SIMULATION 19

NURSE LICENSURE EXAMINATION INTEGRATED COMPREHENSIVE TEST I

INSTRUCTION: Select the correct answer for each of the following questions. Mark only one answer for each item by shading the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED. Use pencil no.2 only. Situation: While working in tertiary hospital, you are assigned to the medical ward. 1. A diabetic hypertensive female client needs a change in diet to improve her health status. She should be referred to a: a. medical pathologist c. dietitian b. nutritionist d. physician The nurse is successful in collaborating with health team members about the care of client. This is because she has the following competencies: a. Mutual respect, negotiation, trust c. Negotiation, decision making b. Conflict management, trust, negotiation d. Communication, trust, decision making Your client is concerned that he cannot pay his hospital bills and professional fees. You refer him to a: a. physician c. social worker b. nurse supervisor d. bookkeeping department When collaborating with other health team members, the best description of the nurses role is: a. shares and implements orders of the health team to ensure quality care b. encourages the clients involvement in his care c. helps client set goals of care and discharge d. listens to the individual views of the team members Which of the following situations would possibly cause a nurse to be sued due to negligence? a. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the clients medicine cup b. Nurse gave a client wrong medication and an hour later, client complained of dyspnea c. As the nurse was the about to administer medication, the client questioned why the medication is still given when in fact the physician discontinued it d. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Client noticed the error and complained Which of the following situations would possibly cause a nurse to be sued due to negligence? a. While preparing a medication, the nurse notices that instead of 1 tablet, she put two tablets into the clients medicine cup b. Nurse gave a client wrong medication and an hour later, client complained of dyspnea c. As the nurse was the about to administer medication, the client questioned why the medication is still given when in fact the physician discontinued it d. Nurse administered 2 tablets of analgesic instead of 1 tablet as prescribed. Client noticed the error and complained A client is ordered to take a Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? a. Measure frequency of urination in 24 hours

2.

3.

4.

5.

6.

7.

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b. c. d. 8.

Report to the physician the effects of the medication on urination Take a full glass of water with the medicine Take the medicine early in the morning

Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital. a. Client with second degree burns c. Client with psoriasis b. Diabetic client type 2 d. Client with COPD The son of a 76 year old male client reports to the nurse in the community health center that his father has been getting out of the bed at night and walks around the house in the early hours of the morning causing him to fall and injure himself. Which instruction would you give? a. Advise hospitalization to prevent future accidents. b. Apply restraints during the night hours only. c. Keep a radio or TV for company and to orient the client d. Have someone check on the client frequently at night

9.

10. You are asked to teach a client who has right sided weakness the use of a cane. Which observation will indicate that the client is using the cane correctly? a. The cane and one foot or both feet are on the floor at all times b. Client keeps the cane on the right side along the weak leg c. Client advances the cane followed by the left leg d. Client leans to the left side which is stronger 11. A 43 year old male executive is scheduled for cardiac bypass surgery. While being prepared for surgery, he says to the nurse I am not going to have the surgery; I may die because of the RISK. Which response by the nurse is most appropriate? a. Without the surgery you will most likely die sooner. b. There is a client in the other room who had had successful surgery and you can talk to him. c. There are always risks involved with surgery. d. This must be very frightening for you. Tell me how you feel about surgery. 12. A registered nurse gets a call from a neighbor who tells her that his 3 years old daughter has been vomiting and has fever and asks for advice. Which of the following is the most appropriate action of the nurse? a. Tell the neighbor to observe the child and give plenty of fluids. If the child does not improve, bring the child to the hospital b. Observe the child for an hour. If the child does not improve, refer to the physician in the neighborhood c. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital d. Recommend to bring the child immediately to the hospital 13. A 30 years-old male client was brought to the hospital due to injuries sustained from a vehicular accident. While being transported to the X-ray department, the straps accidentally broke and the client fell to the floor hitting his head. In this situation, the nurse is: a. liable along with the employer for the use of defective equipment that harms the client b. totally responsible for the negligence c. not responsible because of the doctrine of respondeat superior d. free from any negligence that caused harm to the client 14. A head nurse in a surgical unit hears one of the staff nurses say that she does not touch any client assigned to her unless she performs nursing procedures or conducts physical assessment. To guide the staff nurse in the use of touch, which of the following would be the BEST response of the head nurse? a. Touch is used in physical assessment b. Touch serves as a connection between the nurse and the client c. Use touch when the situation calls for it.

