Subject: Fundamentals of Nursing Number of Hours: 2 Hours Number of Items: 100 Items Passing1. Score: 75 1. a. b.

Which of the following statement describes a violation of the right to confidentiality? Telling the mother of the 18 year old about the result of the ELISA test. Patient Kris Aquinos room number is 15 on the third floor. As a response by Nurse to Kriss relative who asked about the patients room number. c. d. The nurse failed to give the medication on time resulting to patients cardiac arrest. ROOM 1A. PATIENT: SKIPPY PEANUT BUTTER. DOCTOR: DR. ENSURE NUTRITION.

a. b. c. d. 6. a. b. c. d. 7.

Body will try to decrease the glucose level There will be a halt in the release of sex hormone Client will appear restless Blood pressure will increase All of the following are purpose of inflammation except: Increase heat, thereby produce abatement of phagocytosis Localized tissue injury by increasing capillary permeability Protect the tissue from injury by producing pain Prepare for tissue repair Which of these statements least describes Nursing? It is an art and science of caring for the health of the individual, family, or community in any setting. It is a health-oriented profession which requires formal training committed to the ideals of service. It mainly deals with the treatment of health conditions affecting an individual, community or family. It is basically premised on the greatest human principle of love thy neighbor.

2. a. b. c. d. 3.

The last expected process in the stage of inflammation is characterized by: There will be sudden redness of the affected part. Heat will increase on the affected part. The affected part will lose its normal function. Exudates will flow from the injured site.

a. b. c. d.

What kind of exudates is expected where there is an antibody-antigen reaction as a result of microorganism infection? 8. a. b. c. d.

When should the nurse start giving Inderal? When anxiety reaches +1 When the client starts to have narrow perceptual field and selective inattentiveness When problem solving is not possible When the client is immobilized and disorganized Nurse Aida has seen her patient, Roger, for the very first time. She establishes a contract about the frequency of their meetings and introduced Roger about the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR do Nurse Aida and Roger belong?

a. b. c. d. 4.

Serous Serosanguinous Purulent Sanguinous Which of the following is incorrect following the maintenance of a Foley Catheter? a. b. c. d. Keep urine catheter below the neutral pH of 7.0 The use of sterile technique is a prerequisite for the attachment of a Foley Catheter Discourage client from drinking cranberry or fruit juice to avoid urine acidification. Wash genital area twice daily or as often as needed

9.

a. b. c. d.

Pre-orientation Orientation Working Termination

5.

What stress response can you expect from a patient with blood sugar of 50 mg/dl?

14. During the lawsuit, Imelda learned that the suspect, 10. The client is placed on NPO in preparation for a blood test. Adreno-cortical response is activated and which of the following is an expected response? a. b. c. d. Low BP Decreased Urine Output Warm, flushed, dry skin Low serum Sodium levels 15. Imelda is in the recovery stage after the incident. As a nurse, you know that the diet that will be prescribed to Imelda is: a. b. c. d. Low calorie, high protein with Vitamin A and C rich foods High protein, high calorie with Vitamin A and C rich foods High calorie, low protein with Vitamin A and C rich foods High protein, high calories with Vitamin A and E rich foods 16. Side walk vendor Christine was rushed to Bantayan Doctors Hospital after being attacked by a group of 12. Imelda was slashed and hacked by an unknown suspect. She suffered from massive tissue loss and laceration on her arms and elbow in an attempt to evade the criminal. As a nurse, you know that the type of healing that will most likely occur is: a. b. c. d. First intention Second intention Third intention Fourth intention b. c. d. a. muggers. After learning she had no money in her, the health staff recommended her to go to Bantayan Public Hospital without providing basic treatment. In this case, the health staff: Are right because they might get fired for treating a person without money Are wrong under RA 8344 Are right because they are protected under PD 626 Are wrong because they violated RA 8355 and are negligent. 13. After being hospitalized, Imelda learned that the suspect was caught and held in Mandaue City Jail. She then files a lawsuit against the suspect. In this scenario, Imelda would be: a. b. c. d. Defendant Plaintiff Principal Felon b. a. 17. Which of the following scenarios constitutes negligence to Nurse Jackie, an orthopedic nurse? Nurse Jackie delegates a task to LPN Jamie causing a Mercuric thermometer to break and then puncturing Theresas armpit. Nurse Jackie sees a patient on the floor on the oncologic wing who fell after being prescribed with an Sage, was paid to assassinate her. In this case, which pairing would best fit for this scenario? a. b. c. d. Sage Accessory Crime Consummated Crime Frustrated Crime Attempted

