(Test Bank) Nclex-Rn Nursing Board Practice Test Compilation (Complete Solutions Nursing Practice 1-5)

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Nursing Boar d Practice Test Compilation Contents NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE ................................ ................................ .......... 4 NURSING PRACTICE II ................................ ..................... 15 NURSING PRACTICE III ................................ .................... 26 NURSING PRACTICE IV ................................ .................... 36 NURSING PRACTICE V ................................ ..................... 46 TEST I - Foundation of Professional Nursing Practice .... 56 Answers and Rationale – Foundation of Professional Nursing Practice ................................ ......................... 66 TEST II - Community Health Nursing and Care of the Mother and Child ................................ ........................... 74 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ............................. 84 TEST III - Care of Clients with Physiologic and Psychosocial Alterations ................................ ................ 91 Answers and Rationale – Care of Clients with Physiologic and Psychos ocial Alterations ................ 102 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations ................................ .............. 111 Answers and Rationale – Care o f Clients with Physiologic and Psychosocial Alterations ................ 122 TEST V - Care of Clients with Physiologic and Psychosocial Alterations ................................ ................................ .... 133 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 144 PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 ANSWERS AND RATIONALE – FOUNDATION OF NURSING ................................ ................................ .. 158 PRACTICE TEST II Maternal and Child Health ............... 162 ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH ................................ ................................ ..... 167 MEDICAL SURGICAL NURSING ................................ ..... 173 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING ................................ ................................ .. 178 PSYCHIATRIC NURSING ................................ ................ 180 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................ ................................ ................. 185 FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188 ANSWER KEY - FOUNDATION OF PROFESSIONAL NURSING PRACTICE ................................ .................. 199 COMMUNITY HEAL TH NURSING AND CARE OF THE MOTHER AND CHILD ................................ .................... 200 ANSWER KEY: COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .......................... 211 Compre hensive Exam 1 ................................ ................ 213 CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS ................................ ...... 222 ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGI C AND PSYCHOSOCIAL ALTERATIONS ......................... 234 Nursing Practice Test V ................................ ................ 235 Nursing Practice Test V ................................ ................ 245 TEST I - Foundation of Professional Nursing Practice .. 255 Answers and Rationale – Foundation of Professional Nursing Practice ................................ ....................... 265 TEST II - Community Health Nursing and Care of the Mother and Child ................................ ......................... 273 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ........................... 283 TEST III - Care of Clients with Physiologic and Psychosocial Alterations ................................ .............. 290 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 301 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations ................................ .............. 310 Answers and Rationa le – Care of Clients with Physiologic and Psychosocial Alterations ................ 321 TEST V - Care of Clients with Physiologic and Psychosocial Alterations ................................ ................................ .... 332 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 343 PART III ................................ ................................ ......... 352 PRACTIC E TEST I FOUNDATION OF NURSING .............. 352 ANSWERS AND RATIONALE – FOUNDATION OF NURSING ................................ ................................ .. 357 PRACTICE TEST II Maternal and Child Health ............... 361 2 ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH ................................ ................................ ..... 366 MEDICAL SURGICAL NURSING ................................ ..... 372 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING ................................ ................................ .. 377 PSYCHIATRIC NURSING ................................ ................ 379 ANSWERS AND RATIONALE – PSYC HIATRIC NURSING ................................ ................................ ................. 384 FUNDAMENTALS OF NURSING PART 1 ........................ 387 FUNDAMENTALS OF NURSING PART 2 ........................ 392 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 2 ................................ ...................... 397 FUNDAMENTALS OF NURSING PART 3 ........................ 401 ANSWE RS and RATIONALES for FUNDAMENTALS OF NURSING PART 3 ................................ ...................... 