor communication are hard to defend.
Nursing audit is a review of the patient record designed to identify, examine, or verify the performance of certain
specified aspects of nursing care by using established criteria.
Nursing audit is the process of collecting information from nursing reports and other documented evidence about
patient care and assessing the quality of care by the use of quality assurance programmes.
Nursing audit is a detailed review and evaluation of selected clinical records by qualified professional personnel
for evaluating quality of nursing care.
A concurrent nursing audit is performed during ongoing nursing care.
A retrospective nursing audit is performed after discharge from the care facility, using the patient's record.
Meaning :
1. Quality - a judgement of what constitutes good or bad.
2. Audit - a systematic and critical examination to examine or verify.
3. Nursing audit -
(a) it is the assessment of the quality of nursing care
(b) uses a record as an aid in evaluating the quality of patient care.
4. Medical audit - the systematic, critical analysis of the quality of medical care, including the procedures for
diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.
Definition :
I. According to Elison "Nursing audit refers to assessment of the quality of clinical nursing".
II. According to Goster Walfer
a. Nursing Audit is an exercise to find out whether good nursing practices are followed.
b. The audit is a means by which nurses themselves can define standards from their point of view and describe
the actual practice of nursing.
III. Nursing audit is defined as:
.part of the cycle of quality assurance. It incorporates the systematic and critical analysis by nurses, midwives and
health visitors, in conjunction with other staff, of the planning, delivery and evaluation of nursing and midwifery care,
in terms of their use of resources and the outcomes for patients/clients, and introduces appropriate change in
response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services).
History of Nursing Audit :
Nursing audit is an evaluation of nursing service. Before 1955 very little was known about the concept. It was
introduced by the industrial concern and the year 1918 was the beginning of medical audit.
George Groword, pronounced the term physician for the first time medical audit. Ten years later Thomas R Pondon
MD established a method of medical audit based on procedures used by financial account. He evaluated the medical
care by reviewing the medical records.
First report of Nursing audit of the hospital published in 1955. For the next 15 years, nursing audit is reported from
study or record on the last decade. The program is reviewed from record nursing plan, nurses notes, patient
condition, nursing care.
Purposes of Nursing Audit
1. Evaluating Nursing care given,
2. Achieves deserved and feasible quality of nursing care,
3. Stimulant to better records,
4. Focuses on care provided and not on care provider,
5. Contributes to research.
Difference Between Audit and research
Audit Research
Is not randomised May be randomised
Compares actual performance against standards Identifies the best approach, and thus the sets the
standards
Conducted by those providing the service Not necessarily provided by those providing the service
Usually led by service providers Usually initiated by researchers
Does not involve investigation of new treatments, but
evaluates the use of current treatments
Involves comparators between new treatments and
placebos
Involves review of records by those entitled to access
them
Requires access by those not normally entitled to access
them
Ethical consent not normally required Must have ethical consent
Results usually not transferable Results may be generalisable
Hypothesis used to generate the standard Testable hypothesis generated
Compares performance against the standard Presents clear conclusions
Methods of Nursing Audit
There are two methods:
a. Retrospective view - this refers to an in-depth assessment of the quality after the patient has been discharged,
have the patients chart to the source of data.
Retrospective audit is a method for evaluating the quality of nursing care by examining the nursing care as it is
reflected in the patient care records for discharged patients. In this type of audit specific behaviors are described then
they are converted into questions and the examiner looks for answers in the record. For example the examiner looks
through the patient's records and asks :
a. Was the problem solving process used in planning nursing care?
b. Whether patient data collected in a systematic manner?
c. Was a description of patient's pre-hospital routines included?
d. Laboratory test results used in planning care?
e. Did the nurse perform physical assessment? How was information used?
f. Were nursing diagnosis stated?
g. Did nurse write nursing orders? And so on.
b. The concurrent review - this refers to the evaluations conducted on behalf of patients who are still undergoing
care. It includes assessing the patient at the bedside in relation to pre-determined criteria, interviewing the staff
responsible for this care and reviewing the patients record and care plan.
Method to Develop Criteria :
1. Define patient population.
2. Identify a time framework for measuring outcomes of care,
3. Identify commonly recurring nursing problems presented by the defined patient population,
4. State patient outcome criteria,
5. State acceptable degree of goal achievement,
6. Specify the source of information.
7. Design and type of tool
Points to be remembered:
a. Quality assurance must be a priority,
b. Those responsible must implement a programme not only a tool,
c. A co-ordinator should develop and evaluate quality assurance activities,
d. Roles and responsibilities must be delivered,
e. Nurses must be informed about the process and the results of the programme,
f. Data must be reliable,
g. Adequate orientation of data collection is essential,
h. Quality data should be annualized and used by nursing personnel at all levels.
