79 FINAL COACHING NURSING PRACTICE II- CARE OF HEALTHY MOTHER/CHILD Situation 1 - Nurse Kathy is caring for a postpartum patient. Routine postpartum care is rendered to the patient. 1.✓ Which assessment finding would lead the nurse to suspect a postpartum hemorrhage? Blood loss of ______ A. Less than 300 ml/24 hours B. More than 400 ml/24 hours C. Less than 200 ml/2 hours D. More than 500 ml/ 24 hours / Puerperal parturient post : thrombin delivery - clothing trauma woman in labor tone tissue → after 24hrs1 secondary Hemo . retained . 05 Fragments primary hemorrhage - 11000 MI of blood loss : V10 -1 . hematocrit tone /Which of the following is caused by the markedly distended uterus and intermittent uterine contraction within 2 to 3 days after birth? 2. A./ Retained placenta B. Afterpains C. Uterine atony - Flaccid , dx soft test Ultrasound : " " """ → " " """ " " "" D. Boggy uterus / 3. The nurse prepares a care plan for the patient. Based on Ramona Mercer’s becoming a mother (BAM) theory, Which of the following statements fosters the process , I of becoming a Mother? starts A. The woman becomes comfortable with her identity as a married individual . B., It encompasses the dynamic transformation and evolution of a woman’s person C. A woman learns mothering behavior prior as early as a teenager D. It accurately reflects the transitional process from being single to a married relationship C-) childhood from lochia → Infection : 4. The mother asks why she has a gush of blood coming out from the vagina that occurs when she first arises from bed. The nurse’s CORRECT response should be______ A. “Blood pools at the top of vagina and forms clots that are passed upon rising or sitting on the toilet.” B. “Positioning causes blood to flow out when she stands” C. “Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep. D. “ Normal physiologic occurrence that results as the body attempts to eliminate excess fluids.” 5.r Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum. Which PRIORITY nursing measures stimulate the sensation of voiding? A. Encouraging her to void. B./ Running water in the sink or shower C. Helping the mother into the shower D. Providing cold tea or fluids of choice. t blood volume the move o 3- 4cm thru - 40 = frequent b - so -1 . post partial diuresis - ii. not , C- ] Contraction urination U Full bladder → c-) contraction l can traumatized ( t sensation of bladder bladder to urinate Situation 2 -A postpartum mother newly delivered her baby per vagina. She keeps on asking the nurse when the basic physiologic changes occur as her body returns to a prepregnan state. 6. The nurse explains to the mother that the uterus will return to its pre pregnancy state in ____weeks A. I. Six B. Three C. Four D. Five 7. In her capacity to teach , the nurse describes the changes of the uterus after childbirth to return to a nonpregnant state as____ A. Catabolism C. Subinvolution slow return ?⃝ B. Contraction of muscle fibers D./Involution 8./Which of the following conditions does the nurse explains to the patient the contributory factor that slows uterine involution? A. Full bladder during labor B. Prolonged labor sobrang C. Difficult birth banat / stretch she rang tugal ng labor D. Infection during pregnancy 9. The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin? A. Symphysis pubis B. Umbilicus C. Midline D. Sides of the abdomen 10. The FIRST PRIORITY nursing intervention during the immediate postpartum period is focused on _____ A. Monitoring urinary output B. Taking the vital signs every 4 hours C. Observing postpartum hemorrhage D. Checking level of responsiveness ↳ 40 % ER : goes to uterus of blood large bore catheter : Situation 3 - Evelyn a multigravida, in her 20th weeks of gestation visited the community clinic with complaints of dizziness , vertigo, and heartburns. After the physical assessment, Nurse Harper finds the patient as malnourished. 11. Iron supplementation was prescribed because of her low hemoglobin level. Which statement if made by Evelyn would indicate an understanding of health instructions? A. “My body has all the iron it needs and I don't need to take supplements.” B. “Meat does not provide iron and should be avoided.” aggravate C.y “”The iron is best absorbed if taken on an empty stomach.” D. “Iron supplements will give green color to my stool. 