NURSING PRACTICE III

Situation 1: Anthony, 55 years old and a music teacher sought

admission to the hospital because of laryngeal tumor. The A. 1, 3, 4, 5
client is scheduled for total laryngectomy. B. 2, 3, 4, 5
C. 3, 4, 5, 6
1. Before the nurse can develop a relevant care plan, D. 1, 2, 3, 4
the nurse understands that in post-laryngectomy, the
trachea and the esophagus are permanently 8. The most controversial way of communicating
separated. Therefore, which of the following will the doctor’s orders is by phone. It becomes valid and
nurse expect? legal only when
A. No risk of aspiration during swallowing; A. Countersigned by the receiving RN
speech is lost
B. Signed by the physician who gave the order
B. Normal speaking, breathing and swallowing
are restored C. Signed by the resident physician on duty
C. Unable to communicate with difficulty of D. Countersigned by the medical doctor
swallowing and breathing
9. To facilitate effective communication between an
D. Permanent tracheostomy created; normal
immediate post-operative client and the nurse,
speech is lost
he/she should
2. Pre-operatively, the nurse identified the nursing A. Maintain a clam attitude and just care for
dagnosis, “Knowledge Deficit: Post-operative the client as needed
communication strategies”. Which of the following is
B. Encourage the client to discuss feelings/pain
a relevant nursing intervention?
or discomfort openly
A. Clarify information on purpose, anticipate C. Observe non verbal cues
benefits and consequences of total D. Assist the client to comfortable and safe
laryngectomy position while he/she explains what measure
B. Explain that total laryngectomy results in are being done
loss of ability to verbally communicate
C. Arrange a visit to a post-laryngectomy client 10. The nurse instructs the nursing attendant to perform
who effectively uses an alternative form of cleansing enema until the return flow is clear. The
verbal communication nursing attendant understood the instruction when
she says, “I will
D. Illustrate means of communicating post-
operatively
A. Call you when the return flow is clear”
3. In the immediate post-operative period, the nurse B. Stop the enema only if the return flow is
assesses coarse, high-pitched sound on inspiration without formed fecal material”
by listening over the trachea with a stethoscope. The C. Need 1 liter of tap water to have clear
nurse should immediately return flow”
D. Put the client in left Sim’s position to
achieve the desired return flow.”
A. Position client to Fowler’s
B. Reassure the client that he is doing fine Situation 3: Post-operative infection complication is still a
C. Suction the tracheostomy tube concern in surgical client’s care. Hospital staff needs to review
D. Report to the surgeon practices to adhere to the standards of care to improve quality
and safe care delivery.
4. Which of the following expected outcomes for the
patient is most relevant for the nursing diagnosis “At 11. Nurse Mercy is setting up for an emergency
risk for imbalanced nutrition related to impaired caesarian section. The linen packs were damp
swallowing”? although these were just taken from the sterilizer.
The nurse’s appropriate action is
A. Appropriate body weight maintained
B. Fear of choking relieved A. Bring the linen packs back to the Central
C. Oral intake increased Supply section for quality control
D. Swallowing of soft foods facilitated B. Change the damp linen pack
C. Open the linen pack and allow to dry
5. The nurse is preparing Anthony for discharge. The D. Do not use the damp linen
following are instructions regarding stoma and post
laryngectomy care except 12. The clinical instructor assigned a nursing student to
assist the operation. When the nursing student
A. Avoid exposure to persons with upper entered the OR suite, her curly long hair was not
respiratory disease covered by the head cap. What would the circulating
B. Instruct client to assume supine position as nurse do?
necessary
C. Avoid swimming and use care when using A. Welcome the nursing student to the OR
the shower B. Request the clinical instructor to tell the
D. Prevent foreign body from entering the nursing student to use the head cap
stoma properly
C. Assist the nursing student to tuck-in all her
Situation 2: The communication process is essential to the hair inside the head cap
manager or leader in supervising client care D. Do not allow the nursing student to scrub in