11. The client is in stress because he was told by the physician that he needs to undergo surgery for the removal of the tumor in his bladder. Which of the following are expected physiologic responses to this event? i. ii. iii. iv. Constipation Urinary frequency Hyperglycemia Increased BP a. b. c. d. iii, iv i, iii, iv i, ii, iv i, iv

anxiolytic and whose side rails have not been raised. This resulted into a fracture. c. d. Nurse Jackie accidentally gives Phenylhydramine to a patient. The patient receives no reaction. Nurse Jackie transports Patient Theresa to the ward through a wheelchair which broke halfway through the journey causing erythema on Theresas buttocks.

b. c. d.

Patients IV insertion site is pale. Patient complains of pain on the IV insertion site. Upon you assessment, the site is cold to touch. Patients IV insertion site is swelling and pale.

22. Which of the following actions of Nurse Inday are correct? a. Changing the tubing and dressing of patient Nacky receiving PNSS every 24 hours. b. c. d. Mixing Patient Jackies TPN solution Changing the IV solution every 24 hours. Changing the TPN tubing and filter every 72 hours.

18. Patient Aricayos was confined in the hospital due to burning sensation during urination and was diagnosed as UTI. Upon looking on her chart, the doctor orders urine specimen to be collected to determine appropriate antibiotic to provide. Which of the following actions are in line with the Doctors order? a. b. c. d. Ask patient to void, discard the first urine collection. Instruct patient to fill the sample bottle with urine Discard first voided urine and collect the second voided until on the same time the following day. Collect 5-10 mL of urine sample a. b. c. 19. Patient Nacky was diagnosed with DHF and the doctor ordered BT for her. Twenty-five minutes after the induction of the therapy, the patient complains of chapped lips. Nurse Casera would be correct if she: a. b. c. d. Stops the infusion Continues the infusion Checks the tube Calls the physician who ordered the procedure a. b. c. d. d.

23. Which of the following actions of Nurse Theresa is correct for a patient whose BP frequently elevates to around 200/160, is receiving Nitroglycerin, and complains of tingling below the tongue? Activate code blue and prepare crash kit Do nothing and tell patient that its just normal Prepare anti-dysrythmics Play soft music on the background or talk to patient to calm him/her 24. Ava is a ward nurse in the Sang Carlows hospital. During her shift, a patient verbalized I couldnt sleep well because of the noises made by cars outside. Nurse Ava would be correct if she would first: Assess and investigate the cause of the sleep deprivation Provide anxiolytics to patient as ordered Tell patient that the problem lies in her mind Provide patient with a glass of milk prior to sleep

20. With the situation in number 19, Nurse Casera observes the patient to have moist cough. In this case, the next priority action would be to: a. b. c. d. Auscultate the lung fields Provide oxygen through nasal cannula at 1-2 L/min Provide Salbutamol through inhaler Perform Chest Percussion to facilitate drainage of secretions 21. Which of the following scenarios would indicate the need to perform cold compress? a. Patient complains of pain on the IV insertion site. Upon you assessment, the site is erythematous.

Situation: To validate the applicability of Nursing intervention with the rapidly changing technology-based care of client, the nurse should engage in the continuous search for scientific knowledge to improve the knowledge base of the nursing profession. When doing a culturerelated research, the nurse should be aware of the cultural beliefs and practices. 25. Nursing research as a process in based on the: a. Trial and error method

b. c. d.

Step-by-Step process Scientific method Nursing process

a. b. c. d.