01 Supplement total Is no - IRON ! day : black 27mg ( is t me , , - 30mg) / blackish green tab sorption before 1hr : mmHg DR 1 800 mg 1 Upset be , , : calcium absorption : + magnesium ascorbic after meal 2hr , dark / dark green / : : 12. Evelyn was given iron as a supplement vitamin to prevent maternal anemia. She asks if it will not be affected because she is regularly taking vitamin C. Which of the following would be the BEST response of the nurse? A. “Take two other vitamins separately .” B. “Take the iron after a full meal.” G1 upset → take to iron decrease calcium supplements : at bedtime sensation given and month 12 wks op → bone ossification C. “Absorption of iron is enhanced with vit C.” D. “Drink milk when taking the iron supplement.” ÷ / gestation 13. Evelyn was also advised to take calcium supplements on the 2nd 3rd trimester of pregnancy. Which of the following would ENHANCE her intestinal absorption of calcium? A. Fat-soluble vitamins B. Minerals C. Proteins D. Water soluble vitamins Bic 14. Nurse Harper observes Evelyn has a knowledge deficit regarding fetal nutrition. Nurse harper has to explain that the MAIN SOURCE of nutrition for the baby is which of the following? A. Amniotic fluid B. Placenta temperature , Fluid to drink cushion ital Mov 't C. Uterus - , immunoglobulins excretion circulation respiration nutr . D. Chorionic villi 15. Nurse Harper provides health instruction to the patient experiencing heartburn. Which statement by the patient indicates a NEED for further instructions? I have to _____ , A. Drink milk between meals B. Avoid fatty or spicy foods , C. Eat small frequent meals / Lie down after eating D. Situation 4- The giving of medication to a pediatric patient is a serious responsibility of a nurse. Nurse Imelda has just been assigned to the pediatric wards. - 16. When giving medicines to pediatric patients, dosage varies. Which of the following should nurse Imelda consider? A. Height and surface area B./ Size , surface area & age C. Size, & surface area, age, & height D. Size, surface area best source : surface area height } nomogram weight 17. The head nurse checks Nurse Imelda’s knowledge on administering oral medications to pediatric patients. Which of the following statements below should she chosen as CORRECT? A. A child’s reaction to a dose ordered by a physician is not less predictable than an adult's reaction. B. When giving oral medication , the child as young as two years of age☐ cannot be taught to swallow drugs. C. The child should be told to place the tablet in the middle of his tongue and drink water to wash down the tablet. D. The possibility of error is greater in the giving of medication to children than to adults. <3 " old 6- 1- - - impossible years old - possible 18. In infants and toddlers, which part should nurse Imelda often use for intramuscular injection To reduce the risk of vascular and peripheral nerve injuries? A. Gluteus maximus B. Deltoid muscle C. Dorso-gluteal . Vastus lateralis D. 19. Administering medication intramuscularly can produce a variety of serious adverse affects has been revealed in comprehensive surveys of research reports. when asked by the head nurse what is the MOST common complication that may arise , Nurse imelda should mention___ A. Abscess B. Hematoma C. Herve palsies and paralysis D. Muscle contracture 20. Prior to administering the drugs ordered by the pediatrician, nurse imelda needs to know if She is giving the ordered medication to the right patient. The FIRST step is____ A. Check the patient’s hospital bracelet. B. Ask the parent/ significant other to state name of patient and birth date of patient C. Verify patient’s allergies with charts and with patients. D. Compare medication order to identification bracelet. : 21. Nurse Isabelle is concerned about the patient’s welfare and her ability to comply with the doctor’s instructions. What should be the APPROPRIATE action? A. Include a significant other in helping the patient understand the need for rest. B. Instruct the patient that the baby’s health is more important than her studies at this time. C. Develop a routine with the patient to balance her studies and her rest needs. D. Ask her why she is not complying with the prescription for bed rest. 22. Patients Alaia, who seems to be irritated with the nurse , said , “I don’t want to talk to you because you’re only a nurse. I will wait for my doctor.” Which of the following is an APPROPRIATE response by the nurse ? A. “I ‘m angry with the way you dismissed me.” anxiety B. “So then you would prefer to speak with your doctor?” C. “I understand . I should call your doctor.” D. “Your doctor prescribed this for us to do nursing care .” e- → verbalization concern 23. Nurse