Audit Committee :
Before carrying out an audit, an audit committee should be formed, comprising of a minimum of five members who
are interested in quality assurance, are clinically competent and able to work together in a group. It is recommended
that each member should review not more than 10 patients each month and that the auditor should have the ability to
carry out an audit in about 15 minutes. If there are less than 50 discharges per month, then all the records may be
audited, if there are large number of records to be audited, then an auditor may select 10 per cent of discharges.
Training for auditors should include the following :
a. A detailed discussion of the seven components.
b. A group discussion to see how the group rates t he care received using the notes of a patient who has been
discharged, these should be anonymous and should reflect a total period of care not exceeding two weeks in length.
c. Each individual auditor should then undertake the same exercise as above. This is followed by a meeting of the
whole committee who compare and discuss its findings, and finally reach a consensus of opinion on each of the
components.
Steps to problem Solving Process in Planning Care :
a. Collects patient data in a systematic manner,
1. includes description of patients pre-hospital routines,
2. has information about the severity of illness,
3. has information regarding lab tests,
4. has information regarding vital signs,
5. Has information from physical assessment etc.
b. States nurses diagnosis,
c. Writes nursing orders,
d. Suggests immediate and long term goals,
e. Implements the nursing care plan,
f. Plans health teaching for patients,
g. Evaluates the plan of care,
Audit as a Tool for Quality Control
An audit is a systematic and official examination of a record, process or account to evaluate performance. Auditing in
health care organization provide managers with a means of applying control process to determine the quality of
service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to
evaluate the effectiveness of nursing interventions. The audits most frequently used in quality control include
outcome, process and structure audits.
1. Outcome audit
Outcomes are the end results of care; the changes in the patients health status and can be attributed to delivery of
health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention
for clients. These audits assume the outcome accurately and demonstrate the quality of care that was provided.
Example of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length
of hospital stay.
2. Process audit
Process audits are used to measure the process of care or how the care was carried out. Process audit is task
oriented and focus on whether or not practice standards are being fulfilled. These audits assumed that a relationship
exists between the quality of the nurse and quality of care provided.
3. Structure audit
Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursing service,
medical records and environment. This audit assumes that a relationship exists between quality care and appropriate
structure. These above audits can occur retrospectively, concurrently and prospectively.
For the effective quality control, the nurse manager has to play following roles and functions.
Advantages of Nursing Audit :
1. Can be used as a method of measurement in all areas of nursing.
2. Seven functions are easily understood,
3. Scoring system is fairly simple,
4. Results easily understood,
5. Assesses the work of all those involved in recording care,
6. May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept.
Disadvantages of the Nursing Audit :
1. appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not
been implemented,
2. many of the components overlap making analysis difficult,
3. is time consuming,
4. requires a team of trained auditors,
5. deals with a large amount of information,
6. only evaluates record keeping. It only serves to improve documentation, not nursing care
Conclusion
A profession concerns for the quality of its service constitutes the heart of its responsibility to the public. An audit
helps to ensure that the quality of nursing care desired and feasible is achieved. This concept is often referred to as
quality assurance.

7. The nurse is aware that proper documentation when taking care of the client is important. The purposes of client
care documentation include the following:
1. Standardizes plan of care
2. Communicates vital information about clients health status to other health care providers
3. Serves as resource for research and education
4. Serves as a legal document
C. 1, 2, and 4
8. While taking care of a client, a nurse was instructed by her head nurse to file incident report. The following
situations warrant an incident report, EXCEPT:
A. Medico-legal incident
9. The client expresses overall dissatisfaction and frequently objects to the care provided to him. The situation
cannot be resolved. Which of the following is the most appropriate action of the nurse?
A. Report the situation to the head nurse
10. A client who was brought to the hospital for treatment of abdominal discomfort refused the treatment ordered
and refused to sign a consent form. This situation warrants what kind of reporting?
D. Actual anecdotal report

SITUATION 3. The nurse has been asked to administer an injection via Z-track technique.
11. The nurse prepares an IM injection for an adult client using Z-track technique, 4 ml of medication is to be
administered to the client. Which of the following site will be use?
C. Ventrogluteal
SITUATION 4: As a profession, nursing is a dynamic and its practices directed by various theoretical
models. To demonstrate caring behaviour, the nurse applies various nursing models in providing quality
nursing care.
12. When you clean the bedside in it and regularly attend to the personal hygiene of the patient as well as in
washing your hands before and after a procedure and it between patients, you intend to facilitate the bodys
reparative process. Which of the following nursing theory are you applying in the above nursing action?
