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The document discusses several situations involving ethical principles and nursing practice:
1. A nurse ensures a patient properly consented to treatments, reflecting the ethical principle of autonomy.
2. A staff nurse refuses to perform duties for which she is unqualified, practicing the principle of non-maleficence.
3. A community health nurse uses active listening skills like clarifying during an education session to understand attendees' perspectives.
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Angelica Charisse BuliganCopyright
© © All Rights Reserved
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0 ratings0% found this document useful (0 votes)
633 views10 pagesPB3 NP4
The document discusses several situations involving ethical principles and nursing practice:
1. A nurse ensures a patient properly consented to treatments, reflecting the ethical principle of autonomy.
2. A staff nurse refuses to perform duties for which she is unqualified, practicing the principle of non-maleficence.
3. A community health nurse uses active listening skills like clarifying during an education session to understand attendees' perspectives.
Uploaded by
Angelica Charisse BuliganCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NP4 .
The Code of Ethics stipulates thathuman life is
6
inviolable. Which statement correctly translates the
ituation:Mrs. Clau, a 42-year-old patient, is admittedto
S principle to the situation of the Filipino nurse as a
the facility with a chief complaint of severe weakness professional?
after working the entire day. Assessment reveals she has
been experiencing weakness, which is more common . Participating in euthanasia is allowed provided there is
A
after a full day’s work, for almost two years a doctor's order
now. Results of her endocrine work-up confirm the B. Participation is permissible when the patient, family
diagnosis ofGrave’s Disease. and doctor have written agreement on it
C. After the patient, doctor and hospital administrator
. You are the nurse in charge of Mrs. Clau. Which among
1 have agreed, nurses may be allowed to participate
the following manifestations do younot expectto D. Nurses shall not participate in euthanasia
observe? →MERCY KILLING
. warm, moist skin
A . Kian, a patient diagnosed with Leukemia, is admitted to
7
B. weight gain the oncology unit. When thephysician insiststhatKian
C. bounding, rapid pulse undergoes radiation, which is contrary to the wishes of
D. fine, silky hair Kian and his family, the physician is exercising which of
the following?
. During endorsement, Nurse Ram told her co-nurse that
2
Nurse Shie, a newly registered nurse from another unit, is . Veracity
A
suffering from gonorrhea. Nurse Ram can be sued for B. Paternalism
which of the following? C. Autonomy
D. Fidelity
. Defamation
A
B. Slander →VERBAL DEFAMATION . Mohan, a 34-year-old Indian diagnosed with ESRD, is
8
C. Discrimination admitted to the hospital for kidney transplantation. He
D. Libel claims his donor is a Filipino relative as required by law.
Later on, it was discovered that his claim was not true. If
. Ms. Rafa, a Jehovah’s witness, is scheduled to undergo
3 the doctor fails to act accordingly to theincorrect
caesarean section. During pre-operative teaching, she information,the nurse must refer the case to whichof the
emphasized refusal to a blood transfusion intraoperatively. following?
Which of the following can be filled by Ms. Rafa if the
nurse proceeds to transfuse blood duringthe surgery? . Medical Director
A
B. Administrator
. Moral distress
A C. Ethics Committee
B. Battery D. Chief Executive Officer
C. Trespass to person
D. Assault ituation:Nurse Gigi, a community health educator,
S
conducts a teaching session on common allergy and
ituation:Nurses have a responsibility to upholdvalues
S hypersensitivity conditions. The session is attended by
and ethical standards in planning and adults and parents of children with similar conditions.
implementing patients’ plan of care. They must closely
adhere to the ethical principles and rules and not only to . Nurse Gigi conducts an interactive class with parents.
9
the laws. Which communication skill, if used by Nurse Gigi, involves
active listening that is used to gain an understandingof
. Nurse Lia is assigned to a patient who will undergo
4 the attendees’ message?
thyroidectomy. She ensures that the patient hasproperly
consented to all treatmentsand procedures. This reflects . Clarifying
A
which ethical principle? B. Responding
C. Attending
. Fidelity
A D. Confronting
B. Beneficence
C. Veracity 0. During the health education class, Nurse Gigi must be
1
D. Autonomy mindful of barriers in communication so that she can
_________.
. Bea, the head nurse of the Medical-Surgical ward, is
5
planning to deploy one of her staff nurses to the ICU due . Use them when communicating
A
to understaffing. If thestaff nurse refusesto perform B. Communicate better
duties for which she is not qualified, she is practicing C. Use them to enhance interactions
which principle? D. Rationalize wrong styles of communication
. Veracity
A 1. The mother of a child with atopic dermatitis named
1
B. Beneficence Nana is concerned about scarring that will result from
C. Respect Nana’s frequent scratching. How will the nurse best
D. Non-maleficence communicate her response?
. Asking the mother to tell Nana to endure the itchiness
A 6. Nurse Flores admits a 10-year-old female patient.
