5. Benner’s “Proficient” nurse level is different
from the other levels in nursing expertise in the
NURSING PRACTICE I: FOUNDATION OF NURSING context of having:
PRACTICE a. the ability to organize and plan activities
b. having attained an advanced level of
SITUATION: Nursing is a profession. The nurse should education
have a background on the theories and foundation of c. a holistic understanding and perception
nursing as it influenced what is nursing today. of the client
d. intuitive and analytic ability in new
1. Nursing is the protection, promotion and situations
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering SITUATION: The nurse has been asked to administer an
through the diagnosis and treatment of human injection via Z TRACK technique. Questions 6 to 10 refer
response and advocacy in the care of the to this.
individuals, families, communities and the
population. This is the most accepted definition 6. The nurse prepares an IM injection for an adult
of nursing as defined by the: client using the Z track technique. 4 ml of
a. PNA medication is to be administered to the client.
b. ANA Which of the following site will you choose?
c. Nightingale a. Deltoid
d. Henderson b. Rectus femoris
c. Ventrogluteal
2. Advancement in Nursing leads to the d. Vastus lateralis
development of the Expanded Career Roles.
Which of the following is NOT an expanded 7. In infants 1 year old and below, which of the
career role for nurses? following is the site of choice for intramuscular
a. Nurse practitioner Injection?
b. Nurse Researcher a. Deltoid
c. Clinical nurse specialist b. Rectus femoris
d. Nurse anaesthesiologist c. Ventrogluteal
d. Vastus lateralis
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible 8. In order to decrease discomfort in Z track
for the maintenance of the quality of nursing in administration, which of the following is
the country. Powers and duties of the board of applicable?
nursing are the following, EXCEPT: a. Pierce the skin quickly and smoothly at
a. Issue, suspend, revoke certificates of a 90 degree angle
registration b. Inject the medication steadily at around
b. Issue subpoena duces tecum, ad 10 minutes per millilitre
testificandum c. Pull back the plunger and aspirate for 1
c. Open and close colleges of nursing minute to make sure that the needle did
d. Supervise and regulate the practice of not hit a blood vessel
nursing d. Pierce the skin slowly and carefully at a
90 degree angle
4. A nursing student or a beginning staff nurse who
has not yet experienced enough real situations 9. After injection using the Z track technique, the
to make judgments about them is in what stage nurse should know that she needs to wait for a
of Nursing Expertise? few seconds before withdrawing the needle and
a. Novice this is to allow the medication to disperse into
b. Newbie the muscle tissue, thus decreasing the client’s
c. Advanced Beginner discomfort. How many seconds should the nurse
d. Competent wait before withdrawing the needle?
a. 2 seconds
4
, 5
b. 5 seconds that the patient smokes and drinks coffee. When
c. 10 seconds taking the blood pressure of a client who
d. 15 seconds recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
10. The rationale in using the Z track technique in an blood pressure for accurate reading?
intramuscular injection is: a. 15 minutes
a. It decreases the leakage of discolouring b. 30 minutes
and irritating medication into the c. 1 hour
subcutaneous tissues d. 5 minutes
b. It will allow a faster absorption of the
medication 15. While the client has pulse oximeter on his
c. The Z track technique prevent irritation fingertip, you notice that the sunlight is shining
of the muscle on the area where the oximeter is. Your action
d. It is much more convenient for the nurse will be to:
a. Set and turn on the alarm of the
SITUATION: A Client was rushed to the emergency room oximeter
and you are his attending nurse. You are performing a b. Do nothing since there is no identified
vital sign assessment. problem
c. Cover the fingertip sensor with a towel
11. All of the following are correct methods in or bedsheet
assessment of the blood pressure EXCEPT: d. Change the location of the sensor every
a. Take the blood pressure reading on both four hours
arms for comparison
b. Listen to and identify the phases of 16. The nurse finds it necessary to recheck the blood
Korotkoff’s sound pressure reading. In case of such re assessment,
c. Pump the cuff to around 50 mmHg the nurse should wait for a period of:
above the point where the pulse is a. 15 seconds
obliterated b. 1 to 2 minutes
d. Observe procedures for infection control c. 30 minutes
d. 15 minutes
12. You attached a pulse oximeter to the client. You
know that the purpose is to: 17. If the arm is said to be elevated when taking the
a. Determine if the client’s hemoglobin blood pressure, it will create a:
level is low and if he needs blood a. False high reading
transfusion b. False low reading
b. Check level of client’s tissue perfusion c. True false reading
c. Measure the efficacy of the client’s anti- d. Indeterminate
hypertensive medications
d. Detect oxygen saturation of arterial 18. You are to assessed the temperature of the