D. Florence Nightingale
Correct Answer: D. Florence Nightingale, considered as the first nursing theorist defined nursing as the
act of utilizing the environment of the patient to assist him is his recovery. She linked health with five
environmental factors: pure or fresh air, pure water, efficient drainage, cleanliness and light (direct
light). Kozier and Erbs Fundamentals of Nursing, 8th Ed, p. 43.
13. A communication skills is one of the important competencies expected of a nurse. Interpersonal process is
viewed as human to human relationship. The statement is an application of whose nursing model?
B. Joyce Travelbee
Correct Answer: B. Joyce Travelbee is the proponent of the Interpersonal theory which emphasizes
nurse-client relationship.
14. The statement, the health status of an individual is constantly changing and the nurse must be cognizant and
responsive to these changes best explains which of the following facts about nursing?
A. Dynamic
Correct Answer: A. Dynamic: continuously changing.
15. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care working
in assisting the patient to gain interdependence as quickly as possible. Which of the following nursing best
demonstrates this theory in taking care of a 94 year old client with dementia who is totally immobile?
Feeds the patient, brushes the teeth, gives the sponges bath

Situation 5.

16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse
should wait for a period of:
B. 1 to 2 minutes
Correct Answer: B. The nurse should wait 1 to 2 minutes before making further determinations.
This permits blood trapped in the veins to be released Kozier and Erbs Fundamentals of
Nursing, 8th Ed, p. 557.
17. If the arm is said to be elevated when taking the blood pressure reading, it will create:
B. False low reading
Correct Answer: B. The reading will be erroneously low. Kozier and Erbs Fundamentals of Nursing,
8th Ed, p. 555.
18. You are to assessed the temperature of Lady Manahan, the next morning and found out that she ate
ice cream. How many minutes should wait before assessing Christine oral temperature?
C. 30 minutes
Correct Answer: C. If the client has been taking cold or hot food or fluids or smoking, the nurse should
wait 30 minutes in order to ensure that the temperature of the mouth is not affected by the temperature
of the food, fluid or warm smoke. Kozier and Erbs Fundamentals of Nursing, 8th Ed, p. 532.
19. When auscultating the Ladys blood pressure, the nurse hears the following. From 150 mmHg to 130 mmHg:
Silence. Then, thumping sounds continuing down to 100mmHg, muffled sound, continuing, down to 80 mmHg and
then silence. What is the Christines blood pressure?
A. 130/80
Korotkoffs Sounds
Phase 1: First faint, clear tapping or thumping sounds. Considered as the systolic blood pressure
Phase 2: Muffled, whooshing or swishing quality
Phase 3: Blood flows freely to an increasingly open artery, the sounds become crisper, more
intense and again assume a thumping quality but softer than phase 1
Phase 4: Sounds Become muffled and have a soft, blowing quality (Diastolic in Children)
Phase 5: Pressure level when the last sound is heard. (Diastolic in adults)
20. In a client with a previous blood pressure of 130/80, 4 hours ago. How long will it take to release the blood
pressure cuff to obtain an accurate reading?
B. 10-20 sec
Correct Answer: B. The cuff should be deflated at the rate of 2-3 mmHg per second. Four
hours ago, the clients blood pressure is 130/80. In succeeding measurements, 30mmHg
should be added to the systolic pressure in order to know until what pressure the cuff will be
inflated (160mmHg). From 160 mmHg to 80 mmHg, there is a difference of 80 mmHg. This 80
mmHg will be released 2-3mmHg per second. 80 mmHg divided by 2 mmHg/s = 40s.
Situation 6 A client is diagnosed with active tuberculosis. Airborne precaution is observed and he is placed
in isolation. He resents the isolation and appears angry.
21. Your best nursing intervention for the behavior manifested by this client is to:
A. Explain the isolation procedure and provide meaningful stimulation
22. The psychological implication of isolation to the client includes which of the following:
B. Sense of loneliness due to disruption of normal social relationship
23. Which of the following interventions must be carried out by the nurse to improve the clients sensory stimulation
during isolation?
C. Maintain a clean and pleasant environment and allow recreational activities
24. The client was visited by friends. What instruction should you give the visitors who will come in contact with the
client?
D. Talk with the relatives outside the clients room
Situation 7 Bed rest is a therapeutic intervention that achieves beneficial effect. However, prolonged bed
rest can be counterproductive to a clients recovery. The inactivity imposed by bed rest may cause structural
changes in joints and shorten muscles. Moving, turning and positioning of clients are essential aspects of
nursing care.
25. A nurse is giving the 8:00AM medication to a client who happens to have slid down the bed from the Fowlers
position. Which of the following interventions is most effective when the nurse repositions the client?