1
and irritation During the assessment, she notices multiple bruises on
B. Telling the mother matter-of-fact that scars will lighten the child and inquires with the mother about their origin.
as Nana grows older anyway The mother responds by stating that the child frequently
C. Tapping the hand of the mother while explaining experiences accidents and injures herself. In response,
that scarring occurs only when lesions get infected the nurse should ________:
D. Reminding the mother that beauty is only secondary to
comfort derived from scratching . Avoid probing as it pertains to family affairs.
A
B. Suggest that the child consult with a psychiatrist.
2. Nana’s mother tells Nurse Gigi that because of the
1 C. Keep assessing the situation further.
presence of skin lesions, Nana does not want to go out D. Have a confidential conversation with the mother.
anymore and she has been telling her mother howshe
hates herself. What would be Nurse Gigi’s best ituation:Potassium is an essentialelectrolyte thatplays
S
intervention? a vital role in various bodily functions, including muscle
contractions, nerve signaling, and maintaining a proper
. Instructing mother to go to Nana’s primary physician
A heart rhythm. Knowing this, Nurse Confucius applies his
B. Giving instructions and counselling on preventive understanding in the treatment of a patient
measures and treatments who has been admitted due tohypokalemia.
C. Referring them to the dermatologist
D. Referring them to the psychologist 7. Upon Nurse Confucius' evaluation, he determines that
1
he should concentrate on the assessment of _______:
3. Yasmin, a 23-year-old with chronic allergic rhinitis who
1
is taking diphenhydramine (Benadryl), verbalized her . Presence of Chvostek’s sign
A
concern about being sleepy during working hours, which B. Presence of edema
may cause her getting fired. The nurse will BEST calm C. Blood pressure
Yasmin by telling her that her physician can readily D. Heart rhythm
change hismedicineto ________.
8. Nurse Confucius reviews the physician's order, which
1
. Chlorpheniramine (Actifed)
A entails administering a30 mEq potassium bolus in100 ml
B. Brompheniramine (Dimetapp) of normal saline over 30 minutes→SHOULD NOT
C. Loratadine (Allerta) EXCEED 10-20 MEQ/HR.His most suitable course of
D. Dimenhydrinate (Dramamine) action is to _______:
ituation:Knowledge of the legal framework helps
S . Administer the potassium following the provided
A
nurses navigate complex ethical dilemmas and make instructions.
informed choices that uphold patient rights and B. Seek clarification from the physician regarding the
professional standards. Nurse Flores Ipsa Loquitur is order.
currently examining the legal aspects concerning nursing C. Ask the pharmacy to provide 250 ml of saline instead
practice, particularly those related to torts. of 100 ml.
D. Secure an infusion pump for potassium administration.
4. What is the MOST suitable course of action for Nurse
1
Flores after admitting a young woman who has reported 9. The doctor orders athrombolytic medicationforthe
1
beingphysically assaultedand sexually abused byher patient. In this context, it is understood that the intended
boyfriend? result of this drug therapy is to ______:
. Clean and bandage the client's wounds before the
A . Dissolve emboli, thereby reducing DNA damage.
A
physician proceeds with the physical examination. B. Enhance vascular permeability and increase cerebral
B. Remain with the patient throughout the physical blood flow.
examination. C. Reduce vascular permeability and enhance blood flow
C. Direct the patient to a psychiatrist for an assessment in the brain.
of her mental condition. D. Prevent further hemorrhage within the cerebral blood
D. Advocate for the patient to contact an attorney to vessels.
pursue legal action against her boyfriend.
0. Nurse Koykoy documents a nursing assessment.
2
5. Nurse Flores knows that there is a clear delineation
1 What would be a suitable nursing diagnosis for the young
between the terms “assault” and “battery”. She correctly child suffering fromJuvenile Rheumatoid Arthritis(JRA)?
recalls that“assault”is defined as: →6 MONTHS UNTIL 16 YRS OLD
. Employing physical coercion against another person
A . Impaired swallowing
A
without a valid legal justification. →BATTERY B. Total Incontinence
B. A civil wrong committed against a person or a person’s C. Impaired Physical Mobility
property →TORT D. Ineffective Airway Clearance
C. Expressing intentions to cause physical harm to an
individual. 1. The mother inquires Nurse Koykoy about the
2
D. An unlawful act committed against the community and appropriate steps to take after noticing her child's
subject to legal consequences enforced by the state and withdrawn demeanor. Nurse Koykoy's recommendationto
judicial system →CRIME the mother would be to ______:
D. dysthymia
. Advise the mother to consider arranging counseling for
A
the child as a therapeutic measure. 6. As per the research findings, thelikelihood ofdeath
2
B. Offer support and empathy to her child. within a year of diagnosis in individuals with both heart
C. Allocate additional time to spend with the child and failure and major depression is _______:
less time for her other children
D. Facilitate interactions between the child and other kids . Approximately equal to that of individuals with heart
A
with JRA. failure without major depression.