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d.

Use touch with discretion.

15. A male client has been confined for three days. His wife helped take care of him and he has observed her to be too involved in his care. He complained to the head nurse about this. Which of the following would be the BEST response of the nurse? a. What are your thoughts about your wifes involvement in your care? b. Dont worry. I will call the attention of you wife c. Your wife is just trying to help because she is worried about you. d. Your wife can assist you well in your care and recovery. 16. A staff nurse is administering 12:00 PM medication in Ward 9. Two clients have to receive Lanoxin. What should the staff nurse do when one of the clients does NOT have a readable identification band? a. Compare the ID band with the bed tag b. Ask the client his name c. Ask the room mate if the client is Mrs. Sanchez d. Ask the client if she is Mrs. Sanchez 17. While going on evening rounds, the nurse saw the client meditating and afterwards started singing prayerful hymns. What is the BEST response of the nurse? a. Respect the clients actions as this provides structure and support to the client b. Ignore the incidence c. Call her attention so she can go to sleep. d. Report the incidence to the head nurse. 18. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 629. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take? a. Say nothing to avoid embarrassing the staff nurses b. Wait till the nurses finish the discussion and report the situation to the supervisor c. Approach the two nurses and tell them that their actions are inappropriate especially in a public place d. Remain quiet and ignore the discussion 19. The code of ethics for nurses has an interpretive statement that provides : a. identical care to all clients in any setting b. standards of care in carrying out nursing responsibilities c. continuity of care for the improvement of the client d. guide for carrying out nursing responsibilities that provide quality care and for the ethical obligation of the profession 20. A client asks for advice on low cholesterol food. You advise the client to eat the following: a. Lean beef and pork, egg white, fish c. Chicken liver, cow liver, eggs b. Balut, salted eggs, duck and chicken egg d. Pork liempo, cow brain, lungs and kidney Situation: Accurate computation prior to drug administration is a basic skill all nurses must have. 21. A 3 months old baby girl with a congenital heart deformity has an order from her physician, give 3.00 cc of Lanoxin today for 1 dose only. Which of the following is the most appropriate action by the nurse? a. Administer Lanoxin intravenously as it is the usual route of administration b. Clarify order with the attending physician c. Discuss the order with the pediatric heart specialist in the unit d. Refer to the medication administration record for previous administration of Lanoxin 22. The physician ordered Potassium Chloride (KCL) in D5W 1 liter to be infused in 24 hours. Since Potassium Chloride is a high risk drug, the nurse used an intravenous pump. Which of the following should the nurse do to safety administer this drug?

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a. b. c. d.

Check the pump setting every 2 hours Have another nurse check the infusion pump setting Set the alarm of the pump loud enough to be heard Teach the client how the infusion pump operates