A. Ask the client to flex the hips and knees and position the feet for effective pushing up
26. Using an overhead trapeze for repositioning client can be accomplished by instructing the client to grasp the:
Overhead trapeze with both hands and lift and pull during the move
27. A client on bed rest is rolled to a lateral position by the nurse. The nurse is negotiating the move correctly when
he:
Places one hand on the clients far hip and the other on the clients far shoulder rock backward and
roll onto side of the body facing him.
28. A client with injured left is sitting on the bed preparing to transfer to a wheelchair. The nurse is assisting the client
and positions the wheelchair on the:
C. Clients right side
Park the wheelchair as close as possible to the area where you will be transferring the person to
or from. Park the wheelchair so that the person's stronger side of their body is the side that the transfer
will be done on.
29. A client has difficulty walking and needs a wheelchair to facilitate performance of daily activities. Anticipating the
needs of the client, the nurse should have the wheelchair ready by placing it at:
45-degree angle to the bed
Instructions
Things You'll Need
Wheelchair properly fitted to patient
Transfer board, transfer belt, pivot or transfer disk
Slippers with nonslip soles
Assistant (optional)
Advance Planning is Key for Caregivers
1. Talk through your course of action with the elderly person and make sure she knows what you will be doing first.
Demonstrate if necessary.
2. Lock the wheels on the wheelchair and the bed (optional). Make sure the wheelchair is positioned so it is
parallel to the bed, facing the foot end of the bed or at a 45-degree angle to the bed. It also should be near the
middle of the bed.
3. Fold the footrest away. Remove the armrest if possible. Make sure the bed rail is down.
4. Have the elderly person place the hand that is closest to the bed on top of the mattress, with her other arm
poised on the armrest, ready for a push
5. Position yourself toe-to-toe and knee-to-knee with the elderly person. Bend slightly and grab him around his
upper waist and torso
6. Instruct her to lift herself with her arms to help support her weight. Simultaneously, bend your legs to produce a
lift and a pivotal shift toward the bed. Lifting is best done with your legs and gluteus muscles flexed tightly to take
pressure off your back.
7. Once the patient is seated, allow him time to regain his balance. Place one arm over his back to the opposite
shoulder and the other arm under his thigh. Bend your legs slightly. Turn and lower his back onto the bed while
shifting his thighs onto the bed. Note: Using a waist belt with grab handles, a flexible transfer board or a pivot
disk will help with this process tremendously.

Situation 8 The nurses understanding of death as a natural part of mans life cycle allows her to help her
clients.
30. A client, 37 years old, married and mother of two children ages ten (10) and eight (8), was diagnosed with
advanced metastatic breast cancer. She is depressed and expressed concern about the welfare of her family. Which
of the following actions should the nurse plan to do first for a client who is experiencing depression?
Assist the patient to express feelings, beliefs and values
31. The nurse ensures that the client is treated with dignity and assists her in determining her own physical,
psychological and social priorities. Part of the nurses challenge that should be incorporated in the plan of care is:
Supporting the clients will and hope
32. To provide a sense of dignity for the client, the nurse should aim for the client to achieve which of the following?
Acceptance of the diagnosis
33. While the nurse is assisting the client in her care, the client starts to cry and strikes her. The behavior that the
client is manifesting best describes which of the following stages of death and dying?
C. Anger
34. When planning for the care of dying person, the essential elements that the nurse should consider are the
following EXCEPT?
Help in clarifying distorted pattern

35. In the self care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to
fulfil his psychological and social needs. A pregnant client needing prenatal check is classified as:
C. Supportive Educative
Correct Answer: C. Supportive Educative systems are designed for persons who need to learn to perform self-
care measures and need assistance to do so. A pregnant client will be expective an impending delivery thus
needs additional health teachings regarding child bearing and child rearing. Kozier and Erbs Fundamentals of
Nursing, 8th Ed, p. 44.

Situation 9- you are conducting a class on proper nutrition as part of health promotion.
36. Part of your teaching plan that helps address nutrition problems in the community include all EXCEPT:
Eating small meals frequently
37. Through health education, the nurse disseminates information about nutrition related problems that could lead to
serious non-communicable diseases (NCD). The nurse discourages this eating practice to avoid NCD:
Increased salt and increased processed food intake
38. The nurse observes that childhood is more common now. The frequent cause of this is the Filipino parents belief
that:
A fat child is healthy, a thin child is sickly
39. In nutrition education, your targeted participants include all EXCEPT:
C. Food service people
40. One mother asks the nurse why eating food cooked in vegetable oil is considered healthy. The nurses most
appropriate response is that:
Vegetable oil increases energy intake and helps prevent vitamin A deficiency
Situation 10 The nurse has varied functions that helps meet the clients needs depending upon the
situation or phase of illness.