B. Twice as high as in individuals with heart failure
2. Which of the following statements regarding juvenile
2 alone.
rheumatoid arthritis (JRA) areaccurate? C. Three times greater than in individuals with heart
failure without major depression.
. JRA is the most common chronic condition in children
1 D. Tenfold compared to individuals with heart failure
under 16 years old. (+) without major depression.
2.The disease typically begins around the age of8 and
tends to peak during puberty. →PEAK: 1-3 YRS OLD 7. The study examined the factors of pharmacologic
2
3. Initial symptoms are often referred to as "growing intervention in clients with both heart failure and
pains." (+) depression as well as psychosocial and
4. Children with JRA generally have a more favorable psychotherapeutic interventions. The study revealed that
response to the medication Methotrexate (MTX) psychosocial and psychotherapeutic interventions
compared to adults. (+) _______:
. 1 & 2
A . Are notably less effective. → MEDICATIONS
A
B. 1 & 3 B. Tend to exacerbatedyspnea.
C. 1, 2, 3 & 4 C. May require a longer time to show effectiveness.
D. 1, 3 & 4 D. Are not favored by most clients.
ituation:Nurse Junas along with Nurse Juswa areboth
S ituation:Nurse Kiamoy, a nurse manager, plans to
S
examining the results of a recent study, which indicated conduct a refresher training for both the staff nurses and
that although individuals with depression may face an other healthcare team members regarding the proper
increased risk of heart failure, those with cardiovascular procedures for reporting and documenting any incidents
disease are more likely to experience that may occur within the units.
symptoms of depression.
8. Nurse Kiamoy explains to the staff that incident
2
3. The study also indicates thatmajor depressionis most
2 reports serve various purposes, with theexceptionof
commonly found among which of the following groups? → which of the following?
BELOW 40 YRS OLD
. Documenting and ensuring proper follow-up.
A
. Males
A B. Facilitating disciplinary measures.
B. Females C. Enhancing the quality of nursing services.
C.Individuals over the age of 60 D. Providing an objective account of unexpected
D.Individuals under the age of 60 incidents.
4. Both Nurse Junas and Nurse Juswa have come
2 9. Nurse Kiamoy also provided an example of a flawed
2
across information suggesting that clients with chronic reporting leading to a medication error. In this instance, a
heart failure experience the most significantmood 10-year-old child was admitted to the emergency
disturbanceswhen they ________: department. One nurse recorded the child's weight
inaccurately in the chart. Subsequently, another nurse
. Are uncertain regarding the progression of the
A calculated the medication dosage using this erroneous
disease. data, resulting in thechild receiving twice the required
B. Have a history of leading highly active lives. dose. The error was identified after the child hadtaken
C. Face difficulty in maintaining employment. the medication. What is the MOST appropriate course of
D. Also have other cardiovascular disorders. action for the medication nurse to take?
5. In the study of persistent depressive conditions, a
2 . Document the incident in an incident report.
A
term used to describe a state in which the client B. Communicate with the nurse who inaccurately
encountersfewer than five depression symptoms lasting transcribed the weight.
for a duration of two yearsis referred to as _______. C. Skip the second dose.
D. Closely monitor the child for any drug-related side
. minor depression →EPISODES OF AT LEAST 2 WKS
A effects and promptly inform the physician.
OF DEPPRESSIVE SX BUT WITH FEWER THAN 5
CRITERRIA TO DX MDD 0. Nurse Kiamoy further stressed that incidents that are
3
B. major depression →SX OF DEPRESSED MOOD FOR reported will undergoinvestigation_____.
AT LEAST 2 WKS, INTERFERS ADLS
C. depression psychosis →SEVERE DEPRESSION, . Promptly following the incident.
A
DEPPRESSION ALONG WITH PSYCHOTIC DELUSION, B. Within 24 hours following the incident.
HALLUCINATIONS
. Once the patient has been discharged from the
C indicates a diagnosis of aleft-sided cerebrovascular
hospital. accident (CVA)resulting in flaccid hemiplegia ofhis right
D. After consulting with the patient's attending physician. side. Nurse Chikungunya maps out a nursing care plan
for the patient.
1. As a nurse manager, Nurse Kiamoy also
3
characterized the process of documenting a client's 6. Nurse Chikungunya formulates anursing diagnosisfor
3
records, which encompasses incident reports, subsequent the client. Upon her deliberation, which of the following
actions, and follow-up, as: nursing diagnoses is the most suitable option?
. Recording
A . Unilateral Neglect
A
B. Implementation B. Impaired Physical Mobility
C. Investigation C. Sleep Pattern Disturbance
D. Consulting D. Activity intolerance
2. The nurse manager clarifies that incidents that must
3 7. Within the first 24 hours of admission, acrucial
3
be documentedencompass all of the following,EXCEPT: assessmentthat Nurse Chiki would conduct is an
evaluation of the client's:
. Complaints voiced by a client or their family regarding
A
the care they received. . Risk factors for vascular disease
A
B. Complaints from a staff nurse concerning a client B. Health behaviors prior to admission
who exhibits disruptive and uncooperative behavior. C. Patterns of urinary elimination
C. Instances where a client declines treatment. D. Size of the pupils and their response to light
D. Any unexpected or unexplained event that has an
impact on, or the potential to impact, a client, a family 8. Nurse Chiki conducts afunctional status assessment
3
member, or staff. of the client both before and after the CVA because it is
crucial for which of the following purposes?
