SIMULATION 22

NURSE LICENSURE EXAMINATION

INTEGRATED COMPREHENSIVE TEST I
INSTRUCTION: Select the best answer for each of the following questions. Mark only one answer
for each item by shading the box the box corresponding to the letter of your choice on the answer
sheet provided. Strictly no erasures allowed. Use pencil no. 2 only.

Situation 1: Nursing is a profession. The nurse should have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of
the individuals families, communities and the population. This is the most accepted definition of nursing as
defined by the:
a. PNA
b. ANA

c. Nightingale
d. Henderson

2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is
NOT an expanded career role for nurses?
a. Nurse practitioner
b. Clinical nurse specialist

c. Nurse researcher
d. Nurse anesthesiologist

3. The board of Nursing regulated the Nursing Profession in the Philippines and is responsible for the
maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the
following EXCEPT:
a. Issue, suspend, revoke certificates of registration
b. Issue subpoena duces tecum, ad testificandum
c. Open and close colleges of nursing
d. Supervise and regulate the practice of Nursing
4. A nursing student or a beginning staff nurse who has not yet experienced enough real situations to make
judgments about them is in what stage of Nursing Expertise?
a. Novice
b. Newbie

c. Advanced beginner
d. Competent

5. Benners Proficient nurse level is different from the other levels in nursing expertise in the context of
having:
a. the ability to organize and plan activities
b. having attained an advanced level of education
c. a holistic understanding and perception of the client
d. intuitive and analytic ability in new situations

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Situation 2: The nurse has been asked to administer and injection via Z-TRACK technique. Questions 6 to 10
refer to this.
6. The nurse prepares an IM injection for an adult client using the Z tract technique 4 ml of medication is to be
administered to the client. Which of the following site will you choose?
a. Deltoid
b. Rectus femoris

c. Ventrogluteal
d. Vastus lateralis

7. In infants 1 year old and below, which of the following is the site of choice for intramuscular injection?
a. Deltoid
b. Rectus femoris

c. Ventrogluteal
d. Vastus lateralis

8. In order to decrease discomfort in Z track administration, which of the following the nurse should do?
a. Pierce the skin quickly and smoothly at a 90 degree angle.
b. Inject the medication readily at around 10 minutes per milliliter
c. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel.
d. Pierce skin slowly and carefully at a 90 degree angle.
9. After injection using the Z track technique, the nurse should know that she needs to wait for a few seconds
before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue thus
decreasing the clients discomfort. How many seconds should the nurse wait before withdrawing the
needle?
a. 2 seconds
b. 5 seconds

c. 10 seconds
d. 15 seconds

10. The rationale using the Z tract technique in an intramuscular injection is:
a. It decreases the leakage of discoloring and irritating mediations into the subcutaneous tissues
b. It will allow a faster absorption of the medication
c. The Z track technique prevent irritation of the muscle
d. It is much more convenient for the nurse
SITUATION 3: A client was rushed to the emergency room and you are his attending nurse. You are
performing a vital sign assessment.
11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
a. Take the blood pressure reading on both arms for comparison
b. Listen to and identify the phases of Korotkoffs sound
c. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
d. Observe procedures for infection control
12. You attached a pulse oximeter to the client. You know that the purpose is to:
a. Determine if the clients hemoglobin level is low and if he needs blood transfusion
b. Check level of clients tissue perfusion
c. Measure the efficacy of the clients antihypertensive medications
d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
13. After a few hours in the Emergency Room, the client is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood
pressure reading to be:
a. Inconsistent
b. Low systolic and high diastolic
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c. Higher than what the reading should be

d. Lower than what the reading should be
14. Through the clients health history, you gather that the patient smokes and drinks coffee. When taking the
blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before
taking the clients blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes

c. 1 hour
d. 5 minutes

15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining of the area where
the oximeter is. Your action will be to:
a. Set and turn on the alarm of the oximeter
b. Do nothing since there is no identified problem
c. Cover the fingertip sensor with a towel or bed sheet
d. Change the location of the sensor every four hours.
16. The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the
nurse should wait for a period of:
a. 15 seconds
b. 1 to 2 minutes

c. 30 minutes
d. 15 minutes

17. If the arm is said to be elevated when taking the blood pressure, it will create a:
a. False high reading
b. False low reading

c. True false reading

d. Indeterminate

18. You are to assess the temperature of the client the next morning and found out that he ate ice cream. How
many minutes should you wait before assessing the clients oral temperature?
a. 10 minutes
b. 20 minutes