Superficial pain Intractable pain Somatic pain Neuropathic pain

26. Which of the following is considered as the hallmark of scientific research? a. b. c. d. Pre-selected samples Statistical treatment of data The experiment Interpretation of results c. 27. Which of the following behavior of Nurse Inday reflects her sensitivity to the clients cultural beliefs? a. b. Providing immediate post-mortem care to the body of Abdullah. Discussing the possibility of organ donation with the family of a Jehovahs Witness who dies from a motor vehicular accident. c. d. Joining the family of a Baptist client in singing hymn to the dying client. Accepting the anger of the Catholic clients family as a part of the grieving process. 33. Immediately after surgery, the client has two IV lines, 28. The nurse is monitoring the clients IV fluid infusion. Which assessment finding, if noted in a client with ongoing IV fluid infusion should the nurse evaluate further? a. b. c. d. Gastric distention Frequent urination Dyspnea Slight pain at the IV insertion site when client moves. 34. Which of the following clients would qualify for hospice 29. The Doctor prescribes Spironolactone to a client for the treatment of hypertension. Which dietary choice of the client reflects a need for further instruction from the nurse? a. b. c. d. Apples Yogurt Wheat Bread Fresh Oranges 35. Which of the following tasks should not be delegated 30. Phantom limb pain is considered as: by a nurse manager to a staff nurse? d. b. c. a. care? A 25-year-old client with leukemia undergoing chemotherapy A 75-year-old with terminal metastatic cancer A 30-year-old client undergoing rehabilitation for heroin addiction A 45-year-old client with post-partum depression a. b. c. d. a drainage tube, a foley catheter and an order for pain medication. Which of the following is the highest priority for the nurse? Nutrition Safety Input and Output Bladder Elimination a. b. c. d. 32. Which principle does the nurse consider in supporting the clients right to self-determination? Physicians order Consent Clients reaction Diagnosis d. a. b. 31. The management principle span of control is best illustrated in which of the following situations? Instructing the staff to report only to the team leader. Identifying the number of patient for nursing management. Identifying the appropriate number of persons who directly report to the manager. Directing the subordinates to report to all team leaders.

a. b. c. d.

Evaluation of a new piece of equipment to be used by the staff in the unit Selection of a new nursing care delivery system Preparation of vacation schedule Inventory of equipment and supplies in the nursing unit a. b. c. d.

25 mg Meperedine IVTT OD and 500 mg Mefenamic Acid TID. Upon administering the medications to the patient, patient verbalized I usually get only one pill. Nurse Lenie is correct when she: Questions the doctors order Informs the patient that the doctor ordered and it is her responsibility as a nurse to carry out the orders. Leave the medications on the bedside and inform patient to take them when she is ready. Give the medications to the patient and tell her not to ask any questions. 41. Patient Aricayos, suspected with having Urinary Tract Infection was ordered to have a sample of her urine sent to the laboratory for analysis. As a student, you were instructed to observe the procedure in obtaining samples through the indwelling catheter. You noted that the nurse obtained 3-mL sample through a special port in the tube. With your knowledge in this procedure, you knew that the sample will be used to: a. b. c. d. Determine the presence of protein in the urine Identify the specific type of antibiotic to be used Confirm the diagnosis of Renal Failure Quantification of puss cells, if present, in the urine sample

36. When determining the priority needs of a client, which of the following should the nurse consider as the highest priority? a. b. c. d. Providing a safe environment Preservation of life Ensuring growth and development Minimizing environmental stimulation

37. Which of the following activities of Nurse Theresa is correct after receiving orders to terminate Urinary Catheter of Patient Skippy? a. b. c. d. Observe patient for anxiety Intermittent clamping of catheter for 2-4 hours Allow patient to verbalize feelings of termination of catheterization Palpate bladder area every hour - 3 hours before termination to observe blockage or urethral stenosis 38. Which of the following solutions used in enema in indicated for patients with hyperkalemia? a. b. c. d. Kayexalate Neomycin Normal Saline Hypertonic a. b. c. d.