6. The nurse who effectively analyzes the 13. After the surgeon finished doing the surgical hand
communication process recognizes the messages are scrub, she came in to the OR suite swinging her
hands casually. The scrub nurse should do which of
A. Connotative and denotative the following appropriate action?
B. Learned and unlearned
C. Verbal and non-verbal A. Offer a sterile towel to dry her hands
D. Native as well as foreign B. Serve the surgeon her sterile gown and
gloves as usual
7. Basically, communication is part and parcel of C. Tell the circulating nurse to pour alcohol
planning to manage client care. Which of the 70% to the surgeon’s hands.
following skills should be included? Select all that D. Remind the surgeon to scrub again
apply.
1. Focusing 4. Clarifying 14. When the intern-in-charge did the skin prep and
2. Observing 5. Responding catheterized the client, the circulating nurse noticed
3. Attending 6. Teaching when the intern withdrew the catheter from the
 vagina. What is your appropriate and immediate assumption to office, she has been signing
action? documents as master’s graduate affixing “RN, MAN”
to her name. the action of the chief nurse constitutes
A. Stop the intern and do the catheterization
yourself A. Misrepresentation
B. Offer to change the catheter B. Malpractice
C. Alcoholize the tip of the catheter before C. Personification
reinserting the catheter D. Misdemeanor
D. Hold the hand of the intern to stop him from
reinserting the catheter 22. The charge nurse reported to the chief nurse that the
Demerol 50 cc vial inventory has been incorrect for
the last 24 hours. The most appropriate action of the
15. After the last stitch, the surgeon is ready to apply
narcotic nurse is:
dressing to the incision wound. Which of the
following does the nurse expect the surgeon to do?
A. Log every injection of Demerol
B. Make fraction dosage like 0.5 ml as 1 ml
A. Remove his gloves and apply the dressing
C. Demerol inventory must be checked every
B. Apply the dressings and tape and then
endorsement by the narcotic nurse
remove his gloves
D. Review endorsement of clients who received
C. Put the dressings and remove his gloves to
Demerol within the last 24 hours
apply the tape
D. Tape the dressing and remove the gloves
23. A staff nurse was found charting blood glucose result
without actually doing the procedure. What is the
Situation 4: A 57-year-ols male client, post Billroth II was
appropriate initial action of the senior nurse?
admitted to the Post Anesthesia Care Unit (PACU) from the OR.
The client is still sedated but responsive to commands. He has
a nasogastric tube draining orange-yellow fluid to a drainage A. Write and submit an explanation and
bottle reprimand as necessary
B. Go on leave without pay
16. The nurse who admitted the patient recognizes that C. Write an incident report
Billroth II procedure means D. Explain to the patient

A. Enterostomy 24. While making your PM shift endorsement, you saw

B. Esophagojejunostomy the nursing attendant receiving a package from a
C. Gastroduodenostomy patient’s watcher. Your appropriate action would be
D. Gastrojejunostomy
A. Reprimand the nursing attendant right away
B. Remind the patient that gift giving to any
17. After admitting the patient to the PACU, the first
hospital staff is not allowed
action of the nurse would be to
C. Review with the nursing attendant the
hospital policy
A. Assess patency of the airway
D. Endorse to the incoming shift for proper
B. Check the rate of the IV infusion action
C. Monitor the vital signs
D. Assess the clients pain
25. The Code of Ethics states that the nurse’s primary
commitment is to the client whether an individual of
18. As the nurse monitors the client, she notices a bright
family, group or community. Which nursing activity
red spot on the dressings which measures 4cm in
would best demonstrate the ethical principle called
diameter. The nurse should initially do which
justice?
appropriate nursing intervention?