405 MATERNITY NURSING Part 1 ................................ ........ 409 ANSWERS and RATIONALES for MATERNITY NURSI NG Part 1 ................................ ................................ ........ 418 MATERNITY NURSING Part 2 ................................ ........ 428 Answer for maternity part 2 ................................ .... 433 PEDIATRIC NURSING ................................ .................... 434 ANSWERS and RATIONALES for PEDIATRIC NURSING ................................ ................................ ................. 439 COMMUNITY HEALTH NURSING Part 1 ........................ 444 COMMUNITY HEALTH NURSING Part 2 ........................ 454 MEDICAL SURGICAL NURSING Part 1 ........................... 475 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 1 ................................ ........................ 479 MEDICAL SURGICAL NURSING Part 2 ........................... 481 MEDICAL SURGICAL NURSING Part 2 ....................... 485 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 2 ................................ ........................ 489 MEDICAL SURGICAL NURSING Part 3 ........................... 491 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 3 ................................ ........................ 495 PSYCHIATRIC NURSING Part 1 ................................ ...... 497 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 1 ................................ ................................ ........ 502 PSYCHIATRIC NURSING Part 2 ................................ ...... 504 ANSWERS and RATIONALES for PSYCHI ATRIC NURSING Part 2 ................................ ................................ ........ 509 PSYCHIATRIC NURSING Part 3 ................................ ...... 512 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 3 ................................ ................................ ........ 516 PROFESSIONAL ADJUSTMENT ................................ ...... 519 LEADERSHIP and MANAGEMENT ................................ . 522 NURSING RESEARCH Par t 1 ................................ .......... 532 NURSING RESEARCH Part 2 ................................ .......... 542 Nursing Research Suggested Answer Key ................ 546 3 4 NURSING PR ACTICE I: FOUNDATION OF NURSING PRACTICE 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 lth 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, EXCEP T: 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 ab ility 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 fem oris 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 dispers e 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 i s: 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 SITUATI ON: 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 fo r 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 purp ose 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 anti - hypertensive medications d. Detect oxygen saturation of arterial blood before sym ptoms 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 clien t 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 pres sure, 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 cli ent’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 continui ng 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 readin g? 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 an d 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 self - confidence d. improves appetite and taste of food 24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. This can be avoided by: a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity b. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs c. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums d. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: a. salt solution b. petr oleum jelly c. water d. mentholated ointment Situation – Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. 26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? a. Clenching his fist every 2 minutes b. Breathing in and out through the nose with his mouth open c. Tensing the shoulder muscles while lying on his back d. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy , which of the following complains to Fernan should be noted as a possible complication: a. Nausea and vomiting b. Shortness of breath and laryngeal stridor c. Blood tinged sputum and coughing d. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instruct ed Fernan to: a. Exercise the neck muscles b. Refrain from coughing and talking 7 c. Breathe deeply d. Clear his throat 29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: a. Keep the ste rile equipment from contamination b. Assist the physician c. Open and close the three -way stopcock d. Observe the patient’s vital signs 30. Right after thoracentesis, which of the following is most appropriate intervention? a. Instruct the patient not to cough or deep breathe for two hours b. Observe for symptoms of tightness of chest or bleeding c. Place an ice pack to the puncture site d. Remove the dressing to check for bleeding Situation: Knowledge of the acid -base disturbance and the functions of the electrolytes is necessar y to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the development of which type of acid -base imbalance? a. Respirator y acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or test ed before the ABG specimens are drawn? a. Guthrie test b. Romberg’s test c. Allen’s test d. Weber’s test 34. A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, Pco2 is 50 mmHg, and the bicarbonate is 27 mEq/L. The nurse conclude s that which acid base disturbance is present in this client? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 35. Allen’s test checks the patency of the: a. Ulnar artery b. Carotid artery c. Radial artery d. Brachial artery Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 36. Given the above assessment data, the most immediate goal of the nurse would be which of the following? a. Prevent urinary complication b. maintains fluid and electrolytes c. Alleviate pain d. Alleviating nausea 37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post -operative order includes “daily urine specimen to be sent to the la boratory”. Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? a. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container b. empty a samp le urine from the collecting bag into the specimen container c. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container. 8 38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? a. to the patient’s inner thigh b. to the patient’ buttocks c. to the patient’s lower thigh d. to the patient lower ab domen 39. Which of the following menu is appropriate for one with low sodium diet? a. instant noodles, fresh fruits and ice tea b. ham and cheese sandwich, fresh fruits and vegetables c. white chicken sandwich, vegetable salad and tea d. canned soup, potato salad, and di et soda 40. How will you prevent ascending infection to Eileen who has an indwelling catheter? a. see to it that the drainage tubing touches the level of the urine b. change he catheter every eight hours c. see to it that the drainage tubing does not touch the level o f the urine d. clean catheter may be used since urethral meatus is not a sterile area Situation: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. Somatocrinin or the Growth hormone releasing horm one is secreted by the: a. Hypothalamus b. Posterior pituitary gland c. Anterior pituitary gland d. Thyroid gland 42. All of the following are secreted by the anterior pituitary gland except: a. Somatotropin/Growth hormone b. Thyroid stimulating hormone c. Follicle stimulating ho rmone d. Gonadotropin hormone releasing hormone 43. All of the following hormones are hormones secreted by the Posterior pituitary gland except: a. Vasopressin b. Anti-diuretic hormone c. Oxytocin d. Growth hormone 44. Calcitonin, a hormone necessary for calcium regulation is secreted in the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland 45. While Parathormone, a hormone that negates the effect of calcitonin is secreted by the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland Situation : 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. efficient management of human resources c. increasing human resources d. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse -aide who is an unlice nsed staff, Mrs. Guevarra a. makes the assignment to teach the staff member b. is assigning the responsibility to the aide but not the accountability for those tasks c. does not have to supervise or evaluate the aide d. most know how to perform task delegated 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. empathize with the nurse and listen to her b. tell her to take the day off c. discuss how she is adjusting to her new job d. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is 9 a. grievance b. arbitration c. collective bargaining d. strike 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is a. professional course towards credits b. in-service education c. advance training d. continuing education Situation: As a nurse, you are aware that proper documentation in the patient chart is your re sponsibility. 51. Which of the following is not a legally binding document but nevertheless very important in the care of all patients in any health care setting? a. Bill of rights as provided in the Philippine constitution b. Scope of nursing practice as defined by RA 9173 c. Board of nursing resolution adopting the code of ethics d. Patient’s bill of rights 52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communi cation? a. Incident report b. Nursing kardex c. Oral report d. Complain report 53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges? a. Fraud b. Harassment c. Assault and battery d. Breach of confidentiality 54. Which o f the following is the essence of informed consent? a. It should have a durable power of attorney b. It should have coverage from an insurance company c. It should respect the client’s freedom from coercion d. It should disclose previous diagnosis, prognosis and alter native treatments available for the client 55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delega tion? a. The RN must supervise all delegated tasks b. After a task has been delegated, it is no longer a responsibility of the RN c. The RN is responsible and accountable for the delegated task in adjunct with the delegate d. Follow up with a delegated task is necessa ry only if the assistive personnel is not trustworthy Situation: When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 56. The most important risk factor is: a. Cigarette smoking b. binge drink ing c. Hypertension d. heredity 57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: a. Embolic stroke b. diabetic stroke c. Hemorrhagic stroke d. thrombotic stroke 58. Hemmorhagic stroke occurs su ddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: a. phlebitis b. damage to blood vessel c. trauma d. aneurysm 59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? a. Amphetam ines b. shabu c. Cocaine d. Demerol 10 60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: a. “More red blood cells thicken blood and make clots more possible.” b. “Increased RBC count is linked to high cholesterol.” c. “More red blo od cell increases hemoglobin content.” d. “High RBC count increases blood pressure.” Situation: Recognition of normal values is vital in assessment of clients with various disorders. 