17.
Greg
develops
a
nosocomial respiratory tract
infection. He asks you what
that means. Your response
would be:
A. “You acquired infection
after you have been admitted
to the hospital.”
B. “This is a highly contagious
infection which requires
complete isolation.”
C. “You should contact your
physician immediately about
getting gamma globulin.”
D. “this type of infection
usually resolves on its own.”
18. As a nurse, you know that
one of the complications that
you have to watch out for
when caring for Fritz who is
receiving total parenteral
nutrition is:
A. stomatitis
B. hepatitis
C. infection
D. dysrhythmia
19. A solution used to treat
pseudomonas
wound
infection is:
A. Dakin’s solution
B. half strength hydrogen
peroxide
C. acetic acid
D. betadine
20. Which of the following is
most reliable in diagnosing
wound infection?
A. purulent drainage from a
wound
B. culture and sensitivity
C. WBC count of 20,000/µL
D. gram staining
Situation: As a member of
the health and nursing team,
you have a crucial role to
play on ensuring that all
members participate actively
on the various tasks agreed
upon.
21. While eating his meal,
Matt accidentally dislodges
his IV line and bleeds. Blood
oozes on the surface of the
over bed table. It is most
appropriate that you instruct
the housekeeper to clean the
table with:
A. acetone
B. alcohol
C. ammonia
D. bleach
22. You are a member of the
infection control team of the
hospital.
Based
on
a
feedback during a meeting of
the committee there is an
increased
incidence
of
pseudomonas infection in
the burn unit (3 out of 10
patients had positive blood
and wound culture). What is
your priority activity?
A. Establish policies of
surveillance and monitoring
B. Assign point persons who
can implement policies
C. Do data gathering about
the possible sources of
infection (observation, chart
review, interview)
D. Meet with the nursing
group working in the burn
unit and discuss problem
with them
23. Part of your responsibility
as a member of the diabetes
core group is to get referrals
from the various wards
regarding diabetic patients
needing diabetes education.
Prior to discharge today, 4
patients are referred to you.
How would you start
prioritizing your activities?
A. Determine their learning
needs then prioritize
B. Bring your diabetes
teaching kit and start your
session
taking
into
consideration their distance
from your office
C. Contact the nurse-incharge and find out from her
the reason for the referral
D. Involve the whole family in
the teaching class
24. You have been
designated as a member of
the task force to plan
activities for the Cancer
Consciousness week. Your
committee has 4 months to
plan and implement the plan.
You are assigned to contact
the various cancer support
groups in your hospital. What
will be your priority activity?
A. clarify objectives of the
activity with the task force
before
contacting
the
support groups
B. find out if there is budget
for this activity
C. determine the VIPs and
celebrities who will be
invited
D. Find out how many
support groups there are in
the hospital and get the
contact numbers of their
president
25. You are invited to
participate in the medical
mission activity of your
alumni association. In the
planning stage, everybody is
expected to identify what
they can do during the
medical mission and what
resources are needed. You
thought it is also your chance
to share what you can do to
others. What will be your
most important role where
you can demonstrate the
impact of nursing in health?
A. conduct health education
on healthy lifestyle
B. take the initial history and
document findings
C. be a triage nurse
D. act as a coordinator
Situation: As a nurse in the
Oncology Unit, you have to
be prepared to provide safe,
efficient and effective care to
your patients.
26. Which one of the
following
nursing
interventions would be most
helpful in preparing the
patient for radiation therapy?
A. offer tranquilizers and
antiemetics
B. instruct the patient of the
possibility of radiation burn
C.
emphasis
on
the
therapeutic value of the
treatment
D. map out the precise
course of treatment
27. What side effects are
most apt to occur to patient
during radiation therapy to
the pelvis?
A. urinary retention
B. abdominal, vaginal, or
perineal discharge
C. paresthesia of the lower
extremities
D. nausea, vomiting, and
diarrhea
28. Which of the following
can be used on the irradiated
skin during a course of
radiation therapy?
A. adhesive tape
B. mineral oil
C. talcum powder
D. Zinc oxide treatment
29. Earliest sign of skin
reaction to radiation therapy
is:
A. desquamation
B. erythema
C. atrophy
D. pigmentation
30. What is the purpose of
wearing a film badge while
caring for the patient who is
radioactive?