3. During the nurse's assessment, the child mentions
3
that thepain has disappeared, and there is no longerany . Providing direction for the development of a
A
discomfort in his abdomen. In this situation, the nurse rehabilitation plan.
might consider that the: B. Assisting the client in anticipating the potential
recovery of their functioning.
. The child might be anxious about undergoing surgery.
A C. Predicting the outcomes based on the client's
B. The child could be struggling to communicate their functional status before the CVA.
pain effectively. D. Aiding the client in understanding their physical
C. The child may be seeking additional attention. limitations.
D. The appendix may have ruptured.
ituation:Mr. Katsudon has heightened concerns about
S
4. The client's diagnosis has been verified, and the client
3 the well-being of his eyes due to a family history of visual
is set to undergo an appendectomy. Which of the issues. His mother had experienced glaucoma, and his
following actions are included in thepreoperativenursing older brother also developed this same eye condition.
care?
9. Mr. Katsudon inquires the nurse about the most
3
. Evaluate abdominal distention and listen to bowel
A effective ways to prevent glaucoma. The nurse's response
sounds to assess bowel activity. includes which of the following points related to primary
B. Position the child on their left side to localize and open-angle glaucoma? →PERIPHERAL VISION=
prevent the spread of infection. TUNNEL VISION
C. Administer alaxativeas prescribed.
D. Apply warm compresses to the child's abdominal area . Utilizing protective eyewear and avoiding impacts to
A
to alleviate discomfort. the head and neck.
B. Restricting exercises that raise blood pressure and
5. The nurse gets the child ready for surgery. What
3 avoiding sudden temperature changes.
nursing actions should the nurse take from the following C. Regularly conducting optic nerve assessments and
options: tonometry tests during eye examinations.
D. Using proper lighting and maintaining a well- balanced
OURCE ISOLATION– PTS IS INFECTIVE
S diet with sufficient vitamin A intake.
REVERSE ISOLATION– PTX IMMUNOCOMPROMISED
STRICT ISOLATION– HIGHLY INFECTIOUS PT 0. Nurse Oyakodon has identified Mr. Katsudon as
4
having a visual sensory and perceptual issue related to
. Provide clear fluids.
A elevated intraocular pressure. Thecare planshould
B. Ensure complete bed rest. primarily concentrate on:
C. Apply warmth to the abdominal area.
D. Administer an enema as directed. . Managing the intense pain experienced until the optic
A
nerve undergoes atrophy.
ituation:A 70-year-old male patient arrives at the
S B. Acknowledging that damage caused by glaucoma can
emergency department with a complaint of being unable only be reversed in the advanced stages of the disease.
to move his right arm and leg, and he has no muscle tone C. Providing guidance in advance about the potential loss
in that side. The initial assessment by the physician of peripheral vision.
. Promoting adherence to prescribed medication to
D 6. Which of the ensuing principles should be followed to
4
prevent vision loss. decrease the likelihood of infectionin a patient
undergoing skeletal traction? →INVASIVE PROCEDURE
1. Mr. Katsudon is receiving instruction on how to apply
4
one drop of 1% pilocarpine hydrochloride eye drops three . Initiate antibiotic treatment for the patient at least 24
A
times daily. Nurse Oyakodon shouldinformhim thathe: hours before the procedure.
B. Administer the skeletal traction while the patient is
. Needs to check his pulse before using the drops.
A under general anesthesia.
B. May encounter some temporary blurring of vision C. Apply skeletal traction under sterile conditions.
after applying the drops. D. Implement counter-tractions immediately after placing
C. Might experience a tingling sensation in his fingers skeletal pins.
after using the drops.
D. Should keep his eyes closed for20 minutesafter 7. A client in skeletal traction faces an elevated infection
4
applying the drops. risk. Which of the subsequent pin site locations are
regarded as having ahigher susceptibility to infection?
2. When severely high intraocular pressure occurs as a
4
result ofintravenous mannitol, the eye doctor might . Pins inserted through the skin.
A
contemplate treatment. Which nursing intervention should B. Pins inserted directly through the bone.
be prioritized? C. Areas within the line of pull.
D. Locations with substantial soft tissue
. Regularly monitor blood sugar levels.
A →RELATIVELY LOWER BLOOD SUPPLY
B. Place patches over both eyes.
C. Maintain well-lit conditions in the room. 8. Properly caring for pin sites is crucial nursing care for
4
D. Monitor and record all fluid intake and output. patients in skeletal traction to minimize the infection risk.
Which of the followingcleansing solutionsis theMOST
3. What are the fundamental elements included in a
4 efficient?
nursing model ofevidence-based practice?