23. A male client is diagnosed with the amoebiasis and is to receive Metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will receive per oral administration? a. 1,000 mg tid c. 250 mg tid b. 500 mg tid d. 1,500 mg tid 24. When the nurse was about to administer the medications of the client, the relative of the client told the nurse that they buy the medicines and showed the container of medications of the client. Which of the following is the most appropriate action by the nurse? a. Bring the medications of the client to the nurses station and prepare accordingly b. Tell the client that she will inform the physician about this c. Hold the administration of the clients medication and refer to the head nurse d. Put aside the medications she prepared and instead administer the clients medications 25. A 2 year old female client was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125mg/ml. Which of the following should the nurse prepare for each oral dose? a. 1.25 ml c. .5 ml b. 10 ml d. 2.5 ml Situation: A newly hired female nurse is asked to take over an absent nurse in another unit. She will take care of clients with various conditions. 26. When suctioning the endotracheal tube, the nurse should: a. insert suction catheter four inches into the tube, suction 30 seconds using twisting motion as a catheter is withdrawn b. insert catheter until resistance is met, then withdraw slightly, applying suction intermittently as catheter is withdrawn c. explain procedure to client, insert catheter gently applying suction, withdrawn using twisting motion d. hyperoxygenate client then insert catheter using back and forth motion 27. A female client sustained a fracture of the ulna and a cast will be applied. What nursing action before cast application is most important for the nurse to do? a. Use baby powder to reduce irritation under the cast c. Check radial pulses bilaterally and compare b. Evaluate skin temperature in the area d. Assess sensation of each arm 28. Which of the following client conditions should be the nurse priority in the pediatric unit? a. The infant who is brought in for upper respiratory tract infection whose temperature is slightly elevated b. The baby whose fontanel is bulging and firm while asleep c. A baby boy whose circumcision has yellowish exudates d. A baby who is wailing after being awakened by the banging of the door 29. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? a. Save sputum for two days in covered container b. After respiratory treatment, expectorate into a container c. Cough after pursed lip breathing d. Upon waking up, cough deeply and expectorate into container 30. A staff is giving instructions to the daughter of a comatose client to give a sponge bath. While the daughter is doing the sponge bath, what action of the daughter needs correction? a. Rolling the client like a log to do back rub b. Turning the client on the left side with head slightly elevated

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c. d.

Lining the rubber mat with bed sheet as incontinence pad for the client Answering the phone while wearing the gloves used for sponge bath

Situation: When creating your lesson plan for cerebro vascular disease or STROKE, it is important to include the risk factors of stroke. 31. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on caused are the following, EXCEPT: a. thrombotic stroke c. diabetic stroke b. embolic stroke d. hemorrhagic stroke 32. Hemorrhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: a. damage to blood vessel c. aneurysm b. phlebitis d. trauma 33. A participant in the STROKE class asks, what is a risk factor of stroke? Your best response is: a. High RBC count increases blood pressure. b. Increased RBC count is linked to high cholesterol. c. More red blood cells increase hemoglobin content. d. More red blood cells thicken blood and make clots more possible. 34. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? a. Amphetamines c. Cocaine b. Demerol d. Shabu 35. The most important risk factor of stroke is: a. binge drinking b. hypertension c. d. cigarette smoking heredity

Situation: You are taking care of a 66 years old female client who is terminally ill with ovarian cancer, stage IV. 36. The nurse is to administer Demerol 50 mg and Vistaril 50 mg. IM. Demerol is available in a multi-dose vial labeled 100mg/ml while Vistaril comes in an ampoule labeled 50 mg/ml. You are to give the both medications in one injection. You will: a. withdraw the medication from the vial first then from the ampoule b. withdraw medication from the ampoule then from the vial c. inject air into the vial, then into the ampoule d. inject air into the ampoule, aspirate desired dose, then into the vial 37. The client is emaciated and is at risk for developing which problem in skin integrity? a. Blisters c. Pustules b. Reddening of the skin d. Pressure sores 38. When caring for a dying client, you will perform which of the following activities? a. Assist client perform activities of daily living c. Motivate client to gain independence b. Assist the client towards a peaceful death d. Encourage the client to reach optimal health 39. When giving Demerol 50 mg from a multidose vial labeled 100 mg/ml and Vistaril 50mg/ml from an ampoule labeled 50mg/ml, what is the total volume that you will inject to the client? a. 1.5 ml c. 1 ml b. 1.75 ml d. 2 ml 40. The client prepares for her eventual death and discusses with the nurse and her family, how she would like her funeral to look like and what dress she will use. This client is in the stage of:

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a. b.

denial bargaining

c. d.

