NURSING PRACTICE 3

GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions.
2. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
3. Write the subject title NURSING PRACTICE III on the box provided.
4. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is SET B.
5. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
6. AVOID ERASURES.

Situation Ensuring safety is one of your most important responsibilities. You will need to provide instructions and
information to your clients to prevent complications.
1. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
A. empty the drainage system at the end of the shift
B. clamp the chest tube when suctioning
C. palpate the surrounding areas for crepitus
D. change the dressing daily using aseptic techniques
2. Fanny, came in from PACU after pelvic surgery. As Fannys nurse you know that the sign that would be indicative
of a developing thrombophlebitis would be:
A. a tender, painful area on the leg
B. a pitting edema of the ankle
C. a reddened area at the ankle
D. pruritus on the calf and ankle
3. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
A. seek early treatment for respiratory infections
B. take showers instead of tub bath
C. continue to take the same restrictions on fluid intake
D. avoid situations that involve physical activity
4. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy
tube being dislodged. What should you teach him first?
A. Recognize that prompt closure of the tracheal opening may occur
B. Keep calm because there is no immediate emergency
C. Reinsert another tubing immediately
D. Notify the physician at once
5. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to
maintain:
A. supplementary oxygen
B. ventilation exchange
C. chest tube drainage
D. blood replacement

Situation As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening
situations can be prevented.
6. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on
admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what
will be your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway
7. Knowing that for a comatose patient hearing is the last sense to be lost, as Judys nurse, what should you do?

A. Tell her family that probably she cant hear them

B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently
8. Which among the following interventions should you consider as the highest priority when caring for June who
has hemiparesis secondary to stroke?
A. Place June on an upright lateral position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for support
9. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was
diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can
provide a therapeutic environment by doing which of the following?
A. honoring her request for a television
B. placing her bed near the window
C. dimming the light in her room
D. allowing the family unrestricted visiting privileges
10. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This
indicated that he:
A. probably has meningitis
B. is going to be blind because of trauma
C. is permanently paralyzed
D. has received a significant brain injury
Situation With the improvement in life expectancies and the emphasis in the quality of life it is important to
provide quality care to our older patients. There are frequently encountered situations and issues relevant to the
older patients.
11. During a meal a client with hepatitis B dislodge her IV line and bleeds on the surface of the over-the-bed table.
It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
A. Alcohol
B. Acetone
C. Ammonia
D. Bleach
12. Nino is being treated with radiation therapy. What would be included in the plan of care to minimize skin
damage from the radiation therapy?
A. Cover the areas with thick clothing materials
B. Apply a heating pad to the site
C. Wash skin with water after the therapy
D. Avoid applying creams and powders to the area
13. You are assigned to the following patients. Which of the following patients is most at risk for metabolic
alkalosis?
A. Grace, 30 years old post surgical patient who has continuous nasogastric suction
B. Rachel, 55 year old who has just experienced a stroke
C. Helen, 70 year old with altered level of consciousness who is unable to access water freely.
D. Mary Jane a 2 year old infant receiving isotonic sodium chloride IV solution
14. Studies have shown that the highest incidence of Hodgkins disease is common among young adults. Juana, 20
years old approaches you and tells you I am worried about the mass on my neck. What should you do as a nurse?
A. Tell her there is nothing to worry if it does not bother her
B. Palpate Juanas neck and explain the possible cause
C. Tell her Hodgkins disease is common among young adults like her
D. Tell her to see a doctor
15. As a nurse, you accidentally administer 40mg of Propanolol (Inderal) to a client instead of 10mg although the
client exhibits no adverse reactions to the larger dose, you should:
A. Complete an incident report