. Chlorhexidine solution
A
. Integration of medical and nursing approaches to
A B. Soapsuds solution
deliver patient-focused care. C. Hydrochloric Acid Solution
B. Utilization of top medical research, clinical nursing D. Acetic Acid Solution
proficiency, and client preferences.
C. Incorporation of the best research evidence, ituation:Nurse Lubby Santa is working as a staffnurse
S
clinical expertise, and the patient's values and in the ENT department of a government hospital. The
preferences. department presented the results of a survey done on the
D. Incorporation of clinical research, topmost medical incidence of hearing loss in a barangay near an airport.
practices, and patient's values and preferences.
9. What would be thegoal of cooperativecare among
4
4. Which of the subsequent research categories entails
4 the following options?
the methodical gathering ofnumerical data, oftenwith
substantial control? . Addressing symptoms and mitigating the risk of
A
hearing loss.
. Historical
A B. Recognizing which barangay residents require
B. Phenomenology hospitalization.
C. Qualitative C. Organizing a medical mission to provide treatment to
D. Quantitative affected barangay residents.
D. Determining which barangay residents require
5. To comprehend how adolescents aged 16-18perceive
4 additional testing.
teenage pregnancy, which research design would bethe
most suitable for addressing this research issue? 0. The multidisciplinary team engaged in the research
5
opted to conduct additional diagnostic examinations on
. Grounded Theory
A specific patients to assess their hearing abilities. The
B. Ethnography diagnostic test to be performed will be:
C. Qualitative
D. Phenomenology . Whisper test
A
- PERCEPTIONS B. Rinne and Weber test
- LIVED EXPERIENCES C. Audiometry → COMPREHENSIVE TEST
- MEANINGFUL EXPERIENES D. CT scan
ituation:Nurse Bing Bong is currently working inthe
S 1. What kind of goals would Nurse Lubby Santa
5
orthopedic ward in which there is a noticeable rise in establish for the barangay residents dealing with inner ear
infection cases among patients in skeletal traction. Thus, issues among the following options?
the risk management committee attempts to investigate
the level of knowledge among the staff nurses regarding . Self-care: Activities of Daily Living (ADLs)
A
this incident. B. Level of physical mobility
C. Respiratory status: Behavior
D. Safety measures: Preventing falls
. HIV can be transmitted through sexual intercourse
A
2. What would be the primary emphasis of Nurse Lubby
5 with an infected partner.
Santa’s health education for the barangay residents B. Engaging in oral sex is considered to carry some risk.
among the following options? C. Exposure of mucous membranes, such as getting
splashes in the eyes or mouth.
. Addressing deficits and creating coping strategies.
A D. Anal intercourse is the primary mode of HIV
B. Managing nutrition transmission. →VAGINAL
C. Maintaining hearing aid care
D. Avoiding potential complications 8. A patient’s family member inquired about the meaning
5
ofHIV seropositivity. Your response will be:
3. As part of preventive and promotive care functions of
5
Nurse Lubby Santa, which of the subsequent . The individual tested is not currently capable of
A
health-promotion practices represents the most effective infecting others.
approach to prevent hearing impairment among the B. A person infected with HIV can potentially transmit
barangay residents? the virus to their sexual partner.
C. After five years, an infected individual may be eligible
. Care of the ears and ear canal.
A to donate blood.
B. Advocating for environmental noise regulation and D. Through proper medication, the infected person may
the use of ear protection. cease to be infectious within two months.
C. Employing earplugs to safeguard the ears while
swimming or driving. ituation:The Quality Department has received
S
D. Inspecting the hearing aid for blockages. numerous complaints, including some related to patient
falls, which prompted the department to call out agency
ituation:Mr. Mingming, a patient struggling withheroin
S risk management committee.
addiction, is suspected to have HIV-related
complications. Upon recognizing the client’s potential 9. A 54-year-old patient named Meiji was admitted for
5
needs and risks, a nursing care plan for Mr. Mingming fever and experienced a fall from the bed despite the
was set out. presence of a caregiver. The head nurse is concerned
because a fall prevention protocol has been in place for
4. The most likelyreasonfor Mr. Mingming's HIV
5 some time. To prevent similar incidents, what is themost
infection is _______. suitable course of actionfor the head nurse to takein this
situation?
. Being exposed to contaminated bodily fluids
A
B. Having unprotected anal intercourse . Conduct an interview with the nurse on duty.
A
C. His heroin addiction B. Conduct an interview with the patient.
D. Engaging in unprotected sexual activity with his C. Perform a root cause analysis.
fiancée D. Initiate an investigation involving all relevant parties.
5. Mr. Mingming received apositive HIV test result.What
5 0. The nurse reported to the head nurse that the side rail
6
explanation can you provide him regarding this diagnosis? lock sometimes malfunctions and may have become
loose during the night, contributing to the fall incident.