A. Change the top dressing A. The nurse providing care on a “first come –
B. Continue to monitor the vital signs first served” basis
C. Notify the clients surgeon of a potential B. Referring the client for evaluation to the
hemorrhage social worker on duty regarding her socio-
D. Assess the presence of a drain economic status
C. The client’s preference is least considered
D. The nurse’s providing care to maximize
19. In assisting the client to do deep breathing, coughing
health according to available resources
and turning to the sides on the first post-operative
day, which nursing action would be most helpful for
Situation 6: Nurse Fely is in charge of a client who was
the client?
admitted for management of acute episode of cholecystitis.
A. Restate the importance of respiratory
26. Nurse Fely did her admission. She understands that
exercises
the pain is characterized as
B. Give the client reassurance that can he can
cough, breathe deeply and turn to sides
A. Tenderness that is generalized in the upper
safely
epigastric area
C. Administer the prescribed analgesic round
B. Pain in the left upper quadrant radiating to
the clock as prescribed
the left shoulder
D. Apply abdominal splint (pillow) while C. Tenderness and rigidity at the left epigastric
coughing area radiating to the back
D. Tenderness and rigidity at the upper right
20. The client complained of abdominal pain, nausea and abdomen radiating to the midsternal area
vomiting with abdominal distention. The nurse
anticipates which of the following priority
27. To confirm the diagnosis of cholecystitis, the
management after referring to the surgeon?
attending physician ordered a procedure that can
detect gallstones as small as 1 – 2 cm and
A. Gastric decompression inflammation. The nurse would prepare the client for
B. Possible surgery which specific diagnostic procedure?
C. Endoscopy
D. Rectal tube insertion A. Cholangiography
B. Ultrasonography
Situation 5: The behavior or actions of any professional nurse
C. Gall bladder series
especially while on duty are often the reflection of their
D. Oral cholecystogram
values.
28. The diagnosis was confirmed as cholecystitis with
21. Mrs. C. Serdenio is currently enrolled in the master’s
gallstones. The doctor prepared the client for the
program at the State University and is currently
removal of the gallbladder. The client asks the nurse
writing her thesis. She applied as a chief nurse in St.
John’s hospital and was accepted. Since her
 how the procedure will affect digestion. The nurse’s D. To promote renal function
most correct response would be
Situation 8: Drug administration is one of the collaborative
A. Removal of the gallbladder would functions of the nurse that require a written order of the
significantly interfere only with the digestion physician. To date, errors in medication continue to be a
of fatty foods. problem in the health care setting across the globe.
B. Removal of the gallbladder does not usually
interfere with digestion 36. A nurse is obligated to carry out a physician’s order
C. The body will adjust in due time except
D. Removal of the gallbladder usually
interferes with digestion but can be A. When the nurse is very busy
remedied by dietary modifications B. Believes an order to be inappropriate or
inaccurate
29. Reviewing the laboratory findings of the client, the C. When the nurse does not understand the
nurse would found which findings are elevated? order
1. White blood cell count D. When the client refuses
2. Total serum bilirubin
3. Alkaline phosphate 37. When do you carry out the order of the physician?
4. Red blood cell count A. When the consent has been signed by the
5. Cholesterol client or any appropriate person
6. Serum amylase
B. When the physician has signed the order
C. As soon as the medicine or therapy is
A. 1, 2, and 3
available
B. 2, 3, and 4 D. When the guardian of the client is present
C. 3, 5, and 6
D. 1, 2, and 6 38. A nurse encounters a client who refuses to take a
prescribed medication. What is the appropriate
30. A T-tube was inserted and the physician ordered, action of the nurse?
“Monitor the amount, color, consistency and odor of A. Tell the client that he will be subjected to
drainage.” Which of the following procedures can the another mode of treatment like surgery
nurse perform without the doctor’s order? B. Let the client sign the waiver
C. Explore the possible reason why the client
A. Clamping
refuses the prescribed medication
B. Aspirating
C. Irrigating D. Refer the client to the attending physician
D. Emptying the drainage
39. In case of telephone orders, the concerned physician
needs to countersign the order within
Situation 7: Mary Rose, 16 years old, is admitted to the
hospital for observation due to vague epigastric pain. The A. The shift
doctor’s clinical impression is appendicitis. B. As soon as possible
C. A time frame according to hospital policy
31. Based on the initial manifestation on admission, the
nurse is looking for positive manifestations of D. The day
appendicitis which includes the following except
40. The nurse should ensure that all components of
A. Abdominal tenderness on palpation medications are documented. Identify all these
B. Low grade fever components.
1. Dosage, route and frequency
C. Thrombocytopenia
2. Name of client and medication
D. Nausea and vomiting 3. Date and time the medication was ordered
4. Dosage, route, frequency and strength
32. A positive sign of appendicitis is localized and 5. Physician’s signature and specialty