acceptance resolution

Situation: A nurse researcher proposes a study on the relationship between health values and the health promotion activities of staff nurses in a selected college of nursing. 41. The nurse researcher needs to review relevant literature and studies. The following processes are undertaken in reviewing literature, EXCEPT: a. using the library c. locating and identifying resources b. reading and recording notes d. clarifying a research topic 42. The proposed study shows the relationship between the variables. Which of the following is the independent variable? a. Relationship between health values and health promotion activities b. Health promotion activities c. Health values d. Staff nurses in a selected college of nursing 43. The primary purpose for reviewing literature is to: a. gather current knowledge of the problem of interest b. select topics related to the problem of interest c. generate broad background and understanding of information related to the research problem of interest d. organize materials related to the problem of interest 44. In both quantitative and qualitative research, the used of a frame of reference is required. Which of the following items serves as the purpose of a framework? a. Incorporates theories into nursings body of knowledge b. Organizes the development of study and links the findings to nursings body of knowledge.. c. Provides logical structure of the research findings d. Identities concepts and relationships between concepts 45. In formulating the research hypotheses, nurse researcher should state the research question as: a. What is the response of the staff nurses to the health values? b. Is there a significant relationship between health values and health promotion activities of the staff nurses? c. How do health values affect health promotion activities of the staff nurses? d. How is variable health value perceived in a population? Situation: Oral care is an important part of hygienic practices and promoting client comfort. 46. A possible problem while providing oral care to unconscious client is the risk of fluid aspiration to lungs. This can be avoided by: a. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, teeth, tongue, lips and gums b. suctioning as needed while cleaning the buccal cavity c. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs d. cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing and buccal cavity 47. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: a. petroleum jelly c. salt solution b. water d. mentholated ointment 48. The advantages of oral care for a client include all of the following, EXCEPT:

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a. b. c. d.

decreases bacteria in the mouth and teeth improves appetite and taste of food improves clients appearance and self-confidence reduces need to use commercial mouthwash which irritate the buccal mucosa

49. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? a. Clean mouth with oral swabs in a careful and an orderly progression b. Put the client on a side lying position with head of bed lowered c. Keep the client dry by placing towel under the chin d. Wash hands and observe appropriate infection control 50. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? a. Hydrogen peroxide c. Normal saline solution b. Lemon glycerin d. Mineral oil Situation: The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved. 51. The nurse supervisor is not satisfied with the bed bath that is provided by the staff nurse. To improve the care provided to the clients in the unit by the staff nurse, the nurse supervisor should: a. bring the staff nurse to a clients room and demonstrate a cleansing bath b. provide a manual to be read on giving bed baths c. tell the staff nurse how to give bed baths correctly d. ask another staff nurse to do the bed baths instead 52. The staff nurse discusses with the novice nurse the type of wound dressing that is best to use for a client. Together, they observe how well the dressings absorb the drainage. In what step of the decision making process are they? a. Considering effects on results c. Testing options b. Defining the problem d. Making final decisions 53. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. A staff nurse uses such good clinical judgment when she gives priority care to this client: a. A client who received pain medication 5 minutes ago b. A client who needs instructions for home medications c. A post-operative client who has a blood pressure of 90/50 mmHg d. A client who is ambulatory and for surgery tomorrow 54. A good nursing care plan is independent on a correctly written nursing diagnosis. It defines a clients problem and its possible cause. The following is an example of well written nursing diagnosis: a. Acute pain related to altered skin integrity secondary to hysterectomy b. Electrolyte imbalance related to hypocalcaemia c. Knowledge deficit related to proctosigmoidoscopy d. Altered nutrition related to high fat intake secondary to obesity 55. To check if the staff nurses under her supervision use critical thinking, the head nurse observes if the staff nurses act responsibly when at work. Which of the following actions of a staff nurse demonstrates the attitude of responsibility? a. Thinking of alternative methods of nursing care b. Sharing ideas regarding client care c. Planning other approaches for client care d. Following standards of practice

