NURSING PRACTICE I – Foundations of Professional Nursing Practice
Situation 1 – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.
1. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:
A. Client lying flat on his back and then flat on his abdomen.
B. Client lying on his right then left side on Trendelenburg position.
C. Client lying on his back then flat on his abdomen on Trendelenburg position.
D. Client seated upright in bed or on a chair then leaning forward in sitting position then
flat on his back and on his abdomen.
2. When documenting outcome of Richard’s treatment, Mario should include the following in his
recording EXCEPT:
A. Character of breath sounds and respiratory rate before and after the procedure.
B. Color, amount and consistency of sputum
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in the vital signs
3. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
A. Respiratory rate, breath sounds and location of congestion
B. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
C. Teaching the client’s relatives to perform the procedure
D. Amount of food and fluid taken during the last meal before treatment
4. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
A. Percussion slaps the chest to loosen secretions while vibration shakes the secretions
along with the inhalation of air.
B. Percussion uses only one hand while vibration uses both hands
C. Percussion delivers cushioned blows to the chest with cupped palms while vibration
gently shakes secretion loose on the exhalation cycle.
D. In both percussion and vibration, the hands are on top of each other and hand action
is in tune with client’s breath rhythm.
Situation 2 – The use of massage and meditation to help decrease stress and pain have been strongly recommended based on document testimonials.
6. Martha wants to do a study on this topic: “Effects of massage and meditation on stress and pain”. The type of research that best suits this topic is:
A. basic research
B. applied research
C. quantitative research
D. qualitative research
7. The type of research design that does not manipulate independent variable is
A. non-experimental design
B. quasi-experimental design
C. quantitative design
D. experimental design
8. This research topic has the potential to contribute to nursing because it seeks to
A. clarify an ambiguous modality of care
B. resolve a clinical problem
C. include new modalities of care
D. enhance client care
9. Martha does review of related literature for the purpose of
A. to identify if problem can be replicated
B. gathering data about what is already known or unknown about the problem
C. answering the research question
D. determine statistical treatment of data research
10. Client’s rights should be protected when doing research using human objects. Martha identifies these right as follows EXCEPT:
A. right of self-determination
B. right to compensation
C. right not to be harmed
D. right of privacy
Situation 3 – The nurse’s understanding of ethico-legal responsibilities will guide his/her nursing practice:
11. The principles that govern right and proper conduct of a person regarding life, biology and the health professions is referred to as:
A. Morality
B. Religion
C. Bioethics
D. Values
12. The purpose of having a nurses’ code of ethics is:
A. To define the roles and functions of the health care givers, nurses, clients.
B. To help the public understand professional conduct expected of nurses.
C. Identify nursing action recommended for specific health care situations.
D. Delineate the scope and areas of nursing practice
13. The most important nursing responsibility where ethical situations emerge in patient care is to:
A. Be accountable for his or her own actions
B. Not take sides, remain neutral and fair
C. Assume that ethical questions are the responsibility of the health team
D. Act only when advised that the action is ethically sound
14. You inform the patient about his rights which include the following EXCEPT:
A. Right to expect that the records about his care will be treated as confidential
B. Right to obtain information about another patient
C. Right to consent to or decline to participate in research studies or experiments
D. Right to expect reasonable continuity of care
15. This principle states that a person has unconditional worth and has the capacity to determine his own destiny.
A. Bioethics
B. Justice
C. Fidelity
D. Autonomy
Situation 4 – Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience.
16. An example of a management function of a nurse is:
A. Directing and evaluating the staff nurses
B. Performing nursing procedures for clients
C. Teaching patient do breathing and coughing exercises
D. Preparing for a surprise party for a client
17. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone without consulting anybody. This type of leadership is:
A. Democratic leadership
B. Autocratic leadership
C. Managerial leadership
D. Laissez faire leadership
18. When the head nurse in your ward plots and approves your work schedules and direct your work, she is demonstrating:
A. Delegation
B. Authority
C. Accountability
D. Responsibility
19. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:
A. Irrigation of a nasogastric tube
B. Take vital signs
C. Change IV infusions
D. Transfer a client from bed to chair
20. You made a mistake in giving the medicine to the wrong client. You notify the client’s doctor and write an incident report. You are demonstrating:
A. Authoritarian
B. Accountability
C. Autocracy
D. Responsibility
Situation 5 – Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.
21. Instruction on health promotion regarding urinary elimination is important. Which would you include?
A. If burning sensation is experienced while voiding, drink pineapple juice.
B. Tell client to empty the bladder at each voiding.
C. Hold urine as long as she can before emptying the bladder to strengthen her
sphincter muscles.
D. After urination, wipe from anal area up towards the pubis.
22. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?
A. inhibition of the parasympathetic reflex
B. decreased ability to absorb fluids in the lower intestines
C. loss of tone of the smooth muscles of the colon
D. weakness of sphincter muscles of the anus
23. The nurse understands that one of these factors contributes to constipation:
A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives
24. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would be to:
A. ask the client to bring change of underwear “just in case”
B. instruct client to start wearing thin adult diapers
C. teach client pelvic exercise to strengthen perineal muscles
D. tell client to drink less fluids to avoid accidents
25. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is always almost in bed. Your instruction would focus on prevention of skin irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rising and drying of skin area that get wet with urine
D. Making sure that linen are smooth and dry at all times
Situation 6 – 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 causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.