. "You have received a diagnosis of HIV, which is the
A What is the most suitable action for the head nurse to
precursor to AIDS." take in response?
B. "Antibodies to the HIV virus have been detected in
your bloodstream." . Discipline the nurse on duty for failing to report the
A
C. "This indicates that you won't necessarily develop observation prior to the incident.
AIDS in the future." B. Issue a warning to everyone that such lapses will not
D. "Currently, the AIDS virus is not actively replicating be tolerated in the future.
in your blood." C. Implement penalties for all nurses for not reporting the
defect.
6. During your morning medical rounds, you observed
5 D. Draft a memorandum to the Maintenance
that Mr. Papi is experiencingcough, breathlessness,and Department requesting an inspection of the involved
rapid breathing. Which opportunistic infection islikely bed and all other beds.
responsible for these symptoms?
1. The quality improvement officer responsible for the
6
. Cryptococcus neoformans → CNS, LUNGS
A units intends to hold a staff meeting. The PRIMARY focus
B. Toxoplasma gondii of the meeting is to:
C. Cytomegalovirus
D. Pneumocystis carinii . Review the established protocol.
A
B. Address any identified shortcomings.
7. On another occasion, Mr. Papi received a visit from
5 C. Reprimand those who are involved.
his girlfriend, Samara, who confessed to having engaged D. Provide information about potential consequences.
in sexual activity with him. When discussing risky sexual 62. What is the FIRST step the nurse should take
behaviors, which of the following will you inform Samara immediately after the fall to alleviate the situation?
isnot a contributing risk factor?
A. Await the arrival of the head nurse.
. Arrange for an immediate assessment of the
B D. Position the fingers so they are barely flexed.
patient by a doctor.
C. Promptly document the incident. ituation:Cookie, a 22-year-old nurse in the general
S
D. Call the head nurse to report the incident. ward, is currently experiencing contact dermatitis from
gloves.
63. What takeaway will the nurse gain from this incident?
9. Individuals who developdelayed hypersensitivityto
6
. Avoid admitting to any mistakes or oversights.
A latex→LOCALIZED SKIN ALLERGYoften report
B. Ensure that her omissions go unnoticed. symptomssuch as ______.
C. Emphasize the importance of reporting even minor
yet pertinent observations with a focus on safety. . Rhinitis, conjunctivitis, and blisters
A
D. Encourage others to cover her up. B. Papules, vesicles, and pruritus
C. Urticaria and laryngeal edema
ituation:Beshywap, a 64-year-old entrepreneur, was
S D. Flushing and bronchospasm
taken to the Emergency Room due to experiencing
numbness in her left face and arm, along with confusion. 0. The nurse understands that the diagnosis ofcontact
7
The ER doctor's initial assessment indicates a possible latex allergyis typically based on a patient's historyand
ischemic stroke. ______.
4. Beshywap is curious about thecausebehind her
6 . A skin patch test
A
ischemic stroke symptoms. This suggests that there is: B. The presence of IgE in serum
C. ELISA testing
. A potential presence of a cerebral aneurysm.
A D. Latex-specific IgE levels
B. Spasm of cerebral blood vessels, leading to reduced
blood flow to the brain. 1. Latex allergy, in its mostsevere form, can presentas
7
C. Extravasation of blood into the brain. _______.
D. Blockage in the blood flow within cerebral blood
vessels. . Blisters and other skin lesions
A
B. Pruritus, erythema, and swelling
5. The nurse is aware that stroke can lead to
6 C. Asthma
visual-perceptual issues. When patient Beshywap exhibits D. Anaphylaxis
hemianopsia, it means she experiences:
2. Type I IgE-mediatedimmediate hypersensitivity
7
. Partial blindness affecting half of her visual field.
A reactions are promptly managed with _________.
B. Difficulty comprehending spoken language.
C. Challenges in carrying out everyday movements and . Epinephrine
A
actions. B. Corticosteroids
D. Speech difficulties. C. Diphenhydramine
D. Theophylline
6. The nurse is aware that theinitial diagnostictest
6
ordered for stroke is ______. 3. The most effectiveway to preventcontact latexallergy
7
is __________.
. Carotid ultrasound
A
B. MRI . Quitting the job
A
C. CT scan B. Steering clear of rubberized items
D. 12-lead ECG C. Avoiding latex products
D. Applying lotion before putting on gloves
7. The ER nurse expects that a thrombolytic agent may
6
be prescribed to treat ischemic attacks. Understanding ituation:Nurses can make mistakes by either
S
the actions ofthrombolytics, the nurse should be neglecting their responsibilities or taking inappropriate
particularly vigilant for whichadverse reaction? actions while performing their duties. Therefore, they
should exercise extra caution.
. Allergies
A
B. Early onset of infection 4. The patient scheduled for a breast biopsy is highly
7
C. Formation of blood clots anxious and appears to havedifficulty understandingher
D. Bleeding recommended procedure,which is a radical mastectomy.
What is the appropriate course of action for the nurse?