A. identify the nurse who is
assigned to care for such
patient
B. prevent radiation-induced
sterility
C. protect the nurse from
radiation effects
D. measure the amount of
exposure to radiation
Situation: In a disaster, there
must be a chain of command
in place that defines the roles
of each member of the
response team. Within the
health care group, there are
pre-assigned roles based on
education, experience, and
training on disaster.
31. As a nurse, to which of
the following groups are you
best prepared to join?
A. transport group
B. treatment group
C. triage group
D. morgue department
32. There are important
principles that should guide
the triage team in disaster
management that you have
to know if you were to
volunteer as part of the
triage team. The following
principles
should
be
observed in disaster triage,
except:
A. any disaster plan should
have resources available to
triage at each facility and at
the disaster site if possible
B. do the greatest good for
the greatest number of
casualties
C. make the most efficient
use of available resources
D. training on disaster is not
important to the response in
the event of a real disaster
because each disaster is
unique in itself
33. Which of the following
categories of conditions
should be considered first
priority in a disaster?
A. intracranial pressure and
mental status
B. lower gastrointestinal
problems
C. respiratory infection
D. trauma
34. A guideline that is utilized
in determining priorities is to
assess the status of the
following, except:
A. perfusion
B. locomotion
C. respiration
D. mentation
35. Induction of vomiting is
indicated for the accidental
poisoning patient who has
ingested:
A. aspirin
B. rust remover
C. gasoline
D. toilet bowl cleaner
Situation:
Quality
management is essential in
nursing and has been a
critical part of nursing
administration. As nurses, it
is important to know by
heart the concepts related to
such.
36. Which statement made
by a nurse about the goal of
total quality management or
continuous
quality
improvement in a health care
setting is correct?
A. “It is to observe reactive
service and product problem
solving.”
B. “Improvement of the
processes in a proactive,
preventive
mode
is
paramount.”
C. “A chart audits to find
common errors in practice
and outcomes associated
with goals.”
D. “A flow chart to organize
daily tasks is critical to the
initial stages.”
37. The nurse manager
identifies that time spent by
staff charting is excessive,
requiring
overtime
for
completion.
The
nurse
manager states that “staff
will form a task force to
investigate and develop
potential solutions to the
problem, and report on this
at the next staff meeting.”
The
nurse
manager’s
leadership style is best
described as:
A. participative
B. laissez-faire
C. autocratic
D. group
38. The nurse manager
informs the nursing staff at
morning report that the
clinical nurse specialist will
be conducting a research
study on staff attitudes
toward client care. All staff
are invited to participate in
the study if they wish. This
affirms the ethical principle
of:
A. participativeness
B. autonomy
C. anonymity
D. justice
39. The hospital has sounded
the call for a disaster drill on
the evening shift. Which of
these clients would the nurse
put first on the list to be
discharged in order to make
a room available for new
admission?
A. A middle-aged client with
a history of being ventilator
dependent for over 7 years
and admitted with bacterial
pneumonia five days ago
B. An elderly client with a
history of hypertension,
hypercholesterolemia
and
lupus, and was admitted with
Steven-Johnson
Syndrome
that morning
C. A young adult with
diabetes mellitus type 2 for
over 10 years and admitted
with
antibiotic-induced
diarrhea 24 hours ago
D. An adolescent with a
positive HIV test and
admitted for acute cellulites
of the lower leg 48 hours ago
40. A triage nurse has these 4
clients who arrived in the
emergency
department
within 15 minutes. Which
client should the triage nurse
send back to be seen first?
A. A teenager who got a
singed beard while camping
B. A middle-aged client with
intermittent pain behind
right scapula
C. A 2 month old infant with
a history of rolling off the
bed
and
has
bulging
fontanels with crying
D. An elderly client with
complaints of frequent liquid
brown-colored stools
Situation:
Manolo,
a
registered nurse, witnessed
an old woman hit by a
motorcycle while crossing a
train railway. The old woman
fell at the railway. Monolo
rushed at the scene.
