67. Ms.

Libby is a professional nurse who was approached by her cousin to be in a

Television show where she has to wear the nurses uniform and advertise a commercially
prepared beauty product for use in their work setting. Her mother is presently having
dialysis so the accepted the offer. Ms. Libby is violating the _______.

a. nursing law
b. nursing code of ethics
c. nursing jurisprudence
d. consumers fraud law
68. Mr. Larson is scheduled for Coronary Artery-by-pass graft (CABG) surgery. He has to
sign an informed consent prior to operation. The validity of this consent is how long?

a. 36 hours after surgery

b. 24 hours after surgery
c. after the surgical procedure
d. 12 hours after surgery
69. A patient was admitted in a medical center by his physician for an Exploratory
laparotomy. After discharge for two days, he was complaining of chills and fever. The
abdominal incision was passing out yellowish purulent discharge. He had an abdominal
Xray and was was found out to have 3 pcs of gauze inside the abdomen. A libel suit was
filed by the family. Who is liable in this case?

1. Surgeon
2. Circulating nurse
3 Anesthesiologist
4 . Hospital

A. 1, 2, 3, & 4
B. 1, 2, & 3
C. 1&2
D. 2&3

70. Nurse Rose is assigned to a patient in ICU pronouned who is dying due to cardiac
arrest. After two hours, the partient was pronouned dead. Which of following health
status should guide the nurse is the patient is declared dead?

A. All body systems are no longer functioning

NURSING PRACTICE IV – CARE OF CLIENTS (PART B)
November

Situation: A landslide had occurred in x province due to persistent and heavy rainfall.
According to information received by the Emergency Department Staff, there were
about 150 people injured.
1. The nurse prepares the department to receive the injured. This situation would be
BEST classified as a/an:

a. Unnatural Calamity
b. Natural Calamity
c. Mass Casualty Incident
d. Accidental Disaster

2. The first responders to the scene of disaster would MOST likely use which of the
following tools to separate victims for easy recognition of those in need of immediate
care.

a. Number Codes
b. Triage Tag
c. Category Tags
d. SALT Triage
3. The ED nurse plans the coding for disaster victims. Which colors are MOST associated
with triage?

1. Green
2. Yellow
3. Black
4. Blue 5. White

a. 2, 3, 4, 5
b. 1, 2, 3, 4, 5
c. 1, 2, 3, 4
d. 1, 2, 3

4. The ED nurse receives a victim with severe life- threatening injuries and most likely
will not survive. The victim would be triaged as:

a. Yellow
b. Red
c. Black
d. White
5. One of the victims, a female was brought to the ED crying hysterically and looking
frightened. She exclaims she was inside her house when the landslide occurred and just
barely escaped. What is the BEST action by the nurse? *
a. Refer her to the proper authorities for counselling.
a. Triage her and give appropriate treatment.
b. Call a physician to talk to her.
c. Advise her to go home with a relative.
Situation: A nine year old male child is hospitalized for burns on the right arm, right leg
and abdomen. The nurse documents the treatment performed on the child.

6. The nurse determines the extent of burns using the rule of nines. Which of the
following assessment findings should the nurse document?

a. 18% of the child’s body surface is burned.

b. 45% of the child’s body surface is burned.
c. 50% of the child’s body surface is burned.
d. 25% of the child’s body surface is burned.
7 . The nurse writes a nursing diagnosis for the child which is the basis of care for the
first 24 hours of admission. The MOST appropriate nursing diagnosis would be
_______ : a. Fear and Anxiety
a. Disturned Body Image
b. Risk for Infection
c. Impaired Mobility
8. The physician writes an order for the client. Infuse D5 water 500 cc to run for 8 hours.
The IV micro set delivers 60 drops per ml. How many drops should the nurse regulate
the flow and record it in the client’s chart?

a. 50 drops per minute

b. 62 drops per minute
c. 35 drops per minute
d. 30 drops per minute
9. The nurse commits an error in documenting the care of the burnt child. She consults
the charge nurse to find out if the hospital has an established policy on correcting
documentation errors. Which of the following is an accepted form for correcting errors?

a. Enclose in parenthesis the erroneous statements, draw a line across the

statement, and make the correct entry above the 1 drawn.
b. Correct the error by applying correction fluid or tape and write the correct entry
over it.
c. Cross through the erroneous word or statement with a double line, affix your
initials, write the pharse “mistaken entry” then write the correct information.
d. Use the slide rule method. Cross through the erroneous word or statement with
a single line, affix your initials, write the date and time the correction was made, the
write the correct information.

10. The nurse is aware that documentation requires the following EXCEPT:
Documentation should:
a. Be systematic and organized
b. Comply with policy standards of the health care facility.
c. Present exact and correct details pertinent to the event.
d. Include reactions and interpretations of the nurse on the event.
Situation: The assistant chief nurse of X hospital attends a seminar on quality and
performance improvement. The seminar is to increase awareness on how performance
improvement affects client care and the health care organization.