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Situation- Infections are quite commonly the reasons for clients hospitalization. Appropriate interpretation of diagnosis tests and measures for infection control are helpful in the management of client care. 56. Surgical asepsis is observed when: a. placing dirty soiled linen in moisture resistant bags b. washing hands before changing wound dressing c. inserting an intravenous catheter d. disposing of syringes and needles in puncture proof containers 57. Among the clients you are assigned to take care of, who is most susceptible to infection? a. Diabetic client c. Client with pulmonary emphysema b. Client with burns d. Client with myocardial infarction 58. A female client underweight diagnostic test and the result of blood examination are back. On reviewing the result, the nurse notices which of the following as abnormal finding? a. WBC 9000/mm c. ESR 39 mm/hr b. Neutrophils 60% d. Iron 75mg/100ml 59. A client with viral infection will most likely manifest which of the following during the illness stage of the infection? a. Client was exposed to the infection 2 days ago but without any symptoms b. Client feels sick but can do normal activities c. Acute symptoms are no longer visible d. Oral temperature shows fever 60. Which of the following laboratory test results indicate presence of an infectious process? a. Iron 90g/100mml c. Neutrophils 67% b. ESR 12 mm/hr d. WBC 18,000/mm3 Situation The practice of nursing goes with responsibilities and accountability whether you work in a hospital or in a community setting. Your main objective is to provide safe nursing to your clients? 61. You are assigned to a 49 years old female client who was admitted for possible surgery. She complained of recurrent pain at the right upper quadrant of the abdomen 1-2 hours after ingestion of fatty food. She also had frequent bouts of dizziness, blood pressure of 170/100, hot flashes. Which of the above symptoms would be an objective cue? a. Report of pain after ingestion of fatty food c. Complaint of hot flashes b. Complaint of frequent bouts of dizziness d. Blood pressure measurement of 170/100 62. The effectiveness of your nursing care plan for your clients is determined by: a. the number of nursing procedures performed to comfort the client b. the amount of medications administered to the client as ordered c. the outcome of nursing interventions based on plan of care d. the number of times the client calls the nurse 63. While talking with client, it is the most important for the nurse to: a. schedule the laboratory exams ordered for her b. have the client sign an informed consent c. does an assessment of the client to determine priority needs d. tell the client that your shift ends after eight hours 64. You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by: a. creating plans of care for particular clientele b. identifying the correct nursing diagnosis for clients

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c. d.

using standards of nursing care as your criteria for evaluation making a thorough assessment of client needs and problems

65. To provide safe quality nursing care to various clients in any setting, the most important tool of the nurse is: a. understanding of various nursing diagnoses b. critical thinking to decide appropriate nursing actions c. observation skill for data collection d. possession of scientific knowledge about client needs Situation You are taking care of a 48 year old woman who is unconscious after a cerebrovascular accident. You are aware that there are many physical complications due to immobility. 66. You are going to move a client, a 150 lbs. unconscious woman. Some principles to use when moving the client include the following, EXCEPT: a. maintain wide base of support with feet and with knees flexed b. move close to the object to be moved leaning or bending at the waist c. push and pull using arms and legs instead of lifting d. prepare to move client by taking a deep breath and tightening abdominal and gluteal muscles 67. Proper positioning of an immobilized unconscious client is important for the following reasons, EXCEPT: a. facilitates rest and sleep b. maintain skin integrity c. promotes optimal lung expansion d. prevent injuries and deformities of the musculo-skeletal system 68. When positioning the client, the nurse should observe good body mechanics for the nurse and the client. This means that the nurse: a. uses back muscles b. uses large muscles only c. observes rhythmic movements when moving about d. assumes correct body alignment and efficient use of muscles to avoid injury 69. After moving the client to the desired position, which action will you avoid? a. Avoid friction between bony prominences c. Apply restraints b. Place pillows to position clients extremities d. Raise bed rails 70. You should be alert for the following complications the client may experience, EXCEPT: a. impaired mobility c. contractures and muscle atrophy b. pressure sores d. hypostatic pneumonia Situation As you begin work in the hospital where you are on probation, you are tasked to take care of a few clients. The clients have varied needs and you are expected to provide care for them. 71. A 50 year old male executive is recovering from severe myocardial infarction. For the past 3 days, the clients hygiene and grooming needs have been met by the nursing staff. Which of the following activities should be implemented to achieve the goal of independence for the client? a. Preparing a day to day activity list to be followed by client b. Involving the client in his care c. Involving family members in meeting clients personal needs. d. Meeting clients needs till client is ready to perform self-care. 72. You are preparing a plan of care for a client who is experiencing pain related to incisional swelling following laminectomy. Which of the following should be included in the nursing care plan? a. Encourage the client to do self-care

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b. c. d.