c. 30 minutes
d. 15 minutes

19. When auscultating the clients blood pressure the nurse hears the following: from 150 mmHg to 130 mmHg;
silence, then: a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80
mmHg and then silence. What in the clients blood pressure?
a. 130/80
b. 150/100

c. 100/80
d. 150/100

20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood
pressure cuff to obtain an accurate reading?
a. 10-20 seconds
b. 30-45 seconds

c. 1-1.5 minutes
d. 3-3.5 minutes

Situation 4: Oral care is an important part of hygienic practices and promoting client comfort.
21. 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?
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a. Lemon glycerin
b. Hydrogen peroxide

c. Mineral oil
d. Normal saline solution

22. 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. Put the client on a sideling position with head of bed lowered
b. Keep the client dry by placing towel under the chin
c. Wash hand and observe appropriate infection control
d. Clean mouth with oral swabs in a careful and an orderly progression
23. The advantages of oral care for a client include all of the following EXCEPT:
a. Decreases bacteria in the mouth and teeth
b. Reduces need to use commercial mouthwash which irritate the buccal mucosa
c. Improves clients appearance and self confidence
d. Improves appetite and taste of food
24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to lungs. this
can be avoided by:
a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity
b. Swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs
c. Use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums
d. Suctioning as needed while cleaning the buccal cavity
25. 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. Salt solution
b. Water

c. Petroleum jelly
d. Mentholated ointment

Situation 5: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of
the nurse.
26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following
prior to the procedure?
a. Clenching his fist every 2 minutes
b. Breathing in and out through the nose with his mouth open
c. Tensing the shoulder muscles while lying on his back
d. Holding his breath periodically for 30 seconds
27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible
complication:
a. Nausea and vomiting
b. Shortness of breath and laryngeal stridor
c. Blood tinged sputum and coughing
d. Sore throat and hoarseness
28. Immediately after bronchoscopy, you instructed Fernan to:
a.
b.
c.
d.

Exercise the neck muscles

Breathe deeply
Refrain from coughing and talking
Clear his throat

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29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important
function during the procedure is to:
a. Keep the sterile equipment from contamination
b. Assist the physician
c. Open and close the three-way stopcock
d. Observe the patients vital signs
30. Right after thoracentesis, which of the following is most appropriate intervention?
a. Instruct the patient not to cough or deep breath for two hours
b. Observe for symptoms of tightness of chest or bleeding
c. Place an ice pack to the puncture site
d. Remove the dressing to check for bleeding
Situation 6: Knowledge of the acid-base disturbance and the functions of electrolytes is necessary to
determine appropriate intervention and nursing actions.
31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is
at most risk for the development of which type of acid-base imbalance?
a. Respiratory acidosis
b. Metabolic acidosis

c. Respiratory alkalosis
d. Metabolic alkalosis

32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32
mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base
disturbance?
a. Respiratory acidosis
b. Respiratory alkalosis

c. Metabolic acidosis
d. Metabolic alkalosis

33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the
following has been performed or tested before the ABG specimens are drawn?
a. Guthrie test
b. Allens test

c. Rombergs test
d. Webers test

34. A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, PCO2 is 50
mmHg, and the bicarbonate is 27 mEq/L. the nurse concludes that which acid base disturbance is present in
this client?
a. Respiratory acidosis
b. Respiratory alkalosis

c. Metabolic acidosis
d. Metabolic alkalosis

35. Allens test checks the patency of the:

a. Ulnar artery
b. Radial artery

c. Carotid artery
d. Brachial artery

36. The chief life-threatening hazard for surgical patients with uncontrollable diabetes is:
a. Dehydration
b. Hypertension
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c. Hypoglycaemia
d. Glucosuria
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37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative care includes daily
urine specimen to be sent to the laboratory. Eileen as a Foley catheter attached to a urinary drainage
system. How will you collect the urine specimen?
a. Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into
the specimen container
b. Empty a sample urine form the collecting bag into the specimen container
c. Disconnect the drainage tube form the indwelling catheter and allow urine to flow form catheter into the
specimen container.
d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the
specimen container.
38. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation?
a. To the patients inner thigh
b. To the patients lower thigh

c. To the patients buttocks

d. To the patient lower abdomen

39. Which of the following menu is appropriate for one with low sodium diet?
a. Instant noodles, fresh fruits and ice tea
b. Ham and cheese sandwich, fresh fruits and vegetables
c. White chicken sandwich, vegetable salad and tea
d. Canned soup and potato salad
40. How will you prevent ascending infection to Eileen who has an indwelling catheter?
a. See to it that the drainage tubing touches the level of the urine
b. Change the catheter every eight hours
c. See to it the drainage tubing does not touch the level of the urine
d. Clean catheter may be used since urethral meatus is not a sterile area
Situation 7: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine
system is necessary.
41. Somatotropin or the Growth hormone releasing hormone is secreted by the:
a.
b.
c.
d.