Alaia is now in a dilemma. This occurs when _____ A. There is a conflict between the nurse’s decision and that of his/her superior B. Choices are unclear - - allow allow Pt express . to be assessed C. There is a conflict of two or more ethical principles D. A decision had to be made quickly under a stressful situation : 24. Which of the ethical principles stipulates that the nurse is responsible for providing all patients with care, attention and information? A. Beneficence B. Nonmaleficence C. Advocacy - rights / no harm D. Veracity 25. Which action by the nurse provides a safe environment for a preeclamptic patient? A. Maintain fluid and sodium restrictions. ✓ Take off the room lights and draw the windows shades. B. C. Encourage visits from family and friends for psychosocial support D. Take the patient’s vital signs every 4 hours light room → → preeclampsia + eclampsia ( } poor sorioeoon primi adv , maternal age triggers in brain edema poor peak : - → proteinuria edema → + and trimester nasira ang end Ohl t kidney cerebral irritation ) t prostaglandin nephrotic syndrome - → rasospa① PIH tr albumin laeneralized : Mulka -1 hand ) Situation 6- Part II of the training is the giving of the hypothetical situation for application of what was taken during the didactic. A group was given a scenario of a pregnant woman in the OB ward. : 0 26. The scenario states that the nurse is discussing the nursing process with a newly hired nurse. Which of the following describes the planning phase of the nursing process? A. Identify the nursing process? B. Gather information if the patient’s problem has been resolved in the evaluation phase C. Review the patient’s history during the assessment D. Prioritize patient problems. 27. Nurse Jezyl one the group leaders reviewed the steps of the nursing process with the group. Which of the following data should the nurse identify as objective data? Select all that apply I. Respiratory rate is 22/min II. Feels pain after a 10-minute walk III. Pain is rated as 3 on a scale of 10 IV. Akin is pinkish in color, warm and dry. A. II and III C. I and IV B. III and IV D. I and II : Intervention 28. On the second day , the patient delivered an alive baby girl. She complains of leg pain. The nurse took hold of the patient’s chart. Ponstan 500 mg every hours PRN for pain was ordered and was given. After 40 minutes , the patient was relieved. What step of the nursing process should the nurse have conducted? A. Assessment B. Evaluation ÷ C. Planning evaluation D. Intervention 29. According to the nursing process, which of the following actions the nurse takes if the pain does not satisfactorily relieve? A. Wait for more time for the pain reliever to take effect B. Collect additional data as to why the patient has not been relieved of pain. C. Teach the patient relaxation breathing techniques. D. Refer to an attending physician. 30. The nurse trainor discusses the elements of documentation. Which of the following refers to being comprehensive and timely? A. Complete and current B. Organized C. Accurate and concise D. Factual Situation 7- Patient Ellie, a 28-year-old primigravida, is admitted to a birthing center . She has been in labor with an interval of 5 minutes apart for 10 hours now. Hypotonic contractions are observed by nurse Nora. She feels more pain in her back than in her abdomen, sonogram shows her fetus is “ borderline” large for gestation and in occipito - posterior position. 24000 big baby normal i : g 2500 - 3500 31. Nurse Nora observes that the Ellie’s uterine contractions are irregular in frequency and short in duration. Ellie screams in pain during contractions . Which of the / following actions is considered BEST for the nurse to perform? A. Try to divert attention from pain B. Administer pain reliever as ordered C. Stay with the patient and offer her a back rub D. Document and report frequency and duration of contractions :* 32. The physician is considering augmenting her labor with oxytocin. What would make nurse Nora questions the use of oxtocin for patient Ellise? A. She had an amniocentesis performed during pregnancy B. Her fetus is large for gestational age by a sonogram C. Her membrane ruptured after only 1 hour of labor D. Her blood pressure is slightly elevated above normal maim . Augmentation : Help , hypertension - 110 , go contraction mmHg → ' I Mio IS diastolic 33. Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. What would be the nurse’s FIRST action ? A. Give an emergency bolus of oxytocin to relaxed the uterus B. Discontinue the administration of the oxytocin infusion C. Increase the rate of client’s IV infusion D. Ask client to turn to her left side and breath deeply , 34. Nurse Nora monitors the patient's knowledge that which findings indicate an adequate contraction pattern? / A., Three to 5 contractions in a 10 minute period, with resultant cervical dilatation B. Four contractions every 5 minutes , without resultant cervical dilatation C. Once contraction every 10 minutes, without resultant cervical dilatation overstimulated D. One contraction per minute, with resultant cervical dilatation ✗ :S or ✗ more w/out cervical dilation r 35. Which of the following nursing measures would the nurse LEAST CONSIDERS to patient Ellie with oxytocin drip? A. Know how to recognize potential adverse reactions. hypotension B. Administer oxytocin drug with caution C. Monitor patient closely when infusing oxytocin (f) D. Inform patients about potential complications. bonus ( ! "" water t vasopressin : " " diuresis direct " " "" " intoxication : Headache vomiting mat : death coma Situation 8- Miriam at one years of age, is admitted due to pneumonia. She has IV antibiotics , antipyretic, decongestant and vitamins as medications. She also is under oxygen therapy. / 36. Nurse Messy has been worried about Miriam’s refusal to take oral drugs. How will she handle the situation. A. Leave the child alone B. Seek the help of the mother in giving the oral drug. C. Mix the drug with milk to cover up the unfavorable taste. D. Get angry with the mother and the child. ✗ × /As a one year child, nurse Messy understands the reason(s) why Miriam continuously refuses to take her drugs. It is because it is normal for her age to __ 37. A. Have separation anxiety C. Internalize the attitudes of others negativism autonomy us . Shame a doubt B. Utilize magical thinking D. / Be negativity in all matters 38. The BEST way to administer oxygen on Miriam is by _______ / A., Hood B. Incentive spirometer C. Face mask D. Nasal catheter 39. For the IV antibiotic therapy of Miriam , the MOST common gauge used for IV cannula is Gauge____ ✓ A. : ( bid trans a 26 : 922 : newborn adult iiaresucitalion child - violet medical blue 20 PINK B. 24 YELLOW C. 22 BLUE D. 18 GREEN bid transfusion } , surgery 40. What IMPORTANT evaluation parameter should nurse Messy observe that would show improvement in Miriam’s condition? 14 -18 - A. Absence of fever B./ Absence of chest indrawing C. Respiratory rate of 45 beats per minute D. Respiratory rate of 55 beats per minute gauge smallest cannula : gauge possible 24 complication no -50 alive : 5pm breathing movement heartbeat Situation 9 - Ashley a postpartum patient, who has delivered a stillborn wants to leave the hospital without a physician’s order. The patient is still hooked to an intravenous fluid (IVF) and is on closed post partum monitoring. ↳ pataypaqlabas : 41. To avoid liability, which of the following is an APPROPRIATE action by nurse Valerie? A. Notify nursing supervisor of the patient's plans to leave B. Arrange medication prescriptions at the patient’s preferred pharmacy. C. Notify directly the attending obstetrician D. Ask the patient about transportation plans from the hospital . × 42. Nurse Valerie informs Ashley of the need for early ambulation. Which of the nurse’s instructions on ambulation is INCORRECT? A. Assist the patient from sitting to standing position B. Raise the head of the bed slowly to achieve the sitting position of the patient. C.rAllow the patient to rise from the bed to a standing position unassisted. D. Assist patients to rise from lying to sitting position. 43. rWhile waiting for a feedback from the nurse supervisor regarding the patient’s desire to go , home, nurse Valerie opted to check on the patient. Upon entering the room, she discovers that the waste basket is on fire. Sequence the nurse’s actions below. I. rescue the patient II. Activate the fire alarm III. Close the door to confine the fire. IV. Put off the fire with with fire extinguisher A. IV, II, and I C. I, II, III, IV B. I, II, and ,IV D. II, IV, and I - small big - evacuate /After the fire was put off , the patient was found to have absconded. What is the ethico-legal Responsibility of the attending nurse ? 