Instruct the client to do deep breathing exercises Encourage the client to log roll when turning Ambulate the client in the ward premises every twenty minutes

73. An ambulatory client is being prepared for bed. Which of the following nursing actions promotes safety for the client? a. Turning off the lights to promote sleep and rest b. Raising the side rails c. Instructing the client about the use of the call system d. Placing the bed in high position 74. A male client is terminally ill and he chose to be at home with his family. What nursing actions are best initiated to prepare the family of the client? a. Provide support to the family members by teaching ways to care for their loved one b. Talk with the family members about the advantage of staying in the hospital for proper care c. Convince the client to stay in the hospital for professional care d. Tell the client to be with his family 75. A 25 year old female client is admitted with right lower quadrant abdominal pain. The physician diagnosed the client with acute appendicitis and an emergency appendectomy was performed. Twelve hours following surgery, the client complained of pain. Which of the following is the most appropriate nursing diagnosis? a. Impaired movements related to pain due to surgery b. Impaired mobility related to pain secondary to an abdominal incision c. Severe pain related to surgery d. Impaired mobility related to surgery Situation Preparation and administration of medications is a nursing function that cannot be delegated. It is important that the nurse has a deep understanding of this responsibility that is meant to save clients lives. 76. The physician ordered Nembutal Na gr XX. The bottle contains 200 mg/capsule. How many capsules will be administered to the client? a. capsule c. 1 capsules b. 1 capsule d. 2 capsules 77. Following surgery, a client is to receive 20 mEq (milliequivalent) of potassium chloride to be added to 1000 ml of D5W to run for 8 hours. The intravenous infusion set is calibrated at 20 drops per milliliter. How many drops per minute should the rate be to infuse 1 liter of D5W for 8 hours? a. 32 drops c. 20 drops b. 42 drops d. 60 drops 78. You are to administer an intramuscular injection to a 1 year old girl. The most appropriate site to administer the drug is: a. ventral forearm c. vastus lateralis b. gluteal region d. dorso gluteal region 79. An infant is ordered to receive 500 ml of D5NSS for 24 hours. The intravenous drip is running at 60 drops/minute. How many drops per minute should the flow rate be? a. 60 drops per minute c. 21 drops per minute b. 30 drops per minute d. 15 drops per minute 80. A male client is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately, how many drops per minutes should the IV be regulated? a. 15-16 drops c. 10-12 drops b. 17-18 drops d. 13-14 drops