rebound tenderness on palpation at which quadrant 6. Physician’s signature and PRC license number
of the abdomen?
A. All except 4 and 5
A. Left upper quadrant B. All except 4 and 6
B. Right upper quadrant
C. All except 5 and 6
C. Left lower quadrant
D. All except 3 and 5
D. Right lower quadrant
Situation 9: Nurse Mercy is assigned in the medical-surgical
33. The client is scheduled to undergo appendectomy. unit and most of the clients assigned to her were elderly
Preparation for appendectomy includes the following: clients.
1. Intravenous infusion
2. Laxative 41. For a client complaining of mild musculoskeletal pain,
3. Pubic area shaving the nurse will anticipate that the treatment for this
4. Enema client’s level of discomfort will include which of the
5. Shower following?
6. Pain medication
A. Diazepam
A. 2, 3, and 4
B. Acetaminophen
B. 1, 3, and 5
C. Meperidine HCl
C. 1, 2, and 3 D. Fentanyl
D. 1, 5, and 6
42. The nurse is to inject Vitamin B intramuscularly to
34. The nurse monitors for signs of peritonitis, a potential another elderly client. Before injecting, the nurse
complication postoperatively. The manifestations explained that the client may feel some discomfort.
include the following except This is an example of
A. Fever A. Reducing pain perception
B. Tachycardia B. Self-preservation
C. Abdominal tenderness
C. Anticipatory response
D. Soft abdomen
D. Distraction
35. Intravenous therapy was prescribed. Which of the 43. Mr. Gomez, 71 years old, has a history of chronic
following is not an indication of the therapy? back pain. He thinks that his family perceives him as
a “weakling” because he often asks for pain
A. To replace blood and fluid loss medication. Which of the following is the most
B. For antibiotic therapy therapeutic response of the nurse?
C. For parenteral nutrition
 A. “It seems that you are worried. Which
matter to you more? What people will say or A. Pearson r coefficient of correlation
getting relief from your pain?” B. Weighted mean
B. “Taking pain medication as prescribed will C. Chi square test
help you become more active and your D. T-test
family will be happy to see you up and
about.” Situation 11: Pain brings client to the hospital more than any
C. “Chronic pain is very difficult to manage; other symptoms. Nurses should therefore be skillful to assess
use pain medication because that is what it pain and reduce discomfort both for the client and family.
is for.”
D. “Don’t you think your family wants you to 51. Albert came to the hospital with chest pain and fever.
be comfortable, and the only way is to take After a thorough assessment by the doctor, he was
your medicine?” admitted for pericarditis management. The nurse
positions the client to reduce pain and discomfort.
44. Mang Pedring has chronic pain due to osteoarthritis Describe this position.
and has impaired speech. Which of the following is
the most appropriate to determine his medication A. Prone position with one pillow to support the
needs for pain? head
B. Put two pillows to elevate the head and one
A. Observe typical pain behavior through facial pillow under the knees
expressions C. Sit the client upright and lean forward
B. Asking the client to rate his pain on a scale D. Supine lying on either left or right side with
of 0 to 10 by writing on a magic slate one pillow to elevate the head
C. Medicate the client with analgesic as often
as ordered 52. The nurse is aware that pericarditis pain varies from
D. Record frequency of client’s complaint of mild to severe and is typically aggravated by
pain and administer medication accordingly
A. Coughing, talking and eating
45. Aling Juana, 67, diabetic, complained of elevated B. Inspiration, coughing, movement of the
blood glucose since she strained her back a week upper body
ago despite following her diet and drug prescription. C. Breathing, coughing and voiding
Your best explanation would be D. Coughing, inspiration and movement of the
lower extremities
A. Physiologic and psychologic stress can
elevate blood glucose level 53. Albert’s mother asks why the client’s breathing is
B. Client is consuming more food as a coping shallow. The correct response of the nurse would be
mechanism
C. It is a usual occurrence among the elderly A. “The client is conserving his energy.”
D. Parasympathetic stimulation from the B. “That is good because the client is not
body’s normal response to pain wasting the much needed oxygen.”
C. “He is preventing unnecessary movement.”
Situation 10: Research is essential to the development of any D. “Respiratory movement intensifies
profession. Through research, knowledge can be validated and pericardial pain.
defined, and new knowledge can be generated. A team of
researchers proposed a study on the individual effect of 54. Albert is prescribed NSAID every four hours to
preoperative teaching on the early ambulation of women who relieve, fever, inflammation, and pericardial pain. To
have undergone abdominal hysterectomy. Target populations maximize the effect of the drug, the nurse would
are women admitted on the same day for total abdominal administer it
hysterectomy.
A. When the client asks for it
46. Which of the following is the most appropriate B. On an empty stomach
method to use? C. Round the clock on a consistent basis
D. When the client is awake only
A. Non-experimental method
B. Qualitative method
55. The nurse wants to know if the client is aware of the
C. Quantitative method side effects of NSAID. What would be the most
D. Experimental method appropriate question of the nurse?