26. Considering her level of anxiety, the nurse can best assist Nancy by:
A. Giving detailed explanations about the treatments she will undergo
B. Giving her clear but brief information at the level of her understanding
C. Giving her activities to divert her attention
D. Preparing her and her family in case surgery is not successful
27. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:
A. denial
B. anger
C. acceptance
D. bargaining
28. The nurse visits Nancy and prods her to eat her food. Nancy replies “what’s the use? My time is running out.” The nurse’s best response would be.
A. “You sound like you are giving up”
B. “The doctor ordered full diet for you so that you will be strong for surgery”
C. “Have you told your doctor how you feel? Are you changing your mind about your surgery?
D. “I understand how you feel but you have to try for your children’s sake”
29. The nurse feels sad about Nancy’s illness and tells her head nurse during the end of shift endorsement that “It’s unfair for Nancy to have cancer when she is still so young and with two kids”. The best response of the head nurse would be.
A. Advise the nurse to “be strong and learn to control her feelings”
B. Assign the nurse to another client to avoid sympathy for the client.
C. Ask other nurses what they feel about the patient to find out if they share the same feelings.
D. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her.
30. Realizing that she feels angry about Nancy’s condition, the nurse learns that being self-aware is a conscious process that she should do in any situation like these because:
A. The nurse is a role model for the client and should be strong.
B. This is a necessary part of the nurse-client relationship process
C. How the nurse thinks and feels affect her actions towards her client and her work.
D. The nurse has to be therapeutic at all times and should not affected.
Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse’s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.
31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues?
A. Brigette with diarrhea
B. Carol with a tumor in the brain
C. Sonnyboy with a fracture in the femur
D. Theresa with anemia
32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called.
A. Hypoxia
B. Anemia
C. Cyanosis
D. Hypoxemia
33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:
A. eight to ten inches
B. tip of the nose to the base of the neck
C. the distance from the tip of the nose to the middle of the cheek
D. the distance from the tip of the nose to the tip on the ear lobe
34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
A. Using gloves to prevent introduction of pathogens to the respiratory system
B. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserted with gentle suction
35. Myrna has difficulty of breathing when on her back and must sit upright in bed to breath effectively and comfortably. The nurse documents this condition as:
A. Orthopnea
B. Tachypnea
C. Apnea
D. Dyspnea
Situation 8 – Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident.
36. Her priority nursing action would be to:
A. assess the extent of injuries incurred by the victims of the accident
B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police authorities
D. Assess damage to property
37. Priority attention should be given to which of these clients?
A. Ryan who has chest injury, is pale and with difficulty of breathing
B. Noel who has lacerations on the arms with mild bleeding
C. Linda who shows severe anxiety due to trauma of the accident
D. Andy whose left ankle swelled and has some abrasions
38. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms. While assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to:
A. Apply antiseptic to prevent infection
B. Clean the wound vigorously of contaminants
C. Bandage the wound and elevate the arm
D. Control and reduce bleeding of the wound
39. The nurse applies pressure dressing on the bleeding site. This intervention is done to:
A. Protect the wound from microorganisms in the air
B. Promote hemostasis
C. Reduce the need to change dressing frequently
D. Allow the pus to surface faster
40. After the treatment, the client is sent home and asked to come back for follow-up care.
Your responsibilities when the client is to be discharged include the following EXCEPT:
A. Encouraging the client to go to the outpatient clinic for follow-up care
B. Instructing the client to see you after discharge for further assistance
C. Accurate recording of treatment done and instructions given to the client
D. Providing instructions regarding wound care
Situation 9 – You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications for these clients.
41. Mr. Felipe, 36 year old is to be given 2700 ml of D5LR to infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing hourly?
A. 100 ml per hour
B. 210 ml per hour
C. 150 ml per hour
D. 190 ml per hour
42. Mr. Atienza is to receive 150 ml/hour of D5W IV infusion for 12 hours for a total of 1800ml.
He is also losing gastric fluid which must be replaced every two hours. Between 8am and 10am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he receive at 11am?
A. 250 ml per hour
B. 275 ml per hour
C. 400 ml per hour
D. 350 ml per hour
43. You are to apply a transdermal patch of nitroglycerin to your client. The following are important guidelines to observe EXCEPT:
A. Wear gloves to avoid any medication on your hand
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Apply to hairless clean area of the skin not subject to much wrinkling
44. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic drops by instilling the eye drops:
A. pressing on the lacrimal duct
B. into the outer third of the lower conjunctival sac
C. from the inner canthus going towards the side of the eye
D. directly onto the cornea
45. When applying eye ointment, the following guidelines apply EXCEPT:
A. apply the ointment from the inner canthus going outward of the affected eye
B. hold the tube above the conjunctival sac, do not let tip touch the conjunctive
C. discard the first bead of the eye ointment before application because the tube is likely to expel more than desired amount of ointment
D. squeeze about 2 cm of ointment and gently close but not squeeze eye
Situation 10 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self administration of insulin. She wants to ensure that there are nurses available daily to do health education classes.
46. The plan of the nurse supervisor is an example of
A. in service education process
B. primary prevention
C. efficient management of human resources
D. increasing human resources
47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra
A. does not have to supervise or evaluate the aide
B. makes the assignment to teach the staff member
C. most know how to perform task delegated
D. is assigning the responsibility to the aide but not the accountability for those tasks
48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should.
A. discuss how she is adjusting to her new job
B. ask about her family life
C. tell her to take the day off
D. empathize with the nurse and listen to her
49. Process of formal negotiations of working conditions between a group of registered nurses and employer is
A. grievance
B. strike
C. collective bargaining
D. arbitration
50. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is
A. professional course towards credit
B. continuing education
C. in service education
D. advance training
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