Hypothalamus
Anterior pituitary gland
Posterior pituitary gland
Thyroid gland

42. All of the following are secreted by the anterior pituitary gland except:
a. Somatotropin/Growth hormone
b. Follicle stimulating hormone
c. Thyroid stimulating hormone
d. Gonadotropin hormone releasing hormone
43. All of the following hormones are secreted by secreted by the Posterior pituitary gland except:
a. Vasopressin
b. Oxytocin

c. Anti diuretic hormone

d. Growth hormone

44. Calcitonin, a hormone necessary for calcium regulation is secreted in the:

a. Thyroid gland
b. Hypothalamus
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c. Parathyroid gland
d. Anterior pituitary gland
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45. While Parathormone, a hormone that negates the effect of calcitonin is secreted by the:
a. Thyroid gland
c. Parathyroid gland
b. Hypothalamus
d. Anterior pituitary gland
Situation 8: the staff nurse supervisor requests all the staff nurses to brainstorm and learn ways to
instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available
daily to do health education classes.

46. The plan of the nurse supervisor is an example of:

a. In service education process
b. Efficient management of human resources
c. Increasing human resources
d. Primary prevention
47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nursing-aid who is an unlicensed
staff, Mrs. Guevarra
a. Makes the assignment to teach the staff member
b. Is assigning the responsibility to the aide but not the accountability for those tasks
c. Does not have to supervise or evaluate the aide
d. Must know how to perform task delegated
48. Connie, the new nurse appears tired and sluggish and lacks the enthusiasm she had six weeks ago when
she started the job. The nurse supervisor should:
a. Emphasize with the nurse and listen to her
b. Tell her to take the day off
c. Discuss how she is adjusting to her new job
d. Ask about her family life
49. Process of normal negotiations of working conditions between a group of registered nurses and employer is:
a.
b.
c.
d.

Grievance
Arbitration
Collective bargaining
Strike

50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the
hospital employing you. This is:
a.
b.
c.
d.

Professional course towards credits

In-service education
Advance training
Continuing education

Situation 9: as a nurse, you are aware that proper documentation in the patient chart is your responsibility.
51. Which of the following is not a legally binding document but nevertheless very important in the care of all
patients in any health care setting?
a. Bill of rights as provided in the Philippine constitution
b. Scope of nursing practice as defined by RA 9173
c. Board of nursing resolution adopting the code of ethics
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d. Patients bill of rights

52. A nurse gives a wrong medication o the client. Another nurse employed by the sane hospital as a risk
manager will expect to receive which of the following communication?
a. Incident report
b. Oral report

c. Nursing kardex
d. Complain report

53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following
charges?
a. Fraud
b. Assault and battery

c. Harassment
d. Breach of confidentiality

54. Which of the following is the essence of informed consent?

a. It should have a durable power of attorney
b. It should have coverage from an insurance company
c. It should respect ht clients freedom from coercion
d. It should disclose previous diagnosis, prognosis and alternative treatments available for the client
55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always
be accountable and should not lose his accountability. Which of the following is a role included in
delegation?
a. The RN must supervise all delegated tasks
b. After a task has been delegated, it is no longer a responsibility of the RN
c. The RN is responsible and accountable for the delegated task in adjunct with the delegate
d. Follow up with a delegated task is necessary only if the assistive personnel is not trustworthy
Situation 10: when creating your lesson plan for cerebrovascular disease or STROKE. It is important to
include the risk factors of stroke.
56. The most important risk factor is:
a. Cigarette smoking
b. Hypertension

c. Binge drinking
d. Heredity

57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on causes are
the following EXCEPT:
a. Embolic stroke
b. Hemorrhagic stroke

c. Diabetic stroke
d. Thrombotic stroke

58. Hemorrhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage,
EXCEPT:
a. Phlebitis
b. Trauma

c. Damage to blood vessel

d. Aneurysm

59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked
to this?
a. Amphetamines
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b. Cocaine
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c. Shabu

d. Demerol

60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is:
a. More red blood cells thicken blood and make clots more possible.
b. Increased RBC count is linked to high cholesterol.
c. More red blood cell increases hemoglobin content.
d. High RBC count increases blood pressure.