blood before symptoms of hypoxemia client the next morning and found out that he
develops ate ice cream. How many minutes should you
wait before assessing the client’s oral
13. After a few hours in the Emergency Room, The temperature?
client is admitted to the ward with an order of a. 10 minutes
hourly monitoring of blood pressure. The nurse b. 20 minutes
finds that the cuff is too narrow and this will c. 30 minutes
cause the blood pressure reading to be: d. 15 minutes
a. inconsistent
b. low systolic and high diastolic 19. When auscultating the client’s blood pressure
c. higher than what the reading should be the nurse hears the following: From 150 mmHg
d. lower than what the reading should be to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
14. Through the client’s health history, you gather continuing down to 80 mmHg and then silence.
, What is the client’s blood pressure? to lungs. This can be avoided by:
a. 130/80 a. Cleaning teeth and mouth with cotton
b. 150/100 swabs soaked with mouthwash to avoid
c. 100/80 rinsing the buccal cavity
d. 150/100 b. swabbing the inside of the cheeks and
lips, tongue and gums with dry cotton
20. In a client with a previous blood pressure of swabs
130/80 4 hours ago, how long will it take to c. use fingers wrapped with wet cotton
release the blood pressure cuff to obtain an washcloth to rub inside the cheeks,
accurate reading? tongue, lips and ums
a. 10-20 seconds d. suctioning as needed while cleaning the
b. 30-45 seconds buccal cavity
c. 1-1.5 minutes
d. 3-3.5 minutes 25. Your client has difficulty of breathing and is
mouth breathing most of the time. This causes
Situation: Oral care is an important part of hygienic dryness of the mouth with unpleasant odor. Oral
practices and promoting client comfort. hygiene is recommended for the client and in
addition, you will keep the mouth moistened by
21. An elderly client, 84 years old, is unconscious. using:
Assessment of the mouth reveals excessive a. salt solution
dryness and presence of sores. Which of the b. petroleum jelly
following is BEST to use for oral care? c. water
a. lemon glycerine d. mentholated ointment
b. Mineral oil
c. hydrogen peroxide Situation – Ensuring safety before, during and after a
d. Normal saline solution diagnostic procedure is an important responsibility of
the nurse.
22. When performing oral care to an unconscious
client, which of the following is a special 26. To help Fernan better tolerate the
consideration to prevent aspiration of fluids into bronchoscopy, you should instruct him to
the lungs? practice which of the following prior to the
a. Put the client on a sidelying position procedure?
with head of bed lowered a. Clenching his fist every 2 minutes
b. Keep the client dry by placing towel b. Breathing in and out through the nose
under the chin with his mouth open
c. Wash hands and observes appropriate c. Tensing the shoulder muscles while lying
infection control on his back
d. Clean mouth with oral swabs in a careful d. Holding his breath periodically for 30
and an orderly progression seconds
23. The advantages of oral care for a client include 27. Following a bronchoscopy, which of the
all of the following, EXCEPT: following complains to Fernan should be noted
a. decreases bacteria in the mouth and as a possible complication:
teeth a. Nausea and vomiting
b. reduces need to use commercial b. Shortness of breath and laryngeal
mouthwash which irritate the buccal stridor
mucosa c. Blood tinged sputum and coughing
c. improves client’s appearance and self- d. Sore throat and hoarseness
confidence
d. improves appetite and taste of food 28. Immediately after bronchoscopy, you instructed
Fernan to:
24. A possible problem while providing oral care to a. Exercise the neck muscles
unconscious clients is the risk of fluid aspiration b. Refrain from coughing and talking
6
, 7
c. Breathe deeply d. Weber’s test
d. Clear his throat
34. A nurse is reviewing the arterial blood gas values
29. Thoracentesis may be performed for cytologic of a client and notes that the ph is 7.31, Pco2 is
study of pleural fluid. As a nurse your most 50 mmHg, and the bicarbonate is 27 mEq/L. The
important function during the procedure is to: nurse concludes that which acid base
a. Keep the sterile equipment from disturbance is present in this client?
contamination a. Respiratory acidosis
b. Assist the physician b. Metabolic acidosis
c. Open and close the three-way stopcock c. Respiratory alkalosis
d. Observe the patient’s vital signs d. Metabolic alkalosis
30. Right after thoracentesis, which of the following 35. Allen’s test checks the patency of the:
is most appropriate intervention? a. Ulnar artery
a. Instruct the patient not to cough or deep b. Carotid artery
breathe for two hours c. Radial artery
b. Observe for symptoms of tightness of d. Brachial artery
chest or bleeding
c. Place an ice pack to the puncture site Situation 6: Eileen, 45 years old is admitted to the
d. Remove the dressing to check for hospital with a diagnosis of renal calculi. She is
bleeding experiencing severe flank pain, nauseated and with a
temperature of 39 0C.
