SITUATION: Nursing is a profession. The nurse should
have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and
optimization of hea
...
SITUATION: Nursing is a profession. The nurse should
have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering
through the diagnosis and treatment of human
response and advocacy in the care of the
individuals, families, communities and the
population. This is the most accepted definition
of nursing as defined by the:
a. PNA
b. ANA
c. Nightingale
d. Henderson
2. Advancement in Nursing leads to the
development of the Expanded Career Roles.
Which of the following is NOT an expanded
career role for nurses?
a. Nurse practitioner
b. Nurse Researcher
c. Clinical nurse specialist
d. Nurse anaesthesiologist
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible
for the maintenance of the quality of nursing in
the country. Powers and duties of the board of
nursing are the following, EXCEPT:
a. Issue, suspend, revoke certificates of
registration
b. Issue subpoena duces tecum, ad
testificandum
c. Open and close colleges of nursing
d. Supervise and regulate the practice of
nursing
4. A nursing student or a beginning staff nurse who
has not yet experienced enough real situations
to make judgments about them is in what stage
of Nursing Expertise?
a. Novice
b. Newbie
c. Advanced Beginner
d. Competent
5. Benner’s “Proficient” nurse level is different
from the other levels in nursing expertise in the
context of having:
a. the ability to organize and plan activities
b. having attained an advanced level of
education
c. a holistic understanding and perception
of the client
d. intuitive and analytic ability in new
situations
SITUATION: The nurse has been asked to administer an
injection via Z TRACK technique. Questions 6 to 10 refer
to this.
6. The nurse prepares an IM injection for an adult
client using the Z track technique. 4 ml of
medication is to be administered to the client.
Which of the following site will you choose?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis
7. In infants 1 year old and below, which of the
following is the site of choice for intramuscular
Injection?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis
8. In order to decrease discomfort in Z track
administration, which of the following is
applicable?
a. Pierce the skin quickly and smoothly at
a 90 degree angle
b. Inject the medication steadily at around
10 minutes per millilitre
c. Pull back the plunger and aspirate for 1
minute to make sure that the needle did
not hit a blood vessel
d. Pierce the skin slowly and carefully at a
90 degree angle
9. After injection using the Z track technique, the
nurse should know that she needs to wait for a
few seconds before withdrawing the needle and
this is to allow the medication to disperse into
the muscle tissue, thus decreasing the client’s
discomfort. How many seconds should the nurse
wait before withdrawing the needle?
a. 2 seconds
5
b. 5 seconds
c. 10 seconds
d. 15 seconds
10. The rationale in using the Z track technique in an
intramuscular injection is:
a. It decreases the leakage of discolouring
and irritating medication into the
subcutaneous tissues
b. It will allow a faster absorption of the
medication
c. The Z track technique prevent irritation
of the muscle
d. It is much more convenient for the nurse
SITUATION: A Client was rushed to the emergency room
and you are his attending nurse. You are performing a
vital sign assessment.
11. All of the following are correct methods in
assessment of the blood pressure EXCEPT:
a. Take the blood pressure reading on both
arms for comparison
b. Listen to and identify the phases of
Korotkoff’s sound
c. Pump the cuff to around 50 mmHg
above the point where the pulse is
obliterated
d. Observe procedures for infection control
12. You attached a pulse oximeter to the client. You
know that the purpose is to:
a. Determine if the client’s hemoglobin
level is low and if he needs blood
transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s antihypertensive medications
d. Detect oxygen saturation of arterial
blood before symptoms of hypoxemia
develops
13. After a few hours in the Emergency Room, The
client is admitted to the ward with an order of
hourly monitoring of blood pressure. The nurse
finds that the cuff is too narrow and this will
cause the blood pressure reading to be:
a. inconsistent
b. low systolic and high diastolic
c. higher than what the reading should be
d. lower than what the reading should be
14. Through the client’s health history, you gather
that the patient smokes and drinks coffee. When
taking the blood pressure of a client who
recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
15. While the client has pulse oximeter on his
fingertip, you notice that the sunlight is shining
on the area where the oximeter is. Your action
will be to:
a. Set and turn on the alarm of the
oximeter
b. Do nothing since there is no identified
problem
c. Cover the fingertip sensor with a towel
or bedsheet
d. Change the location of the sensor every
four hours
16. The nurse finds it necessary to recheck the blood
pressure reading. In case of such re assessment,
the nurse should wait for a period of:
a. 15 seconds
b. 1 to 2 minutes
c. 30 minutes
d. 15 minutes
17. If the arm is said to be elevated when taking the
blood pressure, it will create a:
a. False high reading
b. False low reading
c. True false reading
d. Indeterminate
18. You are to assessed the temperature of the
client the next morning and found out that he
ate ice cream. How many minutes should you
wait before assessing the client’s oral
temperature?
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 15 minutes
19. When auscultating the client’s blood pressure
the nurse hears the following: From 150 mmHg
to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
continuing down to 80 mmHg and then silence.
6
What is the client’s blood pressure?
a. 130/80
b. 150/100
c. 100/80
d. 150/100
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?
a. 10-20 seconds
b. 30-45 seconds
c. 1-1.5 minutes
d. 3-3.5 minutes
Situation: Oral care is an important part of hygienic
practices and promoting client comfort.
21. An elderly client, 84 years old, is unconscious.
Assessment of the mouth reveals excessive
dryness and presence of sores. Which of the
following is BEST to use for oral care?
a. lemon glycerine
b. Mineral oil
c. hydrogen peroxide
d. Normal saline solution
22. When performing oral care to an unconscious
client, which of the following is a special
consideration to prevent aspiration of fluids into
the lungs?
a. Put the client on a sidelying position
with head of bed lowered
b. Keep the client dry by placing towel
under the chin
c. Wash hands and observes appropriate
infection control
d. Clean mouth with oral swabs in a careful
and an orderly progression
23. The advantages of oral care for a client include
all of the following, EXCEPT:
a. decreases bacteria in the mouth and
teeth
b. reduces need to use commercial
mouthwash which irritate the buccal
mucosa
c. improves client’s appearance and selfconfidence
d. improves appetite and taste of food
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