Situation 11: recognition of normal values is vital in assessment of clients with various disorders.
61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse
would expect the hematocrit level for this client to be which of the following?
a. 60%
b. 47%

c. 45%
d. 32%

62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6
mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory
value?
a. ST depression
b. Inverted T wave

c. Prominent U wave
d. Tall peaked T waves

63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2
mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory
value?
a. U waves
b. Absent P waves

c. Elevated T waves
d. Elevated ST Segments

64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result
the nurse notices which of the following as abnormal finding
a. Neutrophils 60%
b. White blood cells (WBC) 9,000/mm
c. Erythrocyte sedimentation rate (ESR) is 39 mm/hr
d. Iron 75 mg/100 ml
65. Which of the following laboratory test result indicate presence of an infectious process?
a.
b.
c.
d.

Erythrocyte sedimentation rate (ESR) 12 mm/hr

White blood cells (WBC) 18,000/mm3
Iron 90 g/100 ml
Neutrophils 67%

Situation 12: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to
this.
66. Which of the following is a finding that the nurse will be able to assess in a client with pleural effusion?
a. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath
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b. Hypoxemia, hypercapnea and respiratory acidosis

c. Noisy respiration, crackles, stridor and wheezing
d. Tracheal deviation toward the affected side, increased fremitus and loud breath sounds
67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal of fluid should be
slow. Rapid removal of fluid in thoracentesis might cause:
a. Pneumothorax
b. Pleurisy or pleuritis

c. Cardiovascular collapse
d. Hypertension

68. 3 days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleural
effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician orders a
closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to:
a. Restore positive intrathoracic pressure
b. Restore negative intrathoracic pressure
c. To visualize the intrathoracic content
d. As a method of air administration via ventilator
69. The chest tube is functioning properly if:
a. There is an oscillation
b. There is no bubbling in the drainage bottle
c. There is a continuous bubbling in the water seal
d. The suction control bottle has a continuous bubbling
70. In a client with pleural effusion, the nurse is instruction appropriate breathing technique. Which of the
following is included in the teaching?
a. Breath normally
b. Hold the breath after each inspiration for 1 full minute
c. Practice abdominal breathing
d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation
Situation 13: Health care delivery system affects the health status of every Filipino. As a nurse, knowledge of
this system is expected to ensure quality of life.
71. When should rehabilitation commence?
a. The day before discharge
b. When the patient desires

c. Upon admission
d. 24 hours after discharge

72. What exemplified the preventive and promotive program in the hospital?
a. Hospital as a center to prevent and control infection
b. Program for smokers
c. Program for alcoholics and addicts
d. Hospital as wellness center
73. Which makes nursing dynamic?
a. Every patient is unique physical, emotional, social and spiritual being
b. The patient participates in the overall nursing care plan
c. Nursing practice is expanding in the light of modern developments that takes place
d. The health status of the patient is constantly changing and the nurse must be cognizant and responsive
to these changes
74. Prevention is an important responsibility of the nurse in:
a. Hospitals
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b. Community
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c. Workplace

d. All of the above

75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed
periodic payment.
a. Health maintenance organization
b. Medicare
c. Philippine health insurance act
d. Hospital maintenance organization
Situation 14: Nursing ethics is an important part of the nursing profession. As the ethical situation arises so
is the need to have an accurate and ethical decision making.
76. The purpose of having a nurses code of ethics is:
a. Delineate the scope and areas of nursing practice
b. Identify nursing action recommended for specific health care situations
c. To help the public understand professional conduct expected of nurses
d. To define the roles and functions of the health care givers, nurses and clients
77. The principles that govern right and proper conduct of a person regarding life, biology and the health
professionals is referred to as:
a. Morality
b. Religion

c. Values
d. Bioethics

78. A subjective feeling about what is right or wrong is said to be:

a. Morality
b. Religion

c. Values
d. Bioethics

79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If values are going to
be a part of a research, this is categorized under:
a. Qualitative
b. Quantitative

c. Experimental
d. Non experimental

80. The most important nursing responsibility where ethical situations emerge in the care is to:
a. Act only when advised that the action is ethically sound
b. Not take sides, remain neutral and fair
c. Assume that ethical questions are the responsibility of the health team
d. Be accountable for his or her own actions
81. Why is there an ethical dilemma?
a. The choices involved do not appear to be clearly right or wrong
b. A clients legal right co-exist with the nurses professional obligation
c. Decisions has to be made based o societal norms.
d. Decisions has to be mad quickly often under stressful conditions
82. According to the code of ethics, which of the following is the primary responsibility of the nurse?
a. Assist towards peaceful death
b. Health is a fundamental right
c. Promotion of health prevention of illness, alleviation of suffering and restoration of health
d. Preservation of health at all cost.
83. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
a. The Philippine Nurses Association for being the accredited professional organization
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b. Code of Nurses was first formulated in 1982 published in the Proceedings of the third Annual
Convention of the PNA House of Delegates
c. The present code utilized the Code of Good Governance for the Professions in the Philippines
d. Certificates of Registration of registered nurses may be revoked or suspended for violations of any
provisions of the Code of Ethics.
84. Violation of the code of ethic might equate t the revocation of the nursing license. Who revokes the license?
a. PRC
b. PNA