47. Which of the following designs would be most A. “Are you aware that you can be addicted to
appropriate to use in attempting to determine the the drug?”
participants’ early ambulation after they will be given B. “Have you ever vomited blood or noticed
preoperative teachings? very black stools?”
C. “How familiar are you with the drug?”
A. Time series design D. “Have you noticed something unusual with
B. Pretest – posttest control group design your urination?”
C. Solomon four – group design
D. One shot case study Situation 12: Nurse Carla admitted Harry for management of
acromegaly.
48. In the proposed study, the researchers defined the
selected groups and ask what sample size should be 56. The nurse is aware that acromegaly is a condition
used. Since there are many qualifiers that to some when growth hormone occurs in excess in adulthood
extent samples must be specific to the study, the or after epiphyses of the long bones have fused. The
general rule in the sample size is to following are the typical features of the disorder
except
A. Determine the duration of the study
B. Consider the type of the study A. The soft tissues continues to grow
C. Establish the number of variables B. Hands and feet are enlarged
D. Make the sample as large as possible C. The client grows taller
D. Broad and bulbous nose
49. The independent variable that is manipulated is
57. The client was prescribed Ocreotide acetate
A. Women (Sandostatin). Nurse Carla would monitor for which of
B. Abdominal hysterectomy the following side effects?
C. Health outcomes
D. Preoperative teachings A. Abdominal pain
B. Dysuria
50. In treating the data to be collected, the researcher C. Hypotension
will use which of the following statistical tools? D. Constipation
 1. Taking the BP 15 minutes after intake of
58. For effective dosing, Ocreotide acetate must be antihypertensive drug
administered by which appropriate route, three times 2. Measuring the BP after the client has
weekly? been seated for 5 minutes
3. Seating the client with arm bared
A. Intravenously supported and at the heart level
B. Intramuscularly 4. Using the cuff with rubber bladder that
C. Orally encircles at least 80% of the arm
D. Subcutaneously 5. Gauges of BP apparatus should be
calibrated every 8 hours
59. Priority discharge plans should include which of the 6. The client should rest quietly for 5
following? minutes before reading and can talk while
1. Fasting blood sugar monitoring BP is being checked
2. Bone assessment
3. Intake and output A. 1, 2, 3, and 4
4. Urine output B. 3, 4, 5, and 6
C. 2, 3, 4, and 5
A. 2 and 3 D. 2, 4, 5, and 5
B. 1, 2, and 3
C. All except 1 Situation 14: Marina, a newly hired staff nurse in the medical
D. 1 and 2 surgical unit was assigned to work with a senior nurse. A
female client was admitted with a diagnosis of diabetic foot,
60. Acromegaly often develops insidiously that nurses gangrene left toe, type 2 diabetes.
should understand that the client with this disorder
would seek medical care because of 66. From the nursing history obtained from the client,
which information is most likely related to the
A. Alteration in fat and carbohydrate development of gangrene on the client’s left toe?
metabolism
B. Changes in blood sugar level A. Preferred open toed sandals to closed
leather shoes
C. Changes in appearance
B. Type 2 diabetic diagnosed 15 years ago
D. Alteration in their voice C. Father had type 2 diabetes; post-above-
knee amputation right leg
Situation 13: Part of your duty while on PM shift at the medical
D. Accidental cut in big toe while cutting toe
ward is to give health instructions to clients and significant
nails
others especially during visiting hours.