61. A nurse is reviewing the laboratory test results for a client with a diagn osis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following? a. 60% b. 47% c. 45% d. 32% 62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. ST depression b. Prominent U wave c. Inverted T wave d. Tall peaked T waves 63. A nurse is reviewing the electrolyte results of an assigned client and notes that the pota ssium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. U waves b. Elevated T waves c. Absent P waves d. Elevated ST Segment 64. Dorothy underwent diagnostic test and the result of the blood exam ination are back. On reviewing the result the nurse notices which of the following as abnormal finding? a. Neutrophils 60% b. White blood cells (WBC) 9000/mm c. Erythrocyte sedimentation rate (ESR) is 39 mm/hr d. Iron 75 mg/100 ml 65. Which of the following laboratory te st result indicate presence of an infectious process? a. Erythrocyte sedimentation rate (ESR) 12 mm/hr b. White blood cells (WBC) 18,000/mm3 c. Iron 90 g/100ml d. Neutrophils 67% Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this. 66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural effusion? a. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath b. Hypoxemia, hypercapne a and respiratory acidosis c. Noisy respiration, crackles, stridor and wheezing d. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds 67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal o f fluid should be slow. Rapid removal of fluid in thoracentesis might cause: a. Pneumothorax b. Cardiovascular collapse c. Pleurisy or Pleuritis d. Hypertension 68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleu ral effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to: a. Restore positive intrathoracic pressur e b. Restore negative intrathoracic pressure c. To visualize the intrathoracic content d. As a method of air administration via ventilator 69. The chest tube is functioning properly if: a. There is an oscillation b. There is no bubbling in the drainage bottle 11 c. There is a con tinuous bubbling in the waterseal d. The suction control bottle has a continuous bubbling 70. In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the following is included in the teaching? a. Breath normally b. Hold th e breath after each inspiration for 1 full minute c. Practice abdominal breathing d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation SITUATION: Health care delivery system affects the health status of every filipino. As a Nurse, Knowl edge of this system is expected to ensure quality of life. 71. When should rehabilitation commence? a. The day before discharge b. When the patient desires c. Upon admission d. 24 hours after discharge 72. What exemplified the preventive and promotive programs in the hospit al? a. Hospital as a center to prevent and control infection b. Program for smokers c. Program for alcoholics and drug addicts d. Hospital Wellness Center 73. Which makes nursing dynamic? a. Every patient is a unique physical, emotional, social and spiritual being b. The patie nt participate in the overall nursing care plan c. Nursing practice is expanding in the light of modern developments that takes place d. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes 74. Prev ention is an important responsibility of the nurse in: a. Hospitals b. Community c. Workplace d. All of the above 75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic payment. a. Health Maintenance Organization b. Medicare c. Philippine Health Insurance Act d. Hospital Maintenance Organization Situation: Nursing ethics is an important part of the nursing profession. As the ethical situation arises, so is the need to have an accurate and ethical decision making. 76. The purpo se of having a nurses’ code of ethics is: a. Delineate the scope and areas of nursing practice b. identify nursing action recommended for specific health care situations c. To help the public understand professional conduct expected of nurses d. To define the roles an d functions of the health care givers, nurses, clients 77. The principles that govern right and proper conduct of a person regarding life, biology and the health professionals is referred to as: a. Morality b. Religion c. Values d. Bioethics 78. A subjective feeling about w hat is right or wrong is said to be: a. Morality b. Religion c. Values d. Bioethics 79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If Values are going to be a part of a research, this is categorized under: a. Qualitative b. Experime ntal c. Quantitative d. Non Experimental 80. The most important nursing responsibility where ethical situations emerge in patient care is to: a. Act only when advised that the action is ethically sound 12 b. Not takes sides, remain neutral and fair c. Assume that ethical quest ions are the responsibility of the health team d. Be accountable for his or her own actions 81. Why is there an ethical dilemma? a. the choices involved do not appear to be clearly right or wrong b. a client’s legal right co -exist with the nurse’s professional obligat ion c. decisions has to be made based on societal norms. d. decisions has to be mad quickly, often under stressful conditions 82. According to the code of ethics, which of the following is the primary responsibility of the nurse? a. Assist towards peaceful death b. Healt h is a fundamental right c. Promotion of health, prevention of illness, alleviation of suffering and restoration of health d. Preservation of health at all cost 83. Which of the following is TRUE about the Co de of Ethics of Filipino Nurses, except: a. The Philippine N urses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated b. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates c. The present code utilized the Code of Good Governance for the Professions in the Philippines d. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. 84. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the license? a. PRC b. PNA c. DOH d. BON 85. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibi lity and accountability? a. Human rights of clients, regardless of creed and gender b. The privilege of being a registered professional nurse c. Health, being a fundamental right of every individual d. Accurate documentation of actions and outcomes Situation: As a pr ofession, nursing is dynamic and its practice is directed by various theoretical models. To demonstrate caring behaviour, the nurse applies various nursing models in providing quality nursing care. 86. When you clean the bedside unit and regularly attend to t he personal hygiene of the patient as well as in washing your hands before and after a procedure and in between patients, you indent to facilitate the body’s reparative processes. Which of the following nursing theory are you applying in the above nursing action? a. Hildegard Peplau b. Dorothea Orem c. Virginia Henderson d. Florence Nightingale 87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is viewed as human to human relationship. This statement is an application of whose nursing model? a. Joyce Travelbee b. Martha Rogers c. Callista Roy d. Imogene King 88. The statement “the health status of an individual is constantly changing and the nurse must be cognizant and responsive to these changes” best explains which of the following facts about nursing? a. Dynamic b. Client centred c. Holistic d. Art 89. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care working in assisting the patient to 13 gain independence as quickly as possible. Which of the f ollowing nursing actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally immobile? a. Feeds the patient, brushes his teeth, gives the sponge bath b. Supervise the watcher in rendering patient his morning care c. Put the patient in semi fowler’s position, set the over bed table so the patient can eat by himself, brush his teeth and sponge himself d. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready 90. In the self -care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to fulfil his physiological, psychological and social needs. A pregnant client needing prenatal check -up is classified as: a. Wholly compensatory b. Supportive Educative c. Partially compensatory d. Non compensatory Situation: Documentation and reporting are just as important as providing patient care, As such, the nurse must be factual and accurate to ensure quality documentation and reporting. 91. Health care reports have different purposes. The availability of patients’ record to all health team members demonstrates which of the following purposes: a. Legal documentation b. Research c. Education d. Vehicle for communication 92. When a nurse commits medication error, she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes: a. Research b. Legal documentation c. Nursing Audit d. Vehicle for communication 93. POMR has been widely used in many teaching hospitals. One of its unique featu res is SOAPIE charting. The P in SOAPIE charting should include: a. Prescription of the doctor to the patient’s illness b. Plan of care for patient c. Patient’s perception of one’s illness d. Nursing problem and Nursing diagnosis 94. The medical records that are organize d into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording? a. POMR b. Modified POMR c. SOAPIE d. SOMR 95. Which of the following is the advantage of SOMR or Traditional recording? a. Increases efficie ncy in data gathering b. Reinforces the use of the nursing process c. The care giver can easily locate proper section for making charting entries d. Enhances effective communication among health care team members Situation: June is a 24 year old client with symptom s of dyspnea, absent breath sounds on the right lung and chest x ray revealed pleural effusion. The physician will perform thoracentesis. 96. Thoracentesis is useful in treating all of the following pulmonary disorders except: a. Hemothorax b. Hydrothorax c. Tuberculo sis d. Empyema 97. Which of the following psychological preparation is not relevant for him? a. Telling him that the gauge of the needle and anesthesia to be used b. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correc t place c. Allow June to express his feelings and concerns d. Physician’s explanation on the purpose of the procedure and how it will be done 98. Before thoracentesis, the legal consideration you must check is: a. Consent is signed by the client 14 b. Medicine preparation i s correct c. Position of the client is correct d. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: a. Orthopneic b. Low fowlers c. Knee -chest d. Sidelying position on the affected side 100. Which of the follow ing anaesthetics drug is used for thoracentesis? a. Procaine 2% b. Demerol 75 mg c. Valium 250 mg d. Phenobartbital 50 mg