42. Patient Skippy has just undergone Ishiharas test. According to his SO present during the test, the patient failed to read the numbers correctly. You would interpret the statement as: Client has a problem with visual acuity; probably nearsighted or farsighted The air conduction is less than the bone conduction The patient cant properly disseminate colors The patient has tunnel vision

39. The Wong-Baker rating scale is used to determine: a. b. c. d. Degree of proliferation of Cancer cells Intensity and severity of pain Amount of radiation received during a radiation therapy The number of bacterial colony present in a microbial sensitivity test 40. Patient Ava was confined in a hospital due to severe abdominal pain. In her chart, the following were listed:

43. You are a nurse assigned to work in the Emergency Department of USC hospital. During your shift, a male patient was rushed in due to a vehicular accident. In your assessment, patient was mumbling incomprehensible words and after a minute you noted that patients left eye no longer responds to light. You

would question the doctor if he/she orders which of the following? a. b. c. d. Mannitol IV D5 0.9% NaCl at 30 gtts/min EEG determination Drainage of CSF

48. Which of the following is the recommended temperature for a sitz bath: a. b. c. d. 90 F 110 F 120 F 125 F

44. Which would the nurse not list as a purpose of the nursing code of ethics when discussing it with a group of new employees? a. b. c. d. Reminding nurses of the special responsibility they assume when caring for the sick Guiding the profession in self-regulation Providing solutions for specific ethical situations Outlining the major ethical considerations of the nursing profession 45. When performing a neurologic assessment on a client, the nurse finds that the clients pupils are fixed and dilated. What does this assessment indicate? a. b. c. d. The client is paralyzed. The client is going to be blind as a result of an injury. The client may have meningitis. The client has received a significant brain injury.

49. Which of the following combination of needles and routes of medication administration is incorrect? a. b. c. d. 25 G, 5/8 long for insulin administration 26 G, small bone for intradermal injection 20 G, for injection for oil-based medications 23 G, angio-catheter for blood administration in an adult client. 50. Which of the following characteristics of the vein should the nurse consider when initiating an IV infusion in the elderly? a. b. c. d. Smaller size Presence of pathological condition Fragility Prominence

51. The doctor orders an enteric coated medication for a client on gastrostomy tube. What should the nurse do? a. b. c. d. Crush the medication and administer through the tube by mixing with the food preparation. Dissolve it with water before giving the medication Call the pharmacy immediately to request for a change in form Administer it orally

46. Which of the following is not true about a hypothesis? a. b. c. d. It is testable It is proven It is stated in form that it can be accepted or rejected. It states a relationship between variables.

47. A client refuses to take his/her medication. The nurse tells the client that if he/she does not take the medication, he/she will be placed in a restraint. The nurses statement can be used as a basis for which violation? a. b. c. d. Negligence Malpractice Battery Assault

52. The hospital on which Nurse Jackie is working is on fire. In this situation, the first thing that Nurse Jackie has to do is to: a. b. c. d. Confine the fire Try to extinguish the fire Call the fire department and report the fire Rescue as many people as possible.

53. Which of the following considerations in teaching will you provide for an Older Adult patient? a. b. c. d. Learns best when benefit is gained Offer info and encourage participation and

d.

Florence Nightingale Intuitive Period of Nursing?

58. Which of the following statement describes the a. b. c. d. Early Christian On-The-Job Training Opening of the Florence Nightingale School of Nursing Social Changes

independent learning Teach on the afternoon around 1-3 PM to provide time for self-care Present info in small amounts and at a slow pace

54. All of the following statements are true when referring to Clear-Liquid diet except: a. b. c. d. Prevents dehydration Includes foods that are liquid at room and body temperature Contains most nutrients Examples include popsicles, gelatins, and broths

59. Nurse Inday is caring for a client suffering from ESRD and has signed a DNR form. One day, patients vital signs crashed. In this case, Nurse Indays action will be governed by which Ethical Principle? a. b. c. d. Dysthanasia Orthothanasia Active Euthanasia Passive Euthanasia