61. A client with gout asks the nurse what food must be 67. The physician ordered bilateral lower extremities
avoided so that the family can provide support. Doppler ultrasound. Which of the following is the
Which food has the highest in purine content and physician interested to find out through this
must be excluded from the dietary plan? diagnostic test?

A. Chicken A. Distal paresthesias

B. Carrots B. Oxygenation of the tissues in the lower
C. Chocolate extremities
D. Liver C. Occlusion of large vessels and arterioles
D. Isolated peripheral neuropathies
62. A 30-year-old client had cholesterol blood test before
admission to the hospital. The nurse in charge would 68. The senior asked Marina to list nursing interventions
teach the family and significant others that the client for the nursing diagnosis “Ineffective tissue
should exercise to help keep the total cholesterol to a perfusion: peripheral”. From the following list, which
desired level of intervention will the senior nurse consider to be
contraindicated?
A. 140 mg/dl
A. Regular passive and active exercises of all
B. 200 mg/dl extremities
C. 250 mg/dl B. Keep extremities warm using a foot cradle
D. 300 mg/dl C. Encourage frequent changes in position
D. Maintain both extremities in a dependent
63. A hypertensive client is taking herbal supplement for
position
his hypertension. He was prescribed antihypertensive
medication. The client wants to continue taking his
herbal medication to lower his blood pressure. The 69. When Marina checked the capillary blood glucose of
nurse’s most appropriate action is to the client at 6 PM before meals as instructed by the
senior nurse, the result showed 65 mg/dl. Which of
A. Advise the client to discuss this concern the following will Marina do first?
with the attending physician
A. Give juice as prescribed in the insulin scale
B. Tell the client that herbal supplements have
pre-meals
no proven therapeutic effects
B. Recheck CBG
C. Tell the client that herbal and the prescribed
C. Check the physician’s order in case CBG is
medications are not compatible
below 70 mg/dl
D. Instruct the client to have a more frequent
BP checking D. Look for the senior nurse and report

64. The client was placed on a low sodium diet. The wife 70. The senior nurse observes that Marina occasionally
asks the nurse which foods to include in the client’s does not follow agreed upon interventions. The
diet while at home. The nurse should instruct to senior nurse reports that Marina should improve in
include which of these? which of the following?

A. Canned foods A. Identifying own learning needs

B. Preserved foods B. Attitute toward criticism
C. Fruits and vegetables C. Compliance to standards
D. Salt water fish D. Demonstration of proper decorum