8. Patient Beshywap has complained of shoulder pain.
6
The nurse recognizes that she is susceptible toshoulder . Provide the patient with the information that was not
A
adduction. A nursing intervention for this situationis to explained by the doctor.
_______. B. Ask the doctor to provide the patient with more
information
. Insert one pillow in the axilla to keep the arm away
A C. Request the available resident to provide further
from the chest. explanation about the surgery
B. Place a pillow under the arm to keep it close to the D. Contact the supervisor to clarify the procedure
chest.
C. Position the distal joint higher than the proximal joint.
5. The patient declined his/her intramuscular injection,
7 . Because food may interfere with the metabolism of
A
but thenurse administered it against the patient’s wishes. medications.
What might the nurse be accused of? B. To avoid the costs of parenteral feeding.
C. When the client is able to obtain adequate nutritional
. Battery
A requirements by eating.
B. Assault D. For post-operative gastric bypass patients.
C. Moral distress
D. Trespass to person 2. Acontraindicationfor enteral feeding includeswhich
8
of the following patient characteristics?
6. The staff nurse was administering prescribed modified
7
steam inhalation to a pediatric patient, resulting in burns. . Febrile
A
Which statement isNOT relevant in establishing B. Agitated
negligence? C. Unable to swallow →RISK FOR ASPIRATION
D. With suicidal tendencies
. There is a breach of the standard
A
B. The breach caused the harm 3. While reviewing your lectures, you noted that this
8
C. It was a verbal order from the physician statement is true regarding nasogastric tubes.
D. There is a duty of care “Nasogastric tubes…”
ituation:Patient Sally, 2 ½ years old, is broughtto the
S . “Do not require pumps for continuous infusions”.
A
ER for vomiting. According to her mother, Sally vomited B. “Are used for short-term therapy”.
eight times in one day and passed out greenish liquid C. “Should be inserted by a physician”.
stools. Gastroenteritis is the preliminary diagnosis. D. “Containeyeletsalong the tube which help in
controlling flow and reducing clogging”.
7. You are Patient Sally’s nurse. You assess the child
7
and observe her to bemoderately dehydrated. Your 4. Proper insertion of a nasogastric tube is needed for
8
observation is based on which of the followingsigns? patient safety. Which landmarks are involved asmarkers
in inserting NG tubes?
. Diaphoresis
A
B. Absence of tear formation . Sternal notch, nasal bridge, and xiphoid process
A
C. Decreased urine specific gravity B. Xiphoid process, umbilicus, and tip of nose
D. Vomiting C. Top of forehead, nares, and sternal notch
D. Tip ofNo
se, tip ofEar, andXiphoid process →[NEX]
8. Patient Sally is prescribed 250 mL of intravenous
7
fluids to run every four hours. What rate will you set the 5. Nurse Pia is aware of herresponsibilitieswhengiving
8
infusion pump on? medications to a patient with enteral feeding. Which of the
following option(s) is/are correct?
. 10 mL/hour
A
B. 12 mL/hour . Coordinate with the pharmacist regarding the timing of
A
C. 25 mL/hour medications.
D. 63 mL/hour B. Dilute liquid medications with water.
C. Do not mix feedings and medications.
9.Before you add potassium chlorideto the IV fluid,you
7 D. All of the above.
should first ensure that Sally has had:
ituation:Mr. Santos, a 45-year-old male, is admittedto
S
. An ECG baseline → HYPERKALEMIA
A the oncology unit for prostate cancer. Nurse
B. Defecated Kate interacts with the patient who is scheduled for
C. Voided →RENALFUNCTION→REDUCERISKOF prostatectomy.
HYPERKALEMIA
D. A laboratory test for serum calcium level 6. Mr. Santos says, “I feel nervous thinking about the
8
operation I am going to have tomorrow”. As the nurse,
0. Patient Sally is on fluid resuscitation for hours. As her
8 what is your best response?
nurse, you suspect that the child is experiencing
circulatory overloadwhen upon assessment, you noted . “I will ask your doctor for some medication to help you
A
that there is? relax”.
B. “Before admission, you should have asked other
A. A drop in blood pressure patients who underwent prostatectomy about what they
B. A change in respiration to slow and deep breathing felt and experienced”.
C. Moist crackles upon auscultation →PULMO EDEMA C. “Doctor Ausquin is the best surgeon in this hospital, so
D. A marked decrease in urine output you are in good hands!”
D. “It is alright to feel nervous. I don’t recall anyone
81. The doctor’s order reads that enteral feeding should who was not nervous before an operation”.
be started for a patient admitted under acute emergency
care. As a knowledgeable nurse, you know thatenteral 87. Mr. Santos becomes irritated and agitated, telling
feeding is ordered__________. Nurse Kate, “I am now unsure that I want to be operated
on!” Nurse Kate’smost therapeutic responseis:
. “You seem upset about your upcoming operation”.