41.As a registered nurse,
Manolo knew that the first
thing that he will do at the
scene is:
A. Stay with the person and
encourage her to remain still
and immobilize the leg while
waiting for the ambulance
B. Leave the person for a few
moments to call for help
C. Reduce the fracture
manually
D. Move the person to a safer
place
42. Manolo suspects a hip
fracture when he noticed
that the old woman’s leg is:
A. Lengthened, abducted and
internally rotated
B. Shortened, abducted and
externally rotated
C. Shortened, adducted and
internally rotated
D. Shortened, adducted and
externally rotated
43.
The
old
woman
complains of pain. Agua
noticed that the knee is
reddened, warm to touch
and
swollen.
Manolo
interprets that this signs and
symptoms are likely related
to:
A. Infection
B. Inflammation
C. Thrombophlebitis
D. Degenerative disease
44. Barbara, the old woman
was now immobilized and
brought to the emergency
room. The x-ray shows a
fractured femur and pelvis.
The ER nurse would carefully
monitor Barbara for which of
the following sign and
symptoms?
A.
Tachycardia
and
hypotension
B. Fever and bradycardia
C.
Bradycardia
and
hypertension
D. Fever and hypertension
45. Which of the following
serious complications can
occur with long bone
fractures?
A. Bone emboli
B. Fat emboli
C. Platelet emboli
D. Serous emboli
Situation:
Postoperative
infection complication is still
a concern in surgical client’s
care. Hospital staff needs to
review practices to adhere to
the standards of care to
improve quality and safe care
delivery.
46. Nurse Alona is setting up
for an emergency Cesarean
Section. The linen packs were
damp although these were
just taken from the sterilizer.
The nurses’ appropriate
action is:
A. Bring the linen packs back
to the central supply section
for quality control
B. open the linen pack and
allow to dry
C. change the damp linen
pack
D. do not use the damp linen
47. The clinical instructor
assigned a nursing student to
assist in the operation. When
the nursing student entered
the OR suite, her curly long
hair was not completely
covered by the head cap.
What would the circulating
nurse do?
A. assist the nursing student
to tuck-in all her hair inside
the head cap
B. welcome the nursing
student to the OR
C. request the clinical
instructor to tell the nursing
student to use the head cap
properly
D. do not allow the nursing
student to scrub in
48. After the surgeon
finished doing the surgical
hand scrub, she came into
the OR suite swinging her
hands casually. The scrub
nurse would do which of the
following appropriate action?
A. offer a sterile towel to dry
her hands
B. serve the surgeon her
sterile gown and gloves as
usual
C. tell the circulating nurse to
pour alcohol 70% to the
surgeon’s hands
D. remind the surgeon to
scrub again
49. When the intern-incharge did the skin prep and
catheterized the client, the
circulating nurse noticed
when the intern withdrew
the catheter from the vagina.
What is your appropriate and
immediate action
A. stop the intern and do the
catheterization yourself
B. offer to change the
catheter
C. alcoholize the tip of the
catheter before reinserting
the catheter
D. hold the hand of the
intern to stop him from
reinserting the catheter
50. After the last stitch, the
surgeon is ready to apply
dressing to the incision
wound. Which of the
following does the nurse
expect the surgeon to do?
A. remove his gloves and
apply the dressings
B. apply the dressings and
tape and then remove his
gloves
C. put the dressings and
remove his gloves to apply
the tape
D. tape the dressings and
remove his gloves
Situation: A 55 year old male
client, Herald, post Billroth II
was admitted to the post
anesthesia care unit (PACU)
from the OR. The client is still
sedated but responsive to
commands.
He
has
nasogastric
tube
(NGT)
draining orange-yellow fluid
to a drainage bottle.
51. The nurse who admitted
the patient recognizes that
Billroth II procedure means:
A. gastroduodenostomy
B. gastrojejunostomy
C. enterostomy
D. esophagojunostomy
52. After admitting the client
to the PACU, the first action
of the nurse should be:
A. assess patency of the
airway
B. assess the client’s pain
C. monitor vital signs
D. check the rate of the IV
infusion
53. As the nurse monitors
the client, she notices a
bright red spot on the
dressings which measure 4
cm in diameter. The nurse
would initially do which
appropriate
nursing
intervention?
A. notify the client’s surgeon
of a potential hemorrhage
B. assess for presence of
drainage
C. change the top dressing
D. continue to monitor the
vital signs
54. In assisting the client to
do deep breathing, coughing
and turning to the sides on
the first postoperative day,
which nursing action would
be most helpful for the
client?
