NP1 Nursing Board Exam December 2007 Answer Key 'Foundation of Professional Nursing Practice'

100 Nursing Board Exam test questions of December 2007 Nurse Licensure Examination (NLE)
Nursing Practice 1 – Foundation of Professional Nursing Practice
Fundamentals of Nursing

PART 1 Board Exam test questions 1 - 50

NURSING PRACTICE I SET A

NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice

MULTIPLE CHOICE

1. Nurse Suzie is administering 12:00 PM medication in Ward 4. Two patients have to receive Lanoxin. What should Nurse Suzie do when one of the clients does NOT have a readable identification band?

A. Ask the client if she is Mrs. Santos

B. Ask the client his name

C. Ask the room mate if the client is Mrs. Santos

D. Compare the ID band with the bed tag

2. Lizette, 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 BEST response of Lizette?

A. “Use touch when the situation calls for it”.

B. “Touch serves as a connection between the nurse and the patient”.

C. “Use touch with discretion”.

D. “Touch is used in physical assessment”.

3. You are asked to teach the client, Mr. Lapuz, who has right sided weakness the use of a cane. Which observation will indicate that Mr. Lapuz is using the cane correctly?

A. The cane and one foot or both feet are on the floor at all times

B. He advances the cane followed by the left leg

C. Client keeps the cane on the right side along the weak leg

D. Client leans to the left side which is stronger

4. George, a 43 year old executive is scheduled for cardiac bypass surgery. While being

prepared for the 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 are always risks involved with surgery.”

C. “There is a client in the other room who had successful surgery and you can talk to him.”

D. “This must be very frightening for you. Tel me how you feel about the

surgery.”

5. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse?

A. Report to the physician the effects of the medication on urination.

B. Take the medicine early in the morning

C. Take a full glass of water with the medicine

D. Measure frequency of urination in 24 hours

6. Nurse Glenda gets a call from the 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. Observe the child for an hour. If the child does not improve, refer to the physician in

the neighborhood.

B. Recommend to bring the child immediately to the hospital

C. Assess the child, recommend observation and administer acetaminophen. If symptoms continue, bring to the hospital.

D. Tell the neighbor to observe the child and give plenty of fluids. If the child does not

improve, bring the child to the hospital.

7. Wilfred, 30 years old male, 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 to his head. In this situation, the nurse is:

A. not responsible because of the doctrine of respondent superior

B. free from any negligence that caused harm to the patient

C. liable along with the employer for the use of a defective equipment that

harms the client

D. totally responsible for the negligence

8. While going on evening round, Nurse Edna saw Mrs. Pascual meditating and afterwards started singing prayerful hymns. What is the BEST response of Edna?

A. Ignore the incidence

B. Report the incidence to the head nurse

C. Respect the client’s actions as this provides structure and support to the

client

D. Call her attention so she can go to sleep

9. A client asks for advice on low cholesterol food. You advise the client to eat the following:

A. Chicken liver, cow liver, eggs

B. Lean beef and pork, egg ewhite, fish

C. Balut, salted eggs, duck and chicken egg

D. Pork liempo, cow brain, lungs and kidney

10. The code of ethics for nurses has an interpretative statement that provides:

A. continuity of care for the improvement of the client

B. guide for carrying out nursing responsibilities that provide quality care and

for the ethical obligation of the profession

C. standards of care in carrying out nursing responsibilities

D. identical care to all clients in any setting

11. Which of the following situations would possibly cause a nurse to be sued due to negligence?

A. Nurse gave a client wrong medication, and an hour later, client complained of

dyspnea

B. While preparing a medication, the nurse notices that instead of 1 tablet, she put two

tablets into the client’s medicine cup

C. As the nurse was 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. Patient

noticed the error and complained.

12. Your nurse supervisor asks you who among the following clients is most susceptible to getting infection if admitted to the hospital?

A. Diabetic client type2

B. Client with chronic obstructive pulmonary disease (COPD)

C. Client with second degree burns

D. Client with psoriasis

13. Mr. Chris Martinez 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. “Don’t worry. I will call the attention of your wife.”

B. “Your wife is just trying to help because she is worried about you.”

C. “What are your thoughts about your wife’s involvement in your care?”

D. “Your wife can assist you well in your care and recovery.”

14. The nurse is in the hospital canteen and hears two staff nurses talking about the client confined in Room 612. They mentioned his name and discussed details of his condition. Which of the following actions should the nurse take?

A. Approach the two nurses and tell them that their actions are inappropriate

especially in a public place

B. Wait till the nurses finish the discussion and report the situation to the supervisor

C. Say nothing to avoid embarrassing the staff nurses

D. Remain quiet and ignore the discussion

15. The son of Mr. Rosario, a 76 year old man, reports to the nurse in the community health center that his father has been getting out of 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. Apply restraints during night hours only

B. Advise hospitalization to prevent future accidents

C. Keep a radio or TV for company and to orient the client

D. Have someone check on the client frequently at night

Situation 1 – 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 patient’s lives.