65. While the nurse was checking the BP of the client, Situation 15: A 34-year-old female client with Grave’s disease
the wife was intently observing the nurse. The wife was admitted for treatment. The physician prescribed
asks the nurse how to ensure accurate measurement Propylthiouracil to treat the disorder.
of BP reading. Identify all the nurse mentioned that
will ensure accurate BP reading. 71. Before the nurse administers the medication, which
of the following is most relevant for the nurse to ask?
 A. “Do you experience gastric discomforts?” sons in the elementary. The head nurse emphasized
B. “When was the last time you tool alcohol?” that it is her turn to go on PM duty. The action of the
C. “When was your last menstruation?” head nurse exemplifies which of the following?
D. “Do you prefer a liquid form of medication?”
A. Authority
72. The client is to have surgery in 10 days. Lugol’s B. Fidelity
solution 4 gtts po was prescribed in 10 days. The C. Autonomy
client asked the nurse for the purpose of the drug. D. Justice
Which response of the nurse is correct?
79. A scrub nurse is assisting an emergency Cesarian
A. It decreases the risk of bleeding section on a 39-year-old laundry woman. Before
B. It eliminates the needs to take hormone closing the peritoneum, the surgeon asks, “How old
replacement is the client?” Holding the fallopian tube, the surgeon
C. It stabilizes your immune system to asks for a hemostat. The scrub nurse sensing that
withstand surgery the surgeon is about to ligate the tube said, “Doctor
D. It decreases the risk for thyroid crisis there is no signed consent for tubal ligation.” The
nurse just demonstrated which of the following?
73. When the client returns to the unit after surgery,
which technique is most appropriate to monitor A. Insubordination
bleeding from the incision? B. Abandonment of duty
C. Advocacy
A. Weigh all gauze dressing before and after D. Malpractice
changing wound dressings
B. Assess for dampness at the back of the 80. An officer-in-charge signs a document for the chief
client’s neck nurse who went on leave. The OIC signs her full
C. Pass a flashlight across the incision wound name over the name of the chief nurse. The proper
on top of the dressings way to sign for the chief nurse who is on leave is
D. Remove the dressings to directly inspect the
incision wound A. Sign your name over the printed name of
the chief nurse
74. Which of the following assessment findings when B. Write “for” before the title of the chief nurse
observed in a post-thyroidectomy client is indicative then sign your name above it
of a thyroid crisis? C. Erase the name of the chief nurse and write
your name then sign
A. Falling blood pressure D. Sign on a separate line as OIC
B. Regular and noisy respiration
C. High fever Situation 17: Sponge count should be performed by two
D. Spasm in the hand members of the surgical team in any surgical procedure where
there is a possibility that the sponge can be retained.
75. At the start of thyroid replacement post-total
thyroidectomy, the nurse must monitor for side 81. The scrub and circulating nurse should perform
effects. Which side effects would the nurse expect to sponge count during which phases of an abdominal
assess? hysterectomy procedure?
1. Hypertension 1. Before the procedure
2. Tremors 2. Before closing the endometrium
3. Hirsutism 3. Before closing the peritoneum
4. Insomnia 4. At the skin closure
5. Tachycardia 5. When the scrub nurse goes for a lunch
6. Hyperglycemia break

A. 3, 4, 5, and 6 A. All except 5

B. 1, 2, 3, and 6 B. All except 1
C. 1, 3, 4, and 5 C. 3 and 4 only
D. 1, 2, 4, and 5 D. All except 2

Situation 16: The willingness of nurses to accept a set of 82. The OR nurse knows that the correct way to count
professional and ethical principles and apply it in their daily sponge is
affairs is the hallmark of a true professional.
A. Scrub nurse counts singly followed by the
76. A client is being positioned for radical vulvectomy circulating nurse
and a couple of clinical clerks wanted to come in to B. Scrub and circulating nurse count by packs
watch the surgery. The circulating nurse advise them of tens
to enter the OR suite later. Foremost, this decision of C. Scrub nurse and circulating nurse count
the nurse is directed towards audibly by packs of fifties
D. Scrub nurse and circulating nurse count
A. Respecting the client’s rights singly, audibly and concurrently
B. Preventing infection
C. Minimizing a crowd in the room 83. The scrub nurse and circulating nurse also counted
D. Preserving privacy the sharps and miscellaneous items like instruments
before the procedure. Continuous accounting for
77. Nurse Kristine is to inject Demerol 75 mg to a post- these items can primarily
TURP (transurethral resection of the prostate) client
who is in pain. When she checked the narcotic A. Expedite the procedure thus shortening the
cabinet, she found out a vial that is almost empty. surgical time
She was able to aspirate 60 mg only. Nurse Kristine B. Improve hospital miscellaneous revenue
decided to inject it instead of making the client wait C. Minimize injuries and/or liabilities to sterile
until the next Demerol vial is available. The action of surgical team
the nurse violates which of the following ethical D. Shorten surgical cases turnover by 15 – 30
principles? minutes

A. Justice 84. The circulating nurse will document “surgical count”

B. Beneficence in which of the following?
C. Truth
D. Autonomy A. Observation notes
B. Intraoperative record
78. Nurse Nora is assigned on PM shift for the month of C. Nurse’s notes
June. She requested the head nurse if she can be on D. Checklist
night or morning instead to be able to tutor her 2
 85. When the surgeon asked for suture to close the 92. Which doctrine is invoked if an abdominal X-ray of a
abdomen, sponge count has not been completed. postoperative patient shows a forcep inside the
Which of the following is the appropriate action of the abdomen?
scrub nurse?
A. Force majeure
A. Requests the surgeon to recheck the B. Borrowed servant doctrine
abdomen for sponges, if any C. Res ipsa loquitor
B. Continues to count the sponges D. Doctrine of captain of the ship
C. Hands obligingly the suture for closure to
the surgeon 93. When the nurse is called to witness and was told to
D. Informs the surgeon that sponge count has bring the patient’s chart, what is needed to legally
not been completed summon the client’s chart in court?