c. DOH
d. BON

85. Based on the code of ethics for Filipino nurses, what is regarded as the hallmark of nursing responsibility
and accountability?
a. Human rights of clients, regardless of creed and gender
b. The privilege of being a registered professional nurses
c. Health, being a fundamental right of every individual
d. Accurate documentation of actions and outcomes
Situation15: As a profession, nursing is dynamic and its practice is directed by various theoretical models.
To demonstrate caring behavior, the nurse applies various nursing models in providing quality nursing care.
86. When you clean the bedside unit and regularly attend to the personal hygiene of the patient as well as
washing your hands before and after procedure and in between patients, you indent to facilitate the bodys
reparative processes. Which of the following nursing theory are you applying in the above nursing action?
a. Hildegard Peplau
b. Virginia Henderson

c. Dorothea Orem
d. Florence Nightingale

87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process as
viewed as human to human relationships. This statement is an application of whose nursing model?
a. Joyce Travelbee
b. Calista Roy

c. Martha Rogers
d. Imogene King

88. The statement the health status of an individual is constantly changing and the nurse must be cognizant
and responsive to these changes best explains which of the following facts about nursing:
a. Dynamic
b. Holistic

c. Client centered
d. Art

89. Viginia Henderson professes that the goal of nursing is to work interdependently with other healthcare
working in assisting the patient to gain independence as quickly as possible. Which of the following nursing
actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally
immobile?
a. Feeds the patient, brushes his teeth , gives the sponge bath
b. Supervise the watcher in rendering patient his morning care
c. Put the patient in semi fowlers position, set the over bed table so the patient can eat by himself, brush
his teeth, and sponge himself
d. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready.
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90. In the self care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable
to fulfill his physiological, psychological and social needs. A pregnant client needing prenatal check up is
classified as:
a. Wholly compensatory
b. Partially compensatory

c. Supportive educative
d. Non compensatory

Situation 16: documentation and reporting are just as important as providing patient care. As such, the nurse
must be factual and accurate to ensure quality documentation and reporting.
91. Health care reports have different purposes. The availability of patients record to all health team members
demonstrates which of the following purposes:
a. Legal documentation
b. Education

c. Research
d. Vehicle for communication

92. When a nurse commits medication error, she should accurately document clients response and her
corresponding action. This is very important for which of the following purposes:
a. Research
b. Nursing Audit

c. Legal documentation
d. Vehicle for communication

93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting.
The P in SOAPIE charting should include:
a. Prescription of the doctor to the patients illness
b. Plan of care for patient
c. Patients perception of ones illness
d. Nursing problem and Nursing diagnosis
94. The medical records that are organized into separate section form doctors or nurses has more
disadvantages than advantages. This is classified as what type of recording?
a. POMR
b. SOAPIE

c. Modified POMR
d. SOMR

95. Which of the following is the advantage of SOMR or Traditional recording?

a. Increase efficient data gathering
b. Reinforces the use of the nursing process
c. The care giver can easily locate proper section for making charting entries
d. Enhances effective communication among the care team members
Situation 17: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung
and chest x ray revealed pleural effusion. The physician will perform thoracentesis
96. Thoracentesis is useful in treating all of the following pulmonary disorders except:
a. Hemothorax
b. Tuberculosis

c. Hydrothorax
d. Empyema

97. Which of the following psychological preparations is not relevant for him?
a. Telling him that the gauge of the needle and anesthesia to be used
b. Telling him o keep still during the procedure to facilitate the insertion of the needle in the correct place
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c. Allow June to express his feelings and concerns

d. Physicians explanation on the purpose of the procedure and how it will be done
98. Before thoracentesis, the legal consideration you must check is:
a. Consent is signed by the client
b. Medicine preparation is correct
c. Position of the client is correct
d. Consent is signed by relative and physical
99. As a nurse, you know that the position for June before thoracentesis is:
a. Orthopneic
b. Knee-chest
c. Low fowlers
d. Side lying position on the affected side
100.Which of the following anesthetics drug is used for thoracentesis?
a. Procaine 2%
b. Valium 250 mg

Nursing Practice Test 1

c. Demerol 75 mg
d. Phenobarbital 50 mg

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