16. You are to administer an intramuscular injection to Dulce, 1 ½ year old girl. The most

appropriate site to administer the drug is:

A. dorso gluteal region

B. ventral forearm

C. vastus lateralis

D. gluteal region

17. An infant is ordered to receive 500ml 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

B. 21 drops per minute

C. 30 drops per minute

D. 15 drops per minute

18. Following surgery, Henry 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. 42 drops

B. 20 drops

C. 60 drops

D. 32 drops

19. Mr. Lagro 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 drop per minutes should the IV be regulated?

A. 13-14 drops C. 10-12 drops

B. 17-18 drops D. 15-16 drops

20. The physician ordered Nembutal Na gr XX. The bottle contains 100mg/capsule. How many capsule will be administered to the client?

A. 1 capsule

B. 1 ½ capsule

C. 2 capsule

D. ½ capsule

Situation 2 – The nurse supervisor is observing the staff nurses in her hospital to see how quality of care provided to clients can be improved.

21. The nurse supervisor is not satisfied with the bed bath that is provided by Nurse Arthur. To improve the care provided to the patients in the unit by Nurse Arthur, the nurse supervisor should:

A. tell the nurse how to give bed baths correctly

B. ask another staff nurse to do bed baths instead

C. provide a manual to be read on giving bed baths

D. bring the staff nurse to a client’s room and demonstrate

22. 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. Testing options

B. Considering effects on results

C. Defining the problem

D. Making final decisions

23. To check if the nurses under her supervision use critical thinking, Mrs. David observes if the nurses act responsibly when at work. Which of the following actions of the nurse demonstrates the attitude of responsibility?

A. Thinking of alternative methods of nursing care

B. Sharing ideas regarding patient care

C. Following standards of practice

D. Planning other approaches for patient care

24. The nurse who makes clinical judgment can be depended upon to improve the quality of care of clients. Nurse Julie uses such good clinical judgment when she gives priority care to this client:

A. Roman, a client who is ambulatory and for surgery tomorrow

B. A post operative client, Rey, who has a blood pressure of 90/50 mmHg

C. Mr. Abad, a client who needs instructions for home medications

D. Fred, a client who received pain medications 5 minutes ago

25. A good nursing care plan is dependent on a correctly written nursing diagnosis. It defines a client’s problem and its possible cause. The following is an example of a well written nursing diagnosis:

A. Acute pain related to altered skin integrity secondary to hysterectomy

B. Electrolyte imbalance related to hypocalcemia

C. Altered nutrition related to high fat intake secondary to obesity

D. Knowledge deficit related to proctosigmoidoscopy

Situation 3– You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with

ovarian cancer stage IV.

26. When caring for a dying client, you will perform which of the following activities?

A. Encourage the client to reach optimal health

B. Assist client perform activities of daily living

C. Assist the client towards a peaceful death

D. Motivate client to gain independence

27. 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:

A. acceptance

B. resolution

C. denial

D. bargaining

28. The nurse is to administer Demerol 50 mg IM to Mrs. Leyba. Demerol is available in a multidose vial labelled 100 mg/ml and Vistaril comes in an ampule labelled 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 ampule

B. inject air into the vial, then into the ampule

C. inject air into the ampule, aspirate the desired dose, then into the vial

D. withdraw medication from the ampule then from the vial

29. When giving Demerol 50 mg from a multidose vial labelled 100 mg/ml and Vistaril 50 mg/ml from an ampule labelled 50 mg/ml, what is the total volume that you will inject to the client?

A. 2 ml

B. 1 ml

C. 1.5 ml

D. 1.75 ml

30. Mrs. Leyba is emaciated and is at risk for developing which problem in skin integrity?

A. Blisters

B. Reddening of the skin

C. Pressure sores

D. Pustules

Situation 4 – You are assigned to work in an orthopedic ward where clients are expected to have problems in mobility and immobility.

31. Ramil’s right leg is injured and Nurse Karen has to move him from the bed to wheel chair. Which of the following is the appropriate nursing action of Nurse Karen?