41. When the nurse assists the client to identify and cope with stressful emotional problems, the nurse is assuming
the role of:
B. Counselor
42. The expanded role of the nurse acquired after specialized training and credentialing is described as:
C. Clinical nurse specialist
43. When the hospital director gives the nurse a position of authority within a formal organization, she assumes the
role of:
Manager
44. The nurse who uses his interpersonal skills to guide the client in making decisions about his health care is acting
the role of:
C. Advocate
45. An activity that demonstrates autonomy in nursing profession is exemplified by:
Becoming a member in a national professional organization
Situation 11 The nurse is taking care of clients who have varied nutritional needs. The nurse should have
adequate knowledge of nutrition and how it promotes health, affects growth and development and healing of
clients in any setting.
46. In a health education class at the health center, the nurse informs the clients that certain food substances are
related to non-communicable diseases. An example of this is:
Hypertension linked to increased intake of caffeinated products, processed food intake, artificial
flavorings and refined sugars

47. After surgery, a client has lost more than 20% of his body weight. The nurse wants to ensure that the clients
nutritional needs are met at home. The nurse should:
Provide the client a written recommendation of what food to eat using the food pyramid guide
48. The doctor orders clear liquid diet for a post surgery client. The food allowed includes which of the following?
C. Tea, cola drinks, gelatin
CLEAR LIQUID: Transparent liquid foods: vegetable broth; bouillon, clear fruit juices; clear fruit ices; popsicles;
clear gelatin desserts and no carbonated drinks
FULL LIQUID DIET: CLEAR AND OPAQUE LIQUID FOODS WIT A SMOOTH CONSISTENCY milk,
milkshakes, ice cream; pudding; strained cream soup, fruit nectar with pulp, smooth cooked cereals such as
porridge and cream of wheat butter and honey
49. A client practices Islam and his diet must consider his religious practices and beliefs. You are aware that this
client would avoid which of the following food?
1. Shrimps and crabs 4. Pork products like bacon
2. Wine and alcoholic drinks 5. Caffeinated products like cola drinks
3. Fish with scales
D. 1, 2, and 4
Situation 12 The nurse noted encrustations around the stoma of a client with tracheostomy. The client is
due for routine tracheostomy care.
50. The nurse informs the client about the procedure then prepares the equipment needed. When cleaning the
tracheostomy tube site, which of the following should the nurse observe to reduce the transmission of
microorganisms?
Wash hands, don clean disposable gloves and mask
51. In addition to observing appropriate infection control measures the nurse should do which of the following
interventions prior to the removal of the inner cannula?
Suction tracheostomy prior to cleaning
52. The nurse is correctly performing the removal of the inner cannula when he/she:
Unlocks inner cannula by turning counterclockwise and gently withdrawing in line with its curvature
53. After thoroughly cleansing the lumen and the entire inner cannula in hydrogen peroxide solution the nurse is now
ready to return the cannula to the tracheostomy site. To ensure that the cannula is in place the nurse should:
Replace the inner cannula following the curve of the tube, lock by rotating the external ring
clockwise until it clicks in place.
54. The nurse is changing the tracheostomy ties of the client. The most appropriate technique to follow when
changing soiled tracheostomy ties is to:
Thread end of tie through trach flange then thread through slit in tie and pull tight

Situation 13 Urethral catheterization requires a physicians order. Special care and strict aseptic technique
must be observed for clients with indwelling catheter.
55. A day after the insertion of the urinary retention catheter, the client complains of discomfort in the bladder and
urinary meatus. The initial action of the nurse would be to:
A. Establish patency of the catheter
B. Milk the catheter towards the collecting receptacle
C. Check the bladder if distended
D. Inform the head nurse
56. The nurse is preparing to irrigate the indwelling urinary catheter of the client. As ordered by the physician, the
client is to have closed intermittent catheter irrigation. The nurse performs the procedure in the following order:
1. Aspirate sterile solution into the syringe
2. Using aseptic technique, put sterile solution in sterile graduated cup
3. Clamp indwelling retention catheter
4. Withdraw syringe, leave solution for around 20 minutes
5. Slowly inject sterile irrigant into the catheter and bladder
6. Remove the clamp and allow irrigant to drain into the collection bottle/bag
A. 2, 1, 3, 5, 4, 6 C. 2, 3, 1, 4, 5, 6
B. 3, 2, 1, 4, 5, 6 D. 1, 2, 3, 4, 5, 6
57. When a client has a retention catheter, the nurse is expected to:
A. Clean the urinary meatus and adjacent skin periodically
B. Encourage liberal amount of fluid intake
C. Flush the catheter as needed
D. Perform perineal flushing as needed
58. An order to discontinue catheterization of the client was implemented. She complains of difficulty in her first
attempt to urinate. The nurse explains that this is due to:
A. Attempt of the body to adjust to normal reflex mechanism
B. Fluid and electrolyte imbalance
C. Irritation of the urethra
D. Irritation of the urinary bladder
59. When considering the safety needs of a client with a urinary catheter, which of the following should the nurse
observe?