Situation: Knowledge of the acid-base disturbance and
the functions of the electrolytes is necessary to 36. Given the above assessment data, the most
determine appropriate intervention and nursing actions. immediate goal of the nurse would be which of
the following?
31. A client with diabetes milletus has a blood a. Prevent urinary complication
glucose level of 644 mg/dL. The nurse interprets b. maintains fluid and electrolytes
that this client is at most risk for the c. Alleviate pain
development of which type of acid-base d. Alleviating nausea
imbalance?
a. Respiratory acidosis 37. After IVP a renal stone was confirmed, a left
b. Respiratory alkalosis nephrectomy was done. Her post-operative
c. Metabolic acidosis order includes “daily urine specimen to be sent
d. Metabolic alkalosis to the laboratory”. Eileen has a foley catheter
attached to a urinary drainage system. How will
32. In a client in the health care clinic, arterial blood you collect the urine specimen?
gas analysis gives the following results: pH 7.48, a. remove urine from drainage tube with
PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. sterile needle and syringe and empty
The nurse interprets that the client has which urine from the syringe into the
acid base disturbance? specimen container
a. Respiratory acidosis b. empty a sample urine from the
b. Metabolic acidosis collecting bag into the specimen
c. Respiratory alkalosis container
d. Metabolic alkalosis c. Disconnect the drainage tube from the
indwelling catheter and allow urine to
33. A client has an order for ABG analysis on radial flow from catheter into the specimen
artery specimens. The nurse ensures that which container.
of the following has been performed or tested d. Disconnect the drainage from the
before the ABG specimens are drawn? collecting bag and allow the urine to
a. Guthrie test flow from the catheter into the
b. Romberg’s test specimen container.
c. Allen’s test
from the other levels in nursing expertise in the
NURSING PRACTICE I: FOUNDATION OF NURSING context of having:
PRACTICE a. the ability to organize and plan activities
b. having attained an advanced level of
SITUATION: Nursing is a profession. The nurse should education
have a background on the theories and foundation of c. a holistic understanding and perception
nursing as it influenced what is nursing today. of the client
d. intuitive and analytic ability in new
1. Nursing is the protection, promotion and situations
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering SITUATION: The nurse has been asked to administer an
through the diagnosis and treatment of human injection via Z TRACK technique. Questions 6 to 10 refer
response and advocacy in the care of the to this.
individuals, families, communities and the
population. This is the most accepted definition 6. The nurse prepares an IM injection for an adult
of nursing as defined by the: client using the Z track technique. 4 ml of
a. PNA medication is to be administered to the client.
b. ANA Which of the following site will you choose?
c. Nightingale a. Deltoid
d. Henderson b. Rectus femoris
c. Ventrogluteal
2. Advancement in Nursing leads to the d. Vastus lateralis
development of the Expanded Career Roles.
Which of the following is NOT an expanded 7. In infants 1 year old and below, which of the
career role for nurses? following is the site of choice for intramuscular
a. Nurse practitioner Injection?
b. Nurse Researcher a. Deltoid
c. Clinical nurse specialist b. Rectus femoris
d. Nurse anaesthesiologist c. Ventrogluteal
d. Vastus lateralis
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible 8. In order to decrease discomfort in Z track
for the maintenance of the quality of nursing in administration, which of the following is
the country. Powers and duties of the board of applicable?
nursing are the following, EXCEPT: a. Pierce the skin quickly and smoothly at
a. Issue, suspend, revoke certificates of a 90 degree angle
registration b. Inject the medication steadily at around
b. Issue subpoena duces tecum, ad 10 minutes per millilitre
testificandum c. Pull back the plunger and aspirate for 1
c. Open and close colleges of nursing minute to make sure that the needle did
d. Supervise and regulate the practice of not hit a blood vessel
nursing d. Pierce the skin slowly and carefully at a
90 degree angle
4. A nursing student or a beginning staff nurse who
has not yet experienced enough real situations 9. After injection using the Z track technique, the
to make judgments about them is in what stage nurse should know that she needs to wait for a
of Nursing Expertise? few seconds before withdrawing the needle and
a. Novice this is to allow the medication to disperse into
b. Newbie the muscle tissue, thus decreasing the client’s
c. Advanced Beginner discomfort. How many seconds should the nurse
d. Competent wait before withdrawing the needle?