A. restate the importance of
respiratory exercises
B. give the client reassurance
that he can cough, breathe
deeply, and turn to sides
safely
C. administer the prescribed
analgesics round the clock
D. apply abdominal splint
while coughing
55. The client complained of
abdominal pain, nausea and
vomiting, with abdominal
distention.
The
nurse
anticipates which of the
following
priority
management after referring
to the surgeon?
A. possible surgery
B. endoscopy
C. rectal tube insertion
D. gastric decompression
Situation:
Nurse
Mak
admitted patientLouie for
management of acromegaly.
56. Nurse Mak is aware that
acromegaly is a condition
when
growth
hormone
occurs in excess in adulthood
or after epiphyses of the long
bones have fused. The
following are the typical
physical features of the
disorder, except:
A. the soft tissues continue
to grow
B. hands and feet are
enlarged
C. client grows taller
D. broad and bulbous nose
57. The client was prescribed
Ocreotide
acetate
(Sandostatin). Nurse Jayne
would monitor for which of
the following side effects?
A. dysuria
B. hypotension
C. abdominal pain
D. constipation
58. For effective dosing,
Ocreotide acetate must be
administered
by
which
appropriate route three
times weekly?
A. intravenously
B. subcutaneously
C. orally
D. intramuscularly
59. Priority discharge plans
should include which of the
following? Select all that
apply. 1. fasting blood sugar
2. bone assessment 3. intake
and output 4. urine output
A. 2 and 3
B. all except 1
C. 1,2 and 3
D. 1 and 2
60.
Acromegaly
often
develops insidiously that
nurses should understand
that the client with disorder
would seek medical care
because of:
A. alteration in fat and
carbohydrate metabolism
B. changes in blood sugar
level
C. changes in appearance
D. alteration in their voice
Situation: A 35 year old
female client, Claire is with
Grave’s disease was admitted
for treatment. The physician
prescribed Prophyl Thraci
(prophylthiouracil) to treat
the disorder.
61. Before the nurse
administers the medication,
which of the following is
most relevant for the nurse
to ask?
A. “Do you experience gastric
discomforts?”
B. “Do you prefer a liquid
form of medication?”
C. “When was the last time
you took alcohol?”
D. “When was your last
menstruation?”
62. The client is prepared for
surgery in about 10 days
time. Lugol’s solution 4 gtts
P.O. was prescribed for 10
days. The client asked the
nurse for the purpose of the
drug. Which response of the
nurse is correct?
A. It eliminates the need to
take hormone replacements
B. It decreases the risk of
bleeding
C. It decreases the risk for
thyroid crisis
D. It stabilizes your immune
system to withstand surgery
63. When the client returns
to the unit after surgery,
which technique is most
appropriate
to
monitor
bleeding from the incision?
A. remove the dressings to
directly inspect the incision
wound
B. weigh all gauze dressing
before and after changing
wound dressings
C. assess for dampness at the
back of the client’s neck
D. pass a flashlight across the
incision wound on top of the
dressings
64. Which of the following
assessment findings when
observed
in
a
post
thyroidectomy
client
is
indicative of a thyroid crisis?
A. spasm in the hand
B. falling blood pressure
C.
regular
and
noisy
respiration
D. high fever
65. At the start of thyroid
replacement
post
total
thyroidectomy, the nurse
must monitor for side effects.
Which side effects would the
nurse expect to assess?
Select all that apply. 1.
hypertension
2.tremors
3.hirsutism 4. insomnia 5.
tachycardia 6. hyperglycemia
A. 1,2,4 and 5
B. 3,4,5 and 6
C. 1,2,3 and 5
D. 1,3,4 and 5
Situation: It is often said that
“ignorance of the law
excuses no one.” In the
practice
of
professional
nursing the same applies.The
following
questions
are
related to ethico- legal
dimension in the practice of
nursing.
66. For failure of the nurse to
check the nasogastric tube
placement
before
administering feeding, the
patient aspirated and died.
The nurse may incur:
A. Administrative liability
B. Civil liability
C. All liability may be filed
D. Criminal liability
67. The following are sources
of laws/rules/policies that
affect the nursing practice in
the
Philippines:
1.
International Council of
Nurses/ Philippine Nurses
Association Advisories 2.