a. Keep a closed sterile drainage system C. Keep the bag lower than the bed
B. Irrigate the catheter daily D. Measure intake and output daily

Situation 14 Nurses communication skills are often put to test when interacting with clients assigned to
them.
60. A 70 year old client is admitted to the hospital for difficulty of breathing and chest pain. He is accompanied by his
son who asks the nurse what he should do about his fathers hearing problem. Which of the following responses by
the nurse reflects therapeutic communication?
A. I will ask your father for more information
B. What kind of hearing problems does your father have?
C. Your father will be referred to a specialist after a hearing test is done.
D. Hearing problems occur as people get older.
61. While conducting nursing rounds, the nurse found a 30-year-old, post mastectomy client lying on her side facing
the wall. When the nurse approached her, she says leave me alone, I need rest. The nurse responds by saying:
A. I understand you.
B. I will be back.
C. You sound upset.
D. Dont worry you can cover up the loss.
62. While waiting for three hours to be called in the doctors clinic, a client suddenly shouts: Why is this taking so
long? I have been waiting for several hours and nobody attends to us? What should be the initial response of the
nurse?
A. Approach client and tell her that there are other clients to be attended to
B. Instruct the client to be quiet and assure her that she will be attended to soon.
C. Talk to the client and determine her immediate needs
D. Pacify the client and send her to the adjacent room
63. A 26 year old mother of 8 month old twins brought one infant to the doctors clinic for fever and cough. She tells
the nurse, I cant handle this anymore with other children to attend to, this is overwhelming for me. Which of the
following is the best initial response by the nurse?
A. You will survive this crisis, just like other mothers in similar situations.
B. I will refer you to the social services for assistance.
C. You should know what is best for the infant.
D. What seems to be the problem? It must be tough having other children to attend to.
64. The day prior to surgery, a 40 year old client says to the nurse, Im nervous. Is the doctor competent in this kind
of surgery How should the nurse best respond?
A. Several clients who have undergone similar surgery always recover.
B. Do you want to talk with the client who has similar surgery and has fully recovered?
C. You seem concerned about the surgery.
D. Your doctor is very competent
Situation 15 The nurse is taking care of a client newly diagnosed with asthma. The client tells the nurse
that a relative with asthma has been prescribed Salmotorol Xinaloate, a long acting medication and wonders
why she has been prescribed Salbutamol, a short acting drug.
65. To provide accurate information the nurse should do which of the following activities?
A. Consult the attending physician regarding the medication prescribed
B. Refer to the head nurse the concern of the client
C. Ask the client what she knows about the action of both drugs
D. Collect the most relevant and best evidence to answer the question
66. The nurse is ready to implement the decision of the health care team on the prescribed medication to the client.
Which of the following should be considered?
1. Integrate the evidence found from the literature search with the health care provider
2. Expertise in the clinical assessment of the client
3. Available health care resources
4. Preferences and values of the client
A. 1, 2, 3, and 4 C. 2, 3, and 4
B. 1 and 2 D. 1 and 4
67. The treatment plan has been implemented. Which of the following is the MOST appropriate action based on
clinical decision?
A. Ask the client what he feels about the treatment
B. Conduct physical assessment and gather more data
C. Evaluate how effective the clinical decision is with the client
D. Generate more information by doing literature search
Situation 16 Nurses are expected to use critical thinking in the practice of nursing.
68. The nurse determines that her client has altered elimination. She identifies the following as the possible causes
for the nursing diagnosis EXCEPT?
A. Decreased mobility C. Reduced fluid intake
B. Hip replacement D. Low fiber diet
69. A nurse writing a nursing diagnosis after assessing his client. Which of the following is the appropriate nursing
diagnosis?
A. Chronic pain related to insufficient pain medication
B. Anxiety related to cardiac monitor
C. Using bedpan frequently as a result of altered elimination pattern
D. Pain related to difficulty ambulating
Situation 17 The nurse researcher would like to see the importance of humor to hospitalized clients that
can reduce anxiety associated with being in the hospital.