a. 2 seconds
4
, 5
b. 5 seconds that the patient smokes and drinks coffee. When
c. 10 seconds taking the blood pressure of a client who
d. 15 seconds recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
10. The rationale in using the Z track technique in an blood pressure for accurate reading?
intramuscular injection is: a. 15 minutes
a. It decreases the leakage of discolouring b. 30 minutes
and irritating medication into the c. 1 hour
subcutaneous tissues d. 5 minutes
b. It will allow a faster absorption of the
medication 15. While the client has pulse oximeter on his
c. The Z track technique prevent irritation fingertip, you notice that the sunlight is shining
of the muscle on the area where the oximeter is. Your action
d. It is much more convenient for the nurse will be to:
a. Set and turn on the alarm of the
SITUATION: A Client was rushed to the emergency room oximeter
and you are his attending nurse. You are performing a b. Do nothing since there is no identified
vital sign assessment. problem
c. Cover the fingertip sensor with a towel
11. All of the following are correct methods in or bedsheet
assessment of the blood pressure EXCEPT: d. Change the location of the sensor every
a. Take the blood pressure reading on both four hours
arms for comparison
b. Listen to and identify the phases of 16. The nurse finds it necessary to recheck the blood
Korotkoff’s sound pressure reading. In case of such re assessment,
c. Pump the cuff to around 50 mmHg the nurse should wait for a period of:
above the point where the pulse is a. 15 seconds
obliterated b. 1 to 2 minutes
d. Observe procedures for infection control c. 30 minutes
d. 15 minutes
12. You attached a pulse oximeter to the client. You
know that the purpose is to: 17. If the arm is said to be elevated when taking the
a. Determine if the client’s hemoglobin blood pressure, it will create a:
level is low and if he needs blood a. False high reading
transfusion b. False low reading
b. Check level of client’s tissue perfusion c. True false reading
c. Measure the efficacy of the client’s anti- d. Indeterminate
hypertensive medications
d. Detect oxygen saturation of arterial 18. You are to assessed the temperature of the
blood before symptoms of hypoxemia client the next morning and found out that he
develops ate ice cream. How many minutes should you
wait before assessing the client’s oral
13. After a few hours in the Emergency Room, The temperature?
client is admitted to the ward with an order of a. 10 minutes
hourly monitoring of blood pressure. The nurse b. 20 minutes
finds that the cuff is too narrow and this will c. 30 minutes
cause the blood pressure reading to be: d. 15 minutes
a. inconsistent
b. low systolic and high diastolic 19. When auscultating the client’s blood pressure
c. higher than what the reading should be the nurse hears the following: From 150 mmHg
d. lower than what the reading should be to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
14. Through the client’s health history, you gather continuing down to 80 mmHg and then silence.
, What is the client’s blood pressure? to lungs. This can be avoided by:
a. 130/80 a. Cleaning teeth and mouth with cotton
b. 150/100 swabs soaked with mouthwash to avoid
c. 100/80 rinsing the buccal cavity
d. 150/100 b. swabbing the inside of the cheeks and
lips, tongue and gums with dry cotton
20. In a client with a previous blood pressure of swabs
130/80 4 hours ago, how long will it take to c. use fingers wrapped with wet cotton
release the blood pressure cuff to obtain an washcloth to rub inside the cheeks,
accurate reading? tongue, lips and ums
a. 10-20 seconds d. suctioning as needed while cleaning the
b. 30-45 seconds buccal cavity
c. 1-1.5 minutes
d. 3-3.5 minutes 25. Your client has difficulty of breathing and is
mouth breathing most of the time. This causes
Situation: Oral care is an important part of hygienic dryness of the mouth with unpleasant odor. Oral
practices and promoting client comfort. hygiene is recommended for the client and in
addition, you will keep the mouth moistened by
21. An elderly client, 84 years old, is unconscious. using:
Assessment of the mouth reveals excessive a. salt solution
dryness and presence of sores. Which of the b. petroleum jelly
following is BEST to use for oral care? c. water
a. lemon glycerine d. mentholated ointment
b. Mineral oil
c. hydrogen peroxide Situation – Ensuring safety before, during and after a
d. Normal saline solution diagnostic procedure is an important responsibility of
the nurse.