55. Nurse Skippy listens attentively to the fears and concerns of her patient Ensure. Which of the following roles does Nurse Skippy portray? a. b. c. d. Caregiver Teacher Advocate Counselor 60. Which statement best describes Rose? 56. Community Health Nurse Jackie is the sole health care worker in Barangay Alumnos. On the morning, she visits the homes of the members of the community to check their vital signs and dresses the wounds of some client. In this scenario, Nurse Jackie portrays which role of a nurse? a. b. c. d. Community Organizer Caregiver Teacher Client Advocate a. b. c. d. 57. Defined nursing as the involvement in the diagnosis and treatment of human responses to actual or potential health problems: a. b. c. ANA WHO Dorothea Orem 62. After an arduous legal battle, Judge Nacky has decided that the evidence against Grace was strong and decided Grace guilty on the suit against her. Months later, Grace petitioned the Court of Appeals to 61. Who would be the accomplice if lawsuits were filed by the state against them? Rose Nina Grace None of the above a. b. c. d. A Principal Accomplice Accessory Plaintiff Situation: Mary, 18-years-old found out that she was pregnant. She told Rose, a friend, about her condition. Rose offered to assist her to solve her problem by referring to Grace, an abortionist. After the abortion was performed, Nina, the helper of Grace, burned the linens and equipment used in the abortion.

reconsider the decision. Which of the following describes the position of the state? a. b. c. d. Respondent Principal Plaintiff Defendant

a. b. c. d.

Legitimate Expert Referent Information

67. The research entitled Nurses and Unions: Evolution of Filipino Nurses Perception Towards Unionism is of what type of qualitative research? a. b. c. d. Phenomenological Ethnographic Historical Grounded Theory

63. Nurse Harry Potter is assigned to take care of a postop patient who undergone an appendectomy. You have received an order, written on the patients chart to reinforce dressing PRN. Which of the following procedures done would require a relearning in the basics of Nursing procedures? a. b. Nurse Harry Potter uses only normal saline in moistening some gauzes to be used in wound care. Nurse Harry Potter packs the wound carefully and meticulously and ensured the all spaces are carefully filled up. c. Nurse Harry Potter ensures that the gauzes used in the procedure are sealed and have not been opened prior to its use. d. Nurse Harry Potter adds new dressing without removing the old one. a. 64. Which of the following correctly identifies a leader? a. b. c. d. Productivity Stability Vision Smooth Operations d. c. b. a. b. c. d.

68. The research entitled Most Commonly Used Herbal Remedies in Brgy. Talamban can be classified as: Methodological Study Case Study Survey Study Correlation Study

69. Which of the following entries in the chart would warrant Nurse Terai a relearning in the basics of charting? The client has a Respiratory Rate of 19 CPM. The client says, Im beginning to hear the voices again. The client has fever when oral temperature was taken at 7:00 AM BP 130/100

65. A plane crashes in a community where Nurse Jamie is working. During the initial response of the incident, which type of leadership is best suited? a. b. c. d. Authoritarian Democratic Laissez-faire Multi-critic

70. During her routine visit to a client in Room 3, patient asked Nurse Casera if she could read her chart and bring it home. The best response to this situation would be: a. Im sorry maam but I need to consult the Medical Director about this because the hospital is the keeper of the medical records, and thus is responsible for it. b. Yes, you are allowed to see it and bring it home. Yes you can actually read it! But unfortunately, you can only photocopy the chart. d. Im sorry, that request cannot be granted. It has always been a policy of this institution to protect the c.

66. Mrs. Pascual, RN, MAN, MSN is a US trained psychiatric nurse. As a dean, she derives her authority over the faculty from which of the following types of power?

clients record against breaches in confidentiality. This could be achieved by prohibiting anybody outside the medical team from accessing your record, and that includes you. 71. Which of the following statements in the Physical Assessment records would indicate a need to relearn the basics of charting? a. b. c. d. Patients lip is cyanotic Patient is hallucinating Trachea is midline CRT > 2 sec.

b. c. d.