44. A. Autonomy B. Beneficence C. Nonmaleficence D. Justice 45. Absconding is inevitable in any health care facility . who will be informed IMMEDIATELY if the patient found out absconded? A. Attending physician B. Resident on duty C. Security guard on duty D. Nursing staff Situation 10 - Catherine , 5 years of age , is admitted to the pediatric ward due to severe otalgi, fever and irritability. The mother informed nurse Selma that the patient "" i¥ had upper respiratory infection three weeks prior to admission. The admission diagnosis is acute otitis media ( AOM). Heeding Short eustachian tube 46./ Nurse Selma conducts her INITIAL assessment on Catherine. The patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action? A.rRequest parent to carry the child B. Take Catherine’s vital signs C. Refer to the attending physician. D. Assess the description and frequency of pain ÷ 47. Nurse Selma is preparing to administer Ofloxacin ear drop on Catherine per doctor’s order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for ____. A. 5-6 minutes B. 3-4 minutes C. r 1 to 2 minutes D. 6-7 minutes 48. After washing her hands and gently cleaning any discharge that can be removed easily from the outer ear, Nurse selma positions the child . Which of the following steps follows? 0 A. Gently press the tragus of the ear four times in a pumping motion B. Gently pull the outer ear C. Drop the medicine into the ear canal. D. Keep the ear up for five minutes. / ' → 49. Based on her knowledge on otitis media , Nurse Selma recalls that children are predisposed to AOM due to the following risk factors, EXCEPT __________ A. Absence of breastfeeding B. Exposure to cigarette smoke C. Swimming D. Poor hygiene 50. To promote drainage and reduce pressure from fluid, nurse Selma’s nursing intervention is to have the child assume any of the following positions, EXCEPT _ A. Tilt head to side if sitting up. B. Put the pillows behind the head C. ILie on the affected are ÷ D. Lie on the non-affected ear Situation 11 – Nurse Ester is rotated to the Pediatrics Ward. As such, she needs to review the principles and concept of human growth and development to better appreciate her role as a professional nurse. 51. Being assigned to care for pediatric patients, nurse Ester should remember which of the following statements? A. Toddler period ranges from 12 to 36 months B. An infant’s tongue is smaller than the adult C. Early childhood period ranges from 3 to 7 years. D. Breast milk provides complete infant nutrition 52. While nurse Easter was taking the temperature of Baby Chooka, the mother asked nurse Ester when growth and development become more rapid. Her answer should be, during at ______ months of life. A. Ten B. Twelve C. Nine D. Eleven 53. It is vital for nurse Ester to give concrete examples of activities to stimulate gross and fine motor development. Examples are , which of the following / 1. push/pull 2. Use of scissors and pencil appropriately 3. Poking straws into holes 4. Stand on tiptoes if shown : first / / A./ 1 & 2 B. 2 & 3 C. 3 & 4 D. 1,2,3 &4 ✓ 54. According to the world health organization ( WHO) ,suicide has becomes a global phenomenon. When taking care of emotionally disturbe adolescent patient’s, / CNurse Ester should be alerted with warning signs which often occur for at least one month before a suicide attempt, EXECPT _____ ) A./ Increase in initiative /B. Crying during C. Verbalization of suicidal thouhts endorsement sudden happiness D. Sleep disturbances 55. During one of the nursing rounds, the pediatric ward headnurse asked nurse Ester the inclusive ages considered as the transition from childhood to adulthood but sometimes extending until college graduation. Her CORRECT answer should be _____ A. 15 to 18 B. 11 to 18 C. 12 to 16 D. / 12 to 18 Situation 12 – In a birthing station , five postpartum mothers delivered 2 hours, 4 hours , and 6 hours ago, respectively . All of them are multigravida patients. Adalynn, the nurse educator opted to conduct health education on a postpartum hemorrhage. 0 56. Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is ____ A. Increasing pulse and decreasing blood pressure B. Altered mental status and level of consciousness C./ Dizziness and increasing respiratory rate Compensation D. Cool, clammy skin, and pale mucous membranes snoot - - last VIS O 57. The nurse educator Adalynn reviewed the risk factors for postpartum hemorrhage for the Mothers . Which of the following factors is NOT included___? A. Ruptured uterus B. Overdistended uterus bent back + bent forward C. Uterine atony Rmf trauma / titled Far Hex + : retroflexion Hex : backward anteitexim / Far forward - anteversion } less chance of getting pregnant D. Retroversion of the uterus inversion 1 inside out ) 58. During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus? r ; tone A. Immediately after the delivery B. When the client’s bladder is full ① C. 4 days after the delivery side D. The day after the delivery I tb below 59. A postpartum patient asks nurse adalynn when she may safely resume sexual activity. Which of the following information should the nurse tell the patient on resumption of sexual Activity? A. In 2 to 4 weeks B. At any time C. After the 6-weeks physician check-up D. When her normal menstrual period has resumed vaginal ME : t.fi M : - e- when 4 2- 3 Months Mos lochia - disappears - Gmos . r rNurse Adalynn discusses the possibilities of future postpartum hemorrhage with the patients. Which of the following increases the absorption of vitamin k? 60. A. Proteins B. Mineral C. Carbohydrates D. ' Fats Situation 13 - during the nurse’s rounds, the head nurse noticed that the intake & output sheets have not been filled up. r 61. Based on the findings , what should the head nurse do? A.. Ask the staff nurses the reasons for the failure to properly fill up the intake & output flow sheet. B. Give the staff nurses first warning C. Conduct a need assessment D. Review the orientation program / 62. The head nurse decided to coach her staff nurses. One of the questions she raised was what fluids should be excluded in the I & O flow sheet. The CORRECT response should be, Which of the following ? ① Fluids A. Intravenous fluids B. Solid foods C. Gelatin D. Beverages ' 63. /The head nurse emphasized to the staff nurses what NOT to be included under the output list. the answer should be, which of the following? A. Drainage from tubes B. Urine C.✓solid/hard faces → frequency > describe D. Vomitus 64. The BEST time to record the intake & output is _____, ÷ A. During endorsement B. Right before endorsement C. After endorsement D. Anytime before duty 65. A patient’s I & O is vital for patients with chronic heart failure. The MAIN purpose of recording accurately the I & O of such patient is to ____ A. Determine if client is improving or not B. Find out if there is still water retention in the interstitial cells C. Detect cardiac overload D. Determine weight gain/loss r Situation 14- The group of nurses assigned in the delivery room is interested in conducting a study on the experiences of pregnant women in labor. They are thinking of qualitative research. 66. In the presentation of results of qualitative research , the nurse researcher uses as a reference in the write-up the ____ person. A./ First Patient B. Fourth C. Second nurse D. Third another reference 67. /Nursing as a human science , deals with the critical and fundamental differences in attitude Towards their respective phenomena. Which of the following is an aim of human science? A. Construct prediction B. Set control. C. Seeks causal explanation r Makes meaningful interpretation. D. 68. rThe group was observant as to the activities taking place in the delivery room. One of the Activities involve social processes, which can be better explored. Which of the following qualitative research method should be used? A./Grounded theory B. Descriptive phenomenology C. Historical research D. Case study 69. After the data analysis of their study, experiences of pregnant woman in labor, they returned to the participants to determine the accuracy of the emerged themes. Which criteria of Trustworthiness is the group doing? b- A. Confirmability B. Transferability 2 C. / Credibility / same results 5 . authenticity D. Dependability 4 70. The group used an audio recorder to capture what transpired during the interview. After the transcription, which of the following action is APPROPRIATE for the group to do with the Audiotape? 3 A. Keep audiotape in a vault and dispose it a year after. B. Submit the audiotape to their research adviser C. Throw it in the trash bin immediately after it was used. D. Post the recording on their university research website for others to listen. - ✓ Situation 15- Marie, OB-GYN head nurse, conducted an in service program on staff development. - Ifor employees / 71. Head nurse Marie, discussed that the MOST frequently neglected area in management is ____ A. Managerial knowledge B. Clinical skills C. Professional development D. Successful communication 72. A critical component of the supervisory process is delegation. Which of the following is the MOST empowering to staff? : A. Effective delegation does not require nurses to know the abilities and weaknesses of staff. B. Delegation frees the manager to do other tasks while empowering staff C. Delegation fosters