A
B. “You don’t want to have the operation now?” 4. Nurse Thalia is monitoring the patient. She alerts the
9
C. “I will call your doctor so he can help you”. team when which respiratory sign is assessed, indicating
D. “Do you want me to call on the doctor so he can that there isincreasing intracranial pressureinthe
postpone the operation for now?” brainstem?
8. Mr. Santos continues, saying, “I don’t know if I can
8 . Nasal flaring
A
survive the operation”. Nurse Kate wouldnot wantto reply B. Asymmetric chest excursion
which? C. Rapid, shallow respirations
D. Slow, irregular respirations
. “You fear that you’ll die?”
A
B. “Don’t worry, everything will be okay”. 5. Nurse Thalia should be alert for the earliest indication
9
C. “Undergoing an operation can be a frightening ofneurologic deteriorationin the client, which is?
experience”.
D. “You sound afraid”. . Fixed, dilated pupils
A
B. Widening pulse pressure
9. Mr. Santos says to Nurse Kate,“My wife is quite
8 C. Bradycardia
upset because she thinks that the surgery will make D. A change in level of consciousness
me impotent”. Nurse Kate’sbest responseshould be:
ituation:Nurse Pia from the oncology unit is caringfor
S
. “I am positive that your wife loves you enough to make
A Patient Elle, 35-years-old, female, diagnosed with
this sacrifice, especially if it’s for your own health and colon cancer.
well-being”.
B. “The surgeon will be very careful and precise during 6. Elle tells Nurse Pia that she has a family history of
9
the operation”. colon cancer. Which is the mostappropriate actionby
C. “Your wife may not be as keen about sex than you Nurse Pia?
think she is”.
D. “Let’s talk about how you feel regarding the .Inform the patient to ask her physician about
A
operation”. diagnostic tests that specify colon cancer.
B. Educate the patient that she needs to undergo a
0. “I think I am going to die on the operating table.” To
9 colonoscopy once she reaches 50 years old.
which, Nurse Kate responds,“You feel as though you C. Instruct the patient step-by-step on how to get a
are going to die?”Whichtherapeutic communication stool specimen for occult blood.
techniquedid Nurse Kate utilize? D.Tell the patient to inform her physician of herneed for
a sigmoidoscopy which helps provide baseline data for
. Validating →RESTATING
A patients with colon cancer.
B. Reflecting
C.Paraphrasing 7. Patient Elle is scheduled for external radiation therapy
9
D. Focusing to the abdomen. Which information belowwarrants further
informationby the nurse-in-charge? The patient _____.
ituation:Nurse Thalia is working in the emergency
S
room. A 22-year-old vehicular accident victim is brought to . Swims in chlorinated pools five days a week. →IT
A
the ER with apparent head injury. He is unconscious and CAN CAUSE IRRITATION, DRYING→LESIONS
exhibiting signs of increasing ICP. B. Showers with a moisturizing soap everyday.
C. Eats a small amount of food five to six times during
1. When the patient arrives in the ER, theinitialpriority
9 the day.
is? D. Has a history of dental caries.
. Stopping bleeding from the open head wound.
A 8. The physician comes in and tells the patient, “The
9
B. Replacing blood loss. tumor cells in the bowels arepoorly differentiated”.If Elle
C. Establishing an airway. asks Nurse Pia what this means, Nurse Pia knows that:
D. Assessing if there is fracture in the cervical area.
. “The tumor cells have DNA that is different from your
A
92. The most appropriatepositionfor this patientis? normal bowel cells”.
B. “These are immature fetal cells which look different
. Left Sim’s
A from normal bowel cells”.
B. Trendelenburg C. “The cells in the tumor have mutated from normal
C. Elevate head using two pillows bowel cells”.
D. Elevate head of bed to 30-45 degrees D. “The cells in your tumor do not look any different from
normal bowel cells”.
3. Nurse Thalia should be aware of thesigns of
9
increasing ICP, which includes? 9. Patient Elle appearsirritated, anxious, and angry,
9
leading Nurse Pia to the nursing diagnosis, “Anxiety
. Unequal pupil size
A related to fear of the unknown, as manifested by anger”.
B. Tachycardia To provide more information related to the patient’s
C. Decreasing body temperature medical diagnosis, the most appropriate action to be done
D. Decreasing systolic pressure for the patient is?
. Provide suggestions to modify the patient’s
A
expression of anger.
B. List a detailed plan for future interventions.
C. Simply explain the proposed treatments to the patient.
D. Educate the patient on specific yet simple scientific
facts related to colon cancer.
00. As a knowledgeable nurse, you are aware that the
1
legal terminology used in child abuse is “battery”.Battery
pertains to:
. Performing an act that a prudent person with the same
A
education or experience would not do.
B. A legal wrong done by one person against the
property of another.
C. Threatening the character of a person while
attempting to do bodily harm.
D. Applying brute force to another person without
lawful justification.
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