70. Which of the following should the researcher consider to be able to determine the type of data to be collected?
A. Research design C. Research process
B. Pilot study D. Scientific method
Seven steps of research process finding info for a research paper and documenting the sources you
find: 1. Identify and develop your topic; 2. Find background info; 3. Use catalogs to find books and media; 4.
Use indexes to find periodical articles; 5. Find Internet resources; 6. Evaluate what you find; and 7. Cite
what you find using a standard format.
Research design: how data are collected
Pilot study: pilot experiment; small scale preliminary study conducted in order to evaluate feasibility, time,
cost, adverse events, and effect size in an attempt to predict an appropriate sample size and improve upon
the study design prior to performance of a full scale research project.
Scientific method: what to ask and answer scientific questions by making observation and doing
experiments; 1. Ask a question; 2. Do background research; 3. Construct a hypothesis; 4. Test your
hypothesis by doing an experiment; 5. Analyze your data and draw a conclusion; 6. Communicate your
results
71. Which of the following is the most appropriate for the researcher to study if she would do a correlational study?
A. Humor experienced by hospitalized patients
B. Humor, a basis for reducing anxiety among hospitalized patients
C. Effect of humor on anxiety of hospitalized patients
D. Anxiety among hospitalized patients experiencing humor
72. Research requires that variables are defined operationally. Which of the following should the researcher consider
when she defines humor and anxiety?
A. Adapt definition of selected theorists on humor and anxiety
B. Define humor and anxiety according to how these are measured in the study
C. Restate definition of humor and anxiety as stated in the conceptual framework
D. Humor and anxiety as defined in Websters dictionary
73. After having been approved, the researcher is now ready for the implementation of the study. Which of the
following should the researcher do first before the actual study is carried out?
A. Review related literature C. Conduct a pilot study
B. Consult an statistician D. Select the target population
Research steps:
Identification or formulation of research problem REVIEW OF RELATED LITERATURE conceptualization
of conceptual or theoretical framework choosing the appropriate design choosing sample from
population conducting final study or pilot study collection of data base analysis and interpretation of
data base disseminating the conclusion and recommendation
74. To obtain 30 appropriate samples for the study, the researcher decided to use simple random sampling. Which of
the following should the researcher do?
A. Include post-operative clients only
B. Select every 3
rd
hospitalized client in the list
C. Pick out 30 from the list of hospitalized clients
D. Choose 15 male and 15 female hospitalized clients
Probability sampling
1. Simple random sampling equal chance to be chosen
2. Stratified random sampling create subdivided population
3. Cluster random sampling sub areas
4. Systematic random sampling sampling frame

Situation 18 Nursing Practice is governed by many legal concepts. Nurses are obligated to provide legal
and ethical client care that demonstrates respect for others.
75. A lawsuit is filed for a negligent act performed by a nurse. Of the following who should be included in the lawsuit?
A. Employer C. Attending Physician
B. Chief nurse D. Hospital administrator
76. Basic nursing care errors resulting in negligence are committed by the nurse during the planning phase when the
nurse fails to:
A. Gather and chart client information adequately - assessment
B. Administer medications correctly - implementation
C. Chart each identified problem
D. Perform nursing task correctly - implementation
77. The nurse is administering the 12:00nn oral medication to a client. When the orange capsule is handed to the
client, he states that he has not been receiving a capsule but a tablet. Which of the following is the MOST appropriate
action of the nurse?
A. Allow the client to describe the medicine he has been receiving
B. Ignore the client since medication order has been checked
C. Tell the client that the medicine is prescribed by the physician
D. Withhold the medication and recheck the medication order
78. A client is complaining of acute abdominal pain. The nurse tells the client that her complaints will be referred to
the physician. Since the nurse is attending to his other clients he failed to call the physician. As a result the client
suffered a ruptured appendix. The action of the nurse constitute:
A. Battery B. Negligence C. Misdemeanor D. Assault
79. in the course of their clinical experience, nursing students may minimize chances of liability when they observe
the following EXCEPT:
A. Ask for additional help or supervision in situations for which they feel inadequately prepared
B. Comply with the policies of the agency in which they obtain their clinical experience
C. Take assigned clients given by the nursing instructors
D. Prepare to carry out the necessary care for assigned clients.
Situation 19 Nurses are expected to assess, contribute and preserve work environment that supports
fulfilling their ethical responsibility. The following questions apply to this.
80. The nurse is attending to a client brought to the Emergency Department for treatment of acute abdominal pain.
Which of the following actions of the nurse demonstrates respect of clients autonomy?