Board
of
Nursing
Promulgations
e.g.
Resolutions
and
Memorandum
3.
DOH
Administrative Order and
CHED Memorandum Order 4.
House Bills/ Senate Bills
A. All are recognized sources
B. 1 and 4
C. 2 and 3
D. 1 and 4
68. The following are true
about the requirements for
applying
to
take
the
Licensure Examination in the
Philippines except: 1. The
applicant must be a person
of Good Moral Character 2.
The applicant must have
gotten an average of 75%
with no grade lower than
60% in any subject in the NLE
3. The applicant must have
finished a BSN degree from
an accredited school 4. The
applicant must be a Filipino
citizen
A. 1and 3
B. 1and 4
C. 1, 3, and 4
D. only 2
69. ASEAN countries now
engage
in
Mutual
Recognition
Arrangement
(MRA)
negotiations
consistent with liberalization
measures of the General
Agreement on Trade in
Services
(GATS).
The
applicable mode for this kind
of agreement is:
A. Via Reciprocity
B. Via Examination
C. Via Temporary/ Special
permit
D. Via Movement of Natural
Persons
70. Upon full implementation
of
Board
of
Nursing
Resolution No.22, series of
2009
(National
Nursing
Career Progression Program),
the following are deemed
legally practicing nursing
except: 1. A “trained” nurse
phlebotomist 2. A duly
certified hemodialysis nurse
who primes a hemodialysis
machine before initiating
hemodialysis to a client 3. An
ACLS- trained and Certified
Nurse clinician who intubates
a patient under accepted
ICCU protocol 4. A certified
Critical Care Nurse Specialist
who extracts arterial blood
every
hour
for
ABG
monitoring of patients
A. only 1
B. only 4
C. only 3
D. only 2
Situation: Nurse Katelyn
admitted a 33 years old,
married, for thyroid work-up.
71.
Which
admission
assessment would make you
suspect that Lucille has
hypothyroidism? Select all
that
apply.
(1)
Heat
intolerance (2) Diarrhea (3)
Bradycardia (4) Coarse and
dry skin
(5)
Somnolence (6) Decreased
appetite
a. 2,3,5,6
b. All except 5
c. 3,4,5,6
d. 1,2,3,4
72. Lucille was ordered to
undergo radioactive iodine
uptake the following day. The
nurse understands that this
test determines which of the
following?
A. Absorption of the iodine
isotope
B. Ingestion of the iodine
isotope
C. Stimulation of the iodine
isotope
D. Reaction of the iodine
isotope
73.
If the doctor will
prescribe Basal Metabolic
Rate (BMR) to Lucille, which
of the following is NOT
indicated?
a. Nothing by mouth for 1012 hours
b. Blood extraction upon
waking up
c. Instruct the client not to
get out of bed until the test is
over
d. A good night sleep of 8-10
hours
74. Cytomel (Liothyronine)
was prescribed to Lucille.
Before administering the
drug, Nurse Karen should not
only verify the doctors order
but also:
a. Take the BP and PR
b. Take the temperature and
respiratory rate
c. Take the weight of the
client
d. Advise the client to stay in
bed
75. Lucille asked the nurse
which
diet
is
most
appropriate for her. The
correct response of the nurse
would be:
a. Low salt, low fat
b. Low calorie and high fiber
c. High calorie and high fiber
d. High protein but low
residue
Situation:Jojo and Jan Jan, a
scrub nurse and circulating
nurse
respectively,
are
preparing
for
hydrocelectomy, their last
case for the day.
76. Jojo discovered a cut in
her palm while she was
opening the sterile packs,
Jojo should:
A. Scrub but put on double
gloves
B. Ask to be relieved as a
scrub nurse
C. Scrub if the cut is properly
bandaged
D. Scrub after writing an
incident report
77. Before any member of
the surgical team proceed to
do the surgical hand scrub,
he/she should have complete
operating room (OR) attire.
Identify all the attire
appropriate for this case: (1)
Head Cap Goggles (2) Face
mask (3) Sterile gown (4)
Gloves
A. 2,3,4
B. 1,2,3
C. 1,2
D. 3,4,5
78.
A sterile set up has
been prepared. The OR was
notified of a delay in
transporting the client from
the ward to the OR. Which of
the following guidelines
should the circulating nurse
follows?