Situation 18: The continuum of care is facilitated by effective A. Request order

communication among the members of the health care team. B. Notarized letter from the complainant
This activity is facilitated by documenting reports. C. Permission from the client
D. Subpoena from the judge
86. The change of shift report of nurses describes the
following except 94. When Nurse Abe presents the patient’s chart as
evidence of a case, this is called a/an
A. Priority clients and impending needs
B. Client health status A. Duces tecum
C. Nurses priority needs B. Appendices
D. Client special needs C. Exhibit
D. Documentation
87. When the staff nurse on duty encounters a problem
that cannot be solved using nursing knowledge, skills 95. When a case is already filed in court, it is a court rule
and available resources, it is best for the nurse to not to discuss the matter outside the court. This is
consult the
A. Malpractice
A. Nurse supervisor B. Motu proprio
B. Medical director
C. Subjudice
C. Head nurse
D. Sine-qua-non
D. Chief nurse
Situation 20: A nursing student was assigned to take care of a
88. When the nurse ensures that the client has plan for client with polycythemia vera.
continuous care after leaving the health care facility
and assists from the transition from one environment 96. You planned the nursing care of the client together
to another, she is doing a with the nursing student. You asked the nursing
student to enumerate the clinical manifestations of a
A. Discharge plan client with polycythemia vera. You expect the nursing
B. Admission plan student to enumerate the following manifestations
C. Referral except
D. Nursing care plan
Answer: A A. Generalized pruritus
Rationale: “Discharge planning is the process of preparing a client B. Hepatomegaly
to leave one level of care for another within or outside the current C. Splenomegaly
health care agency. Usually, discharge planning refers to the client D. Ruddy complexion
leaving the hospital for home. However, discharges occur among
many other settings. Within a facility it can occur from one unit to 97. The nursing student reviews the laboratory findings
another.”
and finds which blood results are elevated?
Reference: - p. 113, Kozier et al, 2004

89. A nurse has to attend a committee meeting for two A. RBC, WBC, and platelets
hours. She delegates her work to another nurse. B. WBC, platelet, and cholesterol
What primary consideration should be observed? C. Bilirubin, RBC, and platelet
D. BP, WBC, and hematocrit
A. Availability of resources
B. Time needed to perform delegated function 98. Phlebotomy was ordered as part of the therapy. You
C. Willingness to assist instructed the client and emphasized that the
D. Competency to perform the given function procedure can be repeated. The client inquired,
“What is the primary aim of the procedure?” Your
appropriate response is
90. When a telephone order is made, it should be
A. “It removes the excess blood and donate to
documented by the nurse who is receiving the order.
patients of the same blood type.”
The following should be included in the order to be
B. “It prevents headache and dizziness.”
executed except
C. “It keeps the BP reading within normal
range.”
A. Time the call was made and its duration
D. “It keeps the hematocrit within normal
B. Who made the call and who received the range.”
order
C. What information was given and for whom
99. The companion asks why the client was advised to
was the order
avoid iron supplements or vitamins. The correct
D. When the order was made and who made
response of the nurse would be
the order
A. “These supplements enhance the
Situation 19: Nurse Abe receives a subpoena as a witness in a production of RBC.”
court case. B. “The vitamins and iron can suppress bone
marrow function.”
91. Which of the following best describes the C. “Actually the patient does not need these
responsibility of the nurse as a witness in a case of supplements.”
court? D. “It is best that the client gets these
supplements from natural sources.”
A. Protect the patient
B. State the truth 100.The client complained of generalized pruritus. The
following are appropriate nursing interventions
C. Collaborate with the primary physician
except
D. Relate a dramatic experience
A. Administer routine antihistamine ‘round the
clock
B. Regulate the temperature to 25 degrees
centigrade or lower
C. Bathe in tepid or cool water followed by
cocoa-based lotion application
D. Wear light material loose-fitting camisa