Give client and relatives brief tour of the physical setup of the unit Take his vital signs for a baseline assessment Establish priority needs and implement appropriate interventions

75. Mr. Mendoza says he has trouble going to sleep. In order to plan your nursing intervention, you will: a. b. c. d. Observe his sleeping patterns in the next few days Ask him what he meant by this statement Check his physical environment to decrease noise level Take his blood pressure before sleeping and upon waking up 76. Mr. Mendozas lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of the client, which of the following interventions would be the most appropriate immediate nursing approach? a. b. c. d. Moisturize lower extremities to prevent skin irritation Measure fluid intake and output to decrease edema Elevate lower extremities Provide the client with a list of foods low in sodium

72. Nurse Jackie rushes to Room 3 to respond to a patient who is experiencing a grand mal seizure. Which of the following interventions would Nurse Jackie likely perform in response to the event? a. b. c. d. Administer Phenobarbitals STAT Put patient in side lying Remove pillows and other objects that would suffocate client Raise side rails to prevent client from falling over

Situation: A 61-year-old man, Mr. Mendoza, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client. 73. When doing an initial assessment, the best way for you to identify the clients priority problem is to: a. b. c. d. Interview the client for chief complaints and other symptoms Talk to the relatives to gather data about history of illness Do auscultation to check for chest congestion Do a physical examination while asking the client relevant questions 74. Upon establishing Mr. Mendozas nursing needs, the next nursing approach would be to: a. Introduce the client to the ward staff to put the client and family at ease a. 78. Considering her level of anxiety, the nurse can best assist Nancy by: Giving her activities to divert her attention Situation: Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts and that she may need surgery. This increases her anxiety as shown by increased pulse and respiratory rate, sweating and feelings of tension. d. b. c. a. 77. Mr. Mendoza will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all except: Making a final physical assessment before client leaves the hospital Giving instructions about his medication regimen Walking the client to the hospital exit to ensure his safety Proper recording of pertinent data

b. c. d.

Giving detailed explanations about the treatments she will undergo Preparing her and her family in case surgery is not successful Giving her clear but brief information at the level of her understanding

a. b. c. d.

Primary care nurse Independent nurse practitioner Nurse-midwife Nurse specialist

83. A vest or jacket restraint is best used for which of the following purposes? I. II. III. IV. To prevent a client from climbing out of bed To prevent a client from falling out of a stretcher To immobilize an arm To prevent inflicting injury to ones self and others a. b. c. d. I, III I, IV I, V I, II

79. The nurse visit Nancy and prods her to eat her food. Nancy replies, Whats the use? My time is running out. The nurses best response would be: a. b. c. d. The doctor ordered full diet for you so that you will be strong for surgery. I understand how you feel but you have to try for your childrens sake. Have you told your doctor on how you feel? Are you changing your mind about the surgery? You sound like you are giving up.

80. The nurse feels sad about Nancys illness and tells her head nurse during the end of shift endorsement that its unfair for Nancy to have cancer when she is still young and with two kids. The best response of the head nurse would be: a. b. c. d. Advise the nurse to be strong and learn to control her feelings. Assign the nurse to another client to avoid sympathy for the client Reassure the nurse that the client has hope if she goes through all the treatments prescribed for her Ask the other nurses what they feel about the patient to find out if they share the same feelings 81. Which of the following does not govern nursing practice? a. b. c. d. R.A. 7164 R.A. 9173 BON Res. Code of Ethics BON Res. Scope of Nursing Practice

84. Which of the following activities indicates a need to reinforce education about Routine Fecalysis to detect ova? a. b. c. d. The use of sterile specimen container Placing sample in the refrigerator to keep sample fresh and prevent microbial outgrowth Collection of 1 inch of stool Helps in detecting parasites

85. You are about to administer iron to a patient parenterally. Being a new hired nurse in the Sang Carlows Hospital, you are expected to: a. b. c. d. Delegate this task to an LPN while providing instruction while the LPN performs the task Ensure that the medication is within the muscle tissues Instill medication though IVTT Always never forget to recap a used needle to avoid accidental puncture 86. Patient Jaja is currently admitted for constipation. The

82. A nurse who is maintaining a private clinic in the community renders service on maternal and child health among the neighborhood for a fee is:

doctor ordered digital removal of the stool. During the procedure, Nurse Daryl notices that Jajas heart

rhythm changed. In response to this, what should Nurse Daryl do? a. Continue the procedure because it is a normal vagal response from the stimulation of the sphincter and rectal wall. b. c. d. Reposition client to reduce stress Stop the procedure Ask client to perform deep breathing exercises to promote relaxation

c. d.