the responsibility of staff while increasing professional growth. D. Delegations start at top management down to subordinates. r 73. Head nurse Marie discussed negotiation. The focus of negotiation is to create a __ A. Sooting situation B. Trade-off C. Third-party consultation D. Win-win situation / 74. Supervision occurs after delegation. What is the PRIMARY purpose of supervision? A. Influences the organization’s approach in recruitment, promotion and personnel evaluation. B. Improves staff compliance with policy and procedure C. Assigns appropriate work tasks to the best qualified individual. D. Enhance the delivery of quality nursing care. : 75. Delegation involves the transfer of care to an individual. What is the BEST criterion when delegating staff? A. Responsibility B. Flexibility C. Adaptability D. / Competence Situation 16- Therapeutic communication promotes understanding between the sender and receiver. Nurse Gary should be absent with the common effective and achievable. / 76. When a patient says, “ I am not sure if I should undergo colonoscopy or not as I am Scared.” Which of the following is the MOST appropriate communication technique that Nurse Gary use? A. Touch nurse did not ( Paraphrasing (understand B. Clarifying C. , Restating D. Silence 77. When a patient says, “ whenever I see my husband visit me, I feel depressed”. Nurse Gary says , “ Your husband depresses you?” the therapeutic communication is which of the following / A. Restatement B. Focusing / C. Focusing D. Seeking clarification 78. When a Nurse gary says to the patient, “ Tell me more about your experience when you have the colonoscopy .`` Which of the following therapeutic techniques is Nurse Gary using? : nurse chooses A. Focusing B. Encouraging elaboration : topic general leads C. Clarifying broad opening : pt . Will choose topic D. Restating 79. When nurse Gary says, “ tell me more about the experience . I wish to hear about..” which of the following therapeutic communication techniques is nurse Gary using? - A. Restating B. Open-ended questions C. Seeking clarification D. Summarizing 80. When Nurse Gary tells the patient, “ You will be wheeled in to the OR and will be hooked to an IVF where the anesthesia will be given intravenously. “ which of the following therapeutic communication techniques is nurse Gary using ? A. Clarification B.y Giving information C. Summarizing D. Reflection y lbalik any tan my 1- siyamag - iisip Situation 17 - A pediatric patient , 12 years old , is admitted to the private room with a tracheostomy tube. r 81. Since the staff nurse assigned to the patient does not have any experience in caring for a patient with tracheostomy tube , who among the following should NOT do the care? A. Medical resident B. Charge nurse C. Medical intern D. / Mother of child with care of tracheostomy tube experience 82. The otolaryngologist arrives to change the tracheostomy tube. Which of the following should the nurse collaborate with for the appropriate equipment/supplies needed in changing the tracheostomy tube. / A. Emergency department C. Central supply unit I B. Anesthesia department D. Operating room department 83. /To assure that nurse Mica will learn the proper way of caring for patients with tracheostomy tube, the head nurse should collaborate with , who among the following personnel for the training? A. Asst. chief nurse for clinical C. Chief of unit D. Chief of clinics /B./ Asst. chief nurse for education training " "" are g- 84. The otolaryngologist ordered a change of the tracheostomy tube ties? who among the following should the doctor collaborate with? A. Medical intern B. Nursing aids : C. Medical resident ✓ D. Staff nurse 85. The skills of suctioning using a single use catheter for tracheostomy is more safely performed with which of the number of assistants? A. Four B. Three C.. Two D. One Situation 18 - Josephine, a multiparous patient is admitted due to labor pains which started an hour ago . During the vaginal examination, the nurse noted the complete dilatation of the cervix and effacement is 100 percent. The patient is in true labor pains. 