11. Which of the following principles of quality improvement is MOST appropriate for
patient care?

a. The priority is to benefit clients and all other internal and external customers.
b. Improvement of the quality of service is a continuous process.
c. Improvement opportunities are developed by focusing on the work process.
d. Quality is achieved through the participation of everyone in the organization.
12 . The assistant chief nurse understands that the implication of quality improvement
for client care can be measured by the overall value of care. Outcomes can be measure
by which of the following?

a. Client’s recommendation
b. Clinical out come
c. Cost of care
d. Client satisfaction
13. The assistant chief nurse is oriented on the various improvement strategies at the
organization level. One of these strategies is benchmarking. Which of the following
describes the bench marking process?

a. Comparing data in the literature with the data collected per client.
b. Reviewing own unit’s data for opportunities.
c. Collecting data of the individual client.
d. Comparing ow data with that of other organization to identify opportunities.
14. The assistant chief nurse understands that a sentinel event review is one strategy to
improve the health care delivery system. The FIRST action to be initiated following a
sentinel event is for the assistant chief nurse to ____.

a. Conduct an immediate investigation

b. Conduct a root cause analysis
c. Recommend corrective action of personnel involved
d. Recommend what action personnel involved should avoid
15. Quality improvement can be achieved through the participation of everybody in the
health care organization at all levels. Which of the following is an example of nurses’
participation as an individual?

a. Work with others in the unit to change the way client’s report is given to be more
time efficient.
b. Suggest the process for notifying the pharmacy department about a missing
medication.
c. Participate in a term to find a solution.
d. Change the activities of her day to spend more time with a client’s family.
Situation: Nurse Edna, a charge nurse of an oncology unit attends a seminar on evidence
based nursing practice.
16. The conference speaker explained the difference between evidence based
practice and evidence based nursing practice. Which of the following is NOT TRUE
regarding evidence based nursing practice? Evidence- based nursing practice ____.
a. Has a medical focus
a. Uses a therory derived and research based information in making decision about
nursing care delivery.
b. Considers the patient’s need and preferences based on nursing theory and research
c. Is a strategry used to improve patient care outcome.
17. The speaker encouraged the nurses to participate in the use of evidence- based
nursing practice. The speaker said that nurses must ____.

1. Participate in the development, use, or evaluation of practice guidelines.

2. Read and analyze outcome of research studies
3. Involve themselves in everyday patient care and nursing practice. 4 . Know why they
are doing what they are doing

a. 2, 3 and 4
b. 1 and 2
c. 1 ,2, 3 and 4
d. 1, 3 and 4

18. Nurse Edna is aware of the importance of patient outcomes as a measure of quality
care. Which of the following statements is TRUE regarding patient-focused outcome
indicators? To _______.

1. Achieve safe, quality, cost effective care for patients in daily practice.
2. Realize that individual nursing practice styles directly affect the rates at which
patients recover.
3. Prevent development of unnecessary complications and injury.
4. Determine satisfaction rate from patients or family care received from nursing staff.

a. 1, 2 ,3 and 4

b. 1 and 3
c. 2 and 4
d. 1, 3 and 4
19. A model for using evidence- based practice was presented. The model has the
following elements: Plan, Do, Study and Act (PSDA). If nurse edna wants to utilize this
model to improve ward management, what questions will she ask?

1. What are we trying to accomplish?

2. How well do we know that a change is an improvement?
3. Will the patient be satisfied with the improvement?
4. What change/changes can we make that will result in an improvement?

a. 2 and 4

b. 3 and 4
c. 1 and 3
d. 1,2,3 and 4

20. Nurse Edna is aware that patient care improvement must be based on which of the
following?
a. Total cost of health care
b. Building and apply knowledge
c. Hospital policy on how to staff a nursing unit.
d. Accreditation standards
Situation: The nurse cares for a client with cancer who had lung surgery. The nurse
educates the client on breathing exercise and ambulation.

21. The nurse teaches the client how to deep breath effectively after a lobectomy. The
nurse instructs the client to:

a. Contract the abdominal muscles, take a deep breath through the mouth and
exhale slowly as one trying to blow out a candle.
b. Relax the abdominal muscle, take a slow deep breath through the nose, and hold
it for 3 to 5 seconds.
c. Relax the abdominal muscle, take deep breath through the mouth and exhale
slowly for 15 seconds
d. Contract the abdominal muscles, take a slow deep breath through the nose, and
hold it for 3 to 5 seconds.

22. The client asks the nurse how much of his lungs are removed. The nurse responds
based on information that in lobectomy, a lobe is removed. In a wedge resection, which
of the following is removed?

a. A small, localized are near the surface of the lung

b. One entire lung
c. Two lobes of the lung
d. A segment of the lung, including a bronchiole and its alveoli.
23. The client asks the nurse, what will fill the space where the lobe was? The correct
response would be: The _____.

a. Lung space will be filled up with serous fluid.

b. Surgeon filled the space with gel.
c. Space stays empty
d. Remaining lobe or lobes over expand to fill the space.

24. On the second post-operative day, the nurse auscultates the lungs and determines
scattered crackles bilaterally. Which of the following interventions would be MOST
appropriate for the nurse to perform?

a. Encourage deep breathing and ambulation as soon as the client is able.

b. Encourage coughing and check the water seal system
c. Reduce the frequency of pain medications and increase the suction in the water seal
bottle.
d. Perform endotracheal suctioning every shift.
25. The nurse teaches the client to perform which of the following exercises to prevent
shoulder ankylosis?

a. Raise and lower the head

b. Turn from side to side
c. Raise the arm on the affected side over the head
d. Flex and extend the elbow on the affected side
Situation: Nurse Elma speciaized in emergency nursing. She collaborates with ED
physician, triage team and other members of the health team provide care to clients of
all age- groups with various illnesses or injuries coming to the emergency department.