A. Complying when the physician attempts to delegate obtaining informed consent
B. Facilitating and supporting clients choices regarding treatment options
C. Describing the risks and benefits of the reasonable alternative treatments
D. Notifying appropriate parties if a patient has not given adequate information
82. Which of the following statements is correct regarding informed consent?
A. Nurse may not be legally liable if they know that informed consent was not obtained
B. It is ethical or legal for nurses to obtain informed consent for procedures that are to be performed by a
physician
C. It is an ethical responsibility of nurses to provide client with opportunities to give informed
consent
D. It is not with a nurses domain of responsibility to notify the health team if a client has not given an
informed consent for the procedure
83. The nurse is taking the blood pressure of a male client and noted a reading of 160/100. When asked the nurse
avoids telling the client that his blood pressure is elevated because she believes the information will upset the client
and consequently further elevate his blood pressure. The situation illustrates an example of:
A. Beneficence C. Self-determination
B. Paternalism D. Autonomy
84. The nurses compassion is aroused when a severely impaired neonate under her care is suffering and in a
prolonged life-sustaining machine. Many times the nurse experiences feeling of uneasiness and anguish. This human
condition that confronts the nurse gives rise to:
A. Ethical dilemma C. Human indignation
B. Unavoidable trust D. Moral suffering
85. The nurse shows respect to human dignity when she observes which of the following situations when caring for
clients?
A. Asking the clients priorities after assessing the clients capabilities of in past and in the present
B. Evaluating response of client to the nursing care rendered by the health care team as planned.
C. Planning nursing care together with the client and immediate relatives
D. Constant monitoring of clients condition and reporting any usual occurrences to the health team
Situation 20 Accuracy in the computation and administration of medications ordered is extremely
important when preparing medications.
86. A client is ordered to receive 20 mEq of Potassium Chloride. The bottle is labeled KCl elixir 10 mEq/ml. How
many ml should be given?
A. 1.5 ml B. 2 ml C. 0.5 ml D. 1 ml
87. A client is ordered to receive Digoxin 0.325 mg OD. The stock is 0.25 mg per tablet. How many tablets should be
given to the client?
A. 2 tablets B. 3 tablets C. 1.5 tablet D. tablet
88. Dilantin 5 mg/kg body weight is ordered to a client who weighs 50 lbs. The drug is to be administered in 3 equal
doses. The label reads Dilantin suspension 125 mg/ml. How much medication should be administered to the client?
A. 1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml
89. A male client had exploratory laparotomy and has an order for Meperidine Hydrochloride 50 mg IM every four
hours PRN. The multiple dose vial is labeled 50 mg/ml. What is the correct dose to be administered to this client
when he complains of pain?
A. 0.5 ml B. 2 ml C. 1.0 ml D. 1.5 ml
90. An order is given to a young adult to receive 1 million units of Penicillin IM. The stock on hand is Penicillin
500,000 units and the direction reads, add 1.3 ml to yield 2 ml. What is the correct amount to be administered?
A. 3 ml B. 2 ml C. 4 ml D. 2.5 ml
Situation 21 Part of your professional development is to participate in various trainings and continuing
professional education. This promotes updating yourself professionally and staying globally competitive in
your skills development.
91. A nurse is attending a cardiopulmonary resuscitation training to review her previous CPR training as a
requirement in the new hospital where she was recently employed. This is an example of:
A. Continuing education C. In-service training
B. Advanced training D. Professional training
92. A new graduate who is seeking employment decides to attend training on IV therapy program offered by an
accredited nursing organization. This is:
A. Advanced training C. Continuing education
B. Professional training D. In-service education
93. Graduating at the top of his class, a nurse says he just wants to be a good nurse, after a year and half of
working in a hospital, he decides to pursue a masters degree in nursing. Graduate education in nursing prepared the
nurse for the following, EXCEPT:
A. Take advance training as a clinical specialist
B. Assume managerial positions in nursing service
C. Carry out research to advance nursing theory
D. Take lead roles in nursing educational settings
94. A nurse believes that health is a fundamental right of every individual. He believes in the worth and dignity of
each human being and recognizers the primary responsibility to preserve health at all costs. These statements are
part of the:
A. Philippine Nursing Act of 2002
B. Code of Ethics for Registered Nurses
C. Code of Good Governance for the Professions
D. Standards of Nursing Practice
95. The objectives of continuing professional education programs in nursing are the following, EXCEPT:
A. Protect and promote the general welfare of the public by attaining the highest standards and quality in
the practice of profession
B. Make the professional globally competitive by maintaining capability for delivering professional services
C. Augment the nurse educational preparation for admission to the practice of his profession
D. Make available latest trends in the profession brought by scientific and technological advancement in
the profession

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