Not go to court and not answer the subpoena Answer the questions only if the patient provides consent to divulge pertinent data

91. As part of working the night shift, Nurse Lenie is currently obtaining the vital signs of patient Jamie. Nurse Jade notices Jamie to be grinding and clenching her teeth during sleep. Nurse Jade knows this as: a. Somnambulism Soliloquy Bruxism Narcolepsy b. c. d.

87. Upon reading the doctors order in the chart, Nurse Nebz cannot comprehend the doctors handwriting. The best response to this is: a. b. c. d. Ask a colleague first to see if he/she can read it Approach the head nurse and ask if he/she can decipher the order Approach the doctor directly and ask about the order Go to the nurse manager and ask her to read the order to decrease liability 88. The major concern associated with Electronic Charting System is: a. b. c. d. Network Delay Privacy Access to records at the same time Network Collision

92. The following are purposes of enema except: a. b. c. d. Reduce body temperature Facilitate administration of medications Promote fecal evacuation Promote water exchange

93. Nurse Theresa is currently taking care of a patient with ileostomy. In taking care of the patient, all of the considerations are true except: a. b. c. d. Moisturize skin around the stoma before applying appliance Appliance can be used up to 2 weeks Avoiding gas-forming foods and nuts Yogurt is recommended to decrease odor of feces

89. Which of the following circumstances affecting criminal liability can be applied to a person who committed a murder and surrenders to the authorities? a. b. c. d. Justifying Mitigating Aggravating Exempting

94. Which of the following statements are true regarding Blood Transfusion? a. b. c. Length of infusion should not be extended beyond 2 hours to prevent blood coagulation and spoilage Cold blood is indicated for patients with Paroxysmal Nocturnal Tachycardia BT patients should be in their rooms alone to promote privacy and reduce the occurrence of tachycardia due to anxiety d. Use of 18 or 19 G angiocatheter during the process

90. A nurse was subpoenaed by the court about a malpractice suit filed against a physician. If asked by the court about certain aspects of the treatment received, the nurse would: a. b. Not divulge any information to the court because it is part of Privileged Communication Answer the questions because it is a legal process

95. Nurse Jackie has just administered Xanax to a patient. An hour after, Nurse Jackie observes client to be

talking a lot and have a lot of energy than usual. Nurse Jackie identifies it as: a. b. c. d. Hypersensitivity reaction Adverse Effect Desired Effect Paradoxical Reaction

99. Peter Paul, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment? I. II. III. IV. a. b. c. d. Peter Paul is giving an objective data Peter Paul is giving a subjective data The source of the data is primary The source of the data is secondary I, III II, III II, IV I, IV

96. At what level of training should a nurse be able to engage in independent nursing practice? a. b. c. d. Student Advanced Practice Newly hired Licensed

100. You are a Nurse assigned in the orthopedic ward of the Sang Carlows Hospital. During your shift, SO immediately calls your attention to a patient who just received large amount of Xanax. Upon entering the room, you have noticed that the patient has been electrocuted in an attempt to pull out the plugs. Your IMMEDIATE response would be to: a. b. c. d. Hold the patient and forcefully pull him away from the plug. Prepare to inject bolus of Epinephrine Activate code blue Call the electrical unit of the hospital to shut down electricity in the unit. ***END OF EXAM***

97. Which among the actions of Nurse Paul indicates lack of knowledge regarding fire safety and response? a. b. Remove all clients from the vicinity of a fire first Nurse Jackie prohibits an ambulatory patient from moving a wheelchair bound client and asks them to leave scene immediately c. d. Nurse Jackie maintains a client on life support with Ambu-bag Nurse Jackie informs clients not to use the elevator

98. Nurse Inday is currently assigned in the PACU. She observes the client to be in a state of Post-Anesthetic Dementia in which client becomes combative, consistently attempts to pull his IV lines, and shouts incoherent words. The doctor, upon seeing the situation writes the order Restraints PRN. Nurse Inday is right when she immediately: a. b. Applies the restraints immediately by tying patients hands to the side rails tightly Applies the restraints by tying patients extremities while providing space for circulation along the extremity c. d. Questions the doctors order Uses the Mitten Restraint because it is less restrictive and still inhibits client from pulling the tubes