B. Call the hospital attorney

C. Inform the clients family
D. Do nothing because the clients condition is stable
Situation Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary
management you have important responsibilities as a nurse
16. Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following
nursing interventions would be most helpful for Albert?
A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
C. Reassures him that these feelings are normal
D. Help him plan his activities
17. Immediately following the radiation teletherapy, Albert is:
A. Considered radioactive for 24hours
B. Given a complete bath
C. Placed on isolation for 6 hours
D. Free from Radiation
18. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following
symptoms:
A. Petechiae, ecchymosis, epistaxis
B. Weakness, easy fatigability, pallor
C. Headache, dizziness, blurred vision
D. Severe sore throat, bacteremia, hepatomegaly
19. What nursing diagnosis should be the highest priority?
A. Knowledge deficit regarding thrombocytopenia precautions
B. Activity intolerance
C. Impaired tissue integrity
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal
20. What intervention should you include in your care plan?
A. Inspect his skin for petechiae, bruising, GI bleeding regularly
B. Place Albert on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C
Situation - You are assigned to take care of four patients with different conditions.
21. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine and
prednisone? You recognized that KJ understood the teaching when he states, I must take these medications:
A. until the anastomosis heals
B. during the preoperative period
C. until the supply is over
D. for the rest of my life
22. After the kidney transplant, you must observe KJ for signs of rejection which includes:
A. fever and weight gain
B. hematuria and seizure
C. polyuria and jaundice
D. moon face and muscle atrophy
23. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his
physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB
tells you I want to go off dialysis, Id rather not live than to be in this treatment the rest of my life. How would
you respond to him?
A. leave the room and allow him to collect his thoughts
B. tell FB that We all have days when we dont feel like going on
C. tell FB that Treatments are only three times a week, you can live with that
D. take a sit next to him and sit quietly

24. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which
statement by DS indicates the need for further teaching before true informed consent can be obtained?
A. a wire from the generator will be attached to my heart
B. the physician will make a small incision in my chest wall and place the generator there
C. I wonder if there is another way to protect these bad rhythms
D. this implanted defibrillator will protect me from those bad rhythms my heart goes into
25. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates
a lack of understanding about his rights as a research study participant?
A. My confidentiality will not be compromised in this study
B. I understand the risk associated in this study
C. I can withdraw from the study anytime
D. Ill have to find a new physician if I dont complete this study
Situation - Foot care among patients with peripheral vascular problems is very important.
26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions:
A. avoid wearing canvas shoes
B. avoid using a nail clipper to cut toe nails
C. avoid use of cornstarch on the foot
D. avoid wearing cotton socks
27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of
sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic,
cold, cadaverous left calf. While the physician determines the appropriate management, you should:
A. shave the affected leg in anticipation of surgery
B. place a healing pad around the calf
C. keep the affected leg level or slightly dependent
D. elevate the affected calf as high as possible
28. Peripheral neuropathies primarily affect:
A. sensory functions
B. vascular functions
C. optic functions
D. motor functions
29. Peripheral neuropathy can BEST be controlled by:
A. good glucose control
B. steroid therapy
C. vitamin supplement
D. nothing, there is no slowing the process
30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a
client with:
A. hypertension
B. hyperthyroidism
C. liver disease
D. diabetes insipidus
Situation - The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a
dissecting aneurysm of the aorta.
31. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank,
how long should you infuse it?
A. 6 hours
B. 1 hour
C. 4 hours
D. 2 hours
32. What should you do FIRST before you administer blood transfusion?

A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date
B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with
another nurse
C. check IV site and use appropriate BT set and needle
D. verify physicians order
33. As WQs nurse, what will you do AFTER the transfusion has started?
A. add the total amount of blood to be transfused to the intake and output
B. discontinue the primary IV of Dextrose 5% Water
C. check the vital signs every 15 minutes
D. stay with WQ for 15 minutes to note for any possible BT reactions
34. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:
A. oliguria and jaundice
B. urticaria and wheezing
C. hypertension and flushing
D. headache, chills, fever
35. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?
A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician
B. stop the blood transfusion and monitor the patient closely
C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank
D. immediately stop the BT, notify the blood bank and administer antihistamines
Situation - The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the
kidneys functions can cause disease. As a nurse it is important that you understand the rationale behind the
treatment regimen used.
36. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for
about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase?
A. urine output directly related to the amount of IV fluid infused
B. urine output is less than 400 ml/24 hours
C. urine output of 30-60 ml/hour
D. no urine output, kidneys in a state of suspension
37. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?
A. increased urine output, increased absorption of sodium and water
B. decreased urine output, decreased absorption of sodium and water
C. increased urine output, decreased absorption of sodium and water
D. decreased urine output, increased absorption of sodium and water
38. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to
do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:
A. hyperkalemia
B. hypercalcemia
C. hypokalemia
D. hypernatremia
39. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm.
What diet instructions will you need to reinforce prior to his discharge?
A. drink plenty of water
B. restrict your salt intake
C. monitor your fruit intake and eat plenty of bananas
D. be sure to eat meat every meal
40. BN, is also advised not to use salt substitute in the diet because:
A. salt substitute contain potassium which must be limited to prevent arrhythmias
B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood
C. fluid retention is enhanced when salt substitutes are included in the diet
D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane

Situation With the improvement in life expectancies and the emphasis in the quality of life it is important to
provide quality care to our older patients. There are frequently encountered situations and
issues relevant to the older patients.
41. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation
42. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
43. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity
44. Cardiac ischemia in an older patient usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion
45. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles
Situation A disaster is a large-scale emergencyeven a small emergency left unmanaged may turn into a
disaster. Disaster preparedness is crucial and is everybodys business. There are agencies that are in charge of
ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the
management of emergency programs and activities for all four emergency
phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural,
man-made, and attack) and for all levels of government and the private sector.
46. Which of the four phases of emergency management is defined as sustained action that reduces or eliminates
long-term risk to people and property from natural hazards and their effects.?
A. Recovery
B. Mitigation
C. Response
D. Preparedness
47. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a
typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support
for the family, organizing counseling debriefing sessions and securing physical care are the services you are
involved with. To which type of prevention are these activities included:
A. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. Secondary prevention
48. During the disaster you see a victim with a green tag, you know that the person:
A. has injuries that are significant and require medical care but can wait hours with
threat to life or limb

B. has injuries that are life threatening but survival is good with minimal
intervention
C. indicates injuries that are extensive and chances of survival are unlikely even
with definitive care
D. has injuries that are minor and treatment can be delayed from hours to
Days
49. The term given to a category of triage that refers to life threatening or potentially life threatening injury or
illness requiring immediate treatment:
A. Immediate
B. Emergent
C. Non-acute
D. Urgent
50. Which of the following terms refer to a process by which the individual receives education about recognition of
stress reaction and management strategies for handling stress which may be instituted after a disaster?
A. Clinical incident stress management
B. Follow-up
C. Debfriefing
D. Defusion
Situation As a member of the health and nursing team you have a crucial role to play in ensuring that all the
members participate actively is the various tasks agreed upon.
51. While eating his meal, Matthew accidentally dislodges his IV lines 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
52. You are a member of the infection control team of the hospital. Based on a feedback during the 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 for surveillance and monitoring
B. Do data gathering about the possible sources of infection (observation,
chart review, interview).
C. Assign point persons who can implement policies.
D. Meet with the nursing group working in the burn unit and discuss problem with
them.
53. Part of your responsibility as a member of the diabetes core group is to getreferrals 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. Bring your diabetes teaching kit and start your session taking into consideration
their distance from your office
B. Contact the nurse in-charge and find out from her the reason for the referral
C. Determine their learning needs then prioritize
D. Involve the whole family in the teaching class
54. 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. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task force before contacting the
support groups
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
number of their president
55. 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 for others. What will be your most important role where
you can demonstrate the impact of nursing in health?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator
Situation One of the realities that we are confronted with is our mortality. It is important for us nurses to be
aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our
patients cope with death and dying.
56. Irma is terminally ill, she speaks to you in confidence. You now feel that Irmas family could be helpful if they
knew what Irma has told to you. What should you do first?
A. Tell the physician who in turn could tell the family
B. Obtain Irmas permission to share the information in the family
C. Tell Irma that she has to tell her family what she told you
D. Make an appointment to discuss the situation with the family
57. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help
her by:
A. Coming back periodically and indicating your availability if she
would like you to sit with her
B. Insisting that Ruby should talk with you because it is not good to keep
everything inside
C. Leaving her alone because she is uncooperative and unpleasant to be
with
D. Encouraging her to be physically active as possible
58. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves,
is depressed. Which of the following would best help him during his depression?
A. Arrange for visitors who might cheer him
B. Sit down and talk with him for a while
C. Encourage him to look at the brighter side of things
D. Sit silently with him
59. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending
death?
A. Im ready to go.
B. I have resigned myself to dying.
C. Whats the use?
D. Im giving up
60. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and emotionally. This is
recognized as:
A. Acceptance that death is inevitable
B. Avoidance of the true situation
C. Denial with planning for continued life
D. Awareness that death will soon occur