A. Keep door of the
operating room closed all the
time to maintain the “sterile
set up”
B. “Sterile set up” should be
replaced after an hour
C.
Cover
appropriately
“sterile set up”
D. Prepare another “sterile
set up”
79.
Identify
which
appropriate
gloving
technique will the assistant
surgeon use when he
performs
the
skin
preparation?
A.
Gloving
self-closed
technique
B. Scrub nurse serves the
gloves
C. Any gloving technique is
accepted
D.
Gloving
self-open
technique
80. The intern 2nd assistant
surgeon contaminated his
gown while the surgery is
ongoing. He is expected to
change his gown and gloves.
Which of the following is the
CORRECT technique to be
followed?
A. The intern removes his
gown and gloves then puts
on another sterile gown and
gloves.
B. The circulating nurse
unties the gown. The intern
removes his gown then
removes the gloves and puts
another sterile gown and
gloves.
C. The intern removes his
gloves, then his gown does a
3 minutes hand scrub and
don another sterile gown and
gloves
D. The intern unties his gown
removes his gown and put on
another gown and gloves.
Situation: Poon Day, who has
an increased risk for cervical
cancer asks you different
points about the condition.
81. With your knowledge of
cervical cancer, which of
these would you include in
your teaching on its risk
factors? Select all that apply.
Captionless Image
a. i, iii iv, v
b. ii, iv
c. ii, iii, iv, v, vi
d. i, iii, iv, vi
82.
Cervical
cancers
metastasize if not detected
and treated. What is
commonly
the
first
metastatic
location
of
cervical neoplasms?
a. Inguinal lymph node
b. Cervical node
c. Pelvic lymph nodes
d. Axillary lymph nodes
83. A surgery is suggested to
treat the patient’s cervical
cancer.
However,
she
exclaims that she still plans
to bear a child. Which of the
following procedures may be
done to the patient granting
her wish?
a. Radical hysterectomy
b.
Radical
vaginal
hysterectomy
c. Radical trachelectomy
d.
Simple
bilateral
salphingoectomy
84.
Norma underwent
hysterectomy
and
was
transferred to your ward 3
hours post-surgery. Which of
these assessments would
warrant you to notify the
doctor?
a. Pain on the incision site
b. Chest pain
c. Vaginal bleeding
d. Post-operative edema
85. Early ambulation for a
patient who underwent
surgery for cervical cancer is
encouraged to prevent:
a. Severe hemorrhage
b. Contractures
c. Deep vein thrombosis
d. Bladder retention
Situation: A patient who has
Stevens - Johnson syndrome
is newly-admitted to the
medical ward. You are
assigned to take the history
and plan for the care of the
patient.
86. While you take your
history, which of these signs
and symptoms would be part
of the prodromal stage of the
syndrome?
a. Dysuria
b. Sore throat
c. Corneal lesion
d. Vaginal stenosis
87.
Which of these
statements by the patient
would
give
you
an
information of the cause of
the syndrome?
a. “I am not sure if I am able
to drink at least 8 glasses of
water because of my busy
schedule.”
b. “I am fond of eating grilled
barbecue and isaw after
work. I buy and eat them
almost everyday.”
c. “I take penicillin whenever
I feel like I will have cough or
colds.”
d. “Paracetamol is my go-to
medication, especially when I
started feeling weak.”
88.
In reviewing the
workup of the patient, which
of these laboratory findings
do you expect her to
manifest?
a. Elevated arterial blood pH
b. Elevated C-reactive protein
c.
Decreased
partial
thromboplastin time
d. Decreased platelet count
89.
Which
of
these
complaints by the patients
indicate a progression to a
complication of SJD?
a. “I have a difficulty
swallowing liquids.”
b. “My eyes feel like they are
drying.”
c. “My whole body is itching
terribly.”
d. “Anything that touches my
skin causes extreme pain.”
90.
Which
of
these
interventions would you not
include in caring for the
patient?
a. Shift to nasogastric gavage
from IV infusions in fluid
administration as soon as
possible.
b.
Prescribed
topical
antibiotic may be applied in
conjunction
with
hydrotherapy in a tub.
c. Ask the patient to limit
blinking and eye movement
to prevent aggravating the
complication.
d. Administer analgesics
before
the
painful
procedures or treatments are
done.