22. When performing oral care to an unconscious
client, which of the following is a special 26. To help Fernan better tolerate the
consideration to prevent aspiration of fluids into bronchoscopy, you should instruct him to
the lungs? practice which of the following prior to the
a. Put the client on a sidelying position procedure?
with head of bed lowered a. Clenching his fist every 2 minutes
b. Keep the client dry by placing towel b. Breathing in and out through the nose
under the chin with his mouth open
c. Wash hands and observes appropriate c. Tensing the shoulder muscles while lying
infection control on his back
d. Clean mouth with oral swabs in a careful d. Holding his breath periodically for 30
and an orderly progression seconds
23. The advantages of oral care for a client include 27. Following a bronchoscopy, which of the
all of the following, EXCEPT: following complains to Fernan should be noted
a. decreases bacteria in the mouth and as a possible complication:
teeth a. Nausea and vomiting
b. reduces need to use commercial b. Shortness of breath and laryngeal
mouthwash which irritate the buccal stridor
mucosa c. Blood tinged sputum and coughing
c. improves client’s appearance and self- d. Sore throat and hoarseness
confidence
d. improves appetite and taste of food 28. Immediately after bronchoscopy, you instructed
Fernan to:
24. A possible problem while providing oral care to a. Exercise the neck muscles
unconscious clients is the risk of fluid aspiration b. Refrain from coughing and talking
6
, 7
c. Breathe deeply d. Weber’s test
d. Clear his throat
34. A nurse is reviewing the arterial blood gas values
29. Thoracentesis may be performed for cytologic of a client and notes that the ph is 7.31, Pco2 is
study of pleural fluid. As a nurse your most 50 mmHg, and the bicarbonate is 27 mEq/L. The
important function during the procedure is to: nurse concludes that which acid base
a. Keep the sterile equipment from disturbance is present in this client?
contamination a. Respiratory acidosis
b. Assist the physician b. Metabolic acidosis
c. Open and close the three-way stopcock c. Respiratory alkalosis
d. Observe the patient’s vital signs d. Metabolic alkalosis
30. Right after thoracentesis, which of the following 35. Allen’s test checks the patency of the:
is most appropriate intervention? a. Ulnar artery
a. Instruct the patient not to cough or deep b. Carotid artery
breathe for two hours c. Radial artery
b. Observe for symptoms of tightness of d. Brachial artery
chest or bleeding
c. Place an ice pack to the puncture site Situation 6: Eileen, 45 years old is admitted to the
d. Remove the dressing to check for hospital with a diagnosis of renal calculi. She is
bleeding experiencing severe flank pain, nauseated and with a
temperature of 39 0C.
Situation: Knowledge of the acid-base disturbance and
the functions of the electrolytes is necessary to 36. Given the above assessment data, the most
determine appropriate intervention and nursing actions. immediate goal of the nurse would be which of
the following?
31. A client with diabetes milletus has a blood a. Prevent urinary complication
glucose level of 644 mg/dL. The nurse interprets b. maintains fluid and electrolytes
that this client is at most risk for the c. Alleviate pain
development of which type of acid-base d. Alleviating nausea
imbalance?
a. Respiratory acidosis 37. After IVP a renal stone was confirmed, a left
b. Respiratory alkalosis nephrectomy was done. Her post-operative
c. Metabolic acidosis order includes “daily urine specimen to be sent
d. Metabolic alkalosis to the laboratory”. Eileen has a foley catheter
attached to a urinary drainage system. How will
32. In a client in the health care clinic, arterial blood you collect the urine specimen?
gas analysis gives the following results: pH 7.48, a. remove urine from drainage tube with
PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. sterile needle and syringe and empty
The nurse interprets that the client has which urine from the syringe into the
acid base disturbance? specimen container
a. Respiratory acidosis b. empty a sample urine from the
b. Metabolic acidosis collecting bag into the specimen
c. Respiratory alkalosis container
d. Metabolic alkalosis c. Disconnect the drainage tube from the
indwelling catheter and allow urine to
33. A client has an order for ABG analysis on radial flow from catheter into the specimen
artery specimens. The nurse ensures that which container.
of the following has been performed or tested d. Disconnect the drainage from the
before the ABG specimens are drawn? collecting bag and allow the urine to
a. Guthrie test flow from the catheter into the
b. Romberg’s test specimen container.
c. Allen’s test