86. Which of the following problems with labor and delivery is completed in less than 3 hours? A. Precipitous B. Induced C. Preterm Ln 7 Wks D. Prolonged dystonia / 87. Patient Josephine was referred to the physician , routine blood examinations were taken. After reviewing the serum electrolyte levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare? hurt A./ 5 percent dextrose in water Dsw B. 0.45 percent sodium chloride solution Hypo C. 10 percent dextrose in water Hyper D. 3 percent sodium chloride solution hyper 88. The patient during labor would anticipate some emotional support. Which of the following nursing interventions should nurse Sarah provide to keep the patient calm? A. Giving praise for her the sense of satisfaction regarding quick labor B. Support in maintaining a sense of control. C. Explanation of the effect of labor on the newborn -D. Allowing the patient to express pain and anxiety. : 89. Patient Josephine asks why her labor is much shorter compared to previous deliveries. Which of the following is the BEST RESPONSE ? A. Onset of contraction was gradual B. Multigravida patient has shorter labor C. Cervical lengthening was longer. shorter D. Induction of labor was done. C- ) / 90. Nurse Sarah reads the physician’s prescription to administer methylergonovine maleate ( methergine) intramuscularly after delivery. The rationale for giving this medication is which of the following? A. Reduces the amount of lochia drainage. B. Prevents postpartum hemorrhage C. Decreases uterine contractions. D. Maintains normal blood pressure. : Situation 19- Jose , 10 years old, has bronchitis. He needs oxygenation 4l/min per doctor’s order. 91. The first standard steps in oxygen therapy that the nurse should do is, which of the following? A. Prepare the patient for the oxygen treatment. B. Check the chart for ordered flow rate and oxygen delivery method. C. Gather all the equipment and supplies. D. Assess the patient's condition. 1 FIRST 11nF OF ER 1)Rub - NEEDED BY bells / ✓ 92. In planning for Jose’s oxygen therapy, the nurse shall consider which of the following, EXCEPT_____) c- A. Need for a humidifier B. Length of tubing C. Determine the age of Jose. D. Manner of administering oxygen, continuous or intermittent . r 93. The PRIORITY nursing action of the nurse for Jose due for oxygen therapy is. A. Attach the humidifier and connect tubing to the oxygen delivery device. B. Connect the flow meter to the pipe in the oxygen outlet. C. Turn on the oxygen D. Check the flow ÷ 94. What PRIORITY precautionary measure should be done by the nurse during the oxygen therapy? A. Limit visitors. B./ Attack “ No Smoking” signage C. Check humidifier’s water regularly D. Connect belt to oxygen tank ✓ ✓ equipments an no ✓ V0 electrically are Flammable tubs highly inflammable ✓ wool ✓ tire 1 synthetic , nearby . ✓ entry grounded hear sparks subs - acetone , ethers . fiber fire exit . 95. One evening , Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse’s INITIAL intervention? A. Give PRN medication. B. Refer patients to the physician. C. Assess the patency of the tubing D. Reassess the patient. ① y l - l oxygenation Hq } liie → threatening n to 5 min 1 emergency patientt Situation 20- Head nurse wilma has been encountering errors in documentation and records management based on her review of the nurses’ notes in the patients charts. To solve the issue, she decided to conduct a lecture on proper nursing documentation and management of records. / 96. At the start of her lecture , head nurse Wilma asked the purpose of the nursing process. Which of the following purposes is the CORRECT answer ? A. Reduce the number of forms of the chart B. List the patients health problems C. Record the patient’s progress D. Provide confidentiality of the chart ÷ 97. One of the staff nurses was asked about the principles to be observed when charting Patient’s progress accurately. Which of the following principles would be the CORRECT Answer? A. Statement are qualified by the use of “seems” and “appears” B. Assumptions and conclusions are reported C. Specific and definite words or phrases are used. D. General statements and measurements are used. 98. Which of the following is NOT a characteristic of charting? A. Complete B. Subjective C. Objective D. Accurate 0 99. During nursing endorsements , the kardex is used. Which of the following statements is NOT correct it is___ A. Kept up to date B. A quick reference for current information about the client. C. Consists of folded card for each patient D. Part of the medical record. ÷ 100. A sample of an error in charting was shown by head nurse Wilma. Which of the following is the CORRECT solution to remedy the error? D. Retroversion A. Recopy the sheet and destroy the original sheet B. Use a single line to cross out the error, the write the date , time and sign the correction made C. Use correction fluid to erase the error D. Use eraser to remove the wrong entry