Situation: You are a nurse in
Indonesia who has been
assigned as part of the triage
team
in
the
recent
earthquake in the capital city.
You assess and prioritize
patients according to their
status and needs. Different
emergency nursing concepts
apply during this process.
91. Which of these should be
done during your secondary
survey of the patients?
a. Cervical spine stabilization
b. Establishing a patent
airway.
c. Splinting of suspected
fractures
d.
Immediate
closed
reductions on pulseless
extremity
92. In a reversed advanced
type of triage, whom would
you give prioritization to?
a. A gasping patient, with
estimated blood loss of
900mL
b. An elderly client with a
fractured femur, mobile, can
respond to voice command
c. A head trauma patient,
unconscious, HR 40bpm, RR
10 cycles/min, BP 145/70
d. A pulseless infant, with
cold and clammy skin
93. Critical incident stress
management is what type of
prevention
in
disaster
management?
a. Primordial
b. Secondary
c. Primary
d. Tertiary
94. Following the external
triage system, which among
these patients would you
highly prioritize?
a. An unresponsive patient
with capillary refill time of
more than 2 seconds, and an
RR of 10 breaths/min
b. A pregnant client, with rib
fractures, responsive to voice
commands, HR 120bpm, RR
20cycles/min
c. A patient with sustained
head injuries, gasping for air,
with bluish appearance
d. A patient with severe
blood loss, PR of 75 bpm, RR
of 10 cycles/min
95. Which of these principles
is not included in performing
START triage in emergencies
and disasters?
a. Never go against the flow
and go back to a previous
casualty
b. Tag under the black
category those persons who
are gasping for air
c. Provide treatment for all
patients requiring intensive
care
d. Begin where you stand.
Situation:
Bed rest is a
therapeutic intervention that
achieves beneficial effect.
However prolonged bed rest
can be counterproductive to
the clients’ recovery. The
inactivity imposed by bed
rest may cause structural
changes in joints and shorten
muscles. Moving, turning,
and positioning of clients are
essential aspect of nursing
care.
96. Nurse Monilia is giving
the 8:00am medication to a
client who happens to have
slid down the bed from the
fowler’s position. Which of
the following interventions is
most effective when the
nurse repositions the client?
a. Raise the head of the bed
to the height of the center of
gravity – Raise the BED to the
height of the center of
gravity
b. Remove all pillows then
place against the head of the
bed
c. Ask the client to flex the
hips and knees and position
the feet for effective pushing
up
d. Adjust the head of the bed
to a flat position or as low as
the client can tolerate
97. Using an overhead
trapeze for repositioning the
client can be accomplished
by instructing the client to
grasp the:
a. Overhead trapeze with one
hand and push with the heels
upward
b. Overhead trapeze with
both hands and lift and pull
during the move
c. Head of the bed with one
hand and maneuvering for an
upward movement
d. Head of the bed with one
arm and the overhead
trapeze with the other arm
then lift and pull upward
98. A client on bed rest is
rolled to a lateral position by
the nurse. The nurse is
negotiating
the
move
correctly when he:
a. Positions himself at the
mid part of the bed and
places both hands at the
back of the client and roll
client onto side
- Pull/roll the client toward
you to the lateral position
b. Places one hand on the
client’s far hip and the other
on the client’s far shoulder,
rock backward and roll onto
side of the body facing him
c. Assume a broad stance
with the foot nearest the bed
placing his arms under the
client’s thighs and shoulder
and roll client onto side
d. Supports the back and
buttocks of the client and
shifts his own weight from
the forward to the backward
foot and roll the client onto
side
99. A client with injured left
leg is sitting on the bed
preparing to transfer to a
wheelchair. The nurse is
assisting the client and
positions the wheel chair on
the:99. Which of these
manifestations is an early
indication of compartment
syndrome?
a. Foot part of the bed
b. Client’s right side
c. Head part of the bed
d. Client’s left side
100. A client has difficulty
walking and needs a
wheelchair
to
facilitate
performance
of
daily
activities. Anticipating the
needs of the client, the nurse
should have the wheelchair
ready by placing it at:
a. 80- degree angle
b.
45degree
angle
Rationale:
Lessen
the
amount of body rotation
required
c. 90- degree angle
d. 30- degree angle