A. Put the client on the edge of the bed and place the wheelchair at her back

B. Face the client and place the wheelchair on her left side

C. Put the client on the edge of the bed and place the wheelchair on the other side of the bed

D. Put the client on the edge of the bed and place the wheelchair on the client’s

left side

32. Carlo has to be maintained on a dorsal recumbent position. Which of the following should be prevented?

A. adduction of the shoulder

B. Lateral flexion of the sternocleidomastoid muscle

C. Hyperextension of the knees

D. Anterior flexion of the lumbar curvature

33. Joseph prefers to be in high fowler’s position most of the time. The nurse should prevent which of the following?

A. Posterior flexion of the lumbar curvature

B. Internal rotation of the shoulder

C. External rotation of the hip

D. Adduction of the shoulder

34. Anthony asks to be assisted to move up the bed. Which of the following should Nurse Diana do first?

A. Move the patient to the edge of the bed near the nurse

B. Adjust the bed to flat position

C. Lock the wheels of the bed

D. Raise the bed rails opposite the nurse

35. Which of the following supportive devices can be used most effectively by Nurse Arnold to prevent external rotation of the right leg?

A. Sandbags C. Pillow

B. Firm mattress D. High foot board

Situation 5 – As you begin to work in the hospital where you are on probation, you are

tasked to take care of a few patients. The clients have varied needs and you are expected to provide care for them.

36. An ambulatory client. Mr. Zosimo, is being prepared for bed. Which of the following nursing actions promote safety for the client?

A. Turning off the lights to promote rest and sleep

B. Instructing the client about the use of call system

C. Raising the side rails

D. Placing the bed in high position

37. Mikka, 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 patient complained of pain. Which of the following is the most appropriate nursing diagnosis?

A. Impaired mobility related to pain secondary to an abdominal incision

B. Impaired movements related to pain due to surgery

C. Impaired mobility related to surgery

D. Severe pain related to surgery

38. 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 log roll when turning

B. Encourage the client to do self-care

C. Instruct the client to do deep breathing exercises

D. Ambulate the client in ward premises every twenty minutes

39. Mr. Lozano, 50 year old executive, is recovering from severe myocardial infarction. For the past 3 days, Mr. Lozano’s 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 Mr. Lozano?

A. Involving family members in meeting client’s personal needs

B. Meeting his needs till he is ready to perform self-care

C. Preparing a day to day activity list to be followed by client

D. Involving Mr. Lozano in his care

40. Mr. Ernest Lopez is terminally ill and he choose to be at home with his family. What nursing action are best initiated to prepare the family of Mr. Lopez?

A. Talk with the family members about the advantage of staying in the hospital for

proper care

B. Provide support to the family members by teaching ways to care for their

loved one

C. Convince the client to stay in the hospital for professional care

D. Tell the client to be with his family

Situation 6 – Myrna, a 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. 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 nursing’s body of knowledge

B. Organizes the development of study and links the findings to nursing’s body

of knowledge

C. Provides logical structure of the research findings

D. Identifies concepts and relationships between concepts

42. Myrna need to review relevant literature and studies. The following processes are undertaken in reviewing literature EXCEPT:

A. locating and identifying resources

B. reading and recording notes

C. clarifying a research topic

D. using the library

43. The primary purpose for reviewing literature is to:

A. organize materials related to the problem of interest

B. generate broad background and understanding of information related to the

research problem of interest

C. select topics related to the problem of interest

D. gather current knowledge of the problem of interest

44. In formulating the research hypotheses, researcher Myrna should state the research question as:

A. What is the response of the staff nurses to the health values?

B. How is variable “health value” perceived in a population?

C. Is there a significant relationship between health values and health

promotion activities of the staff nurses?

D. How do health values affect health promotion activities of the staff nurses?

45. The proposed study shows the relationship between the variables. Which of the following is the independent variable?

A. Staff nurses in a selected college of nursing

B. Health values

C. Health promotion activities

D. Relationship between health values and health promotion activities

Situation 7 – While working in a tertiary hospital, you are assigned to the medical ward.

46. Your client, Mr. Diaz, is concerned that he can not pay his hospital bills and professional fees. You refer him to a:

A. Nurse supervisor

B. Social worker

C. bookkeeping department

D. physician

47. Mr. Magno has lung cancer and is going through chemotherapy. He is referred by the oncology nurse to a self-help group of clients with cancer to:

A. receive emotional support C. provide financial assistance

B. to be a part of a research study D. assist with chemotherapy

48. A diabetic hypertensive client, Mrs. Linao, needs a change in diet to improve her health status. She should be referred to a:

A. nutritionist

B. dietitian

C. physician

D. medical pathologist

49. When collaborating with other health team members, the best description of Nurse Rita’s role is:

A. encourages the client’s involvement in his care

B. shares and implements orders of the health team to ensure quality care

C. she listens to the individual views of the team members

D. helps client set goals of care and discharge

50. Nurse Rita is successful in collaborating with health team members about the care of Mr. Linao. This is because she has the following competencies:

A. Communication, trust, and decision making

B. Conflict management, trust, negotiation

C. Negotiation, decision making

D. Mutual respect, negotiation and trust

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