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Situation Errors while providing nursing care to clients must be avoided and minimized at all times. Effective management or available resources enables the nurse to provide safe quality client care. 81. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nurse supervisor? a. Do the procedure with the nurse b. Assign another nurse to perform the procedure c. Tell the nurse to read the procedure manual d. Ask the nurse to find a way to learn the procedure 82. Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication practice related to this? a. Only officially approved abbreviations maybe used in the prescription orders b. Encourage clients to ask question about their medications c. Note both generic and brand name of the medication in the Medication Administration Record d. Maintain medication in its unit dose package until point of actual administration 83. The hospital has an on going quality assurance program. Which of the following indicates implementation of process standards? a. The unit has well ventilated medication room b. The nurse reports adverse reaction to drugs c. Average waiting time for medication administration is measured d. The nurses check clients identification band before giving medications 84. In the hospital where you work, increase incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of the nursing service department, probable causes were identified. Which of the following is process related? a. Interruptions c. Use of unofficial abbreviations b. Failure to identity client d. Lack of knowledge 85. Which of the following actions indicate that the nurse is performing outcome evaluation of quality care? a. Interviews nurses for comments regarding staffing b. Checks equipment for its calibration schedule c. Determine whether nurses perform skin assessment every shift d. Measures waiting time for clients per nurses call Situation You are a newly hired nurse in tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. 86. Modern day nursing has led to the development of the expanded role of the nurse as seen in the function of a: a. clinical nurse specialist c. staff nurse b. critical care nurse d. community health nurse 87. As you become socialized into the nursing culture you become a client advocate.. Advocacy is explained by the following EXCEPT: a. protecting and supporting another persons rights b. shared respect, trust and collaboration in meeting health needs c. respecting a persons right to be autonomous d. demonstrating loyalty to the institutions rights 88. Benners Proficient nurse level is different from other levels in nursing expertise in the context of having: a. a holistic understanding and perception of the client b. intuitive and analytic ability in new situations c. the ability to organize and plan activities

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d.

having attained an advanced level of education

89. You join a continuing education program to help you: a. gets in touch with colleagues in nursing b. updates your knowledge and skills related to field of interest c. enhance your basic knowledge d. earn credits for license renewal 90. Using the Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an: a. novice nurse c. advanced beginner b. competent nurse d. proficient nurse Situation You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility. 91. A male client asks to be assisted to move up the bed. Which of the following should the nurse do first? a. Move the client to the edge of the bed near the nurse b. Adjust the bed to a flat position c. Raise the bed rails opposite the nurse d. Lock the wheels of the bed 92. Which of the following supportive devices can be used most effectively by the nurse to prevent external rotation of the right leg? a. Pillow c. Sandbags b. Firm mattress d. High foot board 93. A male client has to be maintained on a dorsal recumbent position. Which of the following should be prevented? a. Hyperextension of the knees b. Lateral flexion of the sternocleidomastoid muscle c. Anterior flexion of lumbar curvature d. Adduction of the shoulder 94. A male client prefers to be in high fowlers position most of the time. The nurse should prevent which of the following? a. Posterior flexion of the lumbar c. Internal rotation of the shoulder curvature d. External rotation of the hip b. Adduction of the shoulder 95. A clients right leg is injured and the nurse has to move him from the bed to a wheelchair. Which of the following is the appropriate nursing action of the nurse? a. Face the client and place the wheelchair on her left aside b. Put the client on the edge of the bed and place the wheelchair on the clients left side. c. Put the client on the edge of the bed and place the wheelchair at her back d. Put the client on the edge of the bed and place the wheelchair on the other side of the bed Situation The clients chart is the permanent legal recording of all information that relates to health care management. As such, the entries in the chart must have accurate data. 96. A telephone order is given for a client in your ward. What is your most appropriate action? a. Write the order in the clients chart and have the head nurse co-sign it. b. Tell the physician that you can not take the order but you will call the nurse supervisor c. Repeat the order back to the physician, copy onto the order sheet and indicate that it is a telephone order

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d.

Copy the order onto the chart and sign the physicians name as close to his original signature as possible

97. Information in the clients chart is inadmissible in court as EVIDENCE when: a. the handwriting is not legible b. the clients family refuses to have it used c. it has too many abbreviations that are unofficial d. the client objects to its use 98. The clients chart contains all information about clients health care. The functions of records include all following, EXCEPT: a. recording of actions in advance to save time b. means of communication that health team members use to communicate their contributions to the clients health care c. the clients record also shows a document of how much health care agencies will be reimbursed for their services d. educational resource for student of nursing and medicine 99. An advantage of automated or computerized client care system is: a. the number of people to take care of the client will be reduced b. information concerning the client can be easily updated c. the nursing diagnoses for a clients data can be accurately determined d. cost of confinement will be reduced 100. a. b. c. d. Nursing audit aims to: compare actual nursing done to established standards provide information to health care providers provide research data to hospital personnel